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Procedural memory and emotional attachment in Alzheimer disease: implications for meaningful and engaging activities.

Abstract: With an increasing number of older adults being diagnosed with Alzheimer disease, the need to find meaningful and enjoyable activities in which they can successfully engage is important for providing good quality of life while preventing behavioral difficulties that often accompany this diagnosis. Dementia-related neuropsychological impairments hinder engagement in a variety of enjoyable activities. For many older adults with Alzheimer disease who have been involved in a religious tradition, well-rehearsed rituals and emotionally salient behaviors can be employed well into the later stages of this disease. An approach called procedural and emotional religious activity therapy, or PERAT, can provide enjoyable and meaningful activities that may reduce agitation and increase quality of life for patients as well as for caregivers. Knowledge about the neuropsychology of procedural and emotional memory is needed to understand how PERAT works.


According to Lawton (2001), there are 11 universal human needs, one of which is meaningful activity. Given the neuropsychological impairment of adults with Alzheimer disease (AD), caregivers have difficulty finding stimulating, meaningful activities that will hold the attention of adults with this condition. Kovach and Magliocco (1998) found that adults in institutional settings with late-stage dementia participated in activities for 10 or fewer minutes daily. Caregivers assisted adults with activities 37.5% of the time. Many activities can be too mentally challenging, involve objects that look like children's toys (which may be insulting to those who are in the earlier stages of the disease), or have no inherent or intrinsic purpose or goal. As a result, many adults with AD spend time in unfulfilling ways (Burnside, 1986).

Approximately 4 million adults in the United States have been diagnosed with AD (Samanta, Wilson, Santhi, Kumar, & Suresh, 2006). Within the next two decades, the number of adults diagnosed with AD will increase to approximately 15-20 million (Brookmeyer, Gray, & Kawas, 1998). This increase will represent an enormous strain on families, healthcare and social service providers, and the nurses who care for patients with AD. Agitation and other behavioral problems often accompany an AD diagnosis (Vance et al., 2003), which increases this strain. It is imperative that healthcare researchers find effective means to help address behavioral problems for those with AD and their caregivers. By providing emotionally engaging, stimulating, and, most of all, meaningful activities for adults with AD, agitation and accompanying behavioral problems may be abated, improving quality of life for patients and their caregivers (Cotter, Stevens, Vance, & Burgio, 2000; Gruetzner, 1988; Mace & Rabins, 1991; Madori, 2007; Vance & Johns, 2002; Vance & Porter, 2000).

This article provides a neuropsychological framework for an activity intervention to help mitigate some of the behavioral disturbances accompanying AD while providing meaningful and engaging activities for patients from a religious tradition. This intervention is called procedural and emotional religious activity therapy, or PERAT (Vance, 2004). PERAT can be used by recreational therapists, nurses, and allied health professionals who work with older adults with AD (U.S. Department of Labor, Bureau of Labor Statistics, 2006).

PERAT seeks to match the cognitive ability of the adult with the cognitive demands of an emotionally salient, meaningful activity (in this case, a religious or spiritual activity). In this article, PERAT will be examined within the context of the neurological stages of AD. The procedural and declarative memory declines associated with AD are elaborated upon in relation to activity therapy in general. The role and resiliency of repetitive religious activities in regard to the neuropsychological losses of AD will relate to procedural memory and emotional attachments. PERAT is described in detail, examples are provided, and implications for nursing practice and research are posited.

Neuropsychological Staging of AD

A variety of cognitive and behavioral taxonomies are used to categorize AD's progression. One of the simplest ways to categorize the condition is to frame neuropsychological changes into three progressive stages: early, middle, and late. These stages describe a person's decreasing amount of cognitive reserve.

Cognitive reserve is the amount of remaining neurological integrity that is viable to produce neural activity. Such activity translates into cognitive ability. Cognitive reserve accumulates as neuronal connections are forged by lifelong learning, mentally stimulating and educational pursuits, interactive social supports, and health-promoting opportunities. Someone with a great deal of cognitive reserve may build a strong network of neuronal connections that take longer to be compromised by AD's pathological features, delaying the cognitive symptoms of this illness (Vance & Crowe, 2006).

