Editors: Backman, Lars; Hill, Robert D.; Neely, Anna Stigsdotter
Copyright 2000 Oxford University Press
> Table of Contents > Part IV - Rehabilitation Strategies for Cognitive Loss in Age-
Retrieval Strategies as a Rehabilitation Aid for Cognitive Loss in Pathological Aging
Cameron J. Camp
Michael J. Bird
Katie E. Cherry
Research on memory interventions for persons with dementia and other cognitive impairments is
We will attempt to provide a historical background for the development of SR, including a brief review of early research
Landauer and Bjork's findings concerning SR were
The Original Study
Landauer and Bjork's study (1978)
was based on a line of research begun in the 1960s concerning the spacing effect. In essence, the spacing effect is the phenomenon in which spaced practice for learning and recalling new information results in better long-
It is informative to note the aspects of SR as originally implemented. Information about a person in a photograph, such as his or her name, was presented along with the photo. Then, a number of other photos were interspersed between this original presentation and later presentations of the target photo. For example, the initial photo might be shown, followed by a second photo and then another presentation of the original photograph. At this latter presentation of the target photo, recall of the name or other information presented at initial presentation of the photo was attempted. The number of photos interspersed between the original presentation of the target and latter presentations kept expanding in the SR condition. For example, Figure 12.1 shows a representation of a 1:5:10 expanding recall, or SR, schedule.
Figure 12.1. Example of an expanded recall schedule.
First Uses of SR as a Rehabilitative Technique
Several years after the initial SR study, Dan Schacter and his colleagues (
Schacter, Rich, & Stampp, 1985
) described the use of SR as a cognitive intervention using a small sample of adults with a variety of etiologies and cognitive deficits. They used a procedure similar to that employed by Landauer and Bjork to create SR schedules (i.e., interspersing varying
Several important points are exemplified in Schacter's use of SR as an aid to cognitive rehabilitation. First, this study was
described the use of SR, which he referred to as expanding rehearsal, to rehabilitate a man in his late 60s who had suffered cerebral anoxia as a result of a myocardial infarction. The
Use of SR as an Intervention for Persons with Dementia
also described a case in which a
Several features of this case study add important information about SR. Moffat noted that the numbers of errors made for trained items and their latencies of response grew smaller across training sessions. The first few words, once learned to criterion, were always recalled immediately. These findings
Also, by the third session, only three words had been taught, but the majority of the 20 pictures were named accurately on the probe test. This finding poses some interesting questions. Does this finding mean that SR training produces a generalization of training effects (i.e., does the general ability to name objects improve after exposure to SR training for specific stimuli)? Alternatively, does the sheer act of giving practice at attempting recall as was done in the probe tests (
Landauer and Bjork (1978)
Further Use of SR for Persons with Dementia: Camp's Research
Camp and his colleagues (
Abrahams & Camp, 1993
Brush & Camp, 1998
Camp & Foss, 1997
Camp & Schaller, 1989
Camp & Stevens, 1990
Camp et al., 1993
Hayden & Camp, 1995
McKitrick & Camp, 1993
McKitrick, Camp, & Black, 1992
Stevens, O'Hanlon, & Camp, 1993
This schedule was used in a number of studies in which persons with dementia were trained to remember names of persons or objects, locations of objects, motor activities, and even a strategy (remembering to look at a calendar to learn about daily appointments and other
One important finding in this research was that if participants with dementia were able to successfully recall information over a critical recall interval, perhaps 6 “8 min, they could retain information across training sessions (
Camp et al., 1996b
). In other words, if persons with dementia could be trained by SR to retain new information across a critical interval within a training session, that information seemed to be consolidated into long-term memory and could be recalled across days. Though other researchers have reported that a longer retention interval (15 minutes or 1
Extending the Use of SR: Implementation by Caregivers and Therapists
Most of this research involved persons living at home, the intervention being implemented by researchers. Some of the studies were conducted in home settings. Some were conducted in adult day care centers attended by persons with dementia.
