International Psychogeriatrics: page 1 of 21 C International Psychogeriatric Association 2013 doi:10.1017/S1041610213001233

A literature review of spaced-retrieval interventions: a direct memory intervention for people with dementia

...... Alexandra S. Creighton, Eva S. van der Ploeg and Daniel W. O’Connor Aged Mental Health Research Unit, School of Psychology and Psychiatry, Monash University, Cheltenham, Victoria, Australia

ABSTRACT

Background: With the increasing prevalence of dementia, there is a pressing need to identify effective interventions that prolong independent functioning. As pharmacological interventions aimed at slowing cognitive decline have been found to have a number of limitations, research has now moved toward studying complementary non-pharmacological cognitive training interventions. This review describes the use of spaced- retrieval as a method to teach new information and reduce behavioral problems in people with dementia. Methods: We searched the databases PsychINFO, MEDLINE, and Scopus as well as reference lists of relevant papers to identify articles describing the use of spaced-retrieval with people with dementia. Only primary, peer-reviewed research published in English was included in this review. Results: In total, 34 studies were identified, three of which were randomized controlled trials. We found that across studies, there was wide variability with regard to design, methodology, and outcome measures used. Nonetheless, the existing research demonstrates that spaced-retrieval training can be successfully used to teach people with dementia new and previously known face- and object–name associations, as well as cue–behavior associations aimed at alleviating problem behaviors and improving functional skills. The method can also assist with the recollection of past events. Conclusions: Current evidence indicates that spaced-retrieval training is effective in enabling people with dementia to learn new information and behavioral strategies. Future research should attempt to address the limitations outlined in this review and focus on utilizing this technique to achieve more functional and clinically relevant outcomes. Recommendations are also made with regard to investigating potential secondary benefits of spaced-retrieval and strengthening study design.

Key words: spaced-retrieval training, dementia, memory, cognitive training, non-pharmacological, intervention, rehabilitation, learning

Introduction pharmacological memory interventions to alleviate the cognitive deficits associated with dementia. With the elderly people now the fastest-growing seg- Numerous interventions capitalize on the relatively ment of the general population (Thies and Bleiler, intact implicit memory system, which utilizes an 2012), dementia has become one of the most automatic and unconscious form of remembering common and serious medical problems (Dramé that is expressed through the performance of skills et al., 2012). Given that memory impairment is and habits (see Grandmaison and Simard, 2003 for the earliest and most invalidating core symptom of a review). dementia, the majority of early interventions aim to One such technique is that of spaced-retrieval slow cognitive decline. Currently, pharmacological (SR) training, a direct memory intervention that interventions, such as cholinesterase inhibitors, are teaches new information via active recall attempts most commonly used to achieve this (Aderinwale over progressively longer retention intervals (Camp, et al., 2010). However, studies into their use with 2006). Originally based on early work by Landauer people with dementia have found them to have lim- and Bjork (1978), Camp (1989) adapted SR for ited effectiveness (Evans et al., 2004). Thus, recent people with dementia, finding that the use of research has focused on developing alternative, non- performance-adjusted delays between recall trials enabled participants to successfully learn and retain Correspondence should be addressed to: Professor Daniel O’Connor, name–face associations of nurses. The overall AMHRU, Kingston Centre, Warrigal Road, Cheltenham, VIC 3192, goal of SR is to enable individuals with memory Australia. Phone: +61-3-9265-1700; Fax: +61-3 9265-1711. Email: [email protected]. Received 4 Dec 2012; revision requested 7 Mar impairment to remember information for clinically 2013; revised version received 24 Jun 2013; accepted 24 Jun 2013. relevant periods of time (e.g. days, weeks, and 2 A. S. Creighton et al. months; Vance and Farr, 2007). SR is administered standard for evaluating clinical interventions) have by first providing the client with a prompt question been conducted on SR training (Davis et al., 2001; and associated target response. When successful Hawley et al., 2008; Lin et al., 2010), with most at recalling the response, the client is required to research lacking a control condition or group and/or actively recall the target information using either utilizing a case study or single-subject design. uniform or increasingly longer inter-trial intervals Nevertheless, all published studies found were (Brush and Camp, 1998a). If at any time the client included in this review for the sake of completeness. is unable to recall the response, they are provided with the information and asked to repeat it (Camp et al., 1996b). Typically, the training is considered Methods successful if the participant correctly responds to the prompt question at the beginning of three consecut- From January to April 2012 (and updated ive sessions (Brush and Camp, 1998a), as long-term in September 2012), a search of PsychINFO, retention of the information has been demonstrated. MEDLINE, and Scopus was performed using At present, little research has been conducted the key terms: “spaced-retrieval,” “memory into the theoretical mechanisms underlying SR training,” “memory rehabilitation,” “cognitive training (Camp et al., 2000). However, Camp training,” “cognitive rehabilitation,” “dementia (2006) suggested that the technique integrates four of the Alzheimer’s type,” “dementia,” and different methods of learning. First, SR is a form “Alzheimer’s/Alzheimer disease.” Reference lists of “ecologically valid priming,” whereby previous of relevant papers were also searched to identify exposure to a stimulus influences later detection and articles that described SR in this population. The identification of that stimulus (Sohlberg and Turk- review was restricted to primary, peer-reviewed stra, 2011). Second, SR is also thought to use “spa- research studies that were published in English and cing effect;” information is learned and retrieved focused on the use of SR training for people with more effectively when trials are distributed over time dementia. rather than mass practiced (Camp et al., 2000). The Using the Australian National Health and utilization of both these methods is thought to be Medical Research Council’s (NHMRC, 2000) particularly beneficial to individuals with dementia, level of evidence hierarchy, all studies reviewed as they capitalize on the relatively spared and auto- were graded according to their design quality. matic implicit memory system (Camp et al., 2000). Specifically, systematic reviews of level II studies Third, SR is regarded as a form of conditioning; were considered to be level I evidence; RCTs were strong associations are formed between the target classified as level II evidence; pseudo RCTs question and response through repetition and suc- were classified as level III-1 evidence; non- cessful recall trials may serve as intrinsic reinforcers randomized experimental trials (including pre- (Camp, 2006). Lastly, SR can also be considered a test–post-test studies), cohort studies, case–control form of errorless learning (e.g. Haslam et al., 2011), studies, and interrupted time series studies with a as it minimizes the possibility of errors during the control group were classified as level III-2 evidence; acquisition phase of learning by ensuring mistakes historical control studies, two or more single arm are repeatedly corrected (Camp et al., 2000). studies, and interrupted time series studies without Interestingly, while SR training appears to be a parallel control group were classified as level III-3 gaining increasing support and attention within evidence; and a case series with either post-test or the field of aged care, to our knowledge only two pre-test–post-test outcomes was classified as level literature reviews have been conducted: one for a IV evidence. French audience only (Erkes et al., 2009) and one by Hopper et al. (2005). As a number of new studies using SR training have been conducted in recent Results years, the purpose of this review was to provide In total, 34 studies were included in this review, an up-to-date overview of this promising technique. with the studies being classified into four types Therefore, this paper describes published research based on the goals of SR training: (1) name–face testing the effectiveness of SR training to teach associations, (2) object–name associations, (3) cue– people with dementia new information and behavior associations, and (4) mixed goals/other. behavioral strategies. In addition, when other outcome measures (such as secondary non- cognitive benefits) have been studied, these findings Name–face associations are also presented in the review. In total, eight studies focused on the effectiveness It must be noted that to date, only three of SR to teach people with dementia to associate a randomized controlled trials (RCTs; the gold name with a specific face (see Table 1). One study Memory training for people with dementia 3 0.001), ...... < 0.001) when < 0.05), and final < ...... All members of adjusted 0.01) and greater free < 0.10). 