REVIEWS

Prospective memory impairment in

neurological disorders: implications
and management
Julie D. Henry
Abstract | Prospective memory is a core neurocognitive ability that refers to memory for future
intentions, such as remembering to take medications and to switch off appliances. Any breakdown
in prospective memory, therefore, has serious implications for the ability to function independently in
everyday life. In many neurological disorders, including Parkinson disease and dementia, prospective
memory deficits are common even in the earliest stages and typically become more severe with
disease progression. Consequently, clinical assessment of prospective memory is of critical
importance. This article provides an overview of the various manifestations and neural bases
of prospective memory deficits. To facilitate clinical decision-making, validated measures of this
construct are identified and their suitability for clinical practice is discussed, focusing in particular
on clinical sensitivity and psychometric properties. The article concludes by reviewing the
approaches that can be used to rehabilitate different types of prospective memory impairment,
and algorithms to guide the evaluation and treatment of these impairments are provided.

School of Psychology, The
University of Queensland,
Brisbane, QLD, Australia.
e-mail: julie.henry@uq.edu.au
https://doi.org/10.1038/
s41582-021-00472-1
Prospective memory (PM) refers to the process of form-
ing a future intention and remembering to execute that
intention at a later point in time, or ‘remembering to
remember’. Although difficulties remembering past
experiences or events — that is, deficits in retrospective
episodic memory — have long been recognized to be
one of the most consistently observed cognitive symp-
toms of neurological illness, PM failures are often a more
salient feature and of greater concern in everyday life,
as they fundamentally disrupt the ability to anticipate,
plan and/or act with the future in mind1. Many daily PM
tasks, such as remembering to take medication, check
food cooking or switch off appliances, are crucial for the
maintenance of independence. PM failures are powerful
predictors of functional outcomes: they cause more defi-
cits in activities of daily living and caregiver burden than
retrospective memory failures2,3, with direct implications
for patient management and rehabilitation4–7.
In the clinical setting, the reasons for conducting
a formal assessment of PM are largely self-evident. In
many of the most common neurological disorders, fail-
ures of prospective cognition are an early and salient dis-
turbance (BOX 1). For several of these disorders, including
autism spectrum disorders, Parkinson disease (PD),
traumatic brain injury (TBI), mild cognitive impairment
(MCI) and dementia, the research literature has grown
sufficiently large to warrant meta- analyses, which,
without exception, have identified deficits of moder-
ate to large size for at least some types of PM tasks8–11.
However, despite this extensive clinical literature, many
neurologists are unfamiliar with the methods available
to assess and manage PM impairment.
This Review provides an overview of the different
types of PM impairment, including their neural bases
and clinical implications. It also describes the vali-
dated assessment approaches and presents structured
evidence-based guidelines for managing specific types
of PM impairment, including algorithms to inform
their evaluation and treatment. By contextualizing
and explaining the neurocognitive bases for different
patterns of PM impairment, this article offers a help-
ful resource that can directly aid the interpretation of
clinical deficits.
The process of remembering to remember
Although the term PM implies a single construct
or a defined cognitive skill, PM is in fact a complex
multicomponent process that entails several phases.
Successful completion of a PM task is contingent on
progressing through the intention formation, intention
retention, intention initiation and intention execution
phases12,13, each of which draws on specific neurocog-
nitive resources (FIG. 1). Moreover, a distinction is often
made between the prospective component of PM, which
refers to the requirement to remember that an action
needs to be carried out, and the retrospective component
of PM, which refers to the requirement to remember
what action needs to be executed and when14.

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an intention in the future requires not only the deploy-

