3 - Cognitive Skill Acquisition, Maintenance, and Transfer in the Elderly

Editors: Backman, Lars; Hill, Robert D.; Neely, Anna Stigsdotter

Title: Cognitive Rehabilitation in Old Age, 1st Edition

> Table of Contents > Part II - Cognitive Rehabilitation Strategies in Normal Aging > 5 - Innovative Approaches to Memory Training for Older Adults

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Innovative Approaches to Memory Training for Older Adults

Robin L. West

Duana C. Welch

Monica S. Yassuda

Memory training programs designed to enhance the memory abilities of older adults have been part of the experimental aging literature for decades. The earliest known publication involved the training of mediational strategies for paired-associate learning (Hulicka & Grossman, 1967). Probably long before that, individual clinicians or nurses were offering information about memory to their patients and clients. The purpose of this chapter is not to review the training programs that have been tested over the last three decades, but to focus on recent innovations in the programming of memory interventions for older adults. For the most part, these innovations have been tried but not yet proven, having been applied only in a handful of studies. Our purpose here is to spark the interest of scholars of the aging process, encouraging the pursuit of new directions in cognitive rehabilitation for older adults.

To provide background, we begin with a descriptive overview of previous intervention research, briefly outlining the successes and limitations of that work. We then consider three more recent innovations: (a) videotape training, (b) efficacy-based training, and (c) nondidactic, group study. For each of these, the focus is not on past training data but on future possibilities: What are the characteristic features of this methodology? What empirical evidence suggests that this new approach might have value for older adults? How could this methodology serve to minimize the memory deficits associated with normal aging and/or enhance the impact of training?

What Has Been Learned From Traditional Approaches

Traditional memory intervention programs for older adults have largely consisted of two types: (a) instant strategy training brief training, specific to the recall task

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(e.g., Hulicka & Grossman, 1967), and (b) extended training involving several sessions and/or several strategies with the full-length intervention lasting from 4 to 15 hours (e.g., Zarit, Cole, & Guider, 1981). The traditional approaches can be characterized by the fact that they were didactic the experimenter told the trainees what to do and how to do it and their primary purpose was to teach a strategy (e.g., Treat, Poon, & Fozard, 1981).

These seminal studies provided a solid knowledge base for future cognitive rehabilitation research. We now know that memory strategies, even very complex techniques, can be learned by older adults; that training can lead to improvements that sometimes last for months; and that training tends to be task-specific, with little or no transfer to tasks that were not incorporated in the training regimen. A recent meta-analysis established that training effects are significant when examined across a wide range of studies (Verhaeghen, Marcoen, & Goossens, 1992). Four factors were associated with enhanced training effectiveness: pretraining, group sessions, shorter sessions, and younger participants (Verhaeghen et al., 1992).

At the same time, previous research had limitations, suggesting that new directions might be productive. One limitation of earlier work was that the mechanisms controlling the observed memory improvements were not well understood. Theory took a back seat to empirical issues, and potential mechanisms were not sufficiently explored (Kotler-Cope & Camp, 1990; West & Tomer, 1989; Yesavage, Lapp, & Sheikh, 1989). When improvements occurred after strategy training, it was assumed that the change was due to the learned strategy, even when strategy usage was not assessed (and it rarely has been assessed). But it could be that particular unplanned effects explained or contributed to the impact of training, and these have been studied only rarely (McEvoy, 1992). In a recent training study, Verhaeghen and Marcoen (1996) found that older adults were often noncompliant, not using the imaginal strategy they had learned, especially those older adults who had an effective nonimaginal strategy in their pretest repertoire. Thus, compliance may be an important, unstudied predictor of outcome. Other unplanned or nonstrategic effects could include increased attention or concentration, practice effects (e.g., faster processing, increased familiarity with task requirements), more knowledge about how memory works, reduced depression and improved mood, less anxiety or more confidence during memory testing, enhanced motivation or changed beliefs about one's potential as a memorizer, and superior executive functioning (e.g., better distribution of attention within working memory, improved monitoring and/or self-testing during encoding). Another possible explanation for performance change might be qualitative improvements in the use of association and/or imagery strategies that were already employed before training. Furthermore, trainees could have developed their own idiosyncratic methods of memorizing, unrelated to the trained strategy. Several investigators have begun looking at individual difference factors related to training outcome (e.g., Kliegl, Smith, & Baltes, 1989; Verhaeghen & Marcoen, 1996; Yesavage, Sheikh, Tanke, & Hill, 1988), but relatively few studies have directly addressed the issue of mechanisms: Measurement of pre-post changes in anxiety, mental speed and/or working memory, confidence, memory beliefs, strategy usage, and practice effects (for a nontrained group), in relation to performance outcome, would go a long way toward answering these important questions about mechanisms.

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For instance, in order to make the argument that strategies are the mechanism for change, we must be able to demonstrate directly (a) that the trained strategies were used by trainees at posttest, (b) that the training effects did not simply reflect nonspecific practice effects, and (c) that improvements in performance were related to changes in strategy usage. To accomplish goal (b), a practice-only control group must be included in the investigation. To accomplish goal (a), strategy use must be measured, and for goal (c), measured strategy usage must be related to performance at posttest. Most studies in the adult memory-training literature rely exclusively upon improvements in memory to ascertain training effectiveness, without separate measures of strategy use. The exceptions are seven studies that incorporated independent assessment of strategy self-report (e.g., Anschutz, Camp, Markley, & Kramer, 1987; Rankin, Karol, & Tuten, 1984; Rebok & Balcerak, 1989; Verhaeghen & Marcoen, 1996; Wood & Pratt, 1987), overt rehearsal behavior (Murphy, Schmitt, Caruso, & Sanders, 1987; Sanders, Murphy, Schmitt, & Walsh, 1980; Schmitt, Murphy, & Sanders, 1981), or clustering (ARC scores; e.g., Rankin et al., 1984; Sanders et al., 1980; Schmitt et al., 1981). The best of the studies assessing strategy usage was an investigation by Verhaeghen and Marcoen (1996). They provided evidence that preexisting abilities (mental speed, associative memory) were strong predictors of training-related gain, as were posttest strategy behaviors (the number of list rehearsals during test, for both old and young, and correct strategy usage for the young). Correct method-of-loci application was associated to some extent with better performance for older trainees. These data were suggestive about strategy use as a mechanism, but most of the assessments were different at pretest and posttest so it was not possible, in most cases, to see if pre-to-post change in any particular variable predicted gain (Verhaeghen & Marcoen, 1996). Prior investigations can begin to answer questions about strategy utilization as a mechanism for change, but the results were mixed, and none demonstrated directly that pre-post changes in strategy usage predicted pre-post performance changes.