0.05)...... > > 0.01) recall. of the five conditions forimmediate, recognition, or delayed recall forgroups. both spaced-retrieval training enabled the greatest number of Alzheimer’s disease participants to obtain results thatsignificantly were different not from control group (p name–face associations after spaced-retrieval training (p compared to baseline. 12-month follow-ups. (p consistently better retention of name–face associations (p recall of target on immediate (p spaced-retrieval group successfully transferred association, compared to 50% of uniform expanded retrieval group. delayed (48 hours; p delayed (72 hours; < No significant differences found between each Case study analyses showed that Significant improvement at recalling Improvements in recall maintained at 6- and No significant improvement for control items Adjusted spaced-retrieval condition led to p Live-person transfer: ...... 45-minute 1-hour sessions sessions, one session for each condition. session (duration of sessions not provided). TRAINING OUTCOME held on three alternate days of the week. × × Five weeks 5 Six sessions One photograph per Three weeks 9 DURATION OF ...... Expanded Uniform (30 seconds) (increased by 15 b ...... d a Performance on immediate, 48-hour, and Performance on immediate free and cued Performance on free and cued recall trials . c Expanded . . e f ...... Eight distracter photos, one target photo of an Five photos of unfamiliar individuals (one per Twelve target photos of known individuals. 72-hour delayed recall and recognition;association generalization learned of to the live person. recall and recognition; delayed freerecognition; and number cued of recall errors. and post-intervention and at 1-, 3-, 6-, and 12-month follow-up. unknown person. condition). equivalent number of times as in spaced-retrieval condition) instructions seconds). instructions (Level III-2 evidence) Materials: Materials: Materials: Two conditions: Five conditions: Two conditions: 1. Adjusted spaced-retrieval 1. Spaced-retrieval training. 2. Errorless learning 1. Spaced-retrieval training for six2. target Control: photos No training for six target photos (photos presented Outcome measure(s): 2. Control: Uniform expanded retrieval 3. Method of vanishing cues 4. Control: Trial-and-error with explicit memory task 5. Control: Trial-and-error with implicit memory task Outcome measure(s): Outcome measure(s): Adult day care center Randomized controlled trial (Level IIInter-trial evidence) intervals (for spaced-retrieval): Research center and memory clinic Mixed-method design (Level III-2 evidence) Inter-trial intervals (for spaced-retrieval): Memory clinic Quasi-experimental within-participants pre-test–post-test design Inter-trial intervals: ...... 30): = N 23.70 17.83 29.20 23 probable probable ======73.30 years 82.42 years 72.50 years 71 years = = = = 15 12 15 12 ...... age age MMSE age MMSE age MMSE MMSE = = = = disease Alzheimer’s disease Alzheimer’s disease 1. Early Alzheimer’s N M M N M M 2. Healthy controls N M Diagnosis Two groups ( N M M M Diagnosis SR training to teach name–face associations et al. et al. et al. (2008) (2008) (2002) Table 1. STUDYHawley SAMPLE SETTING AND COMPONENTS Bier Clare ...... 4 A. S. Creighton et al. = 0.001, ...... < 0 .001, effect size r ...... Learned association < 0.52). 0.54). = = ...... transferred to live person forparticipants. half of the 0.76) and errorless learning (p after two sessions, with itat being the maintained six-month follow-up. associations within ten sessions, fivethree learned associations, two learned two associations, one learned one association, and one participant learned none. did not significantly improve recallretention and (p name–face association. spaced-retrieval conditions. recall of significantly more namestrial-and-error than (p effect size r Participant learned name–face association Twenty-three participants learned all Filling ITI with information related to target Spaced-retrieval enhanced retention of No significant difference between the two Live-person transfer: Spaced-retrieval training resulted in correct × ...... week not provided) 30-minute sessions per name–face association, week (duration of sessions not provided). for each of the conditions. TRAINING OUTCOME Three weeks One session per (duration of sessions Maximum of 10 Four sessions per Two weeks Six sessions Four learning trials DURATION OF ...... 6) = N ...... 26) and private home ( = Number of sessions needed to learn Performance on immediate, 48-hour, and Time taken to learn associations; Total number of correct recalls out of ten. . c Expanded Expanded Uniform (30 seconds) Expanded N (baseline condition). g Twelve photos of unfamiliar individuals (different for Eight distracter photos, one target photo of a Two target photos of unfamiliar individuals, two ...... information; maintenance of learned informationmonths. after six name of a nurse (whocare was center. present during training) at the day 72-hour delayed recall and recognition;association generalization learned of to the live person. maintenance of information learned. each condition). previously unknown person. target photos of known individuals. Residential facility ( Memory clinic Within-participants design (Level III-2 evidence) Inter-trial intervals: Within-participants design (Level IV) Inter-trial intervals: Spaced-retrieval used to train participants to remember the Materials: Materials: Three conditions: Two conditions: Outcome measure(s): Outcome measure(s): Outcome measure(s): Outcome measure(s): 1. Trial-and-error 1. Spaced-retrieval sessions provided on2. alternate Spaced-retrieval days. sessions provided on consecutive days. 2. Errorless learning 3. Spaced-retrieval training. Adult day care center Case study design (Level IVInter-trial evidence) intervals: Materials: Adult day care center Randomized mixed-method design (Level IVInter-trial evidence) intervals: ...... 21.27 17.88 not given 14.83 probable not given ======77 years 80.09 years 68 years 84.16 years 2) 5); 30); = = = = 3) 7); = = = 15 32 1 6 = = N N N age MMSE age MMSE age MMSE age MMSE = = = = ( ( Alzheimer’s disease Alzheimer’s disease ( mild-to-moderate Alzheimer’s disease ...... N N Mixed dementia ( Vascular dementia Vascular dementia ( M M Diagnosis N M M Diagnosis N M M Diagnosis N M M Diagnosis N Continued et al. et al. (2011, Experiment 3) (2010) Schaller (1989) Cherry (2004) Table 1. STUDYHaslam SAMPLE SETTING AND COMPONENTS Hopper Camp and Hawley and ...... Memory training for people with dementia 5 < 2.36 sessions) than explicit instruction 3.27 sessions, p = + = M M e picture was immediately ted name, with the experimenter tly guessed on the first attempt. This After four days and two weeks, ted for three seconds and participants give an answer. th the photos in a random order and tated: “Here is a picture of a man, whose ers. Participants were required to guess the the answer after an incorrect response. This l instructions given to participants. Namely, lled the target information. If at any stage the prompt question was king people to generate a response using cues et information. Correct recall was followed by a significantly faster ( name–face associations using traditional spaced-retrieval training. using spaced-retrieval was not successfully learned. new associations ( 0.05). participants were more likely tolearned recall association. a At six weeks, participants were less likely tolearned recall association. a . If during any of the trials the participant provided Participant successfully learned the two In contrast, the name–face association taught Follow-ups: Previously known associations were learned 45-minute session per week. × Three months 1 (2008), the face–name association was presented for 5 seconds with the following et al. Number of sessions needed to learn Expanded Three black and white photographs of unknown information; achievement of learning criterionof (correct name recall after a one-week delay). people. individual. individual. individual. instruction). (2011), participants were presented with the face and the correct name for three seconds, then completed filler tasks for 8 minutes 30 seconds. They Materials: Two conditions: 1. Intervals filled with tasks2. related Intervals to filled known with target