Marin Medical Society

Marin Medicine


WORKING MEMORY: Improving Health Literacy in Older Patients

Older adults are a rapidly growing population in the United States, and a significant percentage of them experience acute and chronic illness. To prevent complications, these older patients need to recall important health information, accurately report their symptoms, observe their progress, report those observations, manage their condition, and stay informed. The most important factor in restoring health is to accurately and consistently follow medical directives. These and other skills have been correlated with positive treatment outcomes, sustained health, and collaborative relationships with healthcare professionals.

For older adults, however, the need for these abilities occurs within the context of a decline in cognitive functions that typically begins in midlife and may continue to fluctuate at various rates through the end of life. Mild declines in cognition may include:

  • Walking into a room and forgetting what you were looking for.
  • Being interrupted during a task and forgetting the original task.
  • Forgetting the names of colleagues.
  • Not being able to memorize a phone number long enough to dial.

We often refer to these examples as “senior moments.” If the decline begins to affect healthcare management, however, the consequences can be devastating. Coping strategies and, in some cases, intervention become necessary to minimize the risk for complications.

More serious evidence of memory decline in a medical setting includes:

  • Forgetting to take medication or the correct dosage or at the correct time.
  • Forgetting your diagnosis or the reason for an appointment.
  • Forgetting medical directives, such as medical interventions and lifestyle changes.
  • Forgetting medical appointments.
  • Forgetting or being unable to explain a condition to others.
  • Forgetting symptoms.

The decline in one particular cognitive function—working memory—has a strong relationship to health literacy. “Working memory” has been defined as the amount of information we can hold in our minds to complete a task.[1] This type of memory allows us to store immediate experiences and a little bit of knowledge. However, if we don’t do anything with that information, it is likely to be forgotten.

Neuropsychologists use the term “manipulation” to describe one of the mental processes that allows material in working memory to become stored in short- or long-term memory. Manipulation typically involves reaching back into our long-term memory (things we already know), bringing out that information, and mixing it with new information. Long-term memory allows us to process working memory in light of our current goal or what’s happening at the moment, such as listening to our physician tell us our diagnosis and the proposed treatment plan. Novel information is always more difficult to process than familiar information.

Working-memory capacity is the way we take what we already know and what we can hold onto in our working memory to satisfy our current goals. People with high working-memory capacity:

  • Tend to be good story tellers.
  • Do well on standardized tests.
  • Have high-level writing skills.
  • Have excellent reasoning abilities.
  •  Are particularly good at problem solving.
  •  Are good at completing practical tasks.
  • But even people with good working memory will experience mild decline as they age. Others may experience a greater decline, which can interfere with health literacy.

Navigating today’s healthcare system takes tremendous mental and physical energy. When experiencing an acute or chronic illness, patients are bombarded with new information, and the demand for quickly learning and processing unfamiliar information is very high. When confronted with their own health crises, even health professionals must exert incredible emotional and cognitive resources in response to their health needs. This response often needs to be accomplished when you feel physically uncomfortable or impaired.

Health literacy has been described as a set of skills that allow patients to engage effectively in the healthcare encounter, including treatment.[2] These skills allow patients to:

  • Take in and remember medical directives.
  • Act on medical directives outside the physician’s office.
  • Recognize when interventions result in improvement.
  • Identify negative side effects or declining condition.
  • Know when to seek medical attention.
  • Know how to self-manage mild symptoms.

Health literacy is affected by a variety of factors, including emotional, cognitive, economic and social stressors, age, language, ethnicity, education and specific personality factors. High health literacy has been correlated with positive treatment outcomes, particularly when the outcome is heavily dependent on patient compliance. Health literacy is particularly important in conditions where the patient is actively involved in the treatment process, whether that involves the use of medication, a medical device, or requiring lifestyle changes.

There are various formal and informal ways a healthcare professional can assess health literacy,[3] but the more important approach is for the physician to create a welcoming and supportive environment that is conducive to helping patients with low health literacy. Being a good observer of human behavior can be an asset. One researcher, for example, found that the patient’s speed in signing their name was positively correlated to health literacy (faster speed, higher literacy).[4]

At some point, it may be necessary to refer a patient for cognitive rehabilitation. Many claims have been made as to the efficacy of brain-training programs. There are scores of studies documenting how cognitive abilities can be changed through various interventions. In the most recent meta-analysis of working-memory training programs, researchers found mixed results.[5] Among their findings:

  • The outcomes of any particular program depended on the population being studied, the structure of the training program and the research methodology.
  • Programs that didn’t include training support (such as coaching) were less effective due to high incompletion rates.
  • Children under 10 and adults over 60 were found to have better outcomes than older children and younger adults.
  •  Personality factors also played into outcome. For example, subjects scoring high in conscientiousness showed greater improvement than less conscientious participants.