Key points
ment of these resources, but also their integration and
Prospective memory (PM) is a core neurocognitive ability that refers to the ability to coordination, in addition to PM-specific skills such as
execute delayed intentions and is an important predictor of the ability to function the formation of a delayed intention and the generation
independently. of retrieval cues. Therefore, the degree of impairment
PM deficits are prominent in many neurological disorders, reflecting the demands that is observed on structured PM assessments, as well
that this complex multicomponent process places on a wide range of neural as the degree to which these PM failures disrupt the
structures and networks and their connectivity.
capacity to function autonomously, can be considerably
Neurological disorders rarely present with a uniform profile of impairment, meaning greater than other neurocognitive deficits would pre-
that clinical assessments are crucial to the quantification of the nature, magnitude
dict. Consequently, if the clinical history or presentation
and specificity of any deficits.
indicates potential PM dysfunction, it is important to
Many validated PM assessments are now available that are appropriate for clinical assess PM directly and not simply make inferences on
use, and can be used to inform prognosis, rehabilitation and discharge planning.
the basis of a patient’s broader neurocognitive profile.
A range of interventions are also available, the selection of which should be guided For example, although episodic memory dysfunction
by the patient’s broader neurocognitive profile and the specific types of PM deficits
often contributes to PM impairment19–21, PM dysfunc-
that the patient exhibits.
tion can also present independently22–25 and typically
has a greater impact on real-world outcomes, such as
In addition to these demands on retrospective epi- medication adherence in patients with multimorbidity26
sodic memory, other key neurocognitive resources and the need for assistance with instrumental activities
implicated in PM include attentional capacity, process- of daily living in older adults27.
ing speed, executive control, metacognition and working Any clinical assessment of PM should include a
memory13,15. A breakdown in any one of these neurocog- range of different types of PM tasks. Substantial clinical
nitive resources can potentially disrupt PM, and for the heterogeneity is observed not only across but also within
many disorders that present with broader neurocognitive neurological disorders, with not all types of PM being
impairment, PM deficits are therefore a natural corollary. affected equally and at least some areas of preservation
However, at both the behavioural and neural systems being typical8–11. Much of this heterogeneity reflects the
levels, PM can at least partially be dissociated from these fact that the critical intention initiation phase of pro-
more basic neurocognitive abilities16–18. Accomplishing spective remembering can be supported either by rel-
atively spontaneous retrieval or by controlled strategic
Box 1 | Disorders with PM impairment monitoring processes, and multiple features of each task
determine the degree to which the latter, more effortful
Neurodegenerative
type of processing is required28–30.
Alzheimer disease
In most neurological disorders that present with
Vascular dementia
PM difficulties, PM tasks that rely heavily on strategic
Frontotemporal dementia monitoring tend to show greater impairment than tasks
Parkinson disease better suited to spontaneous retrieval. In PD, this profile
Huntington disease of impairment has been linked to both specific regional
Multiple sclerosis neural losses, such as dopaminergic depletion of frontal
HIV-associated neurocognitive disorders regions31, and broader neural dysfunction, such as multi-
Dystonia focal alterations of white matter connectivity32. However,
Amyotrophic lateral sclerosis important exceptions exist; for example, in Alzheimer
disease (AD), impairment on tasks well suited to spon-
Neuropsychiatric taneous retrieval is evident even in the earliest stages
Schizophrenia of the disorder. This specific pattern of decline, which
Major depressive disorders differs from most other age-related neurodegenerative
Metacognition
Substance use disorders disorders as well as normal adult ageing, is evident in
Self-awareness and knowledge
about one’s own cognitive Bipolar disorder middle-aged carriers of the apolipoprotein E ɛ4 allele33
abilities, such as being able to Post-traumatic stress disorder and has been linked to early accumulation of pathol-
evaluate how well a task has
Obsessive–compulsive disorder
ogy in key areas of the default mode network in AD34.
been completed, monitor and Attention to specific patterns of PM impairment, there-
detect performance errors,
Neurodevelopmental fore, not only provides important insights into the types
and reflect on the effectiveness
of specific strategies. Autism spectrum disorder of neurocognitive resources that are disrupted and
Attention deficit hyperactivity disorder should be the target of remediation, but might also assist
Delayed intention
Developmental dyslexia in reaching an initial clinical diagnosis.
An objective or goal that needs
to be completed at a later Fetal alcohol syndrome
point in time. The neural bases of PM
Acquired brain damage Findings from neuroimaging, brain lesion and electro-
Default mode network Traumatic brain injury physiological studies have converged to show that many
The large-scale brain network Stroke distinct neural structures and networks need to cooper-
that is active during periods
of wakeful rest (such as when Brain metastases ate to execute a delayed intention (FIG. 2). Historically, the
daydreaming), when there is anterior prefrontal cortex (aPFC) has received the great-
PM, prospective memory.
no focus on the outside world. est attention. Neuroimaging studies have consistently

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Delay interval (ongoing task)

Phase 1 Phase 2 Phase 3

Intention formation Intention retention Intention initiation Intention execution

Planning and LTM storage Automatic Strategic Executive control

encoding capacity retrieval monitoring and retrieval from LTM

Basic neurocognitive resources implicated at each phase

High support Low support

Fig. 1 | The complex process of prospective remembering. The intention formation phase of a prospective memory (PM)
task refers to initial formation of a future intention and involves generation and encoding of an action plan via episodic
memory encoding (creation of memory representations) and planning (a core component of executive control). The
intention retention phase is the delay period between intention formation and intention initiation, during which the task
content must be retained in long-term memory (LTM). During this period, completion of other activities (ongoing tasks)
prevents overt rehearsal of the PM task. The intention initiation phase refers to retrieval of the PM intention from LTM in
response to the PM cue and requires cue recognition and retrieval of the intention. This phase can be supported by either
spontaneous retrieval or strategic monitoring, which involve different levels of environmental support. In the high-support
scenario shown, an external alarm should automatically ‘trigger’ the PM intention. In the absence of a salient external cue
(low-support scenario), effortful strategic monitoring of time is required. The intention execution phase refers to task execution
and requires executive control to disengage from the ongoing task to complete (and avoid erroneous repetition of) the PM
task. Phase 4 also requires episodic memory to retrieve PM content.

