Procedural memory is the acquisition of a skill, knowledge, or ability that comes from overlearned experiences so that the activity is retrieved without any conscious effort. This memory system holds hope, connection, pleasure, and quality of life for people living with Alzheimer’s / dementia, as it is the last cognitive area to fail as it works beneath a level of conscious awareness.
Dementia is a slow, progressive, relentless disease process that gradually takes away a person’s abilities to think clearly and rationally, to function as an adult, to care for themself, to recognize the people in their life, to walk, to talk, to sit without support, even to smile. It can be a long, chronic syndrome that gradually becomes a terminal illness.
This long, chronic neurodegenerative disease by its very nature also takes individuals away from families, from marriages, from friendships, and from co-workers, as few other life-limiting illnesses do. Changing needs and growing dependency continually rewrite relationships so that there is no one definitive turning point along the way, but many. It is a constant saying hello and saying goodbye, as needs emerge and recede, as perceptions and understandings of self and others change, and as the well-known memories and rituals of a lifetime slowly become lost.
At its very core, dementia is the loss of memory. Memories of mind and heart fade away as the body’s organs, muscles, and sensations gradually forget what to do. These losses arise from the damage to four different memory systems of the brain.
Some parts of our memory function on a short-term basis and others are long term. Some parts of our memory are explicit as we consciously recall information, and other parts are implicit as we behave or respond without conscious recollection. All are affected in the course of the disease process, although at varying degrees.
In broad terms there are four categories of memory systems. The impact of three of these causes physical, behavioral, and emotional changes, as mind and body are affected.
Sophie loved to cook and bake. While making Thanksgiving dinner with her daughter, she struggled to follow a familiar recipe but was unaware that she was repeating the ingredients as six teaspoons of poultry seasoning and two sticks of butter, but no onions were added to the stuffing. Her daughter discreetly made a correct version that Sophie was able to mix and did not know about the switch.
This is an example of a decline in episodic memory, the ability to learn new information, to follow multi-step directions, to recall recent events as a part of the short-term memory, and to remember events and experiences in the context of their place, time, and purpose as long-term autobiographical memory. A change to the brain’s episodic memory is often the first behavioral sign of dementia as the memory distortion leads to forgotten familiar routes or plans, the repetition of stories and questions, difficulty in holding a conversation, poor or confused decisions, misplaced items, a decline in safety awareness, and a decrease in personal care and hygiene. Over time, the processes of Alzheimer’s and other forms of dementia most severely affect this memory system.
Diane was in the early stage of Alzheimer’s and at the suggestion of her doctor she decided to join a senior exercise class at a gym to her help keep her more active. As she began to fill out the membership form, she had a difficult time focusing on what was needed. She caught herself listing an old address instead of a current one and could not comprehend the different policies she was agreeing to.
This is an example of a decline in working memory which affects short-term retention as well as concentration and attention span for day-to-day functioning, language skills, reasoning capability decision making, and problem solving. The ability to understand, recognize, process, and use words is central to our working memory as it is how language is applied and manipulated.
For Drew’s family one of the hardest losses was his way with words. Always one with a quick wit, a playful pun and a gift for embellished storytelling, his increasing verbal challenges to find words, to group things in logical categories and to associate people and events coherently made him a very different person.
This is an example of a decline in semantic memory (also known as “declarative memory”), a long-term memory system which manages everyday knowledge and details such as being able to identify, group, and name objects such as colors or types of animals, and to understand both broad concepts and specific meanings. This is how we recall facts of general world knowledge gradually acquired over a lifetime, such as historic dates, people, and events, as well as geographical locations. This memory allows us to use and interpret language and learn about new ideas. As the disease progresses, this knowledge decreases as language skills are diminished since semantic memories are expressed through our words.
It is the fourth memory system of the brain that holds hope, connection, pleasure, and quality of life for people living with Alzheimer’s /dementia, as it is the last cognitive area to fail as it works beneath a level of conscious awareness. This is procedural memory, the acquisition of a skill, knowledge, or ability that comes from overlearned experiences so that the activity is retrieved without any conscious effort. Overlearning, the repetition of an established skill or practice, leads to automaticity so implicit memories are formed by the effects overlearning until the entire nervous system works together automatically. It is our procedural memory that allows us to develop the skill to pick up a pen and write the alphabet without having to consciously think of the name, shape, and sound of the individual letters. It is our procedural memory that allows us to learn a skill such as reading, playing an instrument, or participating in a sport. It is procedural memory that is the foundation of our religious practices as we participate in the actions of prayer, hymns, and sacraments with others in the congregation long before we understand the theology and meaning embodied in the actions.
The psychology of procedural memory recognizes this as how a person’s character is formed, how habits, behaviors, and emotional responses are learned and expressed. People with Alzheimer’s / dementia who are living in the past as their current reality, who tell and retell stories, and who are comforted by loved ones joining with them through an active acceptance of what has brought them connection and contentment, are living in the world of their procedural memory. Meeting people just where they are as dementia progresses, connecting to who they are each step of the way, is grounded in relating to their procedural memory. Who they are is consistent with who they have always been, even when it is expressed in new ways, in old behaviors, or in silence.
It is through procedural memory that the greatest quality of life, the most personal attention and dignity, remains as so much is being shed, becoming lost.
Procedural memory holds and shapes the world in which people with Alzheimer’s/ dementia live as it where their reality is based.
When we look back over our lives, we recall the details of events, snippets of conversation, and the emotions and feelings of an experience. We do not remember the entire day even if we have marked it as “the greatest day ever!” We can anticipate a whole event, we can live out the day with close attention, but we do not hold the whole day in our memory, whether it is a routine day or special occasion. It is the little things, the day-to-day things, that are the ways we authentically live our lives through what is important to us, how we identify ourselves and how we choose to spend our time.
These are the foundations of our procedural memory. Tangible practices of faith, belief systems, habits of home, work, and hobbies all can be the precious objects that reconnect someone living with memory impairment to a past that has re-presented itself. Those earlier days, in a linear measurement of time, may now seem fully real and present. Remaining mindful that spirituality—the sense of all that gives meaning, value, and purpose to our lives, all that encompasses our deepest self, and often draws upon on the earliest and most significant memories that have shaped the person we have become—remains even in the fog of dementia, allows loved ones and caregivers to connect in expressive, familiar, authentic, personal, affirming, comforting, and loving ways.
The comfort of spirituality for those living in the world of Alzheimer’s /dementia is a biographical connection that feeds the soul, evokes the senses, and nurtures the human spirit. How faith beliefs were expressed and lived out, items of work or home or play, music and song, are all ways to bring and hold onto peace, comfort, and individuality.
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