tasks individual. unrelated to known target 3. Intervals filled with tasks related to unknown target 4. Intervals filled with tasks unrelated to unknown target 1. Traditional spaced-retrieval training protocol (using implicit 2. Spaced-retrieval training using explicit instruction. Outcome measure(s): Treatment setting not provided Case study design (Level IVInter-trial evidence) intervals: Four learning conditions: et al. not probable = = 69 years = 1 MMSE = given. Alzheimer’s disease M Diagnosis Mage N Mini-Mental State Examination. = et al. MMSE : (1998) Method of vanishing cues: Participant was provided with progressively stronger or weaker cues following a recall attempt of the target information. Uniform expanded retrieval: Each trial was separated by the same amount of time, regardless of whether the participant correctly or incorrectly reca Trial-and-error: At the beginning of each trial, a photograph was presented along with the first letter of the name and dashes to represent missing lett Adjusted spaced-retrieval: The length of time between each trial was governed by whether the participant correctly or incorrectly recalled the targ Errorless learning: Aims to prevent or eliminate errors during training by either providing the correct answer immediately during learning, or by as Trial-and-error with explicit memory task instruction: Each of the five associations was presented for five seconds. For each photo the experimenter s Trial-and-error with implicit memory task instruction: The method was identical to the one described above, with the only difference being the recal answered correctly, cues were graduallyan withdrawn incorrect from response, subsequent additional trials cues until were they provided could one correctly at recall a the time information until without they any were assistance able to provide the correct response. were then asked to recall the name in the same manner as in the trial-and-error condition. In Bier which eliminate most errors. In Haslam name, with feedback given onwere accuracy. explicitly If asked after to either rememberwas ten the done seconds association. for or To all four ensure 12required attempts a photos to the minimum in recall name of the the had one set corresponding not error and name. been per was They guessed item repeated were correctly, was four encouraged the made, times to correct a in guess name substitute total. if was was The unsure presen used recall of if test the the was correct target then answer. name administered, was whereby correc participants were presented wi Note a b c d e f g longer inter-trial interval, while incorrect recall led to shorter inter-trial intervals. participants were told to give the first answer that came to mind, even if it seemed like a guess, with no reference made to the preceding learning trials. instructions, “Here is a picture of a man, whose name is Mr. X. Can you repeat his name and try to remember it?” The picture and name were hidden, and then th presented again. The participant then had 20 seconds to recall its associated name, with the correct answer provided if they madename a is mistake Mr. or X. could Canexplicitly not you asking repeat the this participant name toprocedure and remember was try the done to name for remember presented each it?” earlier. photo One The (in of participant a the had random photos 20 sequence) was seconds in then to three presented answer, cycles again with of and the three the experimenter presentations. participant providing asked to provide the associa Vanhalle 6 A. S. Creighton et al. was classified as level II evidence (Hawley et al., One study was classified as level II evidence 2008), three were level III-2 evidence (Clare et al., (Davis et al., 2001), four studies were level III-2 2002; Bier et al., 2008; Haslam et al., 2011), and evidence (Cherry et al., 1999; Cherry and Simmons- four studies were level IV evidence (Camp and D’Gerolamo, 2000; 2004; 2005), two studies were Schaller, 1989; Vanhalle et al., 1998; Hawley considered to be level III-3 evidence (Hochhalter and Cherry, 2004; Hopper et al., 2010). Two et al., 2004; 2005), and two studies were level IV studies taught participants the names of familiar evidence (Abrahams and Camp, 1993; McKitrick people (Camp and Schaller, 1989; Clare et al., and Camp, 1993). Six studies (one case study; 2002), while five studies taught participants to one between-participants design; three within- associate an unfamiliar match (Vanhalle et al., 1998; participants design; and one randomized placebo- Hawley and Cherry, 2004; Bier et al., 2008; Hawley controlled crossover design) taught participants et al., 2008; Haslam et al., 2011;). One study the names of previously known but forgotten taught participants the names of both unfamiliar objects (Abrahams and Camp, 1993; Cherry et al., and familiar faces (Hopper et al., 2010). 1999; Cherry and Simmons-D’Gerolamo, 2000; Overall, the articles reviewed were largely 2004; 2005; Davis et al., 2001), while two studies positive. Using a case study design, both Vanhalle used a within-participants design to explore the et al. (1998) and Camp and Schaller (1989) effectiveness of SR training in teaching participants successfully taught their participant name–face the names of previously unknown and unfamiliar associations, while three studies (one randomized pills (Hochhalter et al., 2004; 2005, Experiment 1). mixed-method design; one RCT; and one within- Moreover, McKitrick and Camp (1993) used SR to participants design) found at least half of teach one participant the names of both previously the participants learned the associations taught known and unknown objects. (Hawley and Cherry, 2004; Hawley et al., 2008; All studies were successful in using SR training Hopper et al., 2010). Furthermore, using a to achieve goals with some or all participants. within-participants pre-test–post-test design, Clare Hochhalter et al. (2005, Experiment 1) did not find et al. (2002) found a significant improvement that SR training led to long-term retention of pill in participants’ performance on trained items names more often than other memory techniques, from baseline to post-intervention, while no with the authors finding that random and expanding significant improvement was found for control rehearsal patterns led to long-term maintenance (untrained) items. Haslam et al. (2011) found SR of more pill names. In addition, Cherry and to significantly improve the correct recall of the Simmons-D’Gerolamo (2004) found that while all target name–face associations compared to other participants demonstrated fewer errors per trial and techniques. Conversely, using a mixed-method increased retention duration across sessions, there design, Bier et al. (2008) found that SR was was little evidence of the long-term benefits of not statistically superior to other cognitive training SR training on performance. More specifically, the methods, including errorless learning, the method two participants who had completed SR training of vanishing cues, and trial-and-error. However, 18 to 24 months prior had a greater number of case study analyses demonstrated that SR resulted failed recall trials compared to original testing, in the greatest number of participants with early with little difference in performance also found Alzheimer’s disease achieving similar results to the compared to the two control participants with no healthy controls. prior training. However, this may have been because Two studies also investigated whether the name– the test delay was too long to demonstrate any face association learned using a photograph could potential long-term effects of the technique, with be transferred to the actual person (Hawley and Cherry and Simmons-D’Gerolamo (2005) finding Cherry, 2004; Hawley et al., 2008). Both studies clear evidence that, despite an increase in the found this generalization of the learned response severity of Alzheimer’s disease, prior experience to be successful, with Hawley et al. (2008) finding of SR had both within- (i.e. compared to their that all participants in the adjusted SR condition original performance) and between-subject (i.e. correctly named the person, while Hawley and compared to controls) benefits for five participants Cherry (2004) found three out of six participants who had undertaken the training less than a year were able to correctly name the person from the ago. photograph. Cue–behavior associations Object–name associations Altogether, 11 articles (describing 12 studies) Nine studies utilized the SR technique to help utilized the SR technique to teach associations people relearn the names of objects (see Table 2). between a cue and a specific behavior (see Table 3). Memory training for people with dementia 7 ...... 