identified distinct patterns of haemodynamic changes
in the lateral and medial portions (activation and deac-
tivation, respectively) during PM task performance. This
mediolateral dissociation provides a ‘gateway’ mechanism
that mediates the capacity to engage in internal thought
(maintaining the PM intention actively in mind and mon-
itoring for the PM cue, subserved by the lateral aPFC)
while concurrently attending to external stimuli (completing
the ongoing task, subserved by the medial aPFC)35–37.
Two distinct frontoparietal networks also have a cru-
cial role in PM. The dorsal frontoparietal network medi-
ates the engagement of strategic monitoring resources
and is involved mainly in the maintenance phase of PM,
whereas the ventral frontoparietal network supports
more spontaneous retrieval processes and is impli-
cated in the retrieval phase17,38,39. PM difficulties can
arise owing to disruptions in the connectivity within
and between these large- scale neural networks, and
PM function is often impaired in disorders associated
with white matter pathology, such as multiple sclerosis
(MS)40. Poorer PM performance has also been linked to
reduced prefrontal white matter volume in cognitively
healthy older adults41 and an increased burden of white
matter hyperintensities in amnestic MCI42.
Medial temporal lobe structures such as hippocampal
and parahippocampal areas have key roles in episodic
memory and should theoretically be linked to PM, but
neuroimaging support for their involvement is mixed39.
This apparent anomaly remains a topic of some debate,
particularly in light of structural MRI data showing that
the integrity of these regions is related to PM performance.
For instance, hippocampal atrophy strongly correlates
with PM function across different dementia syndromes43,
and cortical thickness in hippocampal subfields correlates
with performance on the retrospective component of PM
in prodromal AD18. Where medial temporal lobe regions
have been implicated in PM, they seem to predominantly
support spontaneous retrieval processes44.
Deconstructing PM failure
Given the complex cognitive and neural architecture
that underlies prospective remembering, behavioural
deficits can reflect diverse types of underlying impair-
ment. To directly guide clinical interpretation of these
deficits, FIGS 3,4 provide evidence- based algorithms
that describe the patterns of performance typically seen
when impairment in executive neurocognitive resources
or retrospective episodic memory resources contribute
to these difficulties and show how these patterns map
onto the different phases of prospective remembering.
Executive dysfunction. With respect to executive dys-
function (FIG. 3), PM impairments can arise owing to
breakdowns in planning, strategic monitoring, cognitive

