Memory and Traumatic Brain Injury: Assessment and Management Practices of Speech-Language Pathologists

Abstract

Purpose:

Memory impairments are among the most commonly reported deficits and among the most frequent rehabilitation targets for individuals with traumatic brain injury (TBI). Memory and learning are also critical for rehabilitation success and broader long-term outcomes. Speech-language pathologists (SLPs) play a central role in memory management for individuals with TBI across the continuum of care. Yet, little is known about the current practice patterns of SLPs for post-TBI memory disorders. This study aims to examine the clinical management of memory disorders in adults with TBI by SLPs and identify opportunities to improve post-TBI memory outcomes.

Method:

SLPs from across the continuum of care were recruited to complete an online survey. The survey assessed key practice areas specific to memory and memory disorders post-TBI, including education and training, knowledge and confidence, and assessment and treatment patterns.

Results:

Surveys from 155 SLPs were analyzed. Results revealed that TBI-specific training remains low in the field. Respondents varied in their practice patterns in assessing and treating memory disorders. Most SLPs do not appear to have access to appropriate standardized assessments to measure unique forms of memory. Respondents also reported a range of barriers and opportunities to advance memory outcomes following TBI and provided suggestions of areas in which they would like to see more basic and clinical research.

Conclusions:

These findings establish a baseline of the current practices for clinical management of memory impairment in adults with TBI by SLPs. Improved opportunities for clinician training, the development of a single tool to assess multiple forms of memory, better access to existing memory assessments, and implementation of evidence-based interventions promise to lead to improved memory outcomes for individuals with TBI.

Traumatic brain injuries (TBIs) are rising globally (Dewan et al., 2018). In the United States alone, TBI affects more than 1.7 million Americans annually and is a leading cause of long-term disability (U.S. Department of Health and Human Services, 2022). While TBI can cause a broad range of cognitive deficits, impairments in memory are the most commonly reported and among the most frequently targeted in rehabilitation (Cicerone et al., 2011; Murray et al., 2001; Vakil, 2005; Wilson, 1998).

Memory deficits can have a profound impact on post-TBI recovery and can interfere with an individual's ability to participate in medical care, be successful at work or school, and benefit from therapy. Indeed, memory and learning are critical for rehabilitation success, as all therapy depends on a person's ability to learn and relearn information, skills, and strategies (Duff, 2007, 2014; Morrow & Duff, 2020). Despite the prevalence and significance of memory impairment in TBI, there has been limited progress in reducing injury-related disability broadly post-TBI (Roozenbeek et al., 2013).

Speech-language pathologists (SLPs) play a central role in the assessment and treatment of memory disorders in TBI across the continuum of care. Indeed, the American Speech-Language-Hearing Association (ASHA, 2016) states that cognition (e.g., memory) is a service delivery area and SLPs are to play a critical role in the assessment and treatment of cognitive (e.g., memory) aspects of communication and cognitive-communication disorders (ASHA, 2003). Yet, little is known about training related to the clinical management of memory disorders following TBI. The purpose of this study is to examine current practices, beliefs, and confidence of SLPs in the assessment and treatment of adults with post-TBI memory disorders with the long-term goal of identifying opportunities to improve clinician training, access to assessment tools, and implementation of evidence-based interventions that we believe will advance memory outcomes for individuals with TBI.

The Multiple Memory Systems of the Brain

One challenge in the assessment and treatment of memory disorders is that memory is not a unitary function or ability. Rather, memory is instantiated in the brain across multiple functionally and anatomically distinct systems (Eichenbaum & Cohen, 2001; Squire, 1992). Classic taxonomies distinguish between short-term, or working, memory and long-term memory. Short-term memory is the ability to hold a limited amount of information for a short period. We use short-term memory when we try to hold in memory a short shopping list before writing it down. Working memory has the additional component of manipulating the items in short-term memory, such as holding numbers in mind to perform mental arithmetic or re-ordering list items by size or first letter (Cowan, 2008). Short-term memory and working memory are supported by the neural substrates of the prefrontal cortex (D'Esposito & Postle, 2015; Funahashi, 2017).

Long-term memory can be divided into declarative and nondeclarative memory (Cowan, 2008; Gabrieli, 1998; Squire, 1992; Tulving, 1985; Willingham & Goedert, 2001). Declarative memory, dependent on the hippocampus and the medial temporal lobes, supports our ability to acquire and recall autobiographical events from our daily lives (episodic memory) and vocabulary, facts, and general world knowledge (semantic memory; Cohen & Squire, 1980; Eichenbaum & Cohen, 2001; Tulving, 1972). In contrast to short-term or working memory, long-term memory is thought to be capable of storing unlimited amounts of information over indefinite periods. Declarative memory is also critical for the ability to acquire relational knowledge quickly and use that knowledge flexibly across a range of new settings (e.g., for generalization, using information not only in the therapy room but also across different contexts with different people; Eichenbaum & Cohen, 2001; Rubin & Cohen, 2017). We rely on our declarative memory when we learn new vocabulary or the name and occupation of a new acquaintance and when we recall an event from our past.

Nondeclarative memory is an umbrella term for procedural memory (acquisition of skills and habits), priming (change in behavior [e.g., speed] from a previous stimulus or experience), and classical conditioning. Nondeclarative memory is supported by a network of cortical and subcortical (e.g., basal ganglia, cerebellum) structures. Although there are behavioral and anatomical distinctions among the different forms of nondeclarative memory, they have been described as sharing a core set of features that distinguish them from declarative memory (Eichenbaum & Cohen, 2001; McClelland et al., 1995; Reber et al., 1996). For example, nondeclarative memory acquisition is slow and incremental and results directly from experience (e.g., learning to ride a bike takes considerable time and practice). In contrast, declarative memory acquisition is rapid, sometimes requiring only a single exposure (e.g., learning a person's name). Nondeclarative memory also supports knowledge that is largely inaccessible to consciousness or verbal report (Cohen, 1984). For example, when we learn to ride a bike, we are unconsciously learning the specific combination and timing of muscles needed to apply force and torque to the pedals, but this is not knowledge that we can meaningfully put into speech.

Prospective memory is the ability to remember to carry out a planned intention or action at a future time (Brandimonte et al., 1996). These future actions can be in response to an environmental cue (e.g., event-based prospective memory like returning a library book [the intended action] when you pass the library [the cue]) or to self-initiated monitoring (e.g., time-based prospective memory like remembering an appointment at a specific time). The frontal lobes have long been linked to prospective memory ability (e.g., McFarland & Glisky, 2009; Neulinger et al., 2016). There is also evidence that prospective memory (and envisioning the future more broadly) and episodic memory share neural correlates that include both the frontal lobes and medial temporal lobes (e.g., Buckner & Carroll, 2007; Spreng et al., 2009).

The classic taxonomies of memory have been critical in describing key features of multiple memory systems and for generating hypotheses about their behavioral and neural correlates. An early consequence of these taxonomies was the tendency to suggest little to no overlap in the features and neural correlates of different forms of memory. Over the past several decades, the strong demarcations between systems, as proposed in earlier models, have been loosened by new findings that add nuance to our understanding of the neural substrates that underlie human memory. For example, research shows that, in addition to its well-established role in support of long-term declarative memory, the hippocampus makes contributions to representations on the time course of short-term or working memory (e.g., Hannula et al., 2006; Ranganath & D'Esposito, 2001) and to cognitive abilities (e.g., statistical learning and other implicit rule-based or sequence learning) that were previously considered the domain of the basal ganglia and the nondeclarative memory system (Covington et al., 2018; Hannula & Greene, 2012). These developments have led to a move away from terms such as “declarative” and “nondeclarative” in some literatures to reference specific memory systems in favor of more anatomically descriptive terms such as “cortico-hippocampal memory” or “hippocampal-dependent memory.” We note, however, that the terminology from the classic taxonomies is still common in behavioral descriptions of memory ability and in describing tools and approaches for memory assessment and treatment. Thus, we use the classic taxonomy terms (e.g., episodic memory, procedural memory) in this study.

TBI and Memory Impairments

Pathophysiological mechanisms of TBI make multiple brain systems vulnerable to injury, and subsequently, impairments in multiple forms of memory are common. Diffuse axonal injury, often referred to as the hallmark neural impairment in TBI, affects the white matter tracts throughout the brain (Hayes et al., 2016). Diffuse axonal injury has been linked to deficits in short-term and working memory in TBI (McDowell et al., 1997; Palacios et al., 2012). Frontal lobe damage is common in TBI from falls and motor vehicle accidents, which are two leading causes of injury. Frontal lobe damage has long been associated with deficits in executive functions and emotion regulation (Ylvisaker & Feeney, 1998), but frontal lobe damage can also affect memory. For example, the prefrontal cortex assists in encoding and formation of memory (Buckner et al., 1999); retrieval of information in episodic memory, particularly according to goal-relevant information (Blumenfeld & Ranganath, 2007; Kuhl et al., 2007); and assessment of the veracity of retrieved information (Gilboa & Moscovitch, 2002). Neuroimaging research highlights unique and overlapping contributions of different prefrontal cortex regions (ventrolateral, dorsolateral, and anterior) to the executive control of memory processes, specifically processes related to updating and maintaining information, selecting, manipulating, and monitoring that information, as well as the selection of subgoals (Fletcher & Henson, 2001). The frontal lobes also play a critical role in executive and attentional processes required for maintaining representations in working memory (Lara & Wallis, 2015).

The hippocampus and medial temporal lobes are also highly vulnerable to injury mechanisms. Several frequently occurring pathophysiological consequences of TBI (e.g., hypoxia, seizure activity) disproportionately affect the structure and function of the hippocampus, making hippocampal damage one of the most likely consequences of injury (Palacios et al., 2013; Sharp et al., 2014; Tate & Bigler, 2000). Unsurprisingly, deficits in declarative memory are a highly prevalent form of memory impairment in TBI (Rabinowitz & Levin, 2014; Vakil, 2005). Given recent discoveries about the contribution of the hippocampus to processing on the time course of short-term or working memory and to cognitive abilities associated with nondeclarative memory, it is likely that hippocampal damage may also contribute to deficits in multiple forms of memory. The shared vulnerability of the frontal and medial temporal lobe systems in TBI also increases the likelihood of deficits in prospective memory. Indeed, prospective memory impairments are also common following TBI (Mioni et al., 2015; Raskin & Sohlberg, 2009).

