Pamment, James; (2021) Aspects of the Assessment and Intervention with Memory and Executive Functions in People with Neurological Conditions. Doctoral thesis (D.Clin.Psy), UCL (University College London).

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Abstract

This thesis examined two contemporary conundrums relevant to the practice of neuropsychology. Through systematic review and meta-analysis, the first project examined the treatment effects of errorless learning (EL) a compensatory technique designed to facilitate learning for people with memory impairment resulting from neurological conditions. This review of EL in the field of memory rehabilitation is timely. To date, there is only one meta-analysis of the treatment effects of EL, completed nearly twenty years ago which did not control for potential biases. Subsequently there has been a natural progression in the use of EL from well-controlled laboratory-based tasks to its integration into memory rehabilitation programmes. In addition to examining the overall effect of EL in people with amnesic disorders, this review was also the first to report the treatments effects from studies of patients with progressive conditions separately from studies of non-progressive neurological conditions. Results indicate that EL is an effective technique to help people with memory disorders learn new information. This informs clinicians of the appropriateness of its use in practice. However, potential publication bias was identified, along with variation in methodology and quality of the studies reviewed and analysed. Until steps are taken to produce studies which are suffice in size, well controlled and the publication of non-significant results are encouraged, caution must be applied to avoid over-estimating the clinical benefits of EL to patients. The second element of this project aimed to investigate issues around long-reported concerns of a lack of correspondence between test performance on neuropsychological measures and everyday decision-making ability in patients with acquired brain injury (ABI). Reduced decision-making capacity is a common consequence of ABI. The results can have devastating consequences for an individual and the support systems around them. Accurate assessment of a person’s decision-making ability is crucial to inform support needs. This project examined this issue with a service evaluation in a specialist cognitive rehabilitation service. The evaluation explored the relationships between standardised tests of cognitive function and a custom clinician-rated measure of everyday decision-making. Results provide evidence towards the accuracy of the tests used in the service to assess the cognitive components of decision-making. The results also evidence how elements of the assessment battery employed by the service meet existing clinical standards. This evaluation suggests that at a group level, despite concerns in the literature around a lack of ecological validity, tests of executive function are more useful in the assessment of decision-making than those from broader cognitive domains. In addition, the results identify a specific measure of planning to be important in the assessment of decision-making. This work informs clinicians in the service on how to approach the cognitive assessment of decision-making and evidence some potential for modifications in their battery. These results could lead to increased accuracy of assessment, with increased potential for patient challenges in this domain to be identified. This review may also provide a framework for other services on how to approach evidencing their standard of cognitive assessment of decision-making, despite the lack of specific national guidelines.

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