Another limitation of previous work is the lack of evidence concerning strategy maintenance. Tests for strategy maintenance are far less common than tests for maintenance of performance, and often, studies include neither measure. Maintenance of both types must be established if one is to argue for strategic change as the mechanism for improvement. Some studies have demonstrated that memory improvement can be maintained for 1 week to 6 months (see Flynn & Storandt, 1990; Scogin, Storandt, & Lott, 1985; Sheikh, Hill, & Yesavage, 1986; Stigsdotter & B ckman, 1989, Stigsdotter Neely & B ckman, 1993a; West & Crook, 1992) or even years (Stigsdotter Neely & B ckman, 1993b), but the factors explaining successful maintenance are still unclear. Interestingly, the few studies that have directly examined maintenance of strategy use have failed to find it (Anschutz et al., 1987; Schmitt et al., 1981; Wood & Pratt, 1987). Because neither theory nor empirical work has clarified the mechanisms for change, factors that would promote maintenance are poorly understood. The primary motivation for new approaches would be to find an intervention methodology that leads to long-lasting and not just short-term change, so that older adults' deficits can be reduced or eliminated, and so that the mechanisms driving both memory change and maintenance of improved abilities can be understood.

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Video-Based Memory Training

The memory limitations of older adults have been studied extensively. Although researchers disagree about the mechanisms that control age differences in memory, the perspectives that have gained widespread acceptance are those that emphasize the working-memory limitations of older adults, their slower processing time, and the fact that older adults require more support for learning (Craik, 1986). Several features of videotaped learning programs may make it possible for older adults to overcome their memory limitations: enhanced support for learning, opportunities for self-paced training and review, and dynamic multimedia representations of strategies. Although videotape has rarely been studied with older adult groups, these benefits are apparent in research with young adults and children.

Rationale for This Innovation

The primary rationale for videotaped instruction is that it is highly effective often more effective than traditional teaching programs. At one level, videotape can teach people how to use a simple piece of equipment (Le Grice & Blampied, 1994). At a more complex level, a videotape can train therapists, law enforcement personnel, or volunteers to respond appropriately to particular types of crises, through modeling and role playing, without endangering people by placing them in a crisis situation (Holaday & Smith, 1995; Seabury, 1993; Seymour, Stahl, Levine, & Ingram, 1994). Empirical work related to social learning theory has established the advantages of models over traditional didactic learning (Bandura, 1997). Videotape makes it possible for standardized models to be presented at minimum expense. Past uses of videotape for this purpose included teaching students specific therapy techniques (Follette & Callaghan, 1995), teaching disabled or handicapped patients new ways of moving or standing (Dowrick & Raeburn, 1995; Tiong, Blampied, & Le Grice, 1992), and teaching families how to improve social interactions and/or caregiving (Neef, Trachtenberg, Loeb, & Sterner, 1991; Weiner, Kuppermintz, & Guttmann, 1994). In several experimental studies, the video or multimedia approach to training clinicians was much more effective than standard teaching (e.g., Bashman & Treadwell, 1995; Juhnke, 1994).

One of the primary benefits of video is that it takes advantage of the improved learning associated with combined visual and verbal instruction (Banyan & Stein, 1990; Gehring & Toglia, 1988; Slotnick, 1990). Educational psychologists have argued that pictures make text more interesting and motivate learners. More important, visual images may enhance memory. Even at the simplest level (provision of an illustration), reviews of the literature have shown that the combination of visual and verbal information aided retention relative to the case where only text was given (Mayer, 1989). This finding is called the picture facilitation effect (Rusted & Hodgson, 1985). The most common theoretical explanation for this effect, Paivio's dual-code theory (1986), emphasizes that the memory system is structured to encode information in combined visual plus verbal modes, whether or not the material is presented in both modalities. When the information provided uses both modalities in the first place, it supports this memory system.

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Of course, it is possible to provide visual support for memory rehabilitation classes without using video, but past research has demonstrated that animated pictures are better than static graphics. This topic has been investigated for decades, but only research since the late 1980s will be considered here. Christel (1994) showed that illustrations using motion video were better than static slides for remembering college course material. When study time was controlled, Rieber (1990, 1991) showed that students learned more from animated lessons than from lessons using static pictures. Rieber (1991) also showed that children's intentional learning and incidental learning are both higher when verbal text is combined with animation as opposed to static pictures providing essentially the same information. Rieber suggested that animated sequences should be cued with a voice-over that directs attention to the central features because new learners cannot always identify the critical features on their own (Rieber, 1991). Animation worked better for some students than for others and was particularly beneficial for those with learning difficulties or those who benefited from visual information (Ayersman & von Minden, 1995). Low-ability verbalizers and visualizers unable to translate material from visual to verbal or vice versa benefited especially from both forms being available in a lesson (Riding, Buckle, Thompson, & Hagger, 1989). Although this work was not conducted specifically with older adults, one would expect that older adults would show the same benefits as others with learning deficits, particularly because of some difficulties that older adults may have with generating mental pictures on their own (West, Yassuda, & Welch, 1997).