Finally, subcortical structures can be damaged following TBI. For example, volumetric reductions in subcortical structures (e.g., basal ganglia) and disrupted structural connectivity between subcortical and cortical structures have been reported following TBI (Hermans et al., 2017; Leunissen et al., 2013). While studies on the integrity of nondeclarative forms of memory in TBI are less common than those on other forms of memory, there is a growing body of work documenting the presence of nondeclarative deficits in at least a subgroup of the TBI population (Kraus et al., 2010; Rigon et al., 2019; Vakil et al., 2002).

Memory Is a Rehabilitation Target and a Key Component of Rehabilitation Success

Memory deficits are a frequent target of rehabilitation. Systematic reviews and practice guidelines of memory interventions point to a range of evidence-based techniques and approaches (e.g., internal strategies, external strategies and environmental supports, minimizing errors, distributed practice) that vary in the strength of their empirical support (e.g., Cicerone et al., 2011; Velikonja et al., 2023). The bulk of work on memory interventions has focused on episodic, short-term, and prospective memory, with less research on interventions for nondeclarative forms of memory. It is unknown, however, which treatment approaches are most frequently used by SLPs to manage post-TBI memory impairments.

Historically, treatment approaches have been dichotomized into restorative approaches (i.e., promote domain-specific changes in memory ability) and compensatory approaches (i.e., train adaptive techniques to work around memory disruption). Recent work, however, has argued against the use of this dichotomy. For example, Sohlberg et al. argue that any intervention that produces enduring changes in thinking and behavior has changed how the brain operates, making a strong distinction between restorative and compensatory artificial and out of step with advances in our understanding of neuroplasticity (Sohlberg et al., 2022). These authors also raise concern that, by telling a client that their therapy is compensatory, rather than restorative, clinicians convey a message that their brain can no longer change and that we have abandoned hope for basic improvements in cognition (Sohlberg et al., 2022). We agree with these perspectives. In this study, we asked clinicians about restorative and compensatory interventions because many clinicians were taught to conceptualize interventions around this dichotomy and we were interested in their beliefs about the effectiveness of different approaches.

Memory and learning are more than mere targets of rehabilitation. They are key components of rehabilitation success. An individual's memory and learning abilities are the foundation upon which the targets of all our interventions rest: the learning, relearning, and use of skills, knowledge, strategies, and behaviors across diverse settings and contexts (Duff, 2007, 2014; Morrow & Duff, 2020; Skidmore, 2015). For example, if an intervention to treat facial affect recognition is developed to leverage intact procedural (nondeclarative) memory but a given patient has deficits in that form of memory, the intervention may fail, not because the specific intervention is ineffective but because the patient did not have the underlying capacity to learn from that technique.

Memory is argued to be the most basic and important operation of the brain in that many cognitive processes such as language, planning, and problem solving rely on memory for effective operation (Tranel & Damasio, 2002). Different forms of memory make unique and complementary contributions to a range of cognitive abilities and real-world behaviors beyond the domain of memory. For example, hippocampal-dependent declarative memory has been linked to language use, social cognition, decision making, navigation and exploration, and imagination and creativity (e.g., Duff & Brown-Schmidt, 2012; Laurita & Spreng, 2017; Rubin et al., 2014; Schacter et al., 2017; Schlichting & Preston, 2017). Memory impairments are also a significant risk factor for poor community reintegration (Kekes-Szabo et al., 2023; Tate, 2002; Wilson, 2002, 2009). Thus, effective memory interventions may not only improve memory outcomes but also have cascading benefits to other cognitive domains and to community reintegration and functional outcomes.

Characterizing SLP Knowledge and Practice Standards Around Memory

There has been an effort to characterize the knowledge, training, and clinical management practices of SLPs to identify education and training needs and to improve standards of care across disorders and settings (e.g., Brandel & Foeb, 2011; Hutchins et al., 2011; Lanzi et al., 2022). A number of survey studies examining SLP practices and knowledge in the area of pediatric and adult-onset TBI have yielded several recurring themes including insufficient coursework dedicated to TBI, variable knowledge and practice patterns, and low self-reported confidence in serving individuals with TBI (Duff et al., 2002; Duff & Stuck, 2015; Hux et al., 1996; Morrow et al., 2020; O'Brien et al., 2022; Riedeman & Turkstra, 2018).

Memory impairments are common post-TBI and are critical to rehabilitation success. While SLPs play a central role in memory management for individuals with TBI, little is known about the current practice patterns of SLPs for post-TBI memory disorders. The current study sought to address this gap by surveying clinicians about their knowledge, beliefs, confidence, and practice patterns in assessing and treating memory post-TBI. Given recent reflection on the power differential between clinicians and researchers (i.e., where clinicians are often assumed to only be consumers of research rather than drivers of research directions; Douglas et al., 2023), we also asked clinicians for recommendations for desired training opportunities, future research directions, and insights related to the challenges and opportunities in improving post-TBI memory outcomes.

Findings from the current study will establish a rich description of the current practice landscape, provide new insights into the clinical management of memory impairment in adults with TBI by SLPs, and highlight opportunities to impact continuing education and standard of care that may, in turn, improve post-TBI memory outcomes. While our focus here is on memory disorders in adults with TBI, impairments in memory and learning are a feature of many populations served by SLPs including, but not limited to, Alzheimer's disease, Parkinson's disease, stroke, autism, and developmental language disorder. Thus, the results of this study promise to be instructional for evaluating the training needs and current practice standards around memory and learning more broadly.

Materials and Method

Survey Structure and Development

A survey instrument was developed to characterize SLPs' experience related to memory management in TBI. The survey included branching logic, such that some questions were conditional on prior response (see Appendix A for the full survey). For example, questions regarding treatments used to restore memory only appeared if a participant previously endorsed a belief in memory restoration. Thus, the number of questions presented to participants ranged from 43 to 57. Table 1 presents a description of the nine survey sections.

Table 1.

Survey structure, section descriptions, and example questions.

Section	Description	Example question(s)
1. Clinical Practice Setting	Characterized respondents' employment setting(s) and percentage of time spent in each setting	What is your current work setting? Please estimate the proportion of time you spend in a given setting.
2. General TBI Assessment Priorities	Characterized how SLPs approach an initial assessment with a new patient with TBI	Please rank the following domains of cognition in order of priority for your initial assessment. When planning an initial assessment for a patient…. (Respondents are given multiple choices to select from.)
3. Foundational Knowledge of Multiple Memory Systems	Characterized SLPs' knowledge of different memory systems	In the next section, you will see various terms. For each of these terms, match it to its definition from the provided choices. (Respondents are then presented with single terms and multiple definition choices.)
4/5. Memory Assessment After TBI	Characterized assessment practices and result integration for different memory systems	Do you use FORMAL and/or INFORMAL assessments for episodic memory? Please list the FORMAL and/or INFORMAL assessments you use for episodic memory.
6. Treatment Preferences and Practices	Characterized treatment practices, preferences, and beliefs regarding memory	How do you use the results of a memory assessment? For example, (check all that apply) At your facility, do other disciplines ASSESS memory (e.g., neuropsychology, occupational therapy)?
7. Clinical Confidence in Managing Memory	Characterized SLP confidence in clinical management of individuals with TBI	Are you confident in your ability to assess/treat memory?
8. Clinician Demographics	Characterized general demographic and clinical information	What is your highest degree earned? How many overall years of experience do you have as an SLP (including clinical fellowship)?
9. Suggestions for Improving Clinical Management of Memory Disorders	Characterized challenges in managing post-TBI memory disorders and gathered suggested improvements for clinical training and research	What do you wish researchers studied to improve our knowledge base of memory and memory disorders in TBI? What information or training would improve the clinical management of memory in TBI by SLPs?

Note. TBI = traumatic brain injury; SLP = speech-language pathologist.

Participants responded to the questions in the order above except for questions that addressed experience. These questions appeared at the end of the survey to avoid any potential impact that reflecting on experience might have on subsequent confidence ratings in Section 7.

During survey development, six SLPs practicing in varied clinical settings reviewed the survey instrument for face validity. These clinicians all had a master's degree in speech-language pathology (e.g., 18 years of education); held the Certificate of Clinical Competence in Speech-Language Pathology; had, on average, 4 years of clinical experience; and worked in adult acute care (n = 3), adult inpatient rehabilitation (n = 2), and adult outpatient (n = 1). Feedback from these SLPs related to question clarity, organization, and content was incorporated into the final survey design.

Survey Distribution

All study procedures were approved by the Vanderbilt University Institutional Review Board. Invitations to complete the survey directed participants to an online survey via Vanderbilt University's Research Electronic Data Capture management system (Harris et al., 2009), via a link or QR code. All participants were informed that their responses would be reported as part of a larger group, with no collection of identifying data. Survey invitations were mailed through the U.S. Postal Service to 100 SLPs in each of the following 18 states: Alabama, Arizona, California, Colorado, Connecticut, Florida, Illinois, Massachusetts, Minnesota, Nevada, New York, Ohio, Oklahoma, Pennsylvania, Tennessee, Texas, Virginia, and Washington. Furthermore, 1,800 addresses were randomly selected from self-identified SLPs working in settings of interest in each state registered by ASHA. We selected these states to represent high- and low-population states (e.g., New York, Oklahoma) in each major U.S. geographical region (e.g., Southeast, Northwest). Participants receive an initial participation invitation by postal mail, as well as a follow-up/reminder postcard 2 weeks later. Additionally, the survey invitation was posted to relevant listservs and social media groups (e.g., Medical SLP Facebook Group, ASHA Special Interest Group 2: Neurogenic Communication Disorders, Vanderbilt University Medical Center Pi Beta Phi Rehabilitation Institute listserv).

Participants

Clinicians were invited to participate if they had experience working with adults in the settings of interest: (a) if they currently spend 50% or more of their work hours in an acute care, inpatient rehabilitation, long-term acute care, outpatient, or skilled nursing facility or (b) if they spend less than 50% of their hours in these settings but have worked in these settings for at least 3 years. Participants then answered two eligibility questions (“Are you a licensed SLP?” and “Do you practice within the United States?”). If the response to either question was no, the participants were thanked for their interest but told they were ineligible to participate.

Analysis and Interpretation

The goal of this study was to characterize current trends and practices in the clinical management of post-TBI memory disorders by SLPs. Consistent with this goal and norms for exploratory research, we report descriptive statistics alone. Analysis of free-text responses included grouping responses together based on similarity and applying a label that reflected the centralized idea shared by all responses.