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a aPFC b Frontoparietal networks
c Medial temporal lobe structures
Fig. 2 | The neural bases of PM. a | The anterior prefrontal cortex (aPFC, also variously
referred to as the rostral prefrontal cortex, rostrolateral prefrontal cortex, frontopolar
cortex and frontal pole) has been consistently implicated in prospective memory (PM).
The aPFC supports many aspects of PM function, but has a particularly prominent role
during the ‘maintenance of intention’ phase. During PM task performance, a mediolateral
dissociation is observed, involving lateral aPFC activation, which supports attention
to internal representations, and medial aPFC deactivation, which supports attention to
external stimuli36,37. b | Two frontoparietal networks have also been implicated in PM.
The dorsal frontoparietal network (orange), which includes the superior parietal lobule,
precuneus and superior frontal lobule, mediates strategic PM monitoring processes. The
ventral frontoparietal network (purple), which includes ventrolateral prefrontal regions,
the supramarginal gyrus and the inferior parietal lobule, has been implicated in the
engagement of spontaneous retrieval processes17,39. c | Medial temporal lobe structures
such as hippocampal and parahippocampal areas (blue and orange, respectively) have
not been consistently implicated in PM on the basis of functional neuroimaging data39,
but structural neuroimaging studies more strongly support their involvement.
flexibility and/or cognitive inhibition13. Disruption of
planning in the initial intention formation stage of PM
is typically marked by greater impairment on complex
multi-intention tasks, which require the coordination
and execution of several PM tasks, than on single inten-
tion tasks, which require the completion of only a single
PM task.
Cognitive inhibition Executive dysfunction can also disrupt the inten-
The processes that allow the tion execution phase of PM. Because of the dual-task
suppression of cognitive nature of PM, cognitive flexibility is required to disen-
contents that are perceived as gage from the ongoing task to attend to the PM task.
irrelevant or inappropriate, and
the resistance to interference
Cognitive rigidity might therefore manifest as PM fail-
from unwanted but potentially ures (omission errors) or excessive delays in PM task
attention-capturing stimuli. execution, even though the PM cue has been accurately
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detected and recognized and the task instructions
recalled. Executive dysfunction at the intention execu-
tion phase can also lead to erroneous repetition of the
PM task (commission errors). Clinically, these errors
can be just as problematic as omission errors, such as
in the case of accidental medication overdose (‘double
dosing’). Reductions in the volume of the lateral orbitof-
rontal cortex45, which has a key role in inhibitory control,
are associated with an increased risk of commission
errors.
In cases where executive dysfunction contributes to
PM impairment, disproportionate — and sometimes
selective — impairment of PM tasks that rely heavily
on strategic monitoring is the most common finding.
In clinical practice and research, PM tasks that are well
suited to spontaneous retrieval are usually differentiated
from tasks that require strategic monitoring by compar-
ing event-based and time-based variants (EBPM and
TBPM, respectively). The key difference between EBPM
and TBPM is the type of cue used to signal PM execu-
tion. For EBPM, task execution is cued by an event, such
as ‘take your medication after an alarm rings’, with the
event (the alarm) providing an external cue (environ-
mental support) that functions as a signal, automatically
triggering the PM intention (spontaneous retrieval). For
TBPM, task execution is instead cued by time, includ-
ing both time-of-day tasks, such as attending a doctor’s
appointment at 10 am, and time-interval tasks, such as
‘switch off the oven after 15 min’. Most TBPM tasks, and
particularly the time-interval variants, lack an external
cue to signal PM execution, so strategic monitoring of
time is required46. In disorders associated with execu-
tive dysfunction, TBPM is typically more impaired than
EBPM; this profile of impairment has been identified in
MS, TBI, HIV-associated neurocognitive disorders and
PD5,20,40,47–49.
Many other task characteristics also influence stra-
tegic demands. From a clinical perspective, the most
important characteristics are those that reduce the level
of environmental support available to support spon-
taneous retrieval, such as non-distinctive PM cues, a
weak association between the PM cue and the intended
action, and how peripheral (unrelated) the cue initiat-
ing PM retrieval is to the ongoing task. A longer delay
interval between intention formation and execution
also increases strategic demands, but only for those
tasks that require strategic monitoring to detect the PM
cue. If executive dysfunction contributes to PM diffi-
culties, any lengthening of the delay interval therefore
increases the degree of impairment for TBPM more than
for EBPM; this type of differential clinical sensitivity has
been identified in MS40, HIV-associated neurocognitive
disorders50,51 and substance use disorders52.
Retrospective episodic memory dysfunction. In cases
where retrospective episodic memory dysfunction
contributes to PM difficulties (FIG. 4), distinct patterns
of impairment can be expected depending on whether
encoding, storage or retrieval processes are disrupted.
Problems with encoding will typically present clinically
as a failure to acknowledge that a PM task needs to be
completed even when the task characteristics strongly
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support spontaneous retrieval. Failure to encode reflects
a breakdown at the earliest phase of PM, and task features
that would ordinarily influence progression through
later phases of PM are rendered irrelevant. Recognition
of PM task instructions is also expected to be impaired
in this situation. However, regular (recurring) PM tasks
might be less impaired than irregular (one- off) PM
tasks, owing to the greater encoding support associated
with repetition learning.
PM failures that reflect impaired storage capac-
ity often present clinically as loss- of- content errors,
whereby the individual is aware that a PM task needs to
be completed but has either no recollection or incorrect
recollection of task content. Timing errors are also likely,
with TBPM tasks being completed at incorrect times.
In addition, greater impairments on irregular relative to
regular and long-delay relative to short-delay PM tasks
are expected. When limited storage capacity contributes
to difficulties, a longer delay interval should increase the
clinical sensitivity of TBPM and EBPM to a comparable
degree, as both types of PM impose demands on this
resource.
Problems with episodic memory retrieval often man-
ifest clinically as difficulties performing PM tasks where
no recognition cue is provided to support retrieval.
Consequently, any task characteristics that reduce the
level of environmental support available to support
spontaneous retrieval should be associated with greater
impairment. Impaired recall (but preserved recognition)
of PM task instructions on completion of the PM task is
also expected in this scenario.
Clinical assessment of PM
If the patient history or clinical presentation points to
potential PM impairment, a standardized assessment is
vital to objectively quantify the nature and severity of
PM impairment and to identify the strongest residual
abilities that might be used to compensate for losses.
However, despite the prevalence of PM dysfunction
in clinical practice, PM is rarely assessed in standard
neuropsychological evaluations.
To help guide clinical test selection, this section pro-
vides a detailed critique of four different assessment
approaches. Although these measures all provide objec-
tive information regarding PM accuracy and have good
sensitivity to PM impairment, each also has additional
unique characteristics that are likely to be more or less
desirable, depending on the specific goal of the clini-
cal assessment and the features of the clinical setting.
The key characteristics and psychometric properties of
each measure are summarized in TABLE 1 and TABLE 2,
respectively.
Royal Prince Alfred Prospective Memory Test. The
Royal Prince Alfred Prospective Memory Test (RPA-
ProMem)53 is a four-item behavioural measure consisting

Phase 1 Phases 2 and 3 Phase 4

Intention formation Intention retention and initiation Intention execution

Impaired monitoring or
Impaired planning
cue detection

Multi- Single-
TBPM EBPM Perseveration on ongoing task
intention intention

Subtle cue Salient cue Commission errors

Weakly Strongly
associated cue associated cue

Non-focal cue Focal cue

Likely to be impaired
Long-delay Long-delay
TBPM EBPM Minimal or no impairment
Greater impairment
Time-interval Time-of-day
TBPM TBPM impairment

Fig. 3 | Performance patterns consistent with executive dysfunction. As this algorithm illustrates, problems with
prospective memory (PM) can reflect a breakdown in single or multiple executive neurocognitive resources. Impairment
in planning (phase 1) is likely to be associated with greater impairment on multi-intention than on single-intention tasks.
If a reduced capacity for strategic monitoring contributes to PM difficulties (phases 2 and 3), greater clinical impairment
is likely on PM tasks with characteristics that provide little environmental support, such as those that are time-based as
opposed to event-based (TBPM and EBPM, respectively). Contrasts between many other PM task features can also be
clinically valuable as indicators of impairments in intention retention and/or initiation. During the intention execution
phase (phase 4), executive dysfunction can present as problems disengaging from the ongoing task despite intact cue
recognition and memory for PM task content, with either no PM task being executed (omission errors) or PM task
performance being excessively delayed. Executive dysfunction at this stage might also present as commission errors.