The strongest case for the learning value of video per se was made by the work of Mayer and colleagues (e.g., Mayer & Anderson, 1992). Mayer's work was designed to test the contiguity principle derived from Paivio's dual-coding theory. The contiguity principle argues that learning is best when words and pictures are presented contiguously because simultaneous access to words and pictures enhances the conceptual connections between visual and verbal representations in memory, without taxing working memory (Mayer & Anderson, 1992). In testing this principle, Mayer compared the retention and problem solving of college students after their exposure to simple lessons concerning the internal workings of brakes and air pumps. These lessons were presented under various conditions: successive sections of animation and narration, concurrent animation and narration (the typical videotape format), animation alone, narration alone, and no instruction. Although retention of the basic facts did not differ among formats, application skills did vary. Students given concurrent presentation were better able to identify creative solutions to problems involving brakes and air pumps, suggesting that the highest level of information was gained from the video format. If, in fact, simultaneous presentation of animation and narration enhances learning, without taxing working memory, this would represent an important methodology for older adults who have working-memory limitations (Salthouse, 1990). To our knowledge, there is only one published report demonstrating that older adults learn better with video: Gist, Schwoerer, and Rosen (1989) taught older adults how to use computers by presenting a videotaped middle-aged model and found this approach to surpass text-based instruction.

One potentially important benefit of videotaped training for older adults is that video provides learner control over pacing and total study time. Rieber (1991) emphasized the importance of reviewing videos repeatedly, to reinforce learning. His experimental work (Rieber, 1991) demonstrated the benefits of a feature that has been highly

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touted in educational circles for older adults (see Sinnott, 1994): student control over presentation. Videotape provides that control. It affords the possibility of stopping, reviewing a concept, pausing to let an idea sink in, and so forth. Individualized pacing can be especially beneficial for older adults because of the high variability in learning speed (Kausler, 1991).

Newer technologies involving videodisk or interactive computer-based training offer many more options for control over learning, make selective review simpler, and provide individualized feedback on progress. In contrast to video, individuals can sit down at an interactive program and select a particular section to review without having to first view the entire program. The interactive format of the videodisk thus provides more viewer control over content and sequencing. It is important to note, however, that the use of these advanced features may depend on the learning style and computer ability of the learner (e.g., Fitzgerald, 1995; Henry, 1995; Lee, Gillan, & Harrison, 1996), and the results are mixed with respect to the relative value of interactive approaches over noninteractive video (Carrol, Bain, & Houghton, 1994; Lee et al., 1996; Rubenstein, Cherry, & Small, 1993; Yoder, 1993). Videodisk studies with older adults showed that once comfortable with the technology, older adults were able to use the primary interactive features effectively (Baldi, Plude, & Schwartz, 1996; Plude & Schwartz, 1996).

Clearly, then, videotape has demonstrated learning advantages for other populations that could translate into effective learning for older adults as well. But more than that, it has particular advantages for strategy learning, especially imagery-based strategies, effective for recalling names, paired associates, and lists of concrete nouns (McDaniel & Pressley, 1987; Yuille, 1983). Although researchers have discovered many kinds of mnemonics and strategies, the majority of recommended techniques are based on mental imagery. Imaginal strategies such as the peg system, the keyword method, the link method, the method of loci, and the image-name match method focus learners on the semantic meaning of items, provide an interactive image link between items (Begg, 1983), and create a potential cueing system whereby one well-learned item, or a distinctive feature, can cue subsequent items in memory, through pictured connections in the mind. Experimental work also suggests that older adults can learn how to use imagery effectively to improve their memory scores (Yesavage et al., 1989).

What do the benefits of imagery have to do with video-based instruction? We would argue that video-based instruction is very valuable for teaching imagery. Mental imagery occurs inside the head. An instructor can stand before a group of trainees and role-play crisis intervention techniques; that is, the instructor can actually show them what to do. For mental imagery, role playing, while helpful, does not demonstrate the method directly. The instructor can describe an image, but an illustration of an effective mental image requires visual media. And although static two-dimensional pictures can be used as illustrations, the addition of animation should enhance the memorability of sample images, as noted earlier (Christel, 1994; Mayer & Anderson, 1992; Rieber, 1991). Furthermore, imagery is more effective when individuals utilize distinctive, elaborated, interactive mental pictures (see discussions of these issues in McDaniel & Pressley, 1987), and an animated presentation can show trainees how to make images more active and interactive. Interestingly, in a recent study in our laboratory, older adults reported substantial increases in utilization of imagery across trials

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when the testing materials were realistic video representations of people (for a name recall task), even when there were no instructions to utilize imagery of any kind (see West et al., 1997). It is possible that the animated video had a dynamic, realistic quality that may have encouraged the application of imagery.

Finally, videotapes can be seen at home, at relatively low cost. Cost is minimized because no instructor need be present. Videotaping permits homebound and rural older adults to obtain memory training that might not be accessible in other formats. Cost also stays low for older adults who already own VCRs. Approximately three fourths of older adults in the United States have VCRs in their home, whereas many fewer have access to the computer equipment needed for using high-technology interactive programs (Baldi et al., 1996).

Application for Cognitive Rehabilitation

What should one include in a videotaped memory program? First, extant research will be reviewed, followed by a more general list of recommendations. West and Crook (1992) created a 40-minute videotaped training program that described the general benefits of imagery, followed by detailed instruction on the use of imagery to remember names (image-name match method), lists (link method), and object locations (interactive imagery). Vivid animated examples of interactive imagery were provided as the narrator emphasized the importance of images that were active and distinctive, incorporating input from multiple senses. The trained subjects spent one week watching the video at least twice, and they were told to pause the video repeatedly and practice the trained techniques during viewing. The results indicated significant increases on all three target tasks over and above those of a control group, with 1-week maintenance of these gains. More significantly, there was some evidence for generalization to related tasks (such as face recognition), which is rarely shown in the training literature. Generalization may have occurred because the videotaped program enhanced overall learning and made generalization easier, or because the training itself emphasized generalization by illustrating how one basic technique could be applied to several tasks, or because the assessments also used a video format, which may have been a constant reminder to trainees of what they had learned.

Videodisk training, allowing for more interactive learning from a CD-ROM, was employed by Plude and his colleagues (Baldi et al., 1996; Plude & Schwartz, 1996). Their compact-disk interactive (CD-i) program presented the image-name match method for recalling names, as well as the SALT technique, which is based on frequent repetition of a name after hearing it (Plude & Schwartz, 1996). CD-i demonstrated training gains relative to a no-treatment control (Plude & Schwartz, 1996). CD-i has also been compared with a video-based training program similar to the one described above (Baldi et al., 1996). CD-i trainees showed significant gains after a pretest and one training session, but video and control participants did not. After a pretest and a posttest, the control subjects were trained and assessed again and showed gains with both video and CD-i training (Baldi et al., 1996). CD-i trainees maintained their gains on the last assessment, nearly a week after training. Trainees' memory for the strategy was better for CD-i participants than for video participants. These results suggest that the more interactive approach had greater effectiveness for older adults. Plude and his colleagues readily admitted, however, that CD-i technologies are not as

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accessible to older adults as VCRs, in terms of both equipment availability and personal attitudes (Baldi et al., 1996).