Results

One hundred eighty-three clinicians responded to the survey. Four respondents indicated they were located outside the United States. Twenty-four respondents completed Section 1 and then abandoned the survey before completing content questions, which therefore were omitted from analysis. One hundred fifty-five surveys answered questions in at least one content area and were included for analysis. The response rate is provided as a denominator in parentheses for each individual question. Some questions allowed respondents to choose more than one response; therefore, the total percentages reported may exceed 100%.

Education and Experience

Experience

Respondents' overall years of experience as an SLP ranged from 2 to 50 years (M = 14.72 years, SD = 10.75, n = 117). The highest level of educational attainment was a PhD for 3.39% (n = 4/118) of respondents and a master's degree for 96.61% (n = 114/118) of respondents. No respondents reported having only a bachelor's degree.

Education and Continuing Education

During their graduate training, 26.89% (n = 32/119) of respondents indicated that they took a specialty course on TBI. However, the majority of the respondents (63.02%, n = 75/119) indicated they learned about TBI as part of a broader course on adult neurological disorders (e.g., a course that covered aphasia and other neurogenic disorders). Furthermore, 10.08% (n = 12/119) of respondents reported they had not taken any coursework on TBI during graduate school. Regarding courses with a focus on memory and the clinical management of memory disorders, 64.70% (n = 77/119) of respondents indicated they did have this coursework, whereas 35.29% (n = 42/119) of respondents did not. Also, 91.59% (n = 109/119) of respondents reported taking continuing education courses related to memory since the end of their graduate studies, and 8.41% (n = 10/119) of clinicians have not yet had memory-focused continuing education.

Practice Settings

Participants worked in a range of settings, and most reported working in more than one setting. Acute care, inpatient rehabilitation, and outpatient rehabilitation settings were the most frequently reported practice settings, with appropriately 30% of respondents reporting part-time employment in each of these settings. Respondents also indicated working in skilled nursing facilities, academic settings, long-term acute care, home health, and other settings (e.g., day neuro program). Table 2 presents the respondents' practice setting and is presented as the reported percentage of part-time and full-time employment.

Table 2.

Respondents' reported practice setting.

Practice setting (N = 155)	Part-time	Full-time
Acute care	29.68%	7.74%
Inpatient rehabilitation	29.03%	7.10%
Outpatient rehabilitation	30.97%	16.77%
Skilled nursing facility	14.84%	9.68%
Academic setting	9.68%	2.59%
Long-term acute care	4.52%	1.29%
Home health	5.81%	0%
Other settings (private practice, university clinic, nonprofit organization, school district, day neuro program)	1.93%	3.87%

Knowledge of Memory Systems

To assess knowledge of different memory systems, respondents were asked to match the name of a specific memory system to its definition. Respondent accuracy for matching memory system labels with given definitions was high, above 90%, across all forms of memory: semantic memory (98.62%, n = 143/145), procedural memory (97.93%, n = 142/145), prospective memory (97.93%, n = 142/145), short-term/working memory (93.79%, n = 136/145), and episodic memory (91.67%, n = 132/144).

Assessment Practices

Assessment Priorities

We next inquired about clinicians' self-reported priorities when planning their initial assessment. Respondents were asked to rank cognitive domains in order of priority if they were short on assessment time using a ranking matrix of one/first to six/sixth. Respondents were more likely to rank language (receptive/expressive; 40.79%, n = 62/151) or attention (26.32%, n = 40/152) first in order of priority. Memory (19.08%, n = 29/151), executive functioning (9.21%, n = 14/148), and problem solving (4.61%, n = 7/151) followed. Emotion/social cognition was the only domain that was never reported to be prioritized first. Respondents who began by assessing language were likely to progress to an area of cognition such as memory or attention. See Figure 1 for a visual representation of participants' assessment priorities.

Figure 1.

Participants' priority rankings of top six assessment domains. Placement on the x-axis represents priority rankings, 1–6. For example, the column above “1” represents domains clinicians ranked first in the order of priority when they have limited assessment time. Proportions within that column represent the proportion of clinicians who rated a given domain first, that is, the largest proportion of clinicians who ranked language first. Language includes receptive and expressive language. Colored lines leaving a given domain in one column show what clinicians rated next after that domain. For example, the red lines between Columns 1 and 2 represent clinicians who ranked attention first. A large proportion of those clinicians went on to rate memory or language second, but others ranked executive functioning next. The gray boxes at the top of Columns 4–6 represent the percentage of respondents who did not list a fourth, fifth, or sixth assessment priority.

We also asked clinicians whether they used a facility standard assessment (e.g., a battery containing individual items or subtests of standardized assessments used for all patients with a suspected neurogenic communication disorder) or tailored unique assessments based on a screening tool, patient observation, and/or patient-reported complaints/priorities. Of the respondents, 15.07% (n = 22/146) indicated they use a standard facility assessment given to all patients with TBI, whereas most respondents (84.93%, n = 124/146) tailored assessments based on the unique needs of the patient.

Assessment Tools

We asked respondents how they assess the previously defined memory systems. In this section, the correct definition of the memory system was included to ensure mutual understanding of these terms (i.e., in case respondents were unsure in the matching section above). We note that participants were not permitted to “go back” to previous portions of the survey and therefore could not change their answer. Clinicians were asked if they used formal and/or informal assessments for each memory system. Numbers reflect that some clinicians do not assess a given memory system. See Table 3 for a summary of respondents' use of formal and informal assessments.

Table 3.

Clinician endorsement of formal/informal assessments for memory systems.

Memory system	Percentage of respondents who indicated “yes” they conduct formal/informal assessment in a given memory domain
Short-term and/or working memory (n = 127)	95.28%
Episodic memory (n = 127)	77.17%
Semantic memory (n = 127)	77.17%
Prospective memory (n = 126)	62.70%
Procedural memory (n = 128)	60.16%

We next asked respondents to describe (using free text) the formal and informal assessments they use to assess each memory system. Across all memory systems, there was a significant range of formal and informal assessment tools listed by the respondents (e.g., there were over 60 unique formal assessments listed). Appendix B contains the full list of responses provided by clinicians regarding the formal and informal assessment tools they report using along with the number of respondents who listed a given assessment. For brevity, here we report the assessments listed by five or more respondents. For episodic memory, the most frequently listed formal assessments included the Ross Information Processing Assessment (n = 11), Cognitive Linguistic Quick Test (n = 6), Repeatable Battery for the Assessment of Neuropsychological Status (n = 5), and Wechsler Memory Scale (n = 5). For informal assessments of episodic memory, respondents indicated interviews (n = 20), recall of remote and biographical information (n = 15) or recent events (n = 11), word/story recall (n = 7), and observation (n = 6).

For procedural memory, the most frequently listed formal assessment was the Rivermead Behavioral Memory Test (n = 10). For informal assessments of procedural memory, respondents indicated activity of daily living (ADL) observations (n = 17), narrative recall of task (n = 11), observation (n = 9), hospital informal assessment (n = 5), and interview (n = 5). For prospective memory, the most frequently listed formal assessment was the Rivermead Behavioral Memory Test (n = 14). For informal assessments of prospective memory, respondents indicated interview (patient/family; n = 13), completion of clinician assignment tasks (“remind me”/complete questionnaire by deadline; n = 12), verbal probing of upcoming events/tasks (n = 6), organization tasks (calendar/to-do list; n = 5), and immediate and delayed verbal recall (word/dates; n = 5).

For semantic memory, the most frequently listed formal assessments were the Ross Information Processing Assessment (n = 10), Boston Naming Test (n = 6), Repeatable Battery for the Assessment of Neuropsychological Status (n = 5), Woodcock–Johnson Tests of Cognitive Abilities (n = 5), and Brief Cognitive Assessment Tool (n = 5). For informal assessments of semantic memory, respondents indicated interview (patient/family; n = 9). For short-term and/or working memory, the most frequently listed formal assessments were the Ross Information Processing Assessment (n = 13), Rivermead Behavioral Memory Test (n = 13), Repeatable Battery for the Assessment of Neuropsychological Status (n = 12), Woodcock–Johnson Tests of Cognitive Abilities (n = 10), Cognitive Linguistic Quick Test (n = 6), Montreal Cognitive Assessment (n = 5), Scales of Cognitive and Communicative Ability for Neurorehabilitation (n = 5), Saint Louis University Mental Status (n = 5), and Test of Memory and Learning (n = 5). For informal assessments of short-term and/or working memory, respondents indicated verbal word and story recall (immediate/delayed; n = 14), digit span (n = 11), and recall and manipulation (words; n = 6).

Assessment and Clinical Decision Making

When asked how clinicians used the results of memory assessments for clinical decision making, 65.81% (n = 102/155) of respondents indicated they use the assessment to determine if the patient has a memory deficit and in which domain of memory. Furthermore, 68.39% (n = 106/155) of clinicians endorsed using assessment results to make recommendations about safety, supervision, and/or discharge. Half (50.32%, n = 78/155) of the respondents indicated they use assessment results to guide decision making on whether to recommend treatment and/or whether the patient is ready or would be a candidate for treatment.

If clinicians endorsed using assessment results for treatment decision making, they were then asked to specify how they used the assessment to decide patient readiness for rehabilitation in a free-text response. Of the respondents who endorsed this response, 73.08% (n = 57/78) completed a free-text response. Free-text responses appeared to reflect more general practice considerations than memory-specific concerns and included previous functioning, severity, family input, and the impact of other cognitive functions such as attention.

In addition, 7.10% (n = 11/155) of clinicians responded that they used assessment results for another purpose. Respondents who selected using assessments for another purpose were asked to expound in a free-text response; 90.90% (n = 10/11) completed a free-text response for this choice. Clinicians indicated using assessment results to determine the complexity of treatment approaches and relevant and attainable goals for the patient.