0.001). < One participant ...... One participant recalled One participant free recalled ...... training, with them learning aof mean the of items 55% that they had initially failed. intervention pre-test to the lastpre-test session was 1.33 items (p task had fewer failed recallretention trials of and target longer object. all target items, three recalledone two recalled items, one item. Allrecognized participants all target items fromdistracters. array of correctly recalled all three items,recalled one two items, and oneitem. recalled one all items, one recalled tworecalled items, one and item. one Three faileditems. to recall any Fifteen participants received spaced-retrieval Mean improvement from the first Three participants correctly named allParticipants targets. given a target object orientation Immediate recall: Delayed recall (48 hours): Final delayed recall: ...... 1-hour sessions 30–90-minute for each condition. week. condition also completed attention exercised for 30 minutes, Six days per week. sessions held on alternate days TRAINING OUTCOME × × One session per Intervention Five weeks 5 Two weeks 6 DURATION OF ...... 19): = N 18; consisted of unstructured = N ...... Number of personal items correctly Recall failures across trials and training Uniform (increasing by 30 seconds). Doubled to 60 seconds, then increased in ...... Correct recall of personal items. To correctly identify the target objects “jacket,” “bracelet,” conversations and watching videotapes ofissues). general health associations. recalled at the end of each session and across sessions. sessions; performance on immediate, 48-hourfinal delayed, delayed and recall and recognition. to spaced-retrieval training (i.e. engagedthe in target conversation object). about prior to spaced-retrieval training. 30-second increments. and “carrot” out of a set of distracters. Adult day care center Between-participants design (Level III-2 evidence) Inter-trial intervals: Research center clinic Randomized placebo-controlled crossover design (LevelInter-trial II intervals: evidence) Included: Spaced-retrieval training for seven personal object–name Peg task. Cognitive training stimulation. Face–name training task. 2. Control: Placebo group ( 2groups: Goal: Goal: 1. Five-week intervention group ( 1. Three participants given a target object orientation task prior 2. Three participants not given a target object orientation task Outcome measure(s): Outcome measure(s): Two groups: ...... 18.67 22.31 probable = = = = 79 years 70.62 years = = 6 37 age MMSE age = = mild-to-moderate Alzheimer’s disease Alzheimer’s disease ...... M M N Diagnosis Diagnosis N M M MMSE SR training to teach object–name associations et al. Simmons- D’gerolamo (2000) (2001) Cherry and Table 2. STUDYDavis SAMPLE SETTING AND COMPONENTS ...... 8 A. S. Creighton et al...... One participant No participants able ...... One participant correctly No participants freely One participant recalled the Three participants able to ...... recalled the target item fromsession. the previous recalled all target items inrecall the task. final Two delayed correctly recognizeditems all from three array of distracters,participant while correctly one recognized two items. target item at end ofcorrectly session. recognized All the participants target itemarray from of distracters. to freely recall target object. recalled target objects. All correctly recognized target objects from arraydistracters. of found. sessions. correctly recall one target object.participants All correctly recognized all non-recalled target objects from arraydistracters. of recalling target information, as shownfewer by failed recall trials andduration longer across retention sessions. training in both within- andcomparisons between-subject was beneficial. Final delayed recall: Immediate recall: Delayed recall (48 hours): Final delayed recall: No benefit of prior spaced-retrieval experience All participants recognized all items after six Immediate recall: Delayed recall (48 hours): All participants showed improvement in Prior task experience with spaced-retrieval ...... 1-hour sessions 1-hour sessions alternate days. TRAINING OUTCOME given on alternate days. item. × × Two weeks Sessions held on Two weeks 6 DURATION OF 6 Two sessions per ...... Recall failures across trials and training Recall failures across trials and training Recall successes/failures across trials and Doubled to 60 seconds, then increased in Expanded Doubled to 60 seconds, then increased in Eleven small colorful objects; three target objects, and Eleven small colorful objects (three target objects and ...... Associate a jacket, bracelet, and carrot with its correct Associate specific household objects and toys (shark, chair, To correctly identify the target objects “jacket,” “bracelet,” 1 year ago. name. carrot) with their correct name. sessions; performance on immediate, 48-hourfinal delayed, delayed and recall and recognition. sessions; performance on immediate, 48-hourfinal delayed, delayed and recall and recognition. training sessions; performance on immediate,and 48-hour final delayed, delayed recall and recognition. eight distracters. eight distracters). 30-second increments. 30-second increments. 18–24 months earlier. < and “carrot” out of a set of distracters. Materials: Materials: Goal: Goal: Goal: Two groups: Adult day care center Quasi-experimental within-participants design (Level III-2Inter-trial evidence) intervals: Outcome measure(s): Outcome measure(s): Outcome measure(s): 1. Two participants had participated in spaced-retrieval training 2. Two participants had no prior spaced-retrieval training. 1. Five participants had participated in spaced-retrieval training Two groups: Adult day care center Quasi-experimental within-participants design (Level III-2Inter-trial evidence) intervals: 2. Five participants had no prior spaced-retrieval training. Adult day care center Within-participants design (Level III-2 evidence) Inter-trial intervals: ...... 15.75 16 14.75 probable probable ======83 years 81 years 82.50 years = = = 4 10 4 age MMSE age MMSE age MMSE = = = Alzheimer’s disease Alzheimer’s disease mild-to-moderate Alzheimer’s disease ...... N M M Diagnosis N M M Diagnosis N M M Diagnosis . Continued et al Simmons- D’gerolamo (2004) Simmons- D’gerolamo (2005) (1999) Table 2. STUDYCherry and SAMPLE SETTING AND COMPONENTS Cherry and Cherry ...... Memory training for people with dementia 9 object–name associations for both items. generalization (shown by correctly namingcolored a drawing and actual exemplaritems) of and the maintenance (two weeks post-test) of both target items. name in adjusted spaced-retrieval condition, despite leading to morethan errors uniform spaced-retrieval. spaced-retrieval condition. long-term retention of the pillspaced-retrieval names training. using expanding (4/10) and random rehearsal (5/10) conditions. retention (i.e. at least 24training) hours of after association between theconditions. five Both participants successfully learned Both participants demonstrated Eight out of ten participants learned the pill No participants learned pill name in uniform Three out of ten participants showed More participants learned associations under No significant difference in long-term 30-minute sessions, once a week, for each item Sessions continued until participant achieved goal or experimenter judged learning would not occur. Sessions continued until participant mastered goal, or for two more sessions than adjusted spaced-retrieval. week until long-term retention of pill name was shown, or maximum of eight sessions (whichever occurred first). × 3 Uniform spaced-retrieval: Adjusted spaced-retrieval: For each condition: Four to seven sessions per 1) = N f (increased by ten seconds). e a b c Percent of errors made during training; Errors during training; demonstration Maintenance of information learned d Expanded Expanded Expanded 1) and residential facility ( = N Two color pictures of pills (one pill was used for Five color pictures of pills (one pill name used for Two line drawings of target items (dart and Associate a pill with its correct name. Associate a pill with its correct name. achievement of learning criterion (correctinformation recall at of least one daynumber after of previous training training sessions session); required to learn information. of long-term retention (correct recallfirst of trial information of on a the session). both within and between sessions,follow-up; and generalization at of a the two-week trainedother response relevant across stimuli. to each condition). each condition). pretzel) and seven line drawings of control items. Materials: Materials: Goal: Goal: Materials: Two conditions: Five conditions: 1. Adjusted spaced-retrieval 2. Uniform spaced-retrieval 1. Spaced-retrieval training. 