How should researchers proceed? Videotaped instruction could show older adults how to create memorable images, and they could learn in a self-paced fashion and review their training regularly. The two studies above showed that older adults improved performance after video-based or CD-i instruction but did not test potential mechanisms for change or long-term maintenance, and neither demonstrated that this particular approach was more effective than traditional instruction. The extant research with children and younger adults, reviewed above, has established the advantages of video-based presentation over traditional lecture presentations, but this research needs to be replicated with older populations. That critical research for older adults remains to be done. Future work with videotaped training needs to extend the maintenance interval to examine strategy usage and performance several weeks or months after training. In addition, as work proceeds, our conceptual understanding of the benefits of video needs to be complemented with more empirical explorations of potential strategic and nonstrategic mechanisms for change.

Researchers interested in videotape for future studies might benefit from guidelines. These recommendations are derived from several reviews of the older-adult-training literature (Dunlosky & Hertzog, 1998; Hertzog, 1992; Kotler-Cope & Camp, 1990; West, 1995; West & Tomer, 1989; Yesavage et al., 1989) as well as more recent research. For older adults, the videotaped information needs to be clear, involving step-by-step instructions for strategies. It is also important to provide evidence for the effectiveness of the techniques for older age groups. To enhance the overall impact of the program, several features of the more effective long-term training programs ought to be included: multiple strategies for the same task (emphasizing that individuals can select the one that will be most effective personally) or multiple tasks for the same strategy (showing the usefulness of the strategy, in general, and encouraging maintenance and generalization). In addition, trainees should be encouraged to work with the materials repeatedly, to master the strategies, and to monitor recall readiness and strategy effectiveness. As we discuss later in this chapter, presentation of memory and aging facts, to promote realistic, nonstereotyped views of one's potential, could be a beneficial component as well. Multifactorial approaches, including beliefs, attentional training, and/or relaxation techniques, are recommended (see Herrmann & Searleman, 1992; Stigsdotter & B ckman, 1989, Stigsdotter Neely & B ckman, 1993a).

Changing Memory Beliefs

A second area with high potential for success in memory rehabilitation programs is the area of memory beliefs. Many researchers recognize the importance of memory beliefs for understanding age-related memory deficits, but relatively few have carried this issue into the domain of memory intervention (see Lachman in this volume). If negative memory beliefs low self-efficacy, feeling a lack of control, problematic attributions have some influence on performance, then it follows that altering beliefs in a positive direction should enhance the long-term consequences of any memory intervention. Without intervening actively to change beliefs, a number of studies have

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measured self-reported memory to determine whether or not it varies as a function of training. Interestingly, those who have measured memory complaints or self-reported memory before and after interventions have seen a mixture of results, with memory scores improving without self-reported change in some cases (Hill, Sheikh, & Yesavage, 1988; Rebok & Balcerak, 1989; Scogin et al., 1985; Zarit, Cole, & Guider, 1981; Zarit, Gallagher, & Kramer, 1981). In other cases, self-reported memory showed improvement, whereas test scores showed mixed improvement or no change (Dittmann-Kohli, Lachman, Kliegl, & Baltes, 1991; Lachman & Dick, 1987; Lachman et al., 1992; Turner & Pinkston, 1993). In a recent meta-analysis, Floyd and Scogin (1997) examined the effectiveness of memory training on what they called subjective memory functioning. They examined 27 studies with older adults using a wide range of assessments of subjective memory functioning. In their meta-analysis, Floyd and Scogin concluded that the effect size for subjective memory measures is considerably lower than the effect size for objective memory measures (as reported by Verhaeghen et al., 1992). They suggested that subjective memory evaluations may be more difficult to change, and/or that the interventions developed to date are not sufficiently strong. Subjective memory was improved more when participants received mnemonic training combined with expectancy modification (an intervention targeting the development of more adaptive attitudes toward memory).

Rationale for This Innovation

Scholars in aging approach the issue of beliefs from a variety of different perspectives (Berry & West, 1994; Cavanaugh & Green, 1990; Erber, Prager, Williams, & Caiola, 1996; Lachman, this volume). In our laboratory, efforts have focused on raising self-efficacy as the central construct in the memory beliefs system. In fact, self-efficacy theory provides a theoretical rationale for beliefs-oriented training for older adults.

Self-efficacy is the domain-specific belief that one can successfully engage in a particular activity. Its importance is manifested in the finding that efficacy translates into action: Many studies have shown that increases in self-efficacy predict future attempts at coping during a difficult task or in a formerly threatening situation (Bandura, 1986, 1997), and that self-efficacy predicts future cognitive success (e.g., Seeman, McAvay, Merrill, Albert, & Rodin, 1996). The initial testing grounds for the theory were phobia interventions, using young adults as participants (e.g., Bandura, Adams, Hardy, & Howells, 1980; Biran & Wilson, 1981; Williams, Turner, & Peer, 1985). These studies and others have shown that self-efficacy predicts coping behavior. Participants with higher self-efficacy persisted longer and increased their effort in anxiety-provoking or difficult task situations (Bandura et al., 1980; Biran & Wilson, 1981; Williams et al., 1985). Self-efficacy has been increased through inactive mastery experiences experiences that allowed participants to see that they have mastered a feared activity (Bandura et al., 1980; Biran & Wilson, 1981; Gist et al., 1989; Williams et al., 1985; Williams & Zane, 1989). These inactive mastery experiences involved hands-on activities, not just discussions of thoughts or feelings. Mastery experiences were important for building the perception that action can lead to successful outcomes, so that the person has attributional ownership of successes (Bandura, 1986).