As neurons become damaged due to the build-up of AD-associated amyloid plaques and neurofibrillary tangles, the physiological integrity of the brain becomes compromised (Yaari & Corey-Bloom, 2007). These disease processes translate into reduced cognitive efficiency and expressions of cognitive impairment of dementia at a certain threshold of damage. AD compromises the brain and reduces cognitive reserve, resulting in early, middle, and late disease stages with various cognitive abilities declining at different rates (Fig 1).

During the early stage of AD, adults begin to exhibit difficulty performing more complex instrumental activities of daily living (IADL) such as remembering to take medications, operating a vehicle, paying bills and negotiating finances, and executing other tasks requiring a high degree of cognitive ability. Although in most cases they are able to function socially and interact with others, adults may become frustrated with declines in their cognitive ability during this stage.

Cognitive declines occur in several areas, but most notably in attention and concentration, short-term memory, and declarative and episodic memory. Declines in declarative memory manifest as difficulty retrieving learned information (e.g., Who is the president of the United States?). Declines in episodic memory involve difficulties retrieving information about oneself (e.g., What did you have for breakfast yesterday?). These memory abilities often are referred to as explicit memory abilities and entail conscious recollection and information recall. These memory abilities are dependent on the connections between the prefrontal cortex and the hippocampus, which are more negatively affected by the disease process (Grady, Furey, Pietrini, Horwitz, & Rapoport, 2001). These prefrontal and hippocampal areas decline much sooner than and are compromised with disease progression more than other abilities such as procedural memory ability.

Procedural memory abilities, often referred to as implicit memory, involve more rote or unconscious recollections (e.g., riding a bike, using utensils, turning a doorknob). Procedural memory abilities are better spared from AD because these abilities are less dependent on the affected regions of the brain such as the basal ganglia and the cerebellum (Poldrack & Gabrieli, 1997). Figure 1 shows that as cognitive reserves decline, declarative and episodic memory deteriorates faster than procedural memory (De Vreese, Neri, Fioravanti, Belloi, & Zanetti, 2002; Gabrieli, 1998; Hirono et al., 1997).

Similar to procedural memory abilities, attachments and emotional processing also are highly resistant to AD's effects. Although emotional processing and subsequent expressions may at times be exaggerated or inappropriate, it is clear that emotional attachments remain strong during the course of AD. This fact clearly is reflected in the common problem of patients or care recipients who follow or "shadow" their caregivers (Mace & Rabins, 1991). Such shadowing is believed to be caused by two factors. First, there is the attachment to the caregiver, usually a spouse or adult child, who provides emotional and physical support for the confused care recipient. The second factor is the intense emotional reaction brought on by patients' inability to cognitively negotiate their environments (Hall & Buckwalter, 1987).

Developmental psychologists have observed that infants' first automatic, psychological goal is to form intense, emotional attachments to their caregivers (i.e., attachment theory). The development of such attachments is instinctual and necessary for survival. Attachment to caregivers helps to form a dyadic bond that provides infants with warmth, protection, and sustenance (Ainsworth, Blehar, Waters, & Wall, 1978; Bowlby, 1973; Hunter & Maunder, 2001). The limbic system, which is responsible for processing such emotions, may be spared from the ravages of AD more than other higher cortical functions such as declarative and episodic memory (Grady et al., 2001). Maintaining such attachments, even at an unconscious level, occurs whether the objects of attachment are family members or other forms of security.


As the damage caused by AD progresses, the middle stage of the disease is marked by increased confusion, increased short-term memory loss, and more progressive long-term memory loss. Declines in executive functioning and alterations in sensory perception, such as depth perception and odor identification, also are observed (Nebes, 1992; Nordin & Murphy, 1996; Peters et al., 2003). The hallmarks of this decline in conscious memory ability include increasing agitation and disruptive behavior and a greater need for assistance with activities of daily living (ADL), such as dressing and bathing. During this stage, however, procedural memory abilities remain intact along with emotional processing abilities. Patients still can perform basic, familiar tasks and experience emotional attachments to things that are familiar even though they are not able to process emotions consciously.