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of two EBPM and two TBPM tasks. Two of these tasks
are completed in the clinic and the other two are per-
formed up to 1 week later as part of the patient’s everyday
life, thereby increasing the test’s ecological validity while
reducing the in- session administration time to only
~10 min. The RPA-ProMem does not include stand-
ardized ongoing activities, and this freedom to choose
other assessments as the ongoing task is likely to be
a valuable feature in many clinical settings. However,
because the characteristics of the ongoing task influence
PM performance, with highly attention-demanding or
engaging ongoing tasks particularly challenging PM,
the examiner must be sensitive to any potential perfor-
mance trade-offs. To enhance ecological validity, a clock
is required to be visible for the duration of testing, and
external memory aids are permitted. Of the four PM
assessments described in this Review, the RPA-ProMem
has been used the least frequently. However, it has been
shown to be able to differentiate patients with neurolog-
ical disorders from healthy volunteers53 and to be more
sensitive to MCI in older adults than traditional episodic
memory tests54. Owing to its brevity, the RPA-ProMem
is a potentially valuable tool that could have value in
time-pressured clinical environments.
Cambridge Prospective Memory Test. Many early clinical
measures used the two PM items from the Rivermead
Behavioural Memory Test, which were then expanded
to develop the Cambridge Prospective Memory Test
(CAMPROMPT)55. The CAMPROMPT includes three
EBPM and three TBPM tasks with variable delay intervals,
completed while engaged in a range of ongoing distrac-
tor tasks. The total in-session assessment lasts ~25 min.
As for the RPA-ProMem, use of external memory aids is
permitted, and higher levels of spontaneous note-taking
have been linked to better CAMPROMPT performance
in people with amnestic MCI56 and in people with TBI57.
A unique feature of the CAMPROMPT is that the exam-
iner provides standardized prompts to probe errors,
thereby providing insights into the underlying neuro-
cognitive bases of any observed PM impairment. The
CAMPROMPT is one of the most validated and widely
used clinical assessment tools for PM and is sensitive to
the effects of acquired brain damage, neurodegenerative
disorders and neuropsychiatric disturbances (TABLE 2).
Memory for Intentions Screening Test. The Memory for
Intentions Screening Test (MIST)58 is another widely
used and validated behavioural assessment with a total

Phase 1 Phase 2 Phases 3 and 4

Intention formation Intention retention Intention initiation and execution

Impaired encoding Impaired storage Impaired retrieval

High support Low support Irregular Regular TBPM EBPM

Not understanding a PM response is Long-delay Short-delay Subtle cue Salient cue

expected even when highly salient PM PM
cue presented

Long-delay Long-delay Weakly Strongly

Impaired recognition of PM task TBPM EBPM associated cue associated cue
instructions

Loss of content errors Non-focal cue Focal cue

Irregular Regular

Time-interval Time-of-day
Timing errors for TBPM tasks TBPM TBPM
Likely to be impaired
Minimal or no impairment Impaired recall (but intact
Greater impairment recognition) of PM instructions

impairment

Fig. 4 | Performance patterns consistent with retrospective episodic memory dysfunction. As this algorithm shows,
problems with prospective memory (PM) can reflect a breakdown in single or multiple aspects of retrospective episodic
memory. If encoding is impaired, PM failures can be expected even when cues are presented that have high environmental
support, and the individual might not acknowledge that a PM response was expected; recognition of PM task instructions
is also likely to be impaired. However, regular (recurring) PM tasks might be less impaired than irregular (one-off) tasks.
When PM failures reflect impaired storage, loss-of-content errors are common, with either no PM task or an incorrect PM
task being executed. Greater impairment is also likely on tasks with characteristics that increase demands on storage
capacity. Problems with retrieval are associated with poorer performance on tasks where no recognition cue is provided
to support retrieval (such as many time-based PM (TBPM) tasks) than on tasks that provide a distinct recognition cue (such
as many event-based PM (EBPM) tasks); impaired free recall but preserved recognition of PM task instructions is also
expected in this situation.