McKitrick & Camp, 1993)
extended this line of research by having family caregivers implement the training, similar to the approach taken by
. Other researchers likewise trained caregivers to implement SR as an intervention for persons with dementia, (
also reported a case study in which a man in the initial stages of dementia was able to train himself to remember new information by utilizing SR.
Brush and Camp (1998
reported the use of SR by speech-language pathologists to reach clinical goals in persons with dementia, most of whom were living in a long-term care facility.
reported the use of SR within the context of a music
In these contexts, timing of recall intervals was not controlled by computer. For example, caregivers in McKitrick's studies used a hand-held digital timer and a nonelectrical tracking device to track and determine recall intervals (see McKitrick, 1993 , for a detailed description of apparatus and procedures). In the case of speech-language pathologists, recall trials occurred during breaks between therapeutic activities conducted during speech therapy sessions ( Brush & Camp, 1998 , in press ). Though this approach creates less precision than would be the case using more lab-based experimental procedures, SR appears to produce robust effects when applied in these real-world contexts. Furthermore, SR can be implemented by therapists while conducting billable procedures. Thus, it is more likely to be implemented on a large scale than if training effects were attainable only under more tightly controlled conditions, and/or only when applied by researchers.
Further Clinical Applications: Bird's Research
SR also has been implemented as a clinical intervention by Bird and his associates. His research using SR evolved from a more lab-based research paradigm, though it has taken a relatively direct route to using SR in clinical applications. As already noted, the work of Camp and
The basic model is presented in
. The theoretical and experimental rationale that suggested such an operation might be possible drew
There were three findings of particular relevance in the literature. First, there is evidence that there are severe deficits at both acquisition and retrieval, at least in AD and
Figure 12.2. Example from one experiment of the sequence of supplementary cues provided at each trial where failure occurred. Sequence worked through until the participant was successful.
From these findings, it was assumed that behavioral responses would be easier to learn than verbal material for older adults with dementia. In addition, so long as sufficient assistance was provided at acquisition and retrieval, these persons might be able to retain the information over periods long enough for such retention to be clinically relevant. However, the key to this type of intervention would be the cue, as a retrieval aid in itself, and also to ensure that retrieval occurred at the required time and/or place.
University students (
Intons-Peterson & Fourner, 1986
) as well as cognitively intact elderly persons (
Dobbs & Rule, 1987
Einstein & McDaniel, 1990
) use external cues extensively to prompt retrievals in ecologically relevant situations such as
Acquisition Assistance and Use of Cues
The use of environmental cues has long been advocated in care for persons with dementia (e.g., painting
A number of methods are known to assist acquisition of material in dementia, most commonly by inducing active processing. Two examples are requiring participants to decide about the taxonomic category of the item (e.g., Bird & Luszcz, 1991 ; Tuokko & Crockett, 1989 ) and about where it might be found ( Martin, Brouwers, Cox, & Fedio, 1985 ). For the work under discussion, SR effect was used as the primary acquisition aid, for four reasons.
First, a preliminary study (
) showed that a single retrieval trial was as effective as presenting the material in a way that
Two main experiments reported in
Bird and Kinsella (1996)
were part of a series where retrieval was used to teach cue/task associations to samples with either probable AD and/or vascular dementia. Trivial experimental tasks were used, for example,
Figure 12.3. Number of cues required by a
The acquisition technique was an adaptation of SR; it was combined with the method of fading cues. Initial presentations were quite similar to the process described earlier in this chapter, with the first trial occurring immediately after first presentation of the material, for example:
(Short pause). So what will this beeper remind you to do?
Participants had their first delaeyed trial after 30 seconds. If failure occurred, they were given a series of extra cues, each successievely providing more information, until they successfully retrieved the task. The provision of supplementary cues where required also applied at all subsequent trials.
