What should you do if you think you have a problem with memory related to epilepsy? The first thing is to have a frank discussion with your doctor, expressing your concerns about memory. Having treated you and your particular type of epilepsy, your doctor is in a position to consider the probable impact of neurobiological factors like brain abnormalities and seizures as well as the effects of your epilepsy treatment. Your doctor might decide to change your treatment immediately, perhaps by lowering the dose of one or more medications or even changing the approach altogether.

Your doctor also might decide to get further information before making any changes. A referral to a neuropsychologist for testing of memory is often useful for assessing the degree and nature of the disturbance. You also may need other diagnostic procedures such as blood work, additional EEGs, or brain imaging. After your doctor has all the information at hand, he or she will be in the best position to decide what treatment approach is more likely to be successful in helping your memory problem. There are two general approaches:

• An indirect approach, focusing attention on other factors such as seizure control
• A direct approach, treating your memory either with medication or with some form of intervention focusing on behavior and the actual ways that people remember things.

I'm supposed to see a neuropsychologist—What for?

Most of the time, the doctor will begin by referring you to a neuropsychologist. This is a psychologist who is specially trained to assess and treat disorders of thinking or mood resulting from brain damage or disease. The neuropsychologist will administer various tests that will provide objective information about your memory performance in comparison to other individuals. These tests are "standardized," meaning that they are carefully structured so that the same questions are asked in the same way to each person. They have been used in research to address questions like "What should a 30-year-old woman's memory look like?" and "How much change should we expect in somebody's memory functioning between the ages of 40 and 50 years?" Neuropsychological testing is the most appropriate and exact way of determining the nature and severity of memory disturbance.

This testing of your memory may take anywhere between 3 and 8 hours. A longer time spent does not necessarily mean a better evaluation. The tests include measures to evaluate memory for different kinds of information:

• verbal information, tested with word lists or stories
• visual information, tested with drawings or photographs

Other tests typically given are used to assess

• general functioning
• attention
• language
• perceptual skills
• mood
• personality functioning

The neuropsychologist will evaluate the scores from all the tests and compare your performance to others who are similar to you in age and educational background, or to your previous scores if you were tested before. The analysis often reveals the extent to which difficulties with encoding, storage, or retrieval may be contributing to your memory problem. Measures of mood and personality functioning can help to determine the relative contributions of these factors in your overall difficulty. In the end, the neuropsychologist will use all of the available information to determine the cause of your memory disturbance and make suggestions about the most appropriate form of treatment. Neuropsychologists with specialized experience in epilepsy can be found as members of the treatment team in most comprehensive epilepsy centers.

I've been tested—Now what?

Indirect treatment

Why does the doctor want to adjust my seizure medicines?

After receiving all the medical and psychological information, your doctor will decide how to approach the treatment of your memory problem. For people being treated for epilepsy, the most common way to proceed is to try to treat the memory indirectly by managing the epilepsy medication. Optimal treatment of your epilepsy ultimately will also enhance your memory. With the simultaneous goals of reducing both seizure frequency and side effects, the doctor will adjust dosages or will begin to add or delete various medications. Most often your memory will function best when you are taking the smallest amount of medication that is effective. Some medications also have fewer side effects than others, so sometimes a change to a different medication can help. Alternative forms of epilepsy treatment are another possibility. These may include surgery for some people.

Should I take pills for depression too?

The next step in the indirect treatment approach for memory problems may involve treating other conditions that affect memory. People with epilepsy often benefit from further attention to their mood and emotional functioning. Treatment for depression or anxiety disorder can have a significant impact on memory. This often can be accomplished by adding an antidepressant medication to your regimen. At first glance, it may seem as if adding another medication will just compound the risk of side effects, but actually any effect of this kind will be more than cancelled out by the benefits of improving mood. Other methods of treating mood disturbance, particularly psychotherapy, will also have a positive impact by improving your coping skills and self-esteem. Psychiatrists and clinical psychologists sensitive to the specific issues associated with epilepsy can be found in many comprehensive epilepsy treatment centers.