Although not yet widely applied to older adult populations, self-efficacy theory

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may be especially important for examining memory beliefs in older adults (Berry & West, 1994; Cavanaugh, 1996; Hultsch, Hertzog, Dixon, & Davidson, 1988; Welch & West, 1995). Real and imagined memory failures (one's own and those of age peers) associated with the aging process compounded by prevalent negative stereotypes about memory aging can lead older adults to believe that it is not worthwhile to expend the effort required to learn memory strategies. Older adults are less certain about their memory abilities than are younger adults (Berry, West, & Dennehy, 1989), and their lowered self-efficacy could translate into problematic behavior. For example, the inability to locate personal articles in one's home could create more anxiety in an older adult than in a younger adult, given the elder's worries about memory aging. The behavioral consequences of this anxiety might include avoidance of situations in which object locations must be recalled or a lack of perseverance during search. For instance, an older woman who frequently loses her hearing aids might experience lowered memory self-efficacy for object locations. She might subsequently terminate or fail to search for the hearing aids, despite their obvious importance to her independence and comfort. Thus, everyday functioning and independence may be impaired by a low sense of memory self-efficacy in older adults (Welch & West, 1995). Lachman (this volume) expands on these constructs and the interrelationship between different types of beliefs and memory performance.

Application for Cognitive Rehabilitation

At present, it is not known whether altering low self-evaluations and negative beliefs about memory can boost the effectiveness of memory training, although theories about efficacy and attributions suggest that it should. Previous studies that specifically attempted to provide an efficacy- or attribution-based intervention have yielded mixed findings. In our laboratory, for instance, self-efficacy showed significant positive change following memory training in two conditions, one that intended specifically to raise efficacy along with memory change, and a second that provided only strategy training (West, Bramblett, Welch, & Bellott, 1992). For the efficacy condition, the memory training included evaluation and rejection of memory-aging stereotypes, strategy training, and mastery experiences for recalling prose and grocery lists. Training emphasized the malleable nature of memory skills at any age and attempted to dispel the notion that memory is unchangeable and inevitably worsens with age. In the strategy condition, participants received strategy training and extensive practice in recalling prose and grocery lists. Both interventions led to increased self-efficacy after training and improved prose memory scores, but to no change in list recall. The improvements were maintained at a 1-month follow-up test. Interestingly, prose memory scores improved even more between posttest and follow-up, during a period when no training was given, a strong indication of maintenance of training.

Lachman and colleagues (1992) combined cognitive restructuring with memory training. The cognitive restructuring consisted of educating older adults about adaptive and maladaptive conceptions of memory. This study demonstrated pre-to-posttest increases in general memory control beliefs whether or not cognitive restructuring was a feature of training. However, Lachman et al. did find that the combined approach was the most effective in altering maladaptive conceptions of memory. Unfortunately,

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the combined approach did not lead to higher performance increases relative to the groups receiving cognitive restructuring or memory training only.

Best, Hamlett, and Davis (1992) compared memory training (MT) to an expectancy change condition (EC) in which popular negative stereotypes about aging were challenged, and they also included a no-treatment control and an art discussion group (to control for the more general benefits of group participation). A variety of measures of memory, memory beliefs, and affect were administered. Significant training effects occurred only for memory complaints and some memory tests; reduced complaints occurred for EC only, and higher scores on some tests occurred for MT only. This pattern makes sense, showing the targeted change in beliefs for EC and the targeted change in performance for MT. At the 2-week follow-up, there was strong evidence for maintenance: MT memory scores were higher on most tests, and MT and EC showed comparable levels of memory complaints (the MT complaints had decreased over the delay interval). Memory beliefs measures, however, were not correlated with performance, as hoped (Best et al., 1992; also see Zarit, Gallagher, & Kramer, 1981).

A Canadian study by Caprio-Prevette and Fry (1996) provided the strongest evidence, thus far, that changing beliefs are critical to memory change. These authors compared a cognitive restructuring approach with a memory-training approach and incorporated a variety of assessments of memory beliefs, performance, and affect (depression and anxiety). Their cognitive restructuring group (CRG) was based on cognitive behavioral principles and included the following activities: identifying and replacing irrational thoughts about memory problems with rational views, role playing of positive and negative perspectives on memory, emphasis on a learning-oriented approach (memory can be improved with effort and practice), and verbalizing of positive beliefs. A second group, identified as the traditional memory-training group (TMG), received training and skills practice for more than 10 memory techniques (this is, actually, not a traditional program because most traditional programs emphasize only 1 or 2 strategies). Significant posttest changes in memory and beliefs were apparent for CRG, and not for TMG, but there were no significant changes on the affective measures. Most CRG gains were maintained, and group differences were stronger at the 9-week follow-up assessment (Caprio-Prevette & Fry, 1996). The strength of these results may have been due to the extended time of the intervention (20 hours over 10 weeks) or to the relatively large study sample (approximately 60 per group). The authors' conclusions, like those of Best and colleagues (1992), emphasized the potential value of combining beliefs retraining with memory retraining, rather than keeping these two approaches separate.

While not definitive, this evidence is suggestive, supporting the potential value of beliefs-oriented interventions in late life. The theoretical framework and empirical results for cognitive interventions with other populations, such as phobic adults or children (e.g., Bandura & Schunk, 1981), show that an emphasis on changing beliefs (in addition to teaching strategies) results in greater change and more maintenance of intervention effects. But the limited beliefs-intervention data in the aging literature do not allow us to determine whether memory trainees must change their mindset about memory to maximally benefit from training. Objective memory improvement may occur independently of changes in memory beliefs. Nor do previous studies prove that beliefs retraining necessarily enhances training effects. At the same time, it remains

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possible that most previous interventions did not alter beliefs enough to effect a change in memory performance.