In the SR procedure described earlier in the chapter, the intertrial intervals are tailored to the subject's individual learning rate to ensure that successful retrieval will take place on most trials. If failure occurs, the intervals are reduced. For the experiments currently under discussion, it was the level of cued support that was tailored to individual needs. This method permitted standardization of intervals, which were
It also provided the outcome measure, tested 1 day after learning. That is, the dependent variable was not the number of items recalled from a list (the predominant experimental learning paradigm for more than a century), but the number of cues required to retrieve a single item. Single-task learning merits much more attention with this severely impaired population; it is more relevant to the clinical situation, where highly specific problems have to be addressed one at a time. Combining SR with fading cues also has the potential to significantly reduce the number of learning trials required for effective learning, because it increases the
At this stage, however, it is not known whether SR alone or the combined method has any other advantage, for example, in consolidation of the memory trace. In the clinical situation, there is the flexibility to use both, though the number of learning trials
A substantial proportion of participants with mild to moderate dementia could be trained, by SR, to associate a cue with a behavioral task so that the cue had specific recallable meaning after a delay of 1 day ”a retention interval that indicates these findings can have clinical utility.
Participants who could recall the task after a delay of 1 hour were usually able to recall it 1 day later. Capacity to remember after a 15-minute delay was a less reliable marker.
Confirming anecdotal clinical accounts (e.g., McEvoy & Patterson, 1986 ) and experimental work in dementia by B ckman and associates (for review, see B ckman, 1992 ), there was a mnemonic effect of actually performing a task on each trial, as opposed to observing it. It was equivalent to SR effects. That is, motor performance alone, in
Motor performance combined with retrieval on each trial added nothing to the ability to verbally recall the task when tested after 1 day. However, actually performing a task made it much more likely that participants, having verbally recalled the task, would then spontaneously perform the task ”again a minimum requirement for clinical utility.
Research on the Basis of the SR Effect
One issue that has received scant attention in prior research concerns the potential mechanisms underlying the
Accounts of Factors Underlying Spacing Effects in Normal Populations
gave two accounts of the general spacing effect based on research primarily conducted with normal young adults. The first he called
The second general account Greene (1992) gave for the spacing effect he called encoding-variability theories :
Greene noted that encoding variability would best account for spacing effects found in free recall tasks, since factors facilitating retrieval such as encoding variability should have large effects in free recall. He also speculated, however, that spacing effects found in recognition tasks might best be accounted for by processing-deficit hypotheses, where access to memory traces is facilitated more than recall, and thus, the informativeness of traces is a critical component for successful recognition. Greene concluded that a dual-processing approach best explains the spacing effect, and that the underlying cause of the spacing effect seems to be
Attempts to Determine the Locus of SR Effects in Persons with Dementia
Repetition alone does not seem to satisfactorily account for the success of SR in inducing new learning. In a study with patients diagnosed with AD, alcholomastic
, working with a sample of persons with AD, compared effects of a form of SR with a condition he labeled baseline recall. This baseline recall condition was used to control for repetition effects and was similar to SR procedures (in this case, asking participants to name an object in a picture) except that participants were not required to retrieve information from memory, since the required information was kept visible at all times. Bird's results indicated that it is
Accessing an Implicit Memory System as an Explanation for SR Effects
The efficacy of SR for cognitively impaired older adults has been attributed to implicit memory processes that are thought to be spared until the later stages of AD (see
Camp et al., 1993
Camp & McKitrick, 1992
Camp et al., 1996a
). Implicit memory is inferred when task performance is facilitated by previous exposure to test materials, without awareness of prior learning
Much of the evidence behind the assumption that SR
It was also reasoned that SR could be a form of errorless learning, in which persons with memory impairment acquire new information if they are not allowed to make errors at initial presentation and on subsequent training trials (
Wilson, Baddeley, Evans, & Shiel, 1994
). Errorless learning is assumed to access implicit memory and is effective for rehabilitation because external controls prevent errors and thus allow error-free learning to take place (
Wilson et al., 1994
). Without such controls, persons with explicit memory disorders cannot generally self-correct (i.e., they do not have conscious access to previous learning episodes) and thus may experience