2. Expanding rehearsal 3. Random rehearsal 4. Uniform massed rehearsal 5. Uniform distributed rehearsal Outcome measure(s): Outcome measure(s): Outcome measure(s): Residential facility Within-participants experimental design (Level III-3Inter-trial evidence) intervals: Residential facility Within-participants experimental design (Level III-3Inter-trial evidence) intervals: Privatehome( Case study design (Level IVInter-trial evidence) intervals: = 14.64 14.50 probable probable = = = = = Not given 83.60 years 79 years 5); Alcohol = = = 5) = 10 11 2 = N age age age MMSE MMSE = = = dementia 7–27 Alzheimer’s disease ( Alzheimer’s disease Alzheimer’s disease and Anomia N N M N ( Diagnosis MMSE (range) N M M M M Diagnosis Diagnosis (2004) (2005, et al. et al. Experiment 1) Camp (1993) Hochhalter Hochhalter Abrahams and 10 A. S. Creighton et al...... led the target information. et information. Correct recall was followed by a als of spaced-retrieval). This was included to test greater consistency than before SR training. All items were learned and produced with of performance. -trial intervals is sufficient to produce long-term retention...... 1-hour sessions, × one session per week. TRAINING OUTCOME Ten weeks 10 DURATION OF ...... Achievement of goals. Expanded ...... Naming Test. toothbrush and table lamp). disk). Outcome measure(s): 1. Learn the names of familiar objects from the2. Boston Learn the names of common household objects (e.g. 3. Learn the name of a previously unknown object (floppy Private home Case study design (Level IVInter-trial evidence) intervals: Goals: ...... 14 = = 77 = 1 age MMSE = Alzheimer’s disease ...... M M Diagnosis N Mini-Mental State Examination. = Continued Camp (1993) Random rehearsal: The same inter-trial intervals experienced during spaced-retrieval were arranged in a random order. Uniform spaced-retrieval: Each trial was separated by the same amount of time, regardless of whether the participant correctly or incorrectly recal Adjusted spaced-retrieval: The length of time between each trial was governed by whether the participant correctly or incorrectly recalled the targ Expanding rehearsal: The same inter-trial intervals experienced during spaced-retrievalUniform training massed were rehearsal: arranged All in trials increasing were order, separated regardless by a ten-second delay. Uniform distributed rehearsal: All trials were separated by a four-minute delay (which was close to the mean of the eight possible inter-trial interv Table 2. STUDYMcKitrick and SAMPLE SETTING AND COMPONENTS Note: MMSE a b c d e f longer inter-trial interval, while incorrect recall led to shorter inter-trial intervals. if variability in inter-trial intervals is important when distributed practice is used, or if a uniform schedule of trials with relatively long inter ...... Memory training for people with dementia 11 < ...... 50% of ...... Under one or more learning 0.01). < 0.05)...... < learning conditions for participants with dementia (p participants with dementia correctly recalled the task on presentationalarm of alone, the with eight participantsbeing not able to recall the task at all. conditions, ten participants heard the alarm, read the word, recalledsuccessfully the performed task, it and without experimenter support. conditions at 24-hour follow-up (p 0.001), with 18/24 participants spontaneously performing the task after verbally retrieving it. improvements in nutrition and eating(p ability No significant difference found between two Twenty-four-hour follow-up: 24-hour follow-up: PPT-retrieval was superior to all other SR training group had significant ...... 30–40-minute 1-hour sessions × session TRAINING OUTCOME PPT-encoding and one session used EPT-encoding. session. sessions week × 2 Two sessions One goal learned per One session used Two goals learned per Eight weeks 24 Three sessions per DURATION OF ...... a ...... Edinburgh feeding evaluation in Achievement of criterion for success Achievement of criterion for success Expanded Approximately doubled Approximately doubled (15 seconds, 1, ...... To decrease eating difficulty. dementia; Mini-nutritional assessment; body massfeeding index; assistance needed from caregivers. (correct recall of information onenumber day of after cues a required session); during trials and 24-hour recall. (correct recall of information onenumber day of after cues a required session); to assist 24-hour recall. evidence) performed task. not perform task. 2, 4, 8, 15, and 60 minutes). cues. cues. evidence) Three groups: Goal: Two learning conditions: Residential facilities Within-participants pre-test–post-test design (Level III-2 Inter-trial intervals: 1. SR training. 2. Montessori-based activities 1. PPT-encoding: Participant verbally retrieved and 2. Verbal-encoding: Participant verbally retrieved but did Combined spaced-retrieval with fading or supplementary Outcome measure(s): Outcome measure(s): Combined spaced-retrieval with fading or supplementary Outcome measure(s): Residential facility Single evaluator, blind, randomized controlled(Level trial II evidence) Inter-trial intervals: 3. Control: Treatment as usual. Residential facilities Within-participants pre-test–post-test design (Level III-2 Inter-trial intervals: 48): ...... = N 11.62 16.20 27.50 15.0 dementia dementia ======81.18 83.50 85.10 85.10 = = = = 82 24 24 24 age MMSE age MMSE age MMSE age MMSE = = = = patients ...... M M Diagnosis N M M M M 2. Healthy controls N 1. Dementia N M M Diagnosis N Two groups ( SR training to teach cue–behavior associations et al. (2010) Kinsella (1996, Study 2) Kinsella (1996, Study 1) Table 3. STUDYLin SAMPLE SETTING AND COMPONENTS Bird and Bird and ...... 12 A. S. Creighton et al...... 0.05). Significantly < 0.05). 11): < = ...... Significantly more goals 0.05). < ...... stopped engaging in the inappropriate sexual behavior, with this stillfour-month evident follow-up. at a cueing hierarchy in enabling participantsmaster to their goals (23/25 using spaced-retrieval vs. 18/25 using cueing hierarchy, p more goals trained using spaced-retrieval were maintained than those trainedcueing using hierarchy (5 vs. 1, p trained using spaced-retrieval were maintained than those trained usinghierarchy cueing (16 vs. 9, p Four-month post-test (N One-week post-test: ...... 1-hour session Three days post-intervention participant TRAINING OUTCOME × 1 30-minute sessions Spaced-retrieval was significantly superior to DURATION OF ...... Number of goals mastered; number Achievement of goal; maintenance of Expanded Expanded. b ...... To discontinue participant’s inappropriate sexual : To increase the use of external memory aids (e.g. behavior. of sessions and trials neededgoals to maintained master one-week goals; and number four-months post-intervention. of goal 4 months post-intervention. memory wallets, reminder cards, andimprove physical activities cue) of to daily living,activity social participation, interaction, or to decreasequestions. specific repetitive task information and then perform it. displaying of the relevant wordasked (e.g. to glasses), perform and it. then Participant required to correctly retrieveand task then information, watch experimenter perform it. and asked to watch the experimenter perform it. Goal Goal: Two conditions: Outcome measure(s): Combined spaced-retrieval with fading cues. Outcome measure(s): 1. PPT-retrieval: Participant required to correctly retrieve 2. PPT-reminding: Participant reminded of the task by the 3. Experimenter performed task (EPT)-retrieval: 4. EPT-reminding: Participant was reminded of the task Goals (one goal per condition): 1. To put a pair2. of To glasses put in a their cap3. case. on To a put pen. a greeting4. card To in put an a envelope. lid on a jar. 1. Spaced-retrieval training. 2. Cueing hierarchy Residential facilities and adult dayWithin-participants care design centers (Level III-3 evidence) Inter-trial intervals: Psychiatric institution Case study design (Level IVInter-trial evidence) intervals: Four learning conditions: ...... 14.76 8 dementia Vascular = = = = 83.80 87 = = 25 1 age MMSE age MMSE = = dementia ...... M M Diagnosis N M M Diagnosis N Continued (2003) et al. (1994) Table 3. STUDY SAMPLE SETTING AND COMPONENTS Bourgeois Alexopoulos ...... Memory training for people with dementia 13 Participants continued to a one-week interval. use calendar. behaviors were reduced using spaced-retrieval. demonstrated by a reduction inbehaviors problem and/or increased use ofaids. external and disturbance caused by problem behaviors were found post-SR andthree-week at follow-up. a anxiety about soiling himself onlywhen apparent beeper went off. 87% of participants recalled the strategy after Six-month follow-up: Four out of five participants’ problem Five participants completed the study. SR successful for three participants, as Reductions in frequency, severity, distress, P2: successfully learned association, with his 20–30-minute × 30–45-minute weeks session per week participant. training sessions × Maximum of ten 1 Dependent on Three weeks 2to9 Not given P1: verbal and physical aggression ceased. 