Interdisciplinary Approach to Memory Assessment

Respondents were asked if other disciplines (e.g., neuropsychology, occupational therapy) assess memory at their facilities. Of the clinicians, 69.35% (n = 86/124) indicated yes, their facility takes a collaborative, interdisciplinary approach to memory assessment with multiple disciplines contributing, including speech-language pathology, whereas 29.84% (n = 37/124) of clinicians responded no, speech-language pathology is the only discipline responsible for assessing memory. However, 0.81% (n = 1/124) indicated that the responsibility of memory assessment fell to another discipline, not speech-language pathology. Respondents who indicated the involvement of other disciplines were prompted to identify those disciplines and the factors that influence division of assessments across disciplines in a free-text response; the response rate of this question was 89.65% (n = 78/87). The top disciplines responsible for assessing memory included occupational therapy (n = 72), neuropsychology (n = 30), physical therapy (n = 17), nursing (n = 11), medical team (n = 7), social work (n = 6), and neurology (n = 5). Reasons for other disciplines being involved in memory assessments include redundancies in memory assessment (i.e., multiple disciplines perform unique memory assessments rather than a centralized assessment approach) and other disciplines (e.g., occupational therapy, physical therapy, nursing) screening for memory deficits and then using their clinical judgment to refer patients for SLP intervention.

Treatment Practices

Treatment Preferences

Of the respondents, 81.30% (n = 100/123) indicated, when treating memory, they prefer to use a combination of restorative and compensatory interventions, and 18.30% (n = 23/123) endorsed a preference for only using compensatory memory interventions (e.g., to reduce memory load or circumvent memory deficits), while none of the clinicians demonstrated a preference for only using restorative memory interventions (e.g., to restore or improve underlying memory ability).

Treatment Behaviors

Respondents were asked how often they provided intervention for each of the memory systems; the options available were “often,” “sometimes,” or “never.” Clinicians indicated they most often treat short-term and/or working memory as 89.74% (n = 105/117) endorsed this option. Episodic memory was the least often treated system at 23.08% (n = 27/117), but it was the system most endorsed to be treated sometimes at 67.52% (n = 79/117). See Figure 2 for a summary of clinician intervention frequency.

Figure 2.

How often clinicians indicate that they treat different systems of memory.

Clinicians were asked to specify what approaches they used to treat memory impairments, from a list of 12 options selected from reviews of memory interventions (e.g., Cicerone et al., 2019; Sohlberg & Mateer, 2001; Velikonja et al., 2023; Wilson, 2009; see Figure 3). Patient and family education and counseling was the most common approach used by clinicians (71.61%, n = 111/155), followed by external aid training (70.32%, n = 109/155) and spaced retrieval (69.03%, n = 107/155). The least used approaches by respondents included metamemory training (21.94%, n = 34/155), semantic elaboration (27.10%, n = 42/155), and prospective memory training (32.36%, n = 50/155).

Figure 3.

Respondent approaches to treating memory impairment across systems.

Clinicians were given space in free text to indicate any other approaches they used that were not captured in the previous options. The most commonly endorsed approach was WRAP strategies: writing things down, repeating, associating, and picturing information (n = 9). Other approaches included chunking (n = 3), assistive technology (n = 2), music (n = 1), Strategic Memory Advanced Reasoning Tactics (n = 1), Attention Processing Training-3 (n = 1), cognitive pyramid (n = 1), and personal orientation page (n = 1). Respondents were asked if they selected treatment approaches based on which memory system is impaired, and 76.72% (n = 89/116) of them indicated “yes,” with 23.28% (n = 27/116) choosing “no.”

Beliefs About Memory Treatment

Clinicians were probed about their beliefs about the treatment of memory. Respondents were asked if they believed that memory ability could be restored through restorative intervention approaches. Of the clinicians, 21.55% (n = 25/116) indicated yes, they believe memory ability can be restored to pre-injury levels, and 68.10% (n = 79/116) endorsed yes, they believe memory ability can be partially restored but not to pre-injury level. However, 10.34% (n = 12/116) indicated they did not believe memory ability could be restored. See Figure 4 for a visualization of clinician responses regarding their beliefs about memory recovery. If respondents indicated yes, they believe memory could be restored in any capacity, they were given a free-text response to indicate which treatments they use to restore memory. Across 54 respondents, the majority of respondents indicated previously listed approaches, such as spaced retrieval and memory drills. Some also used this space to expand further on their beliefs about the capacity to restore memory. Many contextualized their belief in restoration by stating that it depends on the injury's location and severity, the possibility of spontaneous recovery, and patient buy-in to the rehabilitation plan.

Figure 4.

Respondent beliefs about memory recovery.

When asked what the ideal treatment of memory should look like, 76.92% (n = 90/117) of respondents endorsed a combination of restorative and compensatory interventions, 23.08% (n = 27/117) of clinicians prioritized compensatory memory interventions, and 0.00% prioritized restorative memory interventions. Furthermore, 98.29% (n = 115/117) of clinicians reported they consider a patient's memory ability when treating other cognitive domains (e.g., language, social cognition). When asked to expand on how they consider memory ability through free-text response, 68 respondents indicated that memory affects all other cognitive domains (n = 21/68), memory impacts the level of support needed during treatment (n = 32/68; e.g., types of cues and frequency of cues), and, at times, memory can mask other cognitive issues (n = 15/68; e.g., executive functioning deficits presenting as poor recall).

Respondents were then asked to indicate the outcome measures they use to determine memory intervention effectiveness. They were allowed to choose all measure types that apply. Of the clinicians, 74.84% (n = 116/155) indicated using task-based measures (e.g., clinician observation of the use of compensatory strategies in a functional setting), 61.29% endorsed using patient self-report, and 50.32% use performance on standardized tests.

Involvement of Other Disciplines in Memory Treatment

Clinicians were asked if there were other disciplines responsible for treatment of memory deficits. Almost half (47.46%, n = 56/118) of the respondents indicated that speech-language pathology is the only discipline that treats memory in their facility. Furthermore, 50.85% (n = 60/118) of clinicians endorsed that their facility takes a collaborative, interdisciplinary approach to memory treatment with multiple disciplines, including speech-language pathology, contributing. Two respondents (1.69%) revealed that memory treatment falls under the purview of a single discipline that is not speech-language pathology. Respondents were asked to expand and share which disciplines contribute and the factors influencing the division of responsibility across disciplines. The top disciplines responsible for treating memory included occupational therapy (n = 48), neuropsychology (n = 8), physical therapy (n = 10), nursing (n = 2), and the medical team (n = 3). Free-text responses revealed that patient severity and functional needs dictate the division of treatment responsibilities. For example, occupational therapists can work on memory goals during their therapy session focused on ADLs since memory contributes to effective completion of ADLs.

Clinician Confidence and Knowledge in Assessing and Treating Memory

Participants were asked about their confidence in their ability to assess and treat memory using a yes/no response. Of the respondents, 87.29% (n = 103/118) felt confident in their ability to assess memory, and 81.03% (n = 94/116) were confident in their ability to treat memory. We asked respondents if they considered themselves, as SLPs, the most knowledgeable member of the treatment team regarding memory after TBI; 69.49% (n = 82/118) of clinicians believe themselves to be the most knowledgeable member of the team regarding memory. Using free-text responses, all respondents were asked for their reasoning as to why they believe they are, or are not, the most knowledgeable. Experience and training were major influences on the perception of expertise for clinicians. See Table 4 for clinician reasoning of their positions.

Table 4.

Respondents' reasons about why or why they are not the most knowledgeable about memory.

Position	Reasons
Yes, I am the most knowledgeable member of the treatment team regarding memory after TBI.	Most experienced or a lot of experience (n = 25) Received additional training/certification (e.g., CBIS, CEUs; n = 13) Only team member responsible for memory (n = 3) Other disciplines don't prioritize addressing memory (n = 2)
No, I am not the most knowledgeable member of the treatment team regarding memory after TBI.	Lack of experience (e.g., young SLP, low frequency of TBI at facility, minimal graduate training; n = 13) Another SLP is expert on the team (n = 6) All disciplines collaborate, so no need for experts (n = 7) All disciplines have experts, so no need for unique input (n = 6) Other disciplines have more in-depth knowledge (e.g., medical team, neuropsychology; n = 3) Low priority (personal or facility; n = 2) Lack of additional certification/training (n = 2)

Note. TBI = traumatic brain injury; CBIS = Certified Brain Injury Specialist; CEUs = continuing education units; SLP = speech-language pathologist.

If respondents indicated they were not the most knowledgeable, they were then asked their opinion of who on the team would have the most knowledge. Most indicated other SLPs on their team, believing that SLPs are the most knowledgeable but they do not regard themselves personally as the most knowledgeable. Respondents endorsed other members of the SLP team (n = 7), not believing any one person was an expert (n = 5), neuropsychology (n = 4), neurology (n = 2), outside staff (e.g., psychology, cognitive specialists; n = 2), occupational therapy (n = 1), and not being sure of who is the expert (n = 2). The next question asked participants if they believed SLPs should provide clinical management of memory; 99.15% (n = 116/117) of clinicians responded “yes.” The one clinician who responded “no” expanded to say all disciplines are responsible.

Closing Thoughts From Practicing SLPs

The final section of the survey allowed respondents to give recommendations on training and research to improve our knowledge base of memory and memory disorders in TBI. Of the clinicians, 50.32% (n = 78/155) responded to three prompts requesting suggestions. Regarding training to improve the clinical management of memory in TBI by SLPs, recommendations included better and specific graduate-level education on TBI, better assessment tools, improved accessibility of assessments, accessibility to continuing education units (CEUs; e.g., lower or subsidized costs), and better quality CEUs (e.g., case-based, explicit training on strategies). Clinicians also indicated their desire for future research to focus on the following: clarifying the boundaries between memory systems, specific approaches and efficacy of treatments, long-term outcomes for TBI, compensating versus restoration of memory, effects of concomitant disorders (e.g., depression, anxiety), memory in nonimpaired working adults as benchmarks, and memory recovery over time.

The final question of this survey asked respondents to share the challenges and opportunities within the clinical management of memory disorders in individuals with TBI. Some challenges identified included inadequate education of SLPs, reduced carryover outside of treatment sessions to the “real world,” low patient buy-in, lack of family or caregiver support, managing concomitant disorders, the feasibility of treatments in various settings, low priority compared to other medical needs, time constraints, billing issues, provider burnout, and developing the appropriate combination of strategies for patient success.

Discussion

Memory impairments are among the most commonly reported deficits and among the most frequent rehabilitation targets for individuals with TBI. Memory and learning are also critical for rehabilitation success and long-term outcomes. While SLPs play a central role in memory management for individuals with TBI across the continuum of care, little is known about the current practice patterns of SLPs for post-TBI memory disorders. To address this gap of knowledge, we surveyed practicing SLPs to examine practice patterns and beliefs in the assessment and treatment of post-TBI memory disorders. Reflecting on the power differential between clinicians and researchers (Douglas et al., 2023) and the recognition that clinicians are in the front lines in advancing post-TBI memory outcomes, we also asked clinicians for recommendations for training and research and about the challenges and opportunities to improve post-TBI memory outcomes. Below, we frame the discussion of our findings and recommendations around the clinician responses.