Camp et al. (1996b)
report anecdotal evidence of source amnesia in persons with dementia regarding use of an external memory aid (an appointment calendar). Participants would forget who had trained them or where the calendars had come from but could still remember and use the strategy of looking at the calendar to remember important information. Source amnesia is an indication of impaired explicit memory function. When seen in combination with successful SR training, an
conducted an initial attempt to gather more direct evidence on the underlying basis for the effects produced by SR in persons with dementia. In her study, older adults with probable AD were trained to learn new face-name associations. The interval between retrieval trials was filled with a second activity that varied in the amount of cognitive effort required to do that activity (the Trail Making Task, Forms A and B). In Foss's study, recall intervals were fixed at 60 seconds, and eight trials were given to each participant for each face-name pair, to ensure that all participants would be expending comparable amounts of effort over comparable time periods between recall trials. Foss found that all older adults in her study were able to
Foss assumed that if efforts to manipulate cognitive effort on a task completed between recall trials had no effect on recall performance, then face-name learning could be taking place effortlessly and unconsciously between recall trials. Her findings were interpreted as evidence that implicit memory might be accessed via SR to enable new learning to take place in persons with dementia. This conclusion was reached based on the assumption made by Camp and his colleagues, among others (e.g., Schacter, Rich, & Stampp, 1985 )
noted that other studies using normal participants found that long-term retention is actually improved when a difficulty task is placed between repetitions of information to be remembered (
Bjork & Allen, 1970
). This finding suggests that, at least in normal adults, recall can be influenced during SR training by manipulation of cognitive effort. There was a similar trend is Foss's data regarding better recall performance when the interpolated task required the highest cognitive effort, though small sample
It is interesting to note that Cermak, Verfaellie, Lanzon, Mather, and Chase (1996) found that amnesties could benefit from spaced repetition in a recall task, and that spacing effects found in amnesties were similar in magnitude to those found in normal controls. They speculated that in recall tasks, spacing effects found in amnesties are the result of automatic activation of associates of studied words.
While the work of
Cermak et al. (1996)
might militate against an explanation of SR being based on active rehearsal of items, at least in persons with dementia, other variations of Greene's deficient-processing account might still apply. For example,
Cherry, Simmons, and Camp (in press)
reported preliminary evidence consistent with the notion that implicit memory
To demonstrate implicit retention of the target items trained via SR,
Cherry et al. (in press)
As expected, SR training enhanced retention of the target items for all participants both within and across sessions. These findings provide further evidence of the mnemonic benefit of SR and the maintenance of SR effects over time. Importantly, each participant showed a repetition priming effect for the target item in at least one of the three training sessions, an outcome providing modest evidence of the contribution of implicit memory to SR. A limitation of this study was that one target item was never named in the posttest, while another item was named in the pretest by two of the four participants, so that repetition-priming effects for that item could not be interpreted unequivocally for those participants. Consequently, the two
Cherry and her associates have since conducted a second study to examine the reliability and generality of their earlier findings. They tested four persons with probable AD (ages 96, 84, 82, and 83 years) who were enrolled in the local adult day care program. The materials and general procedures were the same as those used in Cherry et al. (in press) , except that two target items were replaced with new objects to increase the sensitivity of the category exemplar generation task as a measure of implicit retention. They also added a two-letter word-stem completion task as a second measure of implicit retention of the trained objects. The word-stem completion task was administered immediately after the category exemplar generation posttest in each training session.
Table 12.1 Longest Retention Interval Achieved, in Minutes, by Participants Across Training Sessions
One participant named the target item jacket, two participants named the item bracelet, and one participant named the item carrot after SR training in Sessions 1 “3, respectively. These repetition-priming effects can be interpreted unequivocally as evidence of implicit retention, insofar as none of these items were named as exemplars of their respective taxonomic categories in the pretest. Interestingly, repetition-priming effects were not found in the word-stem completion task. In addition, these same participants showed extreme deficits in external memory functioning, as expected. Future research could be directed toward developing other methods of assessing implicit retention in persons with probable AD.