Keeping in mind the mixed nature of the available evidence, a recent pilot study designed by Welch and West was intended to alter self-efficacy beliefs and memory. The participants were 40 older women identified as at risk because they scored 1 standard deviation below their peers on a test of object location recall (the computerized Misplaced Objects Task MOT; Crook, Youngjohn, & Larrabee, 1990) and/or self-efficacy (Spatial Self-Efficacy Questionnaire SSEQ; Welch, West, Thorn, & Clark, 1996). A control group was compared with a training group that was offered both strategy training and efficacy retraining. The 5-week intervention program began approximately 9 months after the initial individual test session. This was the schedule for the training group: group pretest and homework (Week 1), homework (Week 2), group practice session and homework (Week 3), homework (Week 4), and group posttest (Week 5), followed by an individual posttest approximately 1 week later. An individual follow-up test took place 6 weeks after the group posttest. The homework included studying an imagery-training video and a strategy manual. The control group completed all individual assessments on the same schedule, but they received the video and manual, to complete at their own pace, after the individual posttest. By assessing beliefs, performance, and strategy usage at all test sessions, this intervention hoped to examine the mechanisms for performance change.

The group tests utilized a board game version of the MOT, and the individual tests utilized the computerized MOT. The training materials consisted of board game versions of the MOT that were used for practice or testing in the group sessions, an imagery videotape (see West & Crook, 1992), and a written manual describing a variety of strategies for remembering object locations, including external strategies (e.g., writing notes and using a memory place ) and internal strategies (e.g., verbal association, organization, and imagery). The manual provided examples and sample exercises for each strategy. The video and/or the manual was assigned as homework. The experimenter called each participant at home to answer questions and to ensure that the homework was completed. (Participants in a wait-list control group received the materials and assignments, without telephone follow-up, after the posttest was completed). The trainees, but not the control group, also attended one group practice session in which they practiced with the MOT board games to remember locations. As in the Canadian study described earlier (Caprio-Prevette & Fry, 1996), many different elements were incorporated into the training program to enhance efficacy: goal setting, attributional refraining, personal control, and mastery-ordered practice.

Attributional Reframing

Verbal statements were made to trained individuals during the practice session and during weekly phone calls. These statements deflected negative attributions for failure and reinforced positive attributions for success (see Lachman, this volume). One of the reasons that attributional reframing can be effective is that it emphasizes the process of learning rather than performance outcome (Elliott & Lachman, 1989). When the goal is learning, rather than success per se, anxiety is reduced, and participants are more likely to utilize learned strategies after the completion of training.

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Goal Setting

Both experimenters and participants set goals. The experimenter set a goal for participants to complete at least eight exercises during the group practice session. The participants set goals for the number of times they would watch the video, read the chapter, and/or do homework exercises. The setting of reachable, concrete goals has been shown to enhance self-efficacy in children (Schunk, 1985; Schunk & Rice, 1989). When participants reach a goal, they may appropriately infer that they are on their way to task mastery.

Personal Control

The importance of control is explained in the Lachman chapter (this volume). In this research, training-group participants chose how often to watch the video, read the manual, and do the exercises. The manual also enhanced self-efficacy by placing control for strategy selection in the participants' hands. A wide variety of alternative techniques were explained in the manual, and training-group members were encouraged to choose which strategy to use, if any. If they chose to do so, they could avoid using interactive imagery or other strategies high in processing-resources demands. In the practice session, individuals also controlled their own pace and difficulty of the exercises.

Mastery Order

In group sessions for trainees, the practice exercises were structured so that easy tasks were completed first, followed by increasingly difficult tasks (referred to here as mastery order of task presentation). Mastery order allows participants to readily see that they are mastering increasingly difficult tasks, and to infer that their skills are improving. Trainees worked at their own pace and decided, on their own, when they had mastered a given level of the task.

Based on self-efficacy theory, it was expected that both self-efficacy and memory performance would show increases in the training group. The reason is that efficacy-based interventions have been shown, in other domains and with other populations, to increase efficacy as well as performance. The control group was not expected to show significant performance improvements until the follow-up test. The results were encouraging, although with a small-N pilot study the findings were not definitive. The trainees showed greater changes in self-efficacy and significant changes in strategy usage (especially increased use of imaginal strategies) that were not apparent in the control group. Surprisingly, both the control and the training groups showed significant improvements in performance from pretest to posttest and maintained these gains at follow-up (after the control group had received the manual and video). These results may shed some light on mechanisms. In this case, the changes in strategy use by the trained group did not result in greater performance change in that group, a finding indicating that strategy increases were not the reason for performance change. Rather, practice effects explained performance change. Interestingly, there is considerable evidence in the child literature concerning strategy utilization deficiencies (SUDs) that may be relevant here (Bjorklund, Miller, Coyle, & Slawinski, 1997). SUDs occur

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when people spontaneously produce a strategy but do not benefit from it because strategy use, by itself, taxes working memory, and/or because the strategies are not fully mastered. This finding suggests that our at-risk trained group needed more practice with high-difficulty location recall exercises (they received only one practice session, with self-paced learning). At the same time, the greater efficacy increases for trainees indicated that we succeeded in making the trainees feel better about themselves probably because they were accomplishing some of their goals, by learning and utilizing new strategies. Future work should continue to delve into strategies and beliefs in relation to rehabilitation outcomes.

Nondidactic Interventions: The Study Group Methodology

Another potentially valuable approach is based on the notion that learning, especially for older adults, may be more lasting when it is presented in a nondidactic, study group format. With this methodology, each person invests or contributes to her or his own learning, as well as the learning of others in the group. This approach should, theoretically, lead to a greater positive self-evaluation after training because of individuals' greater involvement in their own learning. Study group formats provide for learning at the pace of the older person, a feature that may aid older trainees. Trainees can ask questions or lead discussions that provide for restatement and review of any information that is unclear. Training might be more effective if a particular mnemonic strategy is advertised by a same-age peer, who reports successfully using the new technique, rather than by a younger experimenter, especially if older participants have doubts about their potential as learners. This approach, therefore, could obviate the impact of working-memory deficits, slower learning requirements, or negative self-evaluations characteristic of older adults that could limit learning from didactic formats. Although the study group approach has created a great deal of interest in educational circles, its effectiveness has not been examined for memory intervention.