3) = N Achievement of goal. Maintenance and generalization of Maintenance of goal one-week and Achievement of goals; maintenance 2) and residential facility ( Expanded. Expanded Doubled to 60 seconds, then increased Expanded. = N Different goals for each participant. To reduce problem behaviors through the use of To look at an external memory aid (calendar) when they wanted to remember what activities were on that day. external aids. Different goals for each participant. goals post-intervention. six-month post-intervention; number of sessionsto needed achieve goal; generalization ofsituations. learned goal to relevant of the learned response one-month post-intervention. toilet. in 30-second increments. Goals: Goal: Goals: Participant 1 (P1): To decreaseParticipant verbal 2 and (P2): physical. To associate a beeper with going to the Outcome measure(s): Outcome measure(s): Outcome measure(s): Outcome measure(s): Residential facility Case study design (Level IVInter-trial evidence) intervals: Private home Within-participants design (Level IV evidence) Inter-trial intervals: Goals: Residential facility Case study design (Level IVInter-trial evidence) intervals: Private homes ( Case study design (Level IVInter-trial evidence) intervals: 2); = = = not given 18.5 12 N not given Mild Senile ======not given 72.5 77.60 5); 1) 1); Hypoxic 1) 2); 1) ======2 not given 6 5 N N N N N N age MMSE age MMSE age (range) age MMSE = = = = Alzheimer’s disease ( ( Alzheimer’s disease ( brain damage ( Dementia ( ( ( N M M Diagnosis N M M Diagnosis M 79–95 years MMSE (range) 9–22 Diagnosis N Vascular dementia M M Diagnosis N Vascular dementia Postanoxia dementia . et al. et al. et al (1996a) (2012) (1995) Bird (2001) Hunter Camp Bird 14 A. S. Creighton et al...... resented until the participant provides the ...... n the activities are developed according to each achieved 100% correct responses without any cueing during two consecutive sessions. and the use of errorlessparticipants learning, correctly both used their mobile phone without the aid ofcard. the instruction correct colored coupon after ainterval. seven-day performance when target coupon color changed. performance on the trained tasks,was and maintained this over a five-week period. At the end of three months, both participants Following the repetition of calling exercises All participants able to hand experimenter All participants able to adjust their Both participants demonstrated improved ...... 45–60-minute once or twice a week. weekly (number of sessions varied for each participant). TRAINING OUTCOME sessions per week. × Three months 45-minute sessions, One-hour sessions, Four weeks 2 DURATION OF ...... 1) = N ...... Number of correct responses during Maintenance of learned goal Improvements in performance of new 3) and residential facility ( Doubled to 60 seconds, then increased Uniform (increased by 30 seconds). Expanded = N Participant Performed Task...... = To train participants to use their mobile phone to call : Enable participants to remember to select a specific (2010), activities were designed to improve hand–eye coordination, scooping, pouring, and squeezing. somebody using an instruction card. to teach this goal. sessions; achievement of criterion forcorrect success responses (100% without any cueingconsecutive during sessions). two one-week post-intervention; number of sessionsto needed achieve goal; longest within-sessionachieved. retention interval colored coupon from an array of nine colored coupons. in 30-second increments. machine. skill both within and acrossinformation sessions; learned maintenance five-weeks of post-intervention. Combined spaced-retrieval training and errorless learning Within-participants design (Level IV evidence) Inter-trial intervals: Goal: Goal Outcome measure(s): Outcome measure(s): Outcome measure(s): Participant 1: To use voicemail. Participant 2: To manage messages from answering Private home Single-subject design (Level IV evidence) Inter-trial intervals: Goals: Private homes ( Private home Case study design (Level IVInter-trial evidence) intervals: et al...... 21.50 14.25 22 probable ======Not given 68.25 67 = = = 2 4 2 age MMSE age MMSE age MMSE = = = Alzheimer’s disease Alzheimer’s disease Alzheimer’s disease ...... M M Diagnosis N M M Diagnosis N M M Diagnosis N Mini-Mental State Examination; PPT = Continued et al. (1992) et al. (2002) et al. (2008) Cueing hierarchy: A systematic and graded sequence of cues of increasing power that are response contingent. Successive levels of the hierarchy are p Montessori-based activities: Teach skills to participants by breaking them down into steps or activities that progress from simple to complex. Ofte correct response, after which the order of cues is reversed. The aim is to elicit the desired response with the least powerful cue. Table 3. STUDYLekeu SAMPLE SETTING AND COMPONENTS Note: MMSE a b participant’s background and interest. In Lin McKitrick Thivierge ...... Memory training for people with dementia 15

One study was classified as level II evidence Bourgeois et al. (2003) found SR training to (Lin et al., 2010), two studies were considered be more effective than the method of cueing to be level III-2 evidence (Bird and Kinsella, hierarchy. 1996, Studies 1 and 2), one study was level III-3 evidence (Bourgeois et al., 2003), while eight studies were classified as level IV evidence Mixed goals/other target information (McKitrick et al., 1992; Alexopoulos, 1994; Bird Five studies used SR to teach participants a variety et al., 1995; Camp et al., 1996a; Bird, 2001; Lekeu of new associations and goals, with all studies et al., 2002; Thivierge et al., 2008; Hunter et al., finding that the technique improved and enhanced 2012). retention and recall of target information in the Two studies used SR training to directly majority of the participants (Table 4). One study reduce problem behaviors, with Alexopoulos (1994) was classified as level III-2 evidence (Small, 2012), undertaking a case study, while Lin et al. (2010) while the remaining four studies were considered conducted a RCT. Five studies (three case studies to be level IV evidence (Brush and Camp 1998b; and two within-participants designs) utilized the Anderson et al., 2001; Joltin et al. 2003; Cherry technique to increase the use of external aids (Bird et al., 2010). et al., 1995; Camp et al., 1996a; Bird, 2001; Using a quasi-experimental multiple baseline Bourgeois et al., 2003; Hunter et al., 2012), while design, Small (2012) utilized SR to teach three studies (one within-participants pre-test–post- participants diagnosed with Alzheimer’s disease (N test design; one single-subject design; and one case = 6) or amnesic mild cognitive impairment (N = 2) study) taught participants how to use functionally semantic (i.e. face- or object–name associations), relevant objects (Bird and Kinsella, 1996, Study prospective (i.e. cue–behavior associations), and 2; Lekeu et al., 2002; Thivierge et al., 2008). episodic (i.e. a significant past event) memory Two studies were more exploratory in nature, targets. He found that, compared to their recall at with Bird and Kinsella (1996, Study 1) teaching baseline, all participants had superior target recall 24 participants to associate a verbal and auditory for all three types of information after participating cue with the action of opening a book or box, in SR training, with improvements being found both reading instructions and performing them, while during training and 4 weeks post-intervention. McKitrick et al. (1992) taught four participants to Cherry et al. (2010) utilized a within-participants select a specific colored coupon out of an array of design to train four participants to recall a distracters. name–face–occupation association and attempted Five studies found that all participants to transfer this association over to an actual successfully learned the cue–behavior associations person. Overall, participants found it easier to recall (McKitrick et al., 1992; Alexopoulos, 1994; Bird, occupations compared to names. After one week of 2001; Lekeu et al., 2002; Thivierge et al., 2008), SR training, no participant was able to freely recall while six studies found that more than half of the target person’s name or job when they walked participants learned the strategies or behaviors into the room. However, after prompting from the being taught (Bird et al., 1995; Bird and Kinsella, researcher, one participant was able to recall the 1996, Studies 1 and 2; Camp et al., 1996a; target’s job and another was able to provide her Bourgeois et al., 2003; Hunter et al., 2012). Lin job after recognizing her photo. After two weeks of et al. (2010) did not state for how many participants training, the authors still found that no participants SR training was successful, however, they reported could freely recall the target’s name or job when a significant improvement in participants’ eating they entered the room. However, three participants ability and a decrease in eating dependency post- correctly selected her picture from the array of intervention. distracters, with one participant then being able to Six studies also demonstrated that the functional correctly recall her name and job. goals and strategies learned continued to be A case study analysis of three participants maintained at post-intervention follow-ups ranging by Joltin et al. (2003) demonstrated that SR from 24 hours to six months (Alexopoulos, 1994; training could be successfully implemented over Bird et al., 1995; Camp et al., 1996a; Bourgeois the telephone, with the authors successfully using et al., 2003; Thivierge et al., 2008; Hunter et al., the technique to increase the retention of target 2012). Additionally, Bird et al. (1995) found that information in two of the participants. One one participant was still effectively using a beeper to participant successfully learned three goals during tell him when to go to the toilet one year after SR the study, with two of the goals still being correctly training was implemented, with this learned cue– recalled at a five-day follow-up. behavior association also continuing to reduce his Employing a single-subject design, Anderson anxiety about soiling himself. et al. (2001) compared the effectiveness of SR 16 A. S. Creighton et al. = 2 d ...... Two participants 23.52). 