Accessing the Explicit Memory System as an Explanation for SR Effects
Bird and Kinsella (1996) directly addressed the issue of effortful versus automatic processing underlying SR for persons with dementia. They concluded that while some SR trials seemed to elicit automatic processing, their participants also seemed to consciously attempt retrieval with SR tasks on other occasions. In addition, they noted that memory for the target information could at least fleetingly be made consciously available at recall. As a result, they speculated that expenditure of conscious effort may take place in SR, and that repeated practice in recalling stimuli could make retrieval eventually automatic. The implication of this line of argument is that SR is engaging an explicit memory system and requires expenditure of cognitive effort in order to succeed.
further investigated the possible locus of the SR effect. She conducted a study comparing effects of SR and three other conditions (spaced reminding, massed retrieval, and massed reminding) on face-name recall in older adults with dementia. In her study, SR produced
In addition, Foley wished to determine whether the locus of SR effects might be due to the amount of effort expended when persons with dementia attempt recall. She used an SR training task involving cued recall, rather than free recall. In addition, she
Replicating the results of
Camp et al. (1996b)
, Foley found that SR performance is not related to other measures of explicit memory. While the number of retrieval cues needed to elicit correct recall was smaller for persons in the SR condition than in the other conditions, as described earlier, an average of at least three cues was needed to elicit correct recall. In addition, as in the findings of
Bird and Kinsella (1996)
, some individuals in the SR condition needed substantial amounts of time to correctly recall information at the longest time interval, but others required little time. Foley, like Greene, concluded that it seems
The Problem of Defining Implicit and Explicit Memory: Task Versus Memory System
A problematic feature in discussing the nature of SR effects is that the terms
are sometimes used to describe both experimental tasks (e.g., defining recognition memory as an implicit memory task and recall as an explicit memory task, as was done by
Cermak et al., 1996
) as well as memory systems and processes (e.g., an implicit memory system or an explicit memory system, as was done by
). If a recall task such as successful recall of newly learned information is accomplished by an individual with dementia, researchers are faced with a dilemma. To claim that recall is an explicit memory task, one is faced with the need to describe a form of explicit memory that is not devastated by dementia. Since conscious/effortful process is damaged in dementia, one must decide that there are automatic/effortless/unconscious aspects of explicit memory tasks. Thus, one is faced with using the classification system shown in
to describe memory research
For example, Ostergaard, Heindel, and Paulsen (1995) found that they could induce biasing effects in a recognition task for ambiguous figures in persons with AD by labeling figures at encoding. (In contrast to Cermak et al., 1996 , these researchers categorized their recognition task as an explicit memory task, exemplifying further complexities of the classification problem in this type of research.) This biasing was
Figure 12.4. Classification system to describe memory research outcomes.
In this model, recall training using SR might be
A Case Study
Mrs. D was an 83-year-old woman with vascular dementia. Her MMSE score was 19. She had been admitted a few weeks previously to a hostel following failure to self-care at home and was referred for
Hypotheses about how Mrs. D saw the world are an essential requirement of assessment with problems of this
The intervention involved, first, a session with Mrs. D and the family member who had assisted in disposal of her personal effects, using multiple situational cues to assist her to recall these events. A list was produced in large print, with a prominent, colored Smiley face in the corner, and posted in her wardrobe (she
Thus, after the notice was posted with some ceremony (to make the posting more memorable), learning was initiated with questions such as What will help you remember what happened to your things? How do you find out who you gave your sewing machine
If failure occurred on any trial, Mrs. D was given graded cues as required, for example, Isn't there a notice somewhere that will tell you? Isn't there a notice somewhere with a smiley face? Isn't there a notice somewhere that looks like this? (blank notice with smiley face presented). On each trial after the first closely spaced few, she was encouraged to actually go and look at the notice.