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Table 1 | PM assessment tools
Measure Duration Description
Royal Prince Alfred 10 min Four PM tasks
Prospective Memory
PM cue: event and time
Test (RPA-ProMem)53
In-session delay: 15 min
Out-of-session delay: hours to 1 week
Note taking permitted
Cambridge Prospective 25 min Six PM tasks
Memory Test
PM cue: event and time
(CAMPROMPT)55
In-session delay: 7, 13 and 20 min
Note taking permitted
Memory for Intentions 30 min Eight PM tasks
Screening Test (MIST)58 PM cue: event and time
In-session delay: 2 and 15 min
Out-of-session delay: 24 h
Response type: verbal and action
Provides detailed error data
Virtual Week98 30–90 min Eight or ten PM tasks per virtual day
PM cue: event and time
In-session delay: variable
Irregular (recurring) and irregular (one-off)
Time-interval TBPM and time-of-day TBPM
Provides detailed error data
2, 3, 5 and 7-day variants available
PM, prospective memory; TBPM, time-based PM.
in- session administration time of ~30 min. Relative
to both the RPA- ProMem and the CAMPROMPT,
the MIST provides a more detailed understanding of the
source of any PM impairment, differentiating between
multiple PM task parameters and six distinct types of
errors. In total, eight tasks are presented, which vary
according to cue type (time versus event), delay interval
(2 min, 15 min or 24 h delay), and response type (verbal
versus action), with a word search puzzle being used as
the ongoing task. Following completion of the PM tasks,
a recognition test is administered to assess memory for
PM task instructions. The MIST has good psychomet-
ric properties, is very sensitive to clinical impairment,
and has excellent ecological validity, predicting a range
of important real-world outcomes including medica-
tion adherence6,7,26, functional capacity27,59 and quality
of life60.
Virtual Week. Virtual Week (VW)61 is a multi-intention
paradigm that requires the planning and execution of
multiple PM tasks while engaged in a board game set-
ting. As participants move around the board, they are
required to make choices about plausible daily activities
and remember to carry out PM tasks. The demands of
rolling the die and making decisions about the activities
in which to participate serve as the ongoing task. The
original VW was prohibitively long for most clinical set-
tings (~90 min) but has since been adapted for computer
automation, thereby minimizing demands on adminis-
tration and scoring and also allowing the development of
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Example items Ongoing task
Event: when you arrive home today, Selected by the
I want you to phone and leave a clinician
message on my voicemail, telling me
what the weather is like
Time: in 15 min time, I would like you to
tell me it is time for a coffee break
Time: when there are 7 min left, remind Pencil and paper
me not to forget my keys tasks such as a
general knowledge
Event: put a briefcase under the desk
quiz
after you hear an alarm ring
Event: when I hand you a red pen, Word search puzzle
please sign your name on your paper
Time: in exactly 15 min, please tell me
it is time to take a break
Simulate different types of PM tasks Virtual Week game
Event-based irregular: drop the dry
cleaning off when you are at the shops
Time-based regular: take your asthma
medication every day at 11 am
Time-interval: do a lung test on two
occasions each virtual day (2 min and
4 min on a stop clock)
versions tailored to specific clinical applications, which
can take as little as 30 min to administer21,61. Like the
MIST, VW differentiates between multiple task param-
eters (TBPM versus EBPM, regular versus irregular PM
and time-of-day versus time-interval PM) and provides
a detailed error analysis. VW has good psychometric
properties and excellent clinical sensitivity, and is related
to real-world PM function in terms of activities of daily
living62,63. A conceptually parallel paradigm known as
MEMO, which uses a customized smartphone applica-
tion and allows real-life PM activities to be measured in
actual daily life, has also been developed46.
Other forms of PM assessment. PM can also be measured
via self-report scales, which provide valuable insights
into the patient’s own perspective and have the advan-
tage of being quick to administer and score. However,
because self- report measures of PM often correlate
weakly with objective assessments23,64,65, they should
supplement rather than replace a formal behavioural
assessment.
Simple single-item PM tests such as the Envelope
Task 66 and the Key Task are also available. In the
Envelope Task, patients are told that when the examiner
dictates a name and address, after a 20 min delay, they
need to remember to seal and initial an envelope. In the
Key Task, the patient is informed that keys or another
object will be hidden in a specific out- of- sight loca-
tion such as a bedside drawer, and they are instructed
to remind the examiner to retrieve the hidden object
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Elaborative encoding
Memory aids that link
to-be-remembered information
to previously existing
memories and knowledge,
making it easier to recall the
new information in the future.
Implementation intentions
An encoding strategy that
involves generating and saying
aloud a simple statement that
has a precise format and
structure.
at a designated time. Because of their low cost and brev-
ity, such measures can be readily integrated into routine
clinical practice. However, single-item PM tests have
lower reliability and sensitivity than clinical batteries,
provide limited insights into the nature and causes of
any PM difficulties, and have questionable construct
validity67. As a consequence, such tests should only be
considered as basic screening tools68,69 or as a method
for illustrating to patients or their families how PM
failures can cause problems with completing everyday
tasks70.
Interventions
The goal of any cognitive intervention should be to
improve autonomy and adaptive functioning in every-
day life, which in the case of PM is challenging. Real-life
PM tasks are often considerably more complex and have
much longer retention intervals than those completed in
clinical settings, and they need to be completed against
the backdrop of a dynamic social, cultural and physical
environment.
In the broader cognitive rehabilitation literature,
a distinction has been made between compensa-
tory approaches, which provide skills and resources
that allow weaknesses to be circumvented, and restor-
ative approaches, which are based on principles of neu-
ral plasticity and provide cognitive training to try and
restore function directly. Other interventions include
psychoeducational approaches, which seek to increase
understanding of cognitive weaknesses, and metacog-
nitive approaches, which target self- monitoring by
enhancing both the ability to detect and self- correct
errors and self-knowledge of strengths and weaknesses.
Each of these approaches has potential value, depending
on the nature of the PM impairment (FIG. 5). For instance,
there is strong support for the efficacy of metacogni-
tive training approaches such as Goal Management
Training71 for treating deficits arising from executive
neurocognitive impairment.
To date, compensatory interventions have attracted
the greatest attention and have been most consist-
ently linked to improvement on real-life PM tasks5,72,73.
Common compensatory approaches include external
aids such as memory notebooks or electronic prompt-
ing technologies such as smartphones, the latter of which
have the important advantage of being able to deliver
salient PM cues (alerts) at specific times. These alerts
can be programmed to be content-free, such as a simple
auditory alarm, or content- specific, such as an audi-
tory message, and both have value depending on the
nature of the PM impairment. Compensatory support
can also be provided via environmental modifications,
such as structuring the environment to increase the sali-
ence of PM cues, thereby helping to trigger automatic
retrieval processes, or reducing competing environ-
mental demands to increase the availability of strate-
gic monitoring resources. Specific examples include
the creation of daily routines to act as scaffolding, and
linking important PM tasks to regular events, such as
taking medication at mealtimes. The benefits of external
memory aids have been demonstrated in many groups,
including individuals with acquired brain damage72 and
people with HIV-associated neurocognitive disorders74,
but gains are likely to be larger and more sustained when
significant others are involved in treatment, as use of
these aids can then be supported and reinforced beyond
the rehabilitation environment.
Internal compensatory strategies such as elaborative
encoding have also been shown to partially — and in some
cases completely — restore PM function. Elaborative
encoding includes implementation intentions, a simple
goal-setting strategy that seems to support the inten-
tion formation, cue detection and intention retrieval
phases of PM that are affected in many clinical disorders,