Improving Post-TBI Memory Outcomes: Challenges and Opportunities

Memory and TBI Education and Training

A recurring finding in the literature is that SLPs want and need more specialized TBI training (e.g., Duff & Stuck, 2015; Morrow et al., 2020; Pelatti et al., 2019; Riedeman & Turkstra, 2018). The current study highlights this continued need. Respondents stated they need better and specific graduate-level TBI education and better quality, easily accessible TBI-related CEUs. This need for better training is likely reflected in the lower-than-ideal confidence ratings (69%) of SLPs when asked if they are the most knowledgeable member of the team in the management of memory post-TBI. Indeed, low confidence and limited specialized TBI graduate training are frequently reported in studies examining the clinical management of TBI (e.g., Duff et al., 2002; Duff & Stuck, 2015; Hux et al., 1996; Morrow et al., 2020; Riedeman & Turkstra, 2018). The desire for better TBI training is also evident in clinician responses and feedback around the opportunities and challenges to improve the assessment and treatment of post-TBI memory disorders. Advancing the clinical management of post-TBI memory outcomes begins with improving the training and education opportunities for practicing SLPs.

We have proposed the need to rethink models of graduate training and education around cognitive-communication disorders including for populations like those with TBI (Morrow et al., 2020). Like previous studies (e.g., Duff et al., 2002; Morrow et al., 2020), the majority of the respondents (63%) reported they learned about TBI as part of a broader course on adult neurological disorders (i.e., a course that covered aphasia, dementia, and/or TBI) or have had no TBI-related coursework at all (10%). Two thirds of respondents had courses that addressed memory, but respondents also expressed that these courses were insufficient and did not focus enough on the management of memory disorders. The challenge, of course, is that the field of speech-language pathology is expanding in scope and has struggled to keep pace with this growth in the curriculum. Indeed, our training is not keeping pace with the incidence rates of the populations we serve (where rates of brain injury and neurodegenerative diseases are rising) and has not sufficiently expanded to address the role of cognition in language, communication, and social participation across the life span (see Morrow et al., 2020).

The case for graduate training in memory and learning is critical for advancing post-TBI outcomes but would also benefit the broader SLP curriculum. Impairments in memory and learning cut across the common curriculum training tracks of “medical SLP” and “school-based SLP.” Indeed, disruptions in different aspects of memory and learning are a key feature of many clinical populations served by SLPs including, but not limited to, TBI, Alzheimer's disease, and stroke as well as autism and developmental language disorder. Clinical management of memory deficits by SLPs is important for improved outcomes as different forms of memory support different aspects of language and communication and memory impairment can disrupt language learning and language use (see Duff & Covington, in press, for a review). Graduate training in memory and learning is required for clinicians to understand the underlying mechanisms of prevalent conditions and disorders, to leverage strengths in memory and learning ability to maximize treatment benefits, and for advancing memory and learning outcomes across numerous clinical populations.

High-quality and accessible CEU offerings (i.e., not behind a paywall) are also a high priority. Not only do many SLPs have insufficient graduate-level TBI training, but some clinicians entered the field before cognitive-communication disorders were in the scope of practice (ASLHA Report on the Subcommittee on Language & Cognition, 1987). CEU opportunities are important in the rapid dissemination of new findings. For example, advances in the functional and neural boundaries of distinct memory systems have been a primary focus of research in cognitive neuroscience over the past two decades. Yet, they are only now making their way into psychology and neuroscience textbooks. To improve timely dissemination of these and other advances in the basic and clinical memory research base, journal clubs and local city and state organizations can play a key role by providing affordable and accessible CEUs to practicing clinicians.

Assessment Practices for Memory

Nearly all respondents reported assessing memory ability. Yet, clinicians report prioritizing assessment of basic language function (receptive and expressive) over memory and over other forms of cognition such as attention or executive functioning, despite TBI most typically resulting in disorders of cognition, rather than of language. When asked about what assessment tools they use to assess different memory systems, respondents provided over 60 formal assessments (administered in part or in their entirety). Each tool, however, was endorsed by a small percentage of the sample suggesting a lack of consensus among SLPs as to a gold standard for formal memory assessment or heterogeneity in the tools available to SLPs in limited-resource settings. Respondents also reported using a wide variety of informal assessments, but some measures are not sensitive to capturing deficits in that form of memory (e.g., narrative recall of procedures to assess procedural memory; see below for further discussion on procedural memory assessment).

These patterns cannot be explained by knowledge or training alone. When asked to define the different memory systems, SLP responses were highly accurate (over 90% for each domain of memory). Rather, we speculate that current assessment practices may reflect broader barriers in the availability and accessibility of appropriate tools for measuring multiple forms of memory by SLPs. Indeed, respondents indicated that better assessment tools and improved accessibility of assessments are required to improve post-TBI memory outcomes.

In contrast to existing aphasia batteries that measure multiple domains and aspects of language (e.g., comprehension and production of single words and phrases, connected speech and written language; Western Aphasia Battery, Quick Aphasia Battery), there is no comprehensive memory battery available for assessing all forms of memory. For example, the Rivermead Behavioral Memory Test assesses episodic memory, and the most recent version added a skill learning subtest but does not include assessments of semantic memory or short-term/working memory. Likewise, the Wechsler Memory Scale assesses episodic memory and short-term/working memory, but not prospective or procedural memory.

Given the lack of a comprehensive memory battery, clinicians must piece-meal together a memory assessment from different formal and informal sources if they aim to assess multiple forms of memory. This situation appears to be impacting assessment decisions. Results here suggest that the most frequently assessed forms of memory are also the forms of memory for which there are more available measures. For example, respondents reported assessing short-term or working memory (95%) for which there are multiple available assessments (e.g., digit span from the Woodcock–Johnson Tests of Cognitive Abilities) at much higher rates than forms of memory like procedural memory (60%), for which there are very few assessments.

Another issue that likely influences choice of memory assessment is accessibility. Commercial assessments are frequently grouped by qualification level and sales restricted to those with that qualification. For example, while the Rivermead Behavioral Memory Test is accessible to individuals with a master's degree in psychology, education, speech-language pathology, and other closely related fields, the Wechsler Memory Scale has a higher qualification level and is accessible only to individuals with a doctoral degree in psychology, education, or closely related fields. Several other appropriate memory assessments (e.g., California Verbal Learning Test, Benton Visual Retention Test) have this higher qualification level making them inaccessible to master's-level SLPs. One difference in qualification level is higher expertise in the ethical administration, scoring, and interpretation of clinical assessments related to the intended use of the assessment. While SLPs receive training in ethical test administration and interpretation, we suspect the lack of or uneven training in cognition in our training programs may be a barrier to accessing these assessments.

The assessment of nondeclarative forms of memory such as procedural memory presents a particular challenge. Nondeclarative memory is important in the clinical management of memory as interventions such as errorless learning were developed to leverage preserved nondeclarative memory abilities to compensate for deficits in declarative (episodic) memory (Baddeley & Wilson, 1994; Wilson, 2002). However, most measures of procedural memory are experimental tasks from the memory literature (e.g., mirror-reversed reading, rotary pursuit) with no normative data and no established psychometric properties (i.e., test–retest reliability). Thus, it makes sense that procedural memory was the least frequently assessed form of memory and that clinicians do not have access to appropriate measures of procedural memory. Indeed, to our knowledge, until the most recent version of the Rivermead Behavioral Memory Test, there has been no assessment of skill learning in a standardized clinical memory test. Respondents reported a range of informal approaches to assessing procedural memory including narrative recall of procedures and discourse tasks. Narrative recall tasks assess episodic memory and are not sensitive to procedural memory deficits. Procedural knowledge is not consciously accessible and cannot be relayed in speech. Rather, the assessment of procedural memory requires the acquisition of a new skill or the performance of previously acquired skills or habits (i.e., “doing” not “telling”). There is, of course, useful clinical information to be gleaned about organizational skills by asking individuals to verbally list the steps in completing procedures (e.g., how to change a tire), but these tasks do not give us information about the integrity of the nondeclarative, or procedural, memory system (Duff et al., 2008). The most frequently reported informal assessment of procedural memory was the observation of clients performing skills such as those associated with ADLs. This is an appropriate assessment to determine if there has been a loss of skills that should be targeted in therapy or to monitor the acquisition of new skills.

The lack of an available comprehensive memory assessment and the lack of access to existing high-quality memory assessments are significant barriers for SLPs in the clinical management of post-TBI memory impairments. Ideally, our field would pursue the development of a comprehensive memory assessment that is sensitive to detecting deficits across multiple forms of memory, can guide clinicians in making tailored treatment recommendations based on the specific patterns of memory impairment, is accessible to SLPs, and accommodates a range of populations with deficits in memory and learning (e.g., low language demands for individuals with aphasia). The field should also work to update our training programs to offer more instruction in cognition so that SLPs may gain access to existing memory assessment tools.

Treatment Practices for Memory

Assessment practices mirror treatment patterns. Short-term and/or working memory was the most frequently assessed form of memory, and 90% of clinicians indicated they often treat short-term and/or working memory. In fact, less than 1% of respondents reported never treating short-term and/or working memory. In contrast, all other forms of memory were assessed and subsequently treated less frequently. For example, nearly 10% of respondents indicated they never treat episodic, semantic, procedural, or prospective memory.

We asked respondents about the involvement of other disciplines in the clinical management of post-TBI memory disorders. Whereas only 28% of clinicians indicated that speech-language pathology was the sole discipline responsible for memory assessment at their facility, nearly 50% indicated speech-language pathology was the sole discipline responsible for memory treatment. This means that not only are SLPs disproportionately responsible for treatment but that they are treating individuals based on the assessment results, and potentially a treatment plan, from a clinician in a different discipline (e.g., occupational therapy, neuropsychology). While this scenario may create opportunities for interprofessional collaboration, it may also create confusion around scope of practice across disciplines and leave SLPs without key information they need to deliver effective intervention, which could have unintended consequences for patient care.