Rationale for This Innovation

An extensive body of literature coming from the field of educational gerontology suggests that group discussions with same-age peers are conducive to learning (e.g., Chene, 1994; Clough, 1992). Group discussions foster the sharing of personal experience and make learning more meaningful. For instance, Chene interviewed 28 older adults who were involved in group learning activities to find out their reason for joining these activities. The participants reportedly attached value to being with peers in a learning context. For them, the group made learning more fulfilling (Chene, 1994). Chene concluded that older learners seek recognition beyond that provided by friends and family. They join groups where affinity is found and prefer homogeneous groups that offer opportunities for self-confirmation.

Group discussion is used extensively for adult learning in Sweden. Study circles are the main form of adult education (one out of three adults participates in a study circle every year). Discussions are democratic and draw on participants' experiences. Study circles encourage learning through the exchange of ideas, critical thinking, and the application of knowledge to everyday life. Participants learn to speak and listen,

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a process that leads to increased self-worth and confidence (Kurland, 1982; Oliver, 1987). In the United States, study circles have been used since 1981 by the National Issues Forum (sponsored by the Kettering Foundation) to promote the discussion of public issues (Oliver, 1990).

The American equivalent of this learning format may also be found in many Elderhostel classes. Studies with Elderhostel participants have shown that seniors feel quite favorable to learning through discussions, and to learning from and with peers (Buchanan, 1988; Kaplan, 1981; Mills, 1993). Elderhostel classes (study-travel programs for seniors) are age-segregated, and group discussion is the main learning format. In the Elderhostel context, education specialists (Mills, 1993) have suggested that discussions with peers lead to increased self-discovery, self-confidence, and effective learning.

Although there is no direct evidence on the advantage of study group formats over traditional teaching in a memory intervention, scholars in the cognitive aging field have provided some evidence that group discussion may be a promising learning format for older adults. In a chapter on cooperative learning, Millis, Davidson, and Cottell (1994) stated that comprehension is enhanced by sharing ideas and responding to others. According to Millis and associates, cooperative learning leads to higher levels of achievement as well as to higher motivation to learn. Thompson (1992) also suggested that methods involving social interaction are most advantageous to older learners. In an experimental study, Zandri and Charness (1989) trained younger and older adults to use computers and found that small-group training was more effective than individual training. Participants working in pairs received half the hands-on training obtained by those who were given individual training; however, partnered participants achieved equal or higher test scores. Zandri and Charness (1989) reported that the small-group context provided opportunity for group problem solving and social reinforcement, which led to increased learning.

In the domain of memory, Flynn and Storandt (1990) examined the importance of group discussions for memory training with older adults. They compared the effectiveness of self-instructional bibliotherapy memory training (participants worked with a manual for 16 hours at home), supplemented by group discussions, to bibliotherapy by itself. The supplemental group discussions covered topics such as concerns about aging, ideas for coping with the aging process, and relaxation, as well as the materials in the manual. The group participating in discussion sessions showed significant memory improvement on two recall tasks, whereas the bibliotherapy group did not improve on any of the measures. Although the training gains were modest, these results suggested that memory training involving group interaction may be more effective than bibliotherapy alone.

The Caprio-Prevette and Fry (1996) study described earlier also contained many elements of the study circle approach. The cognitive restructuring group was involved in

small group activity, role playing, index card prompts, and oral point-counterpoint (i.e., verbalizing, between two participants, positive responses in place of negative statements). Participants were encouraged to discuss their views on memory as related to aging and they received feedback from the trainer and other participants. (Caprio-Prevette & Fry, 1996, p. 287)

As indicated earlier, this approach was highly effective in changing memory performance and memory beliefs. It should be noted, however, that these authors reported

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using a similar small-group approach for their traditional memory-training group, which did not show much change. It is clear, however, that the traditional group must have involved considerable didactic instruction, given that more than 10 memory strategies were presented (Caprio-Prevette & Fry, 1996).

Thus, both theoretical and limited empirical evidence supports the view that group discussion is an appropriate format for learning in later life. At the same time, there is little or no evidence that the group discussion format is more effective than traditional teaching formats for older adults. Memory classes utilizing group training have typically offered only the didactic approach for strategy training.

Application for Cognitive Rehabilitation

In light of the limited evidence for the effectiveness of the method, a nondidactic study-circle approach was employed in a memory-training program developed in 1997 by Yassuda and West. The goal was to demonstrate that this kind of intervention methodology could lead to significant training effects, relative to a control group. The program compared (a) a waiting-list control group, (b) a mnemonic training group (with placebo pretraining), and (c) a beliefs pretraining group that received informational pretraining about memory and aging as well as mnemonic training. We expected the guided-group-discussion format to promote positive views about memory in later life in the beliefs group, and to lead to mastery and 1-month maintenance of the trained mnemonic techniques. Although the data collection for this research has just been completed, and few results are available, a detailed description of the training program can serve as an example of the study group format. The primary hypothesis of this research was that teaching older adults about memory and aging in a study group would reduce stereotypical memory beliefs and raise memory self-efficacy. Thus, this program combined beliefs retraining (already discussed in detail) with group learning. There were no explicit comparisons of didactic and nondidactic approaches in this research. Instead, the beliefs-pretraining condition, combined with strategy training, was compared to a placebo-pretraining condition combined with strategy training, and both were compared to a wait-list control condition. The study circle approach was utilized for pretraining and strategy training in all conditions so that we could determine whether the study circle approach would be effective for memory rehabilitation for older adults.

Participants in the placebo-pretraining condition had two pretraining sessions focused on grandparenting and driving (presented as getting-to-know-you sessions), whereas the beliefs-pretraining sessions explored the memory system, aspects of memory that change and do not change with age, and factors other than age that affect memory, such as depression, medications, and nutrition. Subsequently, both groups had three sessions of strategy training in which they practiced active observation (an attentional intervention), the Preview-Question-Read-Summarize-Test (PQRST method for prose recall, and the name sentence method for remembering names (West, 1985). The control group had no pretraining or strategy training until after the third test session, but all groups completed assessments on the same schedule before and after pretraining, after strategy training, and at 1-month follow-up. The assessments evaluated memory beliefs, knowledge about memory, strategy utilization, and memory test

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performance on four tasks, two of which were targeted by training (name recall and prose recall).