Staff were subsequently trained to use graded cues to help Mrs. D remember to use the notice. Demands had dropped from a mean of 35 “40 demands daily to 5 after I week, and they soon ceased entirely. Mrs. Ds' mistake had been corrected by her being given access to information she could not retrieve for herself. At 5-month follow-up, there were still no problems. Though there were other factors in this case, the memory intervention
Comments and Caveats
First, a particular feature of this and many similar cases is that the change in behavior was maintained. This is consistent with the mnemonic effects of SR. Each naturalistic encounter with the cue in which its meaning is retrieved becomes a fresh spaced-learning trial, which may maintain the association.
Second, it should be noted that the cue was an anxious thought, not a
Third, this intervention was multifaceted, both clinically and theoretically. Equally important clinical facets of this case were building up rapport and trust with a very suspicious and
Theoretically, the active
Finally and more generally, SR is not a panacea for behavior problems in dementia. In many cases, as here, it will form only part of the intervention, which may require many therapeutic modalities. In yet other cases, it will be inappropriate or ineffective, or the patient will not cooperate. As discussed elsewhere in this volume, the idiosyncratic and multifaceted nature of each case profile requires detailed assessment and careful selection of the most appropriate techniques. Training in cued recall of adaptive behavior as described here is simply something that, like all other techniques (including sensitive use of medication), will assist some persons with dementia in some situations some of the time.
The use of SR as an intervention for dementia is still relatively new, though it is hoped that readers of this chapter will see that there is considerable cause for
Clinical Application Issues in SR
Camp (1989) listed a number of clinical application issues in SR that needed (and still need) to be addressed. One issue is the amount of information that can be trained and retained by use of SR. To date, most research has focused on a single target or, at most, up to three targets ( Brush & Camp, 1998 , in press ; McKitrick et al., 1992 ). SR has the potential to train a large number of items of information, but we simply don't know the limits (such as potential interference effects) that dementia will place on this potential. For example, though McKitrick et al. (1992) reported little problem with interference effects in their study, this topic has yet to be adequately explored.
In related areas, we don't understand the
Theoretical Explanations of the Locus of SR Effects
The attempt to determine the theoretical locus of SR effects has been hampered by a variety of problems. Is it best to assume that SR accesses one and only one type of memory in free recall and/or cued recall and/or recognition tests? Is it possible for a
An ultimate resolution to this discussion may await the use of on-line measures of brain functioning such as PET used in conjunction with SR training to determine which areas of the brain are being activated in SR. If memory systems' functions show anatomical correlates with areas of brain activation, the basis for SR's success across a variety of experimental contexts (e.g., recall, cued recall, recognition) may be addressed more directly through brain imaging.
Of course, much of the research in this area has taken the approach that an implicit-explicit memory dichotomy is the appropriate perspective from which to view SR training in particular and memory functioning in general. The utility of such a
Evidence amassed from a large number of studies that were conducted over the past 25 years disputes claims that implicit and explicit memory follow different developmental lines and challenges the utility of conscious recollection as the defining characteristic of explicit memory. It seems unlikely that any simple dichotomy could adequately characterize a process as complex as memory, even during the infancy period, (pp. 467 “468)
Adults with dementia usually learn new associations when trained with SR. Some learn associations quickly, with few errors, while others learn more slowly, and it appears possible that some individuals may not learn at all. Some individuals with dementia seem to expend cognitive effort when attempting to recall information trained with SR, and others don't, and the amount of cognitive effort expended by an individual may change over time. Some retain new information learned via SR over long periods, and in others, the memory seems to fade more quickly. Why such diversity of SR effects occurs has both clinical and theoretical significance. Current theoretical formulations have proven unsatisfactory in providing a general explanation for the locus of SR effects, much less in addressing the issues of variability in SR training outcomes just described. Perhaps the studies conducted thus far have not been adequate in their efforts to design critical tests of theory. More likely, in our opinion, current theory is inadequate to deal with outcomes generated by SR training
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