Many clinicians (60%–70% of respondents) endorsed using multiple memory treatment approaches for which there is strong evidence of efficacy. These evidence-based interventions include patient and family education and counseling, memory books, and other external aid training approaches (e.g., Cicerone et al., 2019; Velikonja et al., 2023). High endorsement of these approaches is consistent with research showing that compensatory memory strategies offer the most consistent benefit to individuals with post-TBI memory impairment (Cicerone et al., 2011, 2019; Fish et al., 2008; Rees et al., 2007). Other approaches, which share an overarching goal of reducing errors, have a strong evidence base but appear to have mixed use by clinicians. For example, spaced retrieval and errorless learning were reportedly used by 70% and 50% of the respondents, respectively, while vanishing cues were used by a smaller proportion of clinicians (33%). Internal memory strategies such as visual imagery, elaboration, and metacognitive training have mixed evidence for their efficacy in reducing memory deficits (Velikonja et al., 2023). These strategies are most beneficial for individuals with milder memory deficits and for those with relatively preserved executive functions (Velikonja et al., 2023). This is because it takes some degree of memory and executive skills to both acquire and independently use these strategies. Results here suggest that internal memory strategies are not in widespread use (e.g., semantic elaboration and metamemory training endorsed by 27% and 22%, respectively), although visual imagery was endorsed by nearly 60% of clinicians.

Restorative memory approaches aim to improve memory to premorbid levels of functioning and include drill and practice exercises such as word and list learning tasks or paragraph recall to be completed with a clinician or via computerized programs. There is little to no evidence for using restorative memory approaches (Gopi et al., 2022; Sohlberg & Mateer, 2001; Spreij et al., 2014; Velikonja et al., 2023; Wilson, 2000). Yet, 47% of respondents indicated they use memory drills to treat memory. However, respondents indicated that restorative practices are not used exclusively; that is, no respondent indicated they prioritized restorative approaches. Rather, 77% endorsed using a combination of restorative and compensatory approaches, while 23% prioritized compensatory memory interventions.

The motivation to use specific rehabilitation approaches is likely linked, at least in part, to clinician beliefs, and even hopes, about possible memory treatment outcomes. For example, 22% of respondents indicated they believe memory ability can be restored to pre-injury levels, while 68% indicated they believe memory ability can be partially restored but not to pre-injury level. Our knowledge and beliefs about recovery are important for treatment planning and how we communicate about the rehabilitation process with individuals with post-TBI memory impairments. These are areas in which respondents indicated wanting more training. In addition to more explicit training on treatment efficacy and the implementation of specific approaches, respondents want more training in memory recovery over time and long-term memory outcomes.

Wilson (2009) points out that multiple definitions of recovery have been used in the brain injury literature. These range from full restoration of function to partial recovery of function through considerable substitution and compensation of function, with various degrees of ability in between. These definitions were likely introduced to conceptualize hypothetical recovery patterns rather than as documented outcomes or obtainable treatment goals. Indeed, decades of research on memory recovery suggest that, after the initial period of spontaneous recovery has passed, there is little evidence of major improvements in memory function (Kolb, 1995; Wilson, 2010; Wilson & Kapur, 2008). That is, there is no empirical evidence that memory function can be fully restored to pre-injury levels, suggesting that full restoration of memory function is not a realistic goal of our interventions. Yet, as Sohlberg and Mateer (2001) point out, although there is no empirical support for restorative memory interventions (e.g., memory practice drills, mnemonic strategy training, metamemory training, prospective memory training; also see Schacter & Glisky, 1986), the abundance of memory drill workbooks and computer programs in clinical settings suggests these approaches are widely used. Sohlberg and Mateer go on to suggest that if improvements are observed following restorative memory interventions, like memory practice drills, it is most likely due to increases in attentional ability rather than memory ability.

Following Wilson and colleagues (Wilson, 2000, 2010; Wilson & Kapur, 2008), we recommend a clinical focus on helping individuals reduce the disability associated with memory impairment. This is not giving up on recovery or the rehabilitation process. Indeed, we can facilitate significant and long-lasting behavioral, cognitive, and neural changes that support the use of memory for creating a meaningful life after brain injury (Sohlberg et al., 2022). These significant and long-lasting changes are achieved through the use, and further development and validation, of evidence-based approaches that facilitate new, efficient, and durable memory and learning and that minimize the impact of memory deficits in everyday settings and contexts.

Limitations and Future Directions

We acknowledge several limitations of the current study. First, the wording of some of the questions collapsed deficit presence and absence and severity levels (e.g., would the presence/absence or severity of a memory deficit make you think a patient was not ready to benefit from treatment). The impact of this wording is unknown, and future studies should separate deficit presence and severity levels to achieve a more granular understanding of clinician decision making. Second, in asking clinicians about outcome measures to determine the effectiveness of memory interventions, we did not ask about caregiver report or provide an option for other outcome measures. Future studies should inquire about the role of caregiver report as an outcome measure for evaluating intervention effectiveness. Third, while our interest here was on the clinical management of post-TBI memory disorders, it is important to recognize that most SLPs are also managing patients with other diagnoses (e.g., aphasia). Future work could take a broader lens at understanding memory management by SLPs across distinct and comorbid conditions. Fourth, in this first study to understand the clinical management of post-TBI memory disorders, we did not seek to differentiate practices by injury severity (e.g., mild vs. moderate–severe) or continuum of care (e.g., acute care vs. outpatient rehabilitation). Future work that considers the impact of severity and continuum of care on the clinical management of post-TBI memory disorders is warranted. Finally, while none of the respondents mentioned the lack of cultural or linguistic applicability when reflecting on the selection and use of standardized assessments for memory, the development of culturally and linguistic applicable tools is needed.

Conclusions

This study aimed to characterize the current knowledge, beliefs, confidence, and practice patterns of SLPs serving adults with post-TBI memory impairments. Consistent with SLP feedback, to improve memory outcomes in individuals with TBI, we need (a) better and specific graduate-level education and CEUs in TBI; (b) improved access to appropriate assessment tools to measure different forms of memory; and (c) continued access to, and training in, evidence-based memory treatment approaches. There is a need for the development of a comprehensive memory assessment that is accessible to SLPs. There is also a need for a more extensive research base on effective intervention approaches tailored for specific profiles of spared and impaired memory and learning ability. This study focused on post-TBI memory disorders in adults. Future work should characterize SLP practices in the clinical management of memory in pediatric TBI and the unique challenges and opportunities that exist in the context of development and educational settings. Results of this study, along with clinician feedback and suggestions, highlight opportunities to impact the clinical management of post-TBI memory disorders. Improved opportunities for clinician training, the development of a single tool to assess multiple forms of memory, better access to existing memory assessments, and the implementation of evidence-based interventions promise to lead to improved memory outcomes for individuals with TBI.

Data Availability Statement

The data sets generated and/or analyzed during the current study are available from the corresponding author on reasonable request.

Appendix A

Memory and Traumatic Brain Injury

Please note: This survey was administered via the REDCap online data management system. The branching logic described here directed participants to the appropriate questions automatically, and participants had adequate space to type free-text responses.

We are conducting a survey of speech-language pathologists to explore clinical management of memory disorders in individuals with traumatic brain injury. Clinicians working with adults with TBI are encouraged to participate. Your opinions will provide valuable information regarding practice patterns and perceptions within our speech-language pathology community. Thank you!

Estimated Time to Complete: 10–15 minutes or less

*Note: You should not return to a previous page once you proceed to a next page*

Screening Questions

I am a certified Speech-Language Pathologist (SLP)

◯ True

◯ False

I am an SLP that practices within the United States

◯ True

◯ False

Survey Questions

What is your current work setting? (Please check all that apply.)

◯ Acute care

◯ Inpatient rehabilitation

◯ Long-term acute care hospital

◯ Outpatient

◯ Skilled nursing facility

◯ Home health

◯ Academic

◯ Other

(If selected “Other” above)

What is your other work setting? __________________

Please estimate the proportion of time you spend in a given setting (using percentages). If you work in a single setting, respond with 100 for that setting. If you do not spend any time in a given setting, respond with 0 for that setting. The total for all responses on this page should sum to 100%.

Percentage of time spent in Acute care _______% (The total for all responses on this page should sum to 100)

Percentage time spent in Inpatient Rehabilitation _______% (The total for all responses on this page should sum to 100)

Percentage time spent in Long-term Acute care _______% (The total for all responses on this page should sum to 100)

Percentage time spent in Outpatient _______% (The total for all responses on this page should sum to 100)

Percentage time spent in Skilled Nursing _______% (The total for all responses on this page should sum to 100)

Percentage time spent in Home Health _______% (The total for all responses on this page should sum to 100)

Percentage time spent in Academic setting _______% (The total for all responses on this page should sum to 100)

(If selected “Other” above)

Percentage time spent in Other setting _______% (The total for all responses on this page should sum to 100)

Please rank the following domains of cognition in order of priority for your initial assessment. For example, if you were short on time, which domain would you assess first, second, and so on? If you do not assess one of the domains listed below, please do not rank it:

	First	Second	Third	Fourth	Fifth	Sixth
Attention	◯	◯	◯	◯	◯	◯
Emotion/Social Cognition	◯	◯	◯	◯	◯	◯
Executive Functioning	◯	◯	◯	◯	◯	◯
Language (Receptive/Expressive)	◯	◯	◯	◯	◯	◯
Memory	◯	◯	◯	◯	◯	◯
Problem Solving	◯	◯	◯	◯	◯

When planning an initial assessment for a patient,

◯ I use my facility's standard assessment that is given to ALL patients

◯ I tailor a unique assessment based on a screening tool, patient observation, and/or patient reported complaints/priorities

In the next section you will see various terms. For each of these terms, match it to its definition from the provided choices.

For each of these terms, match it to its definition from the provided choices.

Episodic Memory

◯ Memory for future intentions or future plans.

◯ Memory for concepts, words, and general world knowledge unrelated to specific experiences or events.

◯ Memory for limited amounts of information that can be held and/or manipulated for limited periods of time.

◯ Memory for cognitive and motor skills and for how to complete tasks that can be demonstrated by performing the task or skill but cannot be explicitly recalled or stated.

◯ Memory for past events and experiences including temporal, spatial, and other contextual elements that can be explicitly recalled or stated.

Procedural Memory

◯ Memory for future intentions or future plans.

◯ Memory for concepts, words, and general world knowledge unrelated to specific experiences or events.

◯ Memory for limited amounts of information that can be held and/or manipulated for limited periods of time.

◯ Memory for cognitive and motor skills and for how to complete tasks that can be demonstrated by performing the task or skill but cannot be explicitly recalled or stated.