During the late stage of the disease, short-term and long-term memory declines are pronounced along with the loss of most, if not all, language abilities. Patients require assistance for all ADLs. Loss of self-recognition and additional perceptual and sensory losses also are observed. Even at this stage, rudimentary procedural memory is observed, such as the ability to open a door or twist a knob on a faucet. Gross motor abilities such as walking and grasping still may be present. Primitive attachments, albeit at more implicit levels, may remain. At the very end, even instinctual abilities, such as the ability to swallow, may be compromised (Clibbens, 1996).

In all forms of cognitive and emotional abilities observed with the progression of AD, the gradual loss of these abilities is likened to reverse ontogeny (i.e., backward development). Reisberg and colleagues (2002) remarked that the pattern of myelin loss accompanying AD reflects that of myelin acquisition found in normal development. Similarly, neurological infantile reflexes are the last to remain during the later stages of AD. This reverse ontogeny or retrogenic process is reflected in other neurological abilities.

When an infant is born, the development of attachments is the first goal. Procedural memory abilities form later as infants learn to physically negotiate their environments. Later, declarative and episodic memory abilities emerge and become stronger with maturation. Likewise, with the progression of AD, declarative and episodic memory abilities deteriorate first. More complex procedural memory abilities are lost later and are followed by more gross procedural memory ability loss. Finally, although emotional attachments remain well into the last stage of the disease, as noted by shadowing and emotional responses, these too are lost as the adult enters a vegetative state.

Procedural and Emotional Religious Activity Therapy

According to the Progressively Lowered Stress Threshold Model, agitation and related cognitive problems in adults with AD emerge when environmental stimuli exceed their level of tolerance (Hall & Buckwalter, 1987; Stolley, Koenig, & Buckwalter, 1999). In other words, adults will become agitated when the activities in which they are engaging exceed their cognitive abilities. For example, a 1,000-piece puzzle may be too difficult for those in the early stages of the disease, but a 100-piece puzzle may be just challenging enough without being overwhelming. Finding activities that match patients' cognitive ability levels should result in reduced agitation and more adaptive behavior. Studies indicate that spiritual and religious activities also can assuage agitation and improve quality of life in adults with AD (Abramowitz, 1993; Khouzam, Smith, & Bissett, 1994).

PERAT builds on the above model and posits that activities emphasizing procedural memory and emotional attachment are fundamental requirements to create or target activities that will be salient, meaningful, and engaging for adults with AD. In fact, such carefully targeted activities have the potential for improving quality of life and ameliorating behavioral difficulties. Furthermore, PERAT recognizes religious activities that are meaningful and emotionally salient, especially those that have been repeated over the course of one's life, have the greatest probability of being engaging for adults with AD. This engagement rests on the fact that such religious activities require cognitive and emotional components that remain robust in adults with this condition.

During the early stages of AD, short-term memory is one of the first cognitive abilities to be impaired, although long-term memory still can be accessed to facilitate participation in religious activities (Heyman et al., 1999; Kuzis et al., 1999; Nebes, 1992). This pattern of memory loss is obvious as one observes that people with AD may not be able to tell you with whom they were just talking (i.e., short-term memory), but they can recall in vivid detail precious childhood memories (i.e., long-term memory). It is the dependence on such long-term memory on which much of PERAT relies.

Religious and spiritual activities assimilated and engrained early in life (including the associated behaviors and emotional attachments), paired with lifelong devotion and practice, suggest such activities will hold salience, even during the later stages of the disease. Studying religious texts may be difficult for those with compromised short-term memory and executive ability; however, recalling familiar stories from childhood (e.g., Noah's Ark) is more likely to be appreciated. A simple story time including the telling of such an event would facilitate long-term memory and be engaging.

Procedural memory is more robust against the neurological insults of AD than explicit memory (Farina et al., 2002; Nebes, 1992). Tasks that do not rely on conscious recollection are more likely to be performed effortlessly. Religious and spiritual activities that are well-rehearsed call upon procedural memory and are more likely to be engaged in with success. Singing a familiar hymn, clutching a religious icon (e.g., prayer beads, a Star of David, the Koran, or a cross), or modeling a religious gesture (e.g., facing and praying to Mecca) all are examples of such tasks. In fact, due to the over-rehearsed nature of some of these behaviors, they can be practiced into the later stages of this disease.