24.83). = = ...... During training and at 2 2 During training and at d d 4 weeks post-training), Spaced-retrieval enabled all  ...... using memory tapes retained allinformation of and the one participant retained 5/6 items. One participant usingretained SR 6/7 items, with the5/6 other items. retaining maintenance, correct recall rate ranged from 50% to 100% (weighted group had superior target recall comparedrecall to at their baseline. maintenance ( correct recall rate ranged from100%, 75% with to all participants demonstrating improved recall of the target(weighted information group learning and correctly recalling allinformation. target target information in less sessionsparticipants than in memory tape group. participants to remember prompt response and the core details of(weighted recent mean events 23.49). After spaced-retrieval training, all participants Semantic condition: Both techniques resulted in participants Participants receiving spaced-retrieval learned Follow-up (10 days post-test): Prospective condition: Episodic condition: ...... 2-hour sessions 30-minute × × per target). sessions week). TRAINING OUTCOME Six weeks 12 (Two per week and Three weeks 12 (Four sessions per DURATION OF ...... 7). = ...... N 3) 2) = = N N ( a ...... Percent of correct recall in each : Percent of correct spontaneous and Expanded Expanded Independent recall of target information. Train participants to use an index card as an ...... ). 5 6). = = Goal: Goal: recall information about a past event; evidence) session; number of sessions neededcorrect to recall demonstrate of all targetinformation items; learned maintenance 1-week of post-intervention; generalization of information learned whenanother working examiner. with cued recalls for each session;information maintenance post-intervention. of learned N associations; external cue to recall target information. 3. Episodic memory targets (remembering what to do to Private home Quasi-experimental multiple baseline design (Level III-2 Inter-trial intervals: Two groups/techniques: Outcome measure(s) Outcome measure(s): Three conditions: 2. Prospective memory targets (cue–behavior associations; 1. Semantic memory targets (face- or object–name N 1. Memory tape technique 2. Spaced-retrieval training ( Residential facility Single-subject design (Level IV evidence) Inter-trial intervals: 2) = ...... N 21.25 18.40 Probable = = = = 73 years 86 years 6); = = = 8 5 N age MMSE age MMSE = = Alzheimer’s disease ( impairment ( dementia ...... N M M Mild cognitive Diagnosis M M Diagnosis N SR training to teach mixed goals/other target information (2001) et al. Table 4. STUDYSmall (2012) SAMPLE SETTING AND COMPONENTS Anderson ...... Memory training for people with dementia 17 One dementia participant No participant correctly al interval, after which the participant listened to elated to those facts. Each session required the stated name or job ofcorrectly target, selected but her three photo from the board. the study, with all learninginformation some and achieving their goals. consistently recalled all three goals.participants Three consistently recalled the personal information and compensatory technique and recalled the pathologist’s name 63% of the time.consistently One recalled participant pathologist’s name and the compensatory technique and recalled the personal information 63% of the time. participant learned the information, but retention did not carry oversituation. to The the third real-life participant learnedgoals her and after five dayscorrectly she recall was two still goals. able to name–face–occupation association. remembering target person’s name compared to occupation. r a brief pause for a response. Five participants with dementia completed Four-week follow-up: One participant was lost to follow up. One Spaced-retrieval enhanced retention of Participants had greater difficulty Live-person transfer: 1-hour sessions 30–60-minute sessions per week. sessions per week. 5–47 minutes. × × Three weeks 9 3 Four weeks Minimum of three Sessions ranged from held on alternate days. Achievement of criterion for success Number of correct/incorrect recalls : Proportion of correct and partially Expanded Expanded Expanded Eight distracter color photos, one target color : Different goals for each participant. (successful recall at beginning ofsessions); two number consecutive of session neededmaintenance to of achieve target criterion; information fourpost-intervention. weeks in each session; number ofcriterion sessions for needed success to (retention achieve ofconsecutive information sessions); over maintenance three of information learned post-intervention. photo of a previously unknown teacher at the center. correct trials; frequency of freeinformation; and generalization prompted of recall association of learnedlive to person. the Goals: Goals 1. To learn the speech–language2. pathologist’s Personal name. meaningful information. 3. Compensatory techniques. Outcome measure(s) Outcome measure(s): Outcome measure(s): Materials: Adult day care center Within-participants design (Level IV evidence) Inter-trial intervals: Residential facility Case-study design (Level IV evidence) Inter-trial intervals: Over the telephone Case study design (Level IVInter-trial evidence) intervals: N = 19.44 15.66 probable Dementia dementia = = = = = 82.3 years 83 years 88 years 7); Cerebral = = = = 4 9 3 2) N age age MMSE age MMSE = = = Alzheimer’s disease ( vascular accident ( = 9–19 Diagnosis M MMSE (range) N M M Diagnosis N M M Diagnosis N Mini-Mental State Examination. = . et al et al. (2010) Camp (1998b) (2003) Memory tape technique: Utilized personalized audio-tapes that included short segments of facts relevant to the individual, followed by questions r participant to listen to five repetitions of the tape and recall as much information as possible. This was then followed by a three-minute conversation another five repetitions of the tape. If the participant was unable to recall the information independently, the tape provided the correct answer afte Cherry Note: MMSE a Brush and Joltin 18 A. S. Creighton et al. training to a memory tape technique in helping and draw conclusions. Similarly, both the wide five participants with dementia recall personal variations found across studies in SR methodology orientation information. It was found that while and its similarities with some comparison conditions both techniques improved recall and retention of (e.g. errorless learning), not only makes it difficult the target information, participants in the SR group to draw clear conclusions about the efficacy of learned all the target information in fewer sessions this memory intervention, it also prohibits the than the memory tape group. Thus, the authors formulation of a clear definition of SR training. concluded that this technique was more appropriate Methodologically, only 11 of the 34 studies for training functional information. included a control condition or group. This makes Lastly, using a case study design, Brush and it difficult to draw firm conclusions from these Camp (1998b) used SR training to teach seven studies about the effectiveness of SR, as the gains participants with dementia three goals. Out of the found could be attributed to a number of other five participants that completed the study, all were variables. Moreover, only two of these 11 studies successful in achieving the criterion of correctly used observers that were blind to the conditions recalling the information at the beginning of two (Davis et al., 2001; Lin et al., 2010). Thus, for consecutive sessions. At the four-week follow-up, the remaining nine studies, there was the potential it was found that all participants were still able to for performance bias in the observers assessment of correctly recall at least two target goals, with one participants. participant still able to correctly recall all three. In addition, a general limitation of both face- and object–name association studies is the low ecological validity of the goals, with 13 out of 17 Discussion studies teaching participants information that they are