◯ Memory for past events and experiences including temporal, spatial, and other contextual elements that can be explicitly recalled or stated.

Prospective Memory

◯ Memory for future intentions or future plans.

◯ Memory for concepts, words, and general world knowledge unrelated to specific experiences or events.

◯ Memory for limited amounts of information that can be held and/or manipulated for limited periods of time.

◯ Memory for cognitive and motor skills and for how to complete tasks that can be demonstrated by performing the task or skill but cannot be explicitly recalled or stated.

◯ Memory for past events and experiences including temporal, spatial, and other contextual elements that can be explicitly recalled or stated.

Semantic Memory

◯ Memory for future intentions or future plans.

◯ Memory for concepts, words, and general world knowledge unrelated to specific experiences or events.

◯ Memory for limited amounts of information that can be held and/or manipulated for limited periods of time.

◯ Memory for cognitive and motor skills and for how to complete tasks that can be demonstrated by performing the task or skill but cannot be explicitly recalled or stated.

◯ Memory for past events and experiences including temporal, spatial, and other contextual elements that can be explicitly recalled or stated.

Short-Term and/or Working Memory

◯ Memory for future intentions or future plans.

◯ Memory for concepts, words, and general world knowledge unrelated to specific experiences or events.

◯ Memory for limited amounts of information that can be held and/or manipulated for limited periods of time.

◯ Memory for cognitive and motor skills and for how to complete tasks that can be demonstrated by performing the task or skill but cannot be explicitly recalled or stated.

◯ Memory for past events and experiences including temporal, spatial, and other contextual elements that can be explicitly recalled or stated.

In the following section, you will be asked about the assessments (formal and informal) you use across different forms of memory. Formal assessments include any standardized assessments you use (e.g., California Verbal Learning Test). This category can include those assessments you give in their entirety or just a subtest from a standardized assessment. Informal assessments include any non-standardized assessments you complete. These may include patient observations (e.g., asking for repetitions; failure to remember a future appointment or task) or unique, non-standardized assessment tools used at your facility (e.g., presentation of words to recall for later).

Do you use FORMAL and/or INFORMAL assessments for episodic memory?

Episodic memory—memory for past events and experiences including temporal, spatial, and other contextual elements that can be explicitly recalled or stated.

◯ Yes

◯ No

(If selected “Yes”)

Please list the FORMAL and/or INFORMAL assessments you use for episodic memory. ________

Do you use FORMAL and/or INFORMAL assessments for procedural memory?

Procedural memory—memory for cognitive and motor skills and for how to complete tasks that can be demonstrated by performing the task or skill but cannot be explicitly recalled or stated.

◯ Yes

◯ No

(If selected “Yes”)

Please list the FORMAL and/or INFORMAL assessments you use for procedural memory.________

Do you use FORMAL and/or INFORMAL assessments for prospective memory?

Prospective memory—memory for future intentions or future plans.

◯ Yes

◯ No

(If selected “Yes”)

Please list the FORMAL and/or INFORMAL assessments you use for prospective memory.________

Do you use FORMAL and/or INFORMAL assessments for semantic memory?

Semantic memory—memory for concepts, words, and general world knowledge unrelated to specific experiences or events.

◯ Yes

◯ No

(If selected “Yes”)

Please list the FORMAL and/or INFORMAL assessments you use for semantic memory.________

Do you use FORMAL and/or INFORMAL assessments for short-term and/or working memory?

Working memory - memory for limited amounts of information that can be held and/or manipulated for limited periods of time.

◯ Yes

◯ No

(If selected “Yes”)

Please list the FORMAL and/or INFORMAL assessments you use for short-term and/or working memory.________

How do you use the results of a memory assessment? (check all that apply)

◯ To determine if patient has a memory deficit and in which domain of memory

◯ To make recommendations about safety, supervision, and/or discharge planning

◯ To guide decision making on whether to recommend treatment and/or whether a patient is ready, or would be a candidate, for treatment (i.e., would the presence/absence or severity of a memory deficit make you think a patient was not ready to benefit from treatment)

◯ Other

(If selected “To guide decision making on whether to recommend treatment and/or whether a patient is ready, or would be a candidate, for treatment (i.e., would the presence/absence or severity of a memory deficit make you think a patient was not ready to benefit from treatment)”)

HOW do you use memory assessments to decide if a client is ready, or would be a candidate, for intervention/rehabilitation? Which assessments do you use to make this determination?________

(If selected “Other”)

Please describe other ways you use the results of a memory assessment.________

At your facility, do other disciplines ASSESS memory (e.g., neuropsychology, occupational therapy)?

◯ Yes. My facility takes a collaborative, interdisciplinary approach to memory assessment with multiple disciplines contributing including speech-language pathology.

◯ Yes. At my facility memory assessment falls under the purview of a single discipline that is NOT speech-language pathology.

◯ No. Speech-language pathology is the ONLY discipline that assesses memory at my facility.

(If selected “Yes”)

If yes, which disciplines? What factors influence the division of memory assessment across different disciplines?________

In treating memory impairments, I prefer to use (choose one):

◯ restorative memory interventions (e.g., to restore or improve underlying memory ability)

◯ compensatory memory interventions (e.g., to reduce memory load or circumvent memory deficits)

◯ combination of restorative and compensatory interventions

How often do you provide intervention for each of these forms of memory?

	Often	Sometimes	Never
Episodic memory	◯	◯	◯
Procedural memory	◯	◯	◯
Prospective memory	◯	◯	◯
Semantic memory	◯	◯	◯
Short-term and/or working memory	◯	◯	◯

Do you use any of these approaches below to treat memory impairments? (Please check all that apply)

◯ Errorless Learning

◯ Memory Book

◯ Metamemory Training

◯ Memory Drills (e.g., memory exercises or rote practice/rehearsal of different types of information)

◯ Patient and Family Education and Counseling

◯ Positive Everyday Routines

◯ Prospective Memory Training

◯ Semantic Elaboration

◯ Spaced Retrieval

◯ External aid training (e.g., calendars, smart phones)

◯ Vanishing Cues

◯ Visual Imagery

List other approaches you use to treat memory that are not listed here:________

Do you select a treatment approach based on the form of memory (e.g., episodic, prospective) that is impaired?

◯ Yes

◯ No

Do you believe that memory ability can be restored through restorative intervention approaches?

◯ Yes. Memory ability can be restored to pre-injury levels.

◯ Yes. Memory ability can be partially restored but not to pre-injury levels.

◯ No. Memory ability cannot be restored.

(If selected “Yes”)

Which treatments do you use to restore memory?________

Ideally, the clinical management of memory should include:

◯ primarily restorative memory interventions

◯ primarily compensatory memory interventions

◯ combination of restorative and compensatory interventions

Do you consider a patient's memory ability in the treatment of other cognitive domains (e.g., language, social cognition)?

◯ Yes

◯ No

(If selected “Yes”)

How do you consider a patient's memory ability in the treatment of other cognitive domains (e.g., language, social cognition)?________

To determine the effectiveness of a memory intervention, what type of outcome measures do you use? (Check all that apply)

◯ Performance on standardized test

◯ Patient self-report

◯ Task based (e.g., clinician observation of the use of compensatory strategy in a functional setting such as setting alarms as reminders at work or using a memory book to keep track of other therapy sessions)

At your facility, do other disciplines TREAT memory (e.g., neuropsychology, occupational therapy)?

◯ Yes. My facility takes a collaborative, interdisciplinary approach to memory treatment with multiple disciplines contributing including speech-language pathology.

◯ Yes. At my facility memory treatment falls under the purview of a single discipline that is NOT speech-language pathology.

◯ No. Speech-language pathology is the ONLY discipline that treats memory at my facility.

(If selected “Yes”)

If yes, which disciplines? And, what factors influence the division of memory treatment across different disciplines?________

Are you confident in your ability to assess memory?

◯ Yes

◯ No

Are you confident in your ability to treat memory?

◯ Yes

◯ No

As an SLP, do you consider yourself to be the most knowledgeable member of the treatment team regarding memory after TBI?

◯ Yes

◯ No

Why or why not?________

(If selected “No”)

If no, who is?________

Do you believe speech-language pathologists should provide clinical management of memory?

◯ Yes

◯ No

(If selected “No”)

If no, what other discipline do you believe should provide clinical management of memory?________

What is your highest degree earned?

◯ Bachelor's degree

◯ Master's degree

◯ Ph.D.

How many overall years of experience do you have as an SLP (including clinical fellowship)? ________

Did you take any courses related to TBI as part of your graduate training?

◯ No

◯ Yes, a specialized course in TBI

◯ Yes, as part of a course on adult neurological disorders (e.g., course also included aphasia)

Did any of your graduate level coursework cover memory and clinical management of memory disorders?

◯ Yes

◯ No

Have you completed any continuing education related to memory since graduating?

◯ Yes

◯ No

Our goal is to improve the clinical management of memory disorders in individuals with TBI. We want to hear from you!