Application of PERAT

Figure 1 illustrates that cognitive abilities deteriorate at different rates during disease progression. Well-rehearsed religious and spiritual activities that do not rely heavily on explicit memory are more engaging. Likewise, the emotional salience of these activities as they are associated with peoples' faith, coupled with being resistant to neurological insults, helps ensure PERAT will be an effective approach for identifying activities for adults with all stages of dementia. It is important to keep in mind that such activities must be individualized, given the deeply personal nature of religious and spiritual life. The following guidelines are suggested for developing an individual plan for applying PERAT.

First and foremost, an assessment of the adult's religious and spiritual history is needed. This will require talking to patients, caregivers, and, if possible, the patients' family members. Second, an assessment of patients' cognitive status is needed to match religious and spiritual activities to cognitive levels. If patients are in the early stages of the disease, most activities will be appropriate. Activities requiring more procedural memory ability and less explicit memory ability are recommended for those in AD's middle-to-late stages.

Third, tasks must be selected for their procedural memory component and emotional salience. This requires knowledge about activities with which patients have emotional attachments. Fourth, materials for the activities must be obtained and usually can be acquired by family members. Materials must be items of intense emotional attachment such as religious books or icons. These things are tantamount to a spiritual "teddy bear" that can be calming for patients. When patients start to become agitated, for example, caregivers can hand them religious texts such as the Bible, the Koran, or the Dhampada and prompt them to thumb through them. Items such as family photographs and religious pictures that are strategically placed in the book can help to calm patients as they become engrossed in the activity. These environmental cues can be placed throughout patients' settings and offered as routine activities to provide comfort and support.

For Protestant patients, holding religious symbols such as the Bible, humming, or singing hymns may be appropriate. Protestant patients may place strong emphases on personal interpretations of scripture (Balmer, 1993; Nielsen et al., 1983), which can lead to an activity of reciting comforting scriptures (e.g., Psalm 23; The Beatitudes; 1 Corinthians 13; The Lord's Prayer). Such recitations may serve as especially appropriate activities during the early and middle stages of the disease.

For Catholic patients, many activities may be applicable, such as holding and reciting the Rosary, engaging in ritualistic prayer, or, as with Protestant patients, holding religious icons and singing songs. In fact, for those in the early stages of the disease, actions for a perpetual novena also may be appropriate by lighting a candle for a specific prayer request.

For Jewish patients, simple actions such as singing songs, reciting scripture (e.g., the Ten Commandments), holding sacred items (e.g., a Star of David or a yarmulke), or spinning a dreidel may be appropriate. For Muslim patients, holding religious items such as the Koran or facing toward Mecca to pray (e.g., Salah) are recommended.

For Buddhist patients, spinning a prayer wheel, making and managing a home shrine (e.g., Puja), or stringing prayer flags are activities that may be helpful. For Hindu patients, simple yoga exercises, chanting, or maintaining a shrine may be appropriate. The home shrine often is associated with offering incense, money, or food, and provides maintenance that may be meaningful and provide daily activity (Nielsen et al., 1983).

PERAT has been employed informally in service settings for patients with AD. In an AD daycare program, Jennings and Vance (2002) presented music appreciation classes to adults. Familiar music was selected to ensure participants would experience at least some recollection and be encouraged to participate. In fact, many of the songs had strong religious and patriotic themes. After participating in this activity, nursing assistants reported decreased agitation levels for these adults.

Khouzam and colleagues (1994) assessed nursing home residents on their religious affiliations, practices and rituals, and idiosyncratic beliefs. From this assessment, they focused on specific Bible verses that had strong emotional salience for each person. During a 6-week period, nursing staff were prompted to quote these verses to participants when they exhibited signs of agitation. By using this method, researchers found the overall incidents of agitation were significantly reduced.

Similarly, Carnes (2001) created a calm and relaxing spiritual environment for adults with dementia. This environment was designed to stimulate the senses through votive candles, spiritual music (e.g., chants, hymns, gospel music), and a wall hanging featuring a religious symbol (e.g., labyrinth). In this study, adults also were found to experience a decreased level of agitation. It appears the sensory cues of this environment may have evoked a reverence that, although it may not have been at a conscious level, inspired respect and peaceful feelings.