Table 2 | Psychometric properties and clinical sensitivity of PM assessments

PM test Languages Psychometrics Clinical validity Norms
Royal Prince English Inter-rater reliability 0.90 (REF.53) Sensitive to PM failures associated with No formal norms, but data
Alfred Prospective and 0.97 (REFS54,99); delayed brain damage53,97 and normal ageing53,100, for healthy volunteers
Memory Test alternate form reliability 0.71; and differentiates healthy older adults are reported in several
(RPA-ProMem)53 parallel forms rho 0.68–0.87 (REF.99) from people with MCI or subjective studies
cognitive decline54
Cambridge English, Chinese Inter-rater reliability 0.99 (REF.55); Sensitive to PM deficits associated with Formal norms are
Prospective and Italian test–retest reliability 0.64 (REF.55); bipolar disorder101, schizophrenia102,103, reported in the test
Memory Test inter-item reliability (α) 0.75 (REF.68) substance use disorders104, MCI56,68, manual for 212 controls
(CAMPROMPT)55 neurodegenerative disorders such as and 72 people with brain
bvFTD and AD43,105, TBI57 and stroke106 injury
Memory for English, Alternate-form reliability Sensitive to depression109, HIV-associated Formal norms are
Intentions Portuguese, 0.89 (REF.107); inter-rater reliability neurocognitive disorders49,110, MCI111,112, reported in the test
Screening Test Chinese, Spanish, 0.99 (REF.108); split-half reliability substance use disorders52,113, MS20,40,48, manual for 736 healthy
(MIST)58 Italian and Czech 0.70 (REF.108); subscale reliability α TBI23,114,115, OCD116, schizophrenia59,117, individuals for Form A and
0.89 (REF.108) PD47 and HD118 99 individuals for Form B
Virtual Week98 English, Chinese, Split-half reliabilities range Sensitive to MS77,120,121, AD75, No formal norms, but
German, Italian, 0.66–0.74 for a 3-day version19 and schizophrenia19,122, TBI123, MCI extensive research base
Polish, Swedish, 0.87–0.92 for a 5-day version119; and dementia21, PD124,125, ASD126 and reporting data for healthy
Farsi, Japanese, inter-rater reliability is 100%, substance use disorders127–129 volunteers
Croatian and because computer automation
Hungarian ensures no subjectivity in scoring
AD, Alzheimer disease; ASD, autism spectrum disorder; bvFTD, behavioural variant frontotemporal dementia; HD, Huntington disease; MCI, mild cognitive
impairment; MS, multiple sclerosis; OCD, obsessive–compulsive disorder; PD, Parkinson disease; PM, prospective memory; TBI, traumatic brain injury.