The question is not so much whether brain-training programs are effective, but rather whether someone is a good candidate for a particular type of training program. To maximize effectiveness, physicians who are contemplating making such a referral need to develop a relationship with their providers so they can refer patients who are a good fit.

As mentioned earlier, using prior knowledge encoded in long-term memory is critical to leveraging working memory capacity. To improve health literacy, physicians who present new data need to help patients connect novel information with their current knowledge. Doing so will increase the likelihood of manipulating the data so that it sticks.

Research supports the thesis that prior knowledge supports comprehension.[6] Likewise, a growing body of research suggests that working-memory capacity specifically increases health literacy among older adults, particularly as it relates to medication adherence.[7] It makes intuitive sense that leveraging working-memory capacity would increase learning and therefore health literacy.

Below are guidelines that may contribute to increased health literacy within the context of working-memory deficits. As already mentioned, the first step to improving health literacy is to create an environment that is conducive to increased patient learning. This is not always easy in today’s busy healthcare environment. The goal is not perfection, but doing whatever is possible given the constraints of your particular environment.

  • When imparting health directives, look at the patient so you can receive important nonverbal information that may be indicative of information overload or a lack of understanding. Noticing the patient’s face during conversation can be quite revealing. If the patient looks confused or their eyes are beginning to glaze over, you may need to slow down.
  •  The physician or an assistant may need to spend additional time with the patient to make sure they understand directives and/or treatment recommendations. Encouraging assistants to ask the patient questions to determine if they understand the instructions being communicated.
  • Helping the patient link new information to already acquired knowledge (available in their medical history) is critical to helping them use their working memory capacity to its fullest extent.
  • Write down all medical directives and information necessary for compliance. Auditory communication alone is the least optimal mechanism for learning; visual and auditory together is the best. See the sidebar for specific recommendations about using text and images.
  • Remember that risk information is processed both cognitively and emotionally. Patients may need to discuss their fears about the risks associated with a particular intervention.
  • Visualizing helps people remember. For example, ask a patient to tell you where they keep their medications. Then have them imagine going to that place, opening up the container and taking their medication with a glass of water. Just going through that process can help to consolidate information into short-and long-term memory.
  • Have a patient’s relative or friend present at the appointment.
  • Multimedia can be useful for increasing health literacy, but retention will be greater if there is an opportunity to process the information afterward with a healthcare professional.
  • Smartphone apps can improve health literacy. Some of the more common apps are used to monitor chronic illnesses such as hypertension, diabetes, depression and anxiety. Others help with lifestyle management issues such as diet, sleep and stress management.

SIDEBAR ======================================

When using text to communicate with patients:

  • Avoid using technical jargon.
  • Try not to use handwriting unless it is very legible.
  • In printed text, use a clear simple font and avoid visual clutter.
  • Use lists instead of paragraphs.
  •  Group information into meaningful chunks of a reasonable size so as to avoid information overload.
  • Use headings to organize the information and let readers know what they are about to read.
  • Use pictures to augment the written or spoken word. There is evidence that visual images can enhance health literacy.[8]

Dr. Sonkin, a marriage and family therapist in Sausalito, administers Cogmed Working Memory Training to adults experiencing mild to moderate deficits in working memory.



1. Klingberg T, “Training and plasticity of working memory,” Trends Cog Sci, 14:317-324 (2010).
2. Cornett S, “Assessing and addressing health literacy,” Online J Issues in Nursing, 14;3 (2009).
3. Wallston KA, et al, “Psychometric properties of the Brief Health Literacy Screen in clinical practice,” J Gen Int Med, 29:119-126 (2014).
4. Lindau S, “Growing evidence for ‘time to sign.’” Pat Edu & Counsel, 93:667 (2013).
5. Melby-Lervåg M., Hulme C, “Is working memory training effective?” Dev Psych, 49:270 (2013).
6. Hambrick DZ, “Why are some people more knowledgeable than others?” Mem & Cog, 31:902-917 (2003).
7. Insel K, et al, “Executive function, working memory, and medication adherence among older adults,” J Gerontology Series B, 61:P102-107 (2006).
8. Houts PS, et al, “Role of pictures in improving health communication,” Pat Edu & Counsel, 61:173-190 (2006).