In four adult daycare centers in Israel, Abramowitz (1993) used morning prayers with cognitively impaired Jewish elders. Familiar prayers were recited for approximately 10-15 minutes each morning. During this time, the cantor read the prayers to the participants. Anecdotally, Abramowitz found participants received emotional satisfaction and security from this religious activity even though they may not have consciously recognized the prayers.

Several PERAT caveats should be addressed. First, this approach may not be applicable to adults who do not have a discernible religious tradition. Given the complexity of religious faith, some adults may have abandoned their faith; therefore, applying this approach could be counterproductive and cause agitation. It is for this reason that assessing patients' religious and spiritual histories remains important. Second, some adults may be particularly zealous and become overly excited by participating in religious and spiritual activities. If an older adult is listening to a tape of a sermon that has a hostile tone or disposition, for example, the adult may mirror that tone. Listening to a sermon that inspires holy indignation may result in an agitated or fearful state.

Finally, this approach may not be appropriate for all types of dementias. The approach is based on the cognitive and emotional processing of AD; however, PERAT may not be appropriate for adults with other forms of dementia. For example, Huntington disease specifically affects emotional processing (e.g., emotional prosody, verbally describing emotion; Baker, 1996; Speedic, Brake, Folstein, & Bowers, 1990); consequently, attachment to one's religious tradition may not be a motivating force in engaging in such activities.

PERAT represents a formalized way to incorporate patients' religious and spiritual backgrounds to meet the need for emotionally salient, engaging activities despite the cognitive declines associated with AD. Yet there are several obstacles that demand further research. First, PERAT should be compared with other activity paradigms (e.g., Montessori, sensory stimulation) in a clinical trial to determine the advantages and disadvantages of each paradigm (Vance, 2004). One paradigm may more effectively reduce agitation, but another may require more supervision by staff and caregivers.

Second, PERAT should be studied in several settings such as private homes, adult daycare centers, and nursing homes to determine the settings in which it is more feasible. Third, training materials for familial caregivers, nursing staff, and clergy should be developed. Training materials are essential for taking religious and spiritual assessments of participants; determining participants' cognitive abilities and the cognitive load of an activity; matching cognitive ability with an activity's cognitive load; and monitoring outcomes such as time engaged, agitation, and quality of life. Finally, because other forms of dementia (e.g., vascular, Parkinson, Lewy body, Huntington) have different patterns of cognitive decline, the PERAT approach must be examined in various dementia populations to determine whether it is applicable. Despite these obstacles, the literature supporting PERAT is promising for AD and related dementias.


PERAT fills a void in activity therapy and can be employed with adults with AD who adhere to a religious tradition. Although it may not be appropriate for everyone, it can be an effective approach to providing meaningful, calming, and engaging activities for adults with neuropsychological impairment. Caregivers, both formal and informal, can use this simple and easy approach to improve quality of life for patients while decreasing agitation and increasing caregiving respites. Additional study, particularly qualitative research, is needed to provide published examples of activities undertaken by adults representing different religious traditions. Using the principles of PERAT, additional study also is encouraged to examine how this approach can be employed for those who do not have religious traditions, yet have other meaningful activities. As the number of adults with AD increases, PERAT can be an effective tool to help nurses and other health professionals provide care and comfort to their patients.


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Questions or comments about this article may be directed to David E. Vance, PhD MGS MS BS, at He is an assistant professor in the school of nursing at the University of Alabama at Birmingham. Barbara S. Moore, DSN RN NHA, is an assistant professor in the school of nursing at the University of Alabama at Birmingham.

Kenneth F. Farr, MS CNS BC, is a clinical nurse specialist and instructor in the school of nursing at the University of Alabama at Birmingham. Tom Struzick, MSW/ACSW LCSW MEd, is an associate director of the University of Alabama at Birmingham (UAB) Center for the Study of Community Health.
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Author:Vance, David E.; Moore, Barbara S.; Farr, Kenneth F.; Struzick, Tom
Publication:Journal of Neuroscience Nursing
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Date:Apr 1, 2008
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