What information or training would improve the clinical management of memory in TBI by SLPs?________

What do you wish researchers studied to improve our knowledge base of memory and memory disorders in TBI?________

What would you like us to know about the challenges and opportunities in the clinical management of memory disorders in individuals with TBI?________

Appendix B

Lists of Responses for Formal and Informal Assessments for Distinct Memory Systems Endorsed by Clinicians

Memory system	Formal assessments	Informal assessments
Episodic memory (n = 127) Formal (56 responses) Informal (77 responses)	Ross Information Processing Assessment (RIPA; n = 11) Cognitive Linguistic Quick Test (CLQT; n = 6) Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; n = 5) Wechsler Memory Scale (WMS; n = 5) Orientation Log (O-Log; n = 4) Rivermead Behavioral Memory Test (RBMT; n = 3) Scales of Cognitive Ability for Traumatic Injury (SCATBI; n = 3) Saint Louis University Mental Status (SLUMS; n = 2) Test of Memory and Learning (TOMAL; n = 2) Woodcock–Johnson Test of Cognitive Abilities (WJ; n = 2) Brief Test of Head Injury (BTHI; n = 2) Boston Naming Test (BNT; n = 1) Montreal Cognitive Assessment (MoCA; n = 1) Galveston Orientation and Amnesia Test (GOAT; n = 1) Mini-Mental State Examination (MMSE; n = 1) Orientation sections of formal assessments (n = 1) Everyday Memory Questionnaire (EMQ; n = 1) Figure Visuospatial Memory Task Drawing (n = 1) Autobiographical Memory Test (AMT; n = 1) Arizona Battery for Cognitive-Communication Disorders (ABCD; n = 1) Evaluation of Communication Problems in Right Hemisphere Dysfunction (RICE-3; n = 1) Short Blessed Test (SBT; n = 1)	Interview (n = 20) Recall of remote and biographical information (n = 15) Recall of recent events (24–36 hr; n = 11) Word/story recall (n = 7) Observation (n = 6) Hospital/department informal assessment (n = 4) Nonspecific informal assessment (n = 3) Orientation to temporal/spatial concepts (n = 3) Conversational discourse/reminiscent conversational tasks (n = 2) Prior level of functioning (n = 2) Mayo informal assessment (n = 1) Daily schedule (n = 1) Discourse measures: AphasiaBank (n = 1) Clock drawing (n = 1)
Procedural memory (n = 128) Formal (27 responses) Informal (53 responses)	Rivermead Behavioral Memory Test (RBMT; n = 10) Cognitive Linguistic Quick Test (CLQT; n = 4) Scales of Cognitive Ability for Traumatic Injury (SCATBI; n = 3) Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; n = 2) Montreal Cognitive Assessment (MoCA; n = 1) Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES; n = 1) Saint Louis University Mental Status (SLUMS; n = 1) Ross Information Processing Assessment (RIPA; n = 1) Bedside BAE (n = 1) Rey–Osterrieth Complex Figure (ROCF) Test (n = 1) Mini-Mental State Examination (MMSE; n = 1) Short Blessed Test (SBT; n = 1)	ADL observations (n = 17) Narrative recall of task (n = 11) Observation (n = 9) Hospital informal assessment (n = 5) Interview (patient/family) (n = 5) Clock drawing (n = 1) Nonspecific informal assessment (n = 1) Discourse measure (n = 1) Job/home description rating (n = 1) Complex auditory directions while manipulating objects with prepositions (n = 1) Reading passages (n = 1)
Prospective memory (n = 126) Formal (36 responses) Informal (54 responses)	Rivermead Behavioral Memory Test (RBMT; n = 14) Ross Information Processing Assessment (RIPA; n = 4) Scales of Cognitive Ability for Traumatic Injury (SCATBI; n = 2) Cambridge Prospective Memory Test (CAMPROMPT; n = 2) Patient-Reported Outcome Measures (PROMs; n = 2) Repeatable Battery for the Assessment Neuropsychological Status (RBANS; n = 2) Cognitive Linguistic Quick Test (CLQT; n = 2) Test of Memory and Learning (TOMAL; n = 1) Everyday Memory Questionnaire (EMQ; n = 1) Mini-Mental State Examination (MMSE; n = 1) Short Blessed Test (SBT; n = 1) Montreal Cognitive Assessment (MoCA; n = 1) Self-Administered Gerocognitive Examination (SAGE; n = 1) Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES; n = 1) Communication Activities of Daily Living (CADL; n = 1)	Interview (patient/family; n = 13) Assessment of completion of clinician assignment tasks (“remind me”/complete questionnaire by deadline; n = 12) Verbal probing of upcoming events/tasks (n = 6) Organization tasks (calendar/to-do list; n = 5) Immediate and delayed verbal recall (word/dates; n = 5) Nonspecific informal assessment (n = 3) Informal adapted from formal assessment (RBMT; n = 2) Observation (n = 2) Susan Brubaker's memory cards (n = 1) Informal hospital assessment (n = 1) Cued tasks (n = 1) Memory questionnaire (n = 1) Spontaneous instructions (n = 1) Unspecified situational testing (n = 1)
Semantic memory (n = 127) Formal (98 responses) Informal (34 responses)	Ross Information Processing Assessment (RIPA; n = 10) Boston Naming Test (BNT; n = 6) Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; n = 5) Woodcock–Johnson Test of Cognitive Abilities (WJ; n = 5) Brief Cognitive Assessment Tool (BCAT; n = 5) Cognitive Linguistic Quick Test (CLQT; n = 4) Scales of Cognitive Ability for Traumatic Injury (SCATBI; n = 4) Montreal Cognitive Assessment (MoCA; n = 4) Rivermead Behavioral Memory Test (RBMT; n = 4) Boston Diagnostic Aphasia Examination (BDAE; n = 4) Controlled Oral Word Association Test (COWAT; n = 3) Western Aphasia Battery (WAB; n = 3) Everyday Memory Questionnaire (EMQ; n = 2) California Verbal Learning Test (CVLT; n = 2) Mississippi Aphasia Screening Test (MAST; n = 2) Saint Louis University Mental Status (SLUMS; n = 2) Arizona Battery for Cognitive-Communication Disorders (ABCD; n = 2) Mini-Mental State Examination (MMSE; n = 2) Cambridge Prospective Memory Test (CAMPROMPT; n = 2) Pyramids and Palm Trees Test (n = 2) Orientation Log (O-Log; n = 1) Bedside BAE (n = 1) Clinical Evaluation of Language Fundamentals–Fifth Edition (CELF-5; n = 1) Preschool Language Scales–Fifth Edition (PLS-5; n = 1) Comprehensive Receptive and Expressive Vocabulary Test (CREVT; n = 1) Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN; n = 1) Tablet-based Cognitive Assessment Tool (TabCAT; n = 1) Test of Adult Word Finding (TAWF; n = 1) Test of Language Competency (TLC; n = 1) Test of Memory and Learning (TOMAL; n = 1) Cognistat Cognitive Assessment (n = 1) Camel and Cactus Test (CCT; n = 1) Pediatric Test of Brain Injury (PTBI; n = 1) Brisbane Evidence-Based Language Test (EBLT; n = 1) Brief Interview for Mental Status (BIMS; n = 1) Patient-Reported Outcome Measures (PROMs; n = 1) Arizona Semantic Test (n = 1) Kissing and Dancing Test (n = 1) Evaluation of Communication Problems in Right Hemisphere Dysfunction (RICE-3; n = 1) Hopkins Verbal Learning Test (HVLT; n = 1) Standardized Aphasia Battery (n = 1) Brief Test of Head Injury (BTHI; n = 1) Short Blessed Test (SBT; n = 1) Psycholinguistic Assessments of Language Processing in Aphasia (PALPA; n = 1) National Alzheimer's Coordinating Center items (n = 1)	Interview (patient/family; n = 9) Naming (confrontation/generative; n = 4) Informal hospital assessment (n = 4) Knowledge recall (n = 4) Word recall/repetition (n = 3) Observation (n = 3) Nonspecific informal assessment (n = 2) Repetition (n = 2) Age-appropriate common complex conversational tasks (n = 2) Orientation Qs (n = 1)
Short-term and/or working memory (n = 127) Formal (129 responses) Informal (57 responses)	Ross Information Processing Assessment (RIPA; n = 13) Rivermead Behavioral Memory Test (RBMT; n = 13) Repeatable Battery for the Assessment of Neuropsychological Status (RBANS; n = 12) Woodcock–Johnson Test of Cognitive Abilities (WJ; n = 10) Cognitive Linguistic Quick Test (CLQT; n = 6) Montreal Cognitive Assessment (MoCA; n = 5) Scales of Cognitive and Communicative Ability for Neurorehabilitation (SCCAN; n = 5) Saint Louis University Mental Status (SLUMS; n = 5) Test of Memory and Learning (TOMAL; n = 5) Scales of Cognitive Ability for Traumatic Injury (SCATBI; n = 4) Brief Interview for Mental Status (BIMS; n = 4) Arizona Battery for Cognitive-Communication Disorders (ABCD; n = 4) Brief Cognitive Assessment Tool (BCAT; n = 4) Short Blessed Test (SBT; n = 3) Wechsler Memory Scale (WMS; n = 3) Brief Test of Head Injury (BTHI; n = 2) Cognistat Cognitive Assessment (n = 2) Workbook of Activities for Language and Cognition (WALC-2; n = 2) Cognitive Capacity Screening Exam (CCSE; n = 1) Brief Cognitive Rating Scale (BCRS; n = 1) Serial 7s (n = 1) Auditory Consonant Trigrams Test (ACT; n = 1) Clinical Evaluation of Language Fundamentals–Fifth Edition (CELF-5; n = 1) Contextual Memory Test (CMT; n = 1) Executive Functions Test–Elementary (EMT; n = 1) Boston Naming Test (BNT; n = 1) Wide Range Assessment of Memory and Learning (WRAML; n = 1) Rey Auditory Verbal Learning Test (RAVLT; n = 1) Trail Making Test (TMT; n = 1) Mini-Mental State Examination (MMSE; n = 4) Functional Assessment of Verbal Reasoning and Executive Strategies (FAVRES; n = 1) Western Aphasia Battery (WAB; n = 1) Cognitive Reserve Assessment Scale in Health (CRASH; n = 1) Galveston Orientation and Amnesia Test (GOAT; n = 1) The Cognitive Log (Cog-Log; n = 1) Preschool Language Scales–Fifth Edition (PLS-5; n = 1) Communication Activities of Daily Living (CADL; n = 1) Boston Diagnostic Aphasia Examination (BDAE; n = 1) Mississippi Aphasia Screening Test (MAST; n = 1) Measure of Cognitive Linguistic Abilities (MCLA; n = 1) Assessment of Language-Related Functional Activities (ALFA; n = 1) Hopkins Verbal Learning Test (HVLT; n = 1)	Verbal word/story recall (immediate/delayed; n = 14) Digit span (n = 11) Recall and manipulation (words; n = 6) Nonspecific informal (n = 5) Interview (n = 3) Observation (n = 3) Informal/conversational recall (n = 3) Department/hospital informal assessment (n = 3) Spatial span (n = 2) Mental arithmetic (n = 2) Probe tasks (n = 1) Manipulation of 3–5 digits in ascending order (n = 1) Category word list (n = 1) Associative pair recall (n = 1) Orientation (n = 1)

Note. Formal assessments include any standardized assessment given in part or in its entirety. Informal measures include non-standardized assessments (e.g., patient interviews or hospital-specific assessments). To streamline the reporting, we collapsed different versions of the same assessment. All measures are listed as reported by participants. ADL = activity of daily living.

Funding Statement

Funding was received from National Institute of Neurological Disorders and Stroke R01 NS110661 to M.C.D. The authors thank the clinicians (R.J., H.M.H., S.B., N.W., C.G., and M.Z.) who volunteered their time and insight to contribute to the development of this survey.