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Type of impairment Compensatory strategies

Executive neurocognitive Content-free alerts and

Restorative, resources implementation intentions
metacognitive
and/or
psychoeducational Episodic memory
approaches encoding or storage alerts and spaced retrieval

Episodic retrieval Distinctive external cues

Fig. 5 | Rehabilitation of PM impairments. The clinical benefits of specific rehabilitative approaches vary depending
on the underlying cause of the impairment. In people in whom prospective memory (PM) deficits reflect a breakdown
in executive neurocognitive resources, useful external aids include content-free alerts, which support strategic cue
detection processes by signalling the need to switch attention from the ongoing task to the PM task. Also helpful are
elaborative encoding strategies such as implementation intentions, which support the initial encoding stage and reduce
demands on strategic retrieval at the later cue detection and intention retrieval stages. Where PM deficits reflect a
breakdown in episodic memory encoding or storage, potentially useful external aids include memory notebooks and
content-specific alerts. One of the best-validated internal memory rehabilitation strategies is spaced retrieval. Where
PM failures have been linked to problems with episodic memory retrieval, training patients and their caregivers to make
environmental modifications, such as learning how to generate distinctive external cues that function as recognition cues,
is a valuable approach to consider. In addition, encouraging evidence is emerging that restorative, metacognitive and/or
psychoeducational approaches have clinical benefits both when used in combination with compensatory approaches and
when used separately. Each of these approaches can be tailored to the type of PM impairment.

Visualization
Formation of a mental visual
image.
Spaced retrieval
An encoding strategy in
which information is
retrieved continuously
across increasingly longer
delay intervals.
Errorless learning
An encoding strategy that
prevents patients from giving
wrong answers.
including PD, MS and AD75–77. The benefits of imple-
mentation intentions are potentially greater when com-
bined with visualization78. For clinical groups that do not
benefit from implementation intentions, other encod-
ing strategies such as spaced retrieval79, errorless learning80
and physical enactment81 should be considered. Spaced
retrieval is useful in the treatment of episodic memory
disorders82, so could be a particularly effective approach
when PM difficulties have been linked to episodic
memory dysfunction83. Moreover, in addition to being
effective when combined with other strategies84, visual
imagery techniques often have clinical benefits when
used in isolation85,86.
Although restorative training gains have not been
shown to reliably generalize to real- world PM tasks,
neuroplastic changes associated with this rehabilitative
approach include increased neural connectivity in cog-
nitive control networks and reorganized network mod-
ularity at the whole-brain level87,88. In the rehabilitation
of PM, restorative approaches do not need to target this
type of memory directly; in fact, PM-specific restora-
tive approaches may have limited clinical benefits89,90. A
restorative approach that concurrently targets several of
the broader neurocognitive resources implicated in PM
might be more beneficial and is an important ongoing
area of research.
In other areas of neurocognitive assessment and reha-
bilitative medicine, encouraging evidence suggests that
virtual reality technology can induce neural plasticity
via augmented feedback signals91, thereby potentially
improving diagnostic accuracy and treatment adherence
and outcomes92–94. The viability and efficacy of virtual
reality in the assessment and treatment of PM has yet to
be tested. In other cognitive domains, interest has also
been expressed in the potential benefits of non-invasive
brain stimulation techniques such as transcranial direct
current stimulation, which might enhance cognitive
recovery by promoting neuroplasticity95. Studies are
now needed to explore these techniques in relation to
the rehabilitation of PM. Finally, given the many ways
in which PM failures can present clinically, and the dif-
ficulty of fully capturing this complexity using conven-
tional assessments, the development of customized tools
that measure real-life PM failures is another important
future goal. Such an approach would strongly align with
the NIH Precision Medicine Initiative in guiding more
individualized rehabilitative treatment and, as noted
above, promising inroads have been made in this regard
with the recent development of the MEMO tool46.
Conclusions
The complex, multifaceted nature of PM makes this type
of memory particularly sensitive to neurological insult,
and PM dysfunction is likely to occur to some degree
in most disorders that affect the brain. Depending on
the magnitude of the impairment, the consequences
range from simply frustrating to profoundly debili-
tating, meaning that clinical assessment of PM is cru-
cial to inform prognosis, rehabilitation and discharge
planning96. Validated PM assessments should therefore
be a routine part of any clinical assessment if the patient
history or presentation indicates potential PM impair-
ment, as earlier intervention has been linked to greater
treatment gains97. Each of the PM measures identified
in this Review is a reliable and validated clinical tool
that has the potential to substantially enhance treat-
ment decision- making and outcomes. By providing
detailed information to guide test selection, as well as
evidence-based algorithms to guide interpretation and
treatment of behavioural deficits, this Review should
provide a helpful resource that will encourage greater
consideration of PM in routine clinical practice.
Published online 8 March 2021

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Acknowledgements
J.D.H. was supported by an Australian Research Council
Future Fellowship (FT170100096). The author thanks
D. Lloyd and J.B. Mattingley for preparation of the original
artwork for Fig. 2, and P.G. Rendell, S.J. Haines, G. Terrett
and S.A. Raskin for advice on earlier drafts.
Competing interests
The author declares no competing interests.
Peer review information
Nature Reviews Neurology thanks J. Rusted and the other,
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