Why does the doctor want me to see other specialists?

A wide range of medical conditions also can worsen memory. These include cardiovascular disease, diabetes, pulmonary (lung) conditions, sleep disorders, and various disorders like lupus, which involve many systems of the body. Some research has shown that people with epilepsy may be more likely to experience some of these conditions than the general population. A good holistic approach to treating memory disturbance in someone with epilepsy will extend the focus of the evaluation to include these other conditions. Thus you may be referred to other medical specialists for further studies and treatment, if needed.

Direct treatment

Is there a pill I can take?

When the subject of direct treatments for memory disturbance comes up, everyone naturally thinks of medication. Sometimes a mild stimulant may be helpful. At this point, however, the only pharmaceutical approaches approved by the FDA specifically for memory disorders are for the treatment of early Alzheimer's disease. The principle is that these drugs may increase the brain's level of neurotransmitters thought to be important for memory formation. Even though no accepted guidelines exist for using these medications to treat memory problems in people with epilepsy, some specialized centers are beginning to use them. People with epilepsy and their doctors should consider the indirect treatment approaches first, but direct pharmacological management of memory problems is not out of the question. Clearly, though, the jury is still out with regard to the ultimate future benefit of this kind of treatment.

What's "behavioral management"?

Another approach to treating memory problems is to consider direct behavioral management of the problem. There are typically two ways to go with behavioral management of a memory disorder. The first is to approach the problem from an environmental perspective, trying to enhance memory functioning by using organization and structure. This might involve always placing frequently misplaced items such as keys and glasses in specific places, such as a hook or shelf near the door. The other approach is to use "prosthetic" devices such as notebooks, electronic organizers, and alarms as aids for retaining information and as sources of cues to do something at a specific time. These approaches to the treatment of memory disturbance may seem simple and obvious, but they can be invaluable in helping you to function better.

I've heard of "memory rehabilitation." Does that work?

Many people ask about the nature and benefits of "memory rehabilitation." In the most general terms, proper rehabilitation of memory involves all of the steps we've already listed. After going through all appropriate steps and considering and addressing all of the factors that are affecting your memory, there is some place for direct intervention, however. Often this involves getting assistance in developing methods to help you encode and remember information. Unfortunately, there is no magic, universal form of memory treatment that will work for everyone. The best method is likely to differ for each individual. The people who work in this field, who are called cognitive remediation specialists, can be found among neuropsychologists, speech pathologists, and occupational therapists. Each of these fields uses a slightly different approach.

A lot of of the techniques that are taught today have been around for centuries. A few of them appear in the works of the Greek philosophers! Some techniques involve the use of association: you are asked to find some feature of the person or name that you can relate to something else. Other methods advocate the use of bizarre imagery to get something to stick in your head. For example, to remember that the laundromat is on Maple Lane, you might think of a maple tree sticking out of a washing machine.

Many people compare memory to a muscle and promote the use of repetitive exercises (often involving a computer) to strengthen it. Unfortunately, things do not work that way. You may become skilled at performing a specific drill in the doctor's office, but it is very difficult to apply the same skill in your daily life.

Currently, there is no large body of scientific evidence to indicate that any single form of direct memory treatment is more effective than another, but many patients do report receiving some benefit from the therapy. At this point, it appears that you are likely to achieve the best results by finding a talented and caring therapist who is able to look at the type of memory problems you are experiencing and develop a well-considered intervention program based on your individual needs.

Are any new treatments on the horizon?

Some professionals offer a form of brain-based biofeedback as a method of treating problems with attention and memory. So far, there is very little scientific evidence to establish whether or not this method is effective or who should use it. No systematic studies have used this procedure in people with epilepsy.

In general, in deciding whether to try a new treatment for your memory disturbance, you first should be absolutely sure that the practitioner has properly addressed all the many factors that could be affecting your memory.