highly unlikely to need during the course of Overall, the 34 studies reviewed provide some their daily activities. For example, Haslam et al. evidence that SR training can effectively teach (2011) and Hawley et al. (2008) used SR to people with dementia both new and previously teach participants the names of individuals who known information, as well as strategies that were unknown and unfamiliar, while Abrahams aim to reduce behavioral problems and increase and Camp (1993) used the technique to teach functional skills. While the majority of studies participants to correctly name line drawings of a found that participants learned some or all of “pretzel” and “dart.” Additionally, with regard to the target information following the intervention, the ecological validity of studies teaching name–face the range of methodological shortcomings found associations, only three studies investigated whether across the studies does warrant some caution when the associations taught using photographs could be interpreting results. successfully transferred over to the actual person Nevertheless, despite this and the variability (Hawley and Cherry, 2004; Hawley et al., 2008; found across studies with regard to the training Cherry et al., 2010). conditions, interval schedules, duration, type of The type of filler tasks undertaken during inter- goals, and participants’ severity, and type of de- trial intervals is also a potential limitation. For mentia, SR training consistently resulted in positive example, of the 11 studies that described filler tasks, outcomes. This demonstrates the versatility and three studies filled this time with activities such as reliability of this memory intervention, providing logic, word, and numerical puzzles (Bourgeois et al., further evidence of its practical application for 2003; Hopper et al., 2010; Haslam et al., 2011), this diverse population. In addition, this review while another two engaged in conversations about replicates and extends the conclusions drawn by the past with the participant (Camp and Schaller, Hopper et al. (2005). More specifically, through 1989; Vanhalle et al., 1998). These activities could the inclusion of a number of more recent studies, be seen as potential confounding variables, as the current review highlights and provides further recalling early memories and completing puzzles evidence of the positive effects and especially the have been found to have cognitively enriching clinical applicability of SR training for people with effects that may improve memory and recall. dementia. Moreover, 11 studies made their findings on SR training less clear and more complex by using Limitations of studies the technique in combination with other memory One key limitation of the literature as a whole is training interventions. For instance, Alexopoulos the wide variability found between studies with (1994), Bird (2001), and Bird et al. (1995) used SR regard to study design, outcome measures, and training in combination with fading cues to teach the presentation of results. This diversity makes five participants to associate a specific external cue it challenging for readers to compare findings with an alternative behavior aimed at reducing a Memory training for people with dementia 19 variety of problem behaviors, while Thivierge et al. accurate, the following recommendations could be (2008) used a combination of SR and errorless made: learning to teach one participant to successfully use his voicemail. Furthermore, while there is 1. Future studies should aim to address the limitations evidence of long-term retention and maintenance of previous research by including a control of information learned using SR training, only nine condition and blinding evaluators and observers. studies followed up participants for more than one 2. Future studies should aim to minimize the use month post-intervention. of memory during inter-trial intervals. Therefore, Lastly, 23 studies did not conduct any statistical thoughtful consideration should be given to the comparisons between pre- and post-intervention types of filler tasks undertaken during these periods. data, often because the sample consisted of one 3. A large enough sample should be recruited so that or two participants. This should not be seen as a strong statistical techniques can be used to compare limitation of previous research per se, as the number pre- and post-intervention data, as this will help to of positive results from case studies and single- provide empirical evidence for the effectiveness of SR training for this population. subject designs demonstrates the effectiveness of 4. Future research should aim to recruit a more SR training at an individual level. However, for uniform sample to determine the effectiveness SR to be deemed an empirically valid intervention, of SR training for specific subgroups and/or quantitative measurements and analyses should be populations. For example, studies could recruit undertaken. individuals who all have the same level of impairment and are at the same phase of dementia Limitations of this review (i.e. mild, moderate, and severe), as this may help to establish the stage at which the technique is most While this review provides evidence and support and least effective. for the use of SR training, it has a couple of 5. SR training should explicitly be used to teach limitations. First, we only included papers written functional and clinically relevant associations. For in English. Second, as with most reviews, it could instance, the technique could be used to help be argued that there is a systematic bias as studies prompt people to independently engage in activities with significant and positive findings are more likely of daily living, such as remembering to use to be published than those with non-significant or their walking aids when needed, maintenance negative results (Olson et al., 2002). This may have of personal hygiene (e.g. brushing their teeth, led to an overestimation of the success of SR training washing), and dressing. for people with dementia. 6. Studies should aim to conduct longitudinal (e.g. one year) RCTs that periodically track participants’ retention and maintenance of the Implications target information, as this will help determine the In terms of the clinical implications, the efficacy long-term benefits of this technique. of SR training in teaching new information and 7. With Small (2012) finding that SR training could behavioral strategies is a particularly significant effectively improve the recall of episodic memory finding, as it requires little expenditure of cognitive targets, future research should aim to replicate and effort and is a simple memory intervention for extend these findings using a larger sample size and people with dementia. The findings suggest that conducting longer follow-up sessions. 8. Future research should also aim to assess a range this technique could be effectively implemented of outcome measures, as this will help establish by caregivers or staff in a variety of settings. In the presence and/or extent of any secondary non- addition, the finding by Joltin et al. (2003) that cognitive benefits. For example, it would be of SR could also be successfully administered over interest to expand on Hawley and Cherry’s (2008) the telephone has significant implications for both findings and assess both the participants’ and their community-dwelling individuals and underserved caregivers self-reported quality of life pre- and post- populations, such as those who are immobile, intervention. live in remote areas, or do not have access to transport. Furthermore, the finding that successful SR performance produces significant secondary benefits with regard to improved overall quality Conclusion of life (Hawley and Cherry, 2008) is also of In conclusion, results from this review suggest that considerable clinical importance. SR training is an effective and viable memory intervention for elderly people with dementia. Recommendations for future research Future studies should aim to address the limitations To expand on current research and to ensure noted above and focus on a more practical that the conclusions drawn about SR training are application of SR training that enhances the 20 A. S. Creighton et al. independence and everyday functioning of people (eds.), Memory and Aging: Theory, Research and Practice with dementia. (pp. 212–225). New York: Springer Publishing. Camp, C. J. (2006). Spaced retrieval: a model for dissemination of a cognitive intervention for persons with dementia. In D. K. Attix and K. A. Welsh-Bohmer (eds.), Conflict of interest Geriatric Neuropsychology: Assessment and Intervention None. (pp. 275–292). New York: The Guilford Press. Camp, C. J. and Schaller, J. R. (1989). Epilogue: spaced-retrieval memory training in an adult day-care center. Educational Gerontology, 15, 641–648. Description of authors’ roles Camp, C. J., Foss, J. W., O’Hanlon, A. M. and Stevens, A. B. 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