The pretraining and strategy sessions were structured in such a way that the information was elicited from participants, rather than presented in lecture. All participants had reading assignments on the session topics (Fogler & Stern, 1994; West, 1985) and knew, in advance, that they would be involved in group discussion. To encourage participants to read and deeply process the information, the homework assignment sheet included questions and indicated to participants that they were going to discuss the answers with peers. The objective was to make participants accountable for the reading. At the beginning of each session, trainees were asked to outline their answers to the preassigned questions and to discuss them with a partner. This method tends to prevent group contamination by opinions contrary to the readings (see Boninger, Brock, Cook, & Gruder, 1990) in this case, to discourage individual statements that might reinforce age stereotypes about memory.

The experimenter followed a predetermined script, which included a list of session topics. In the first beliefs-pretraining session, for example, trainees needed to learn about the memory system. The experimenter elicited the information from the homework by asking:

In your readings you read about the three stages of memory. What are they? Does anyone remember?

After someone volunteered an answer, the experimenter continued asking questions such as:

How long does information stay in sensory, short-term, and long-term memory? Can anyone give me an example of a situation when information is kept in short-term memory and is soon discarded? When the McDonald's clerk tells you the price of your meal, in what memory store do you keep that information?

When exploring age-related memory changes, the experimenter probed:

So you have read about some things that seem to change in memory as we get older. Does anyone remember some of the things that change with age? Have you noticed any of these changes?

Trainees would volunteer:

Well, I have learned that I can't remember it all. I have to choose the things that are most important to me and pay close attention to those.

Another trainee would react to that idea:

I think attention is the most important thing for a good memory, and it is our biggest problem. Many times we just don't pay enough attention. That is why we can't remember things.

The experimenter would then help the group to expand productively on this point:

So what have you learned about attention and aging in the reading? Is it easier or more difficult for us to focus our full attention as we get older?

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When a topic had been fully explored, the experimenter would summarize:

So we have learned that it is very important to avoid distractions when we are learning something new. It is critical to make a conscious effort to pay close attention to the things that we may want to remember later.

After summarizing, the experiment moved to another topic:

What else changes as we get older?

If no one volunteered an answer, the experimenter continued questioning, providing more specific guidance in the question, to lead the trainees to the answers they knew from their reading:

How about remembering names and words on demand? Has anyone been in a situation when you knew someone's name but just could not remember it on the spot? What is happening in the memory system when that happens?

The discussion continued for approximately 2 hours per session until all preassigned topics for that session had been explored. Although the topics were different, the same methodology was used for the placebo discussion sessions on grandparenting and driving, to ensure that the group experience was comparable for these two conditions. It was expected that the questions assessing knowledge about memory would show more accurate responses for those individuals who had beliefs pretraining than for those in the placebo-pretraining or control conditions. Initial analyses indicated that the beliefs group did have more knowledge about memory at the first posttest but that all groups had gained in knowledge by the time of the delayed follow-up, after all groups had obtained training.

Study circles were also used for strategy training. Instead of lecturing about the mnemonic techniques, the experimenter elicited the information from participants who had already read assigned strategy materials. For example, when participants reviewed the name sentence method, they were encouraged to create short sentences to remember each others' names. Participants suggested some possibilities; the group elaborated on them and then reached consensus on the best sentence for a particular name. All participants (with rare exceptions) reported doing the homework reading, and the sessions were quite lively. The reading materials were brought to life when trainees volunteered examples and personal anecdotes.

In sum, current literature suggests that study circle or group learning approaches are appropriate and often successful for older adults, and that older adults subjectively enjoy group learning. A detailed example of the methodology was provided. It is important to recognize, however, that there are no known tests examining the power of this approach, as compared to didactic memory training, with older adults. The potential is clearly there, but empirical evidence is necessary to establish the objective benefits of this type of intervention format.

Conclusions

This chapter has presented three possible approaches to memory rehabilitation for older adults that have not been sufficiently tested, even though all three hold great

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promise for helping older adults to reverse some memory deficits and maintain memory ability as they age. In each case, we provided a rationale for the value of the methodology, as well as at least one example of the method, although sometimes without empirical results. By presenting each of these possible techniques separately videotape, self-efficacy enhancement, and nondidactic study groups we did not intend to suggest that they must always be used separately. In fact, both of the current studies presented in detail here have employed more than one innovation: The Welch project has combined the use of videotape with an intervention focused on enhanced efficacy and mastery, and the Yassuda project has focused on changing beliefs, at the same time testing the effectiveness of a nondidactic group-study intervention. Both studies have measured strategy usage and short-term maintenance. Thus, both studies have simultaneously built on the intervention ideas discussed here while trying to address some of the limitations of earlier research.

As researchers begin to examine these and other innovations, tests of the impact of combinations of techniques may have heuristic value. Herrmann and Searleman (1992) recommended multifactorial training that takes into account a wider variety of factors that influence memory by optimizing the psychological and physiological systems in which the memory system itself is embedded (p. 13). Thus, an intervention that is multifactorial should take into account as many processes as possible that could impact successful memory: emotional state (general anxiety or depression, specific memory fears), attitudes or beliefs (self-efficacy, control, stereotyping with respect to age decline), social context (social needs that enhance or impede memory ability), sensory-perceptual processing (wearing glasses and hearing aid, focusing attention), and physiological state (rest, good nutrition, cardiovascular function). Researchers who have already developed successful memory intervention methodologies may find that the addition of videotapes, self-efficacy manipulations, or nondidactic discussions enhances training impact or maintenance of newly learned skills. Recent comparisons of a multifactorial approach (strategy training, attentional retraining, and relaxation) with strategy training or cognitive activation by itself showed greater effects and better maintenance after multifactorial training (Stigsdotter & B ckman, 1989; Stigsdotter Neely & B ckman, 1993a).

Scholars of memory training and aging have left a number of questions partially answered or unanswered. What is the impact of training over and above the effects of practice alone? Can training effects (performance improvement and/or strategic processing changes) be maintained over long intervals of time? What are the mechanisms for memory improvement? As we move in new directions, testing out new approaches and combining approaches to offer multifactorial interventions, these questions should not continue to be ignored. Whatever innovative directions are taken in terms of offering new types of training, it behooves us as scholars to become more sophisticated about examining these critical issues.

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