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DOI: 10.1177/153331759100600404

1991 6: 17AM J ALZHEIMERS DIS OTHER DEMENSharon M. Arkin

Memory training in early Alzheimer's disease: An optimistic look at the field

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Memory training in early Alzheimer's disease: An

optimistic look at the field

Sharon M. Arkin, MEd

Abstract

The purpose of this article is to en-

courage caregivers and treatmentproviders ofearlyAlzheimerpatients totry various memory stimulation strat-egies since, as this article will show,some patients do benefit cognitively,while most- caregivers and patients

benefit emotionally andpsychologi-callyfrom the cooperative effort.

This article will review three pub-lished studies with encouraging resultsor elements, five with negative results,and three studies involving work withother populations that would seem tohave applicability to early stageAlzheimer patients. This author willalso describe two unpublishedmemorytraining interventions for early

Alzheimer patients that have hadpromising results, but are not yet pub-lished. Related research and encourag-ing trends will be summarized, andtreatment and rehabilitation strategiessuggested by these and otherpublishedliterature will be presented.

Lack of memory therapyfor AD patients

My interest in memory traininggrew out of a quest for such a servicefor my mother, who was diagnosed as"probable Alzheimer's" in June 1988,with memory loss as her only symp-tom. My search encompassed the fol-lowing publications of the National In-stitutes of Health on the latest federal-ly-funded Alzheimer research andtreatment programs:

*National Institute of MentalHealth, 1989;1

*National Institute of NeurologicalDisorders and Strokes, July 1989;2

*National Institute on Aging, March1989;3 and

*The Group forthe AdvancementofPsychiatry's (GAP) 1988 book, ThePsychiatric Treatment of Alzheimer'sDisease; and Publications of the Na-tional Alzheimer's Association, as wellas literature searches by three majordatabases (Psyclit, Medlars, and theAlzheimer's Disease Education andReferral (ADEAR) Center, a federally-funded Alzheimer's clearinghouse).This search yielded no references tocurrently available memory treatmentfor early stage patients, though mem-ory difficulties are frequently cited as

one of the symptoms that sufferers andfamily members often notice first.'-'

... The therapeuticbenefit ofpatient andcaregiver involvingthemselves with eachother in an effortfultask that addressesone ofthe patient'smost distressing andnoticeable problems

has enormousface validity.

The only memory treatment pro-gram for early stage AlzheimerpatientsI was able to find was an experimentalone being conducted by Curt Sandmanat the University of California at Ir-

6vine. I'd heard mention of this treat-ment on a television program about thebrain during the spring of 1989.Sandman's program, known as theMemory Enhancement and GeneralAwareness (MEGA) training program,will be described, along with an inter-vention I developed to helpmy mother,following this article's review of the

published literature.

Optimism needed

According to the Group for the Ad-vancement of Psychiatry's (GAP's)1988 book, The Psychiatric TreatmentofAlzheimer's Disease,4 there was no

The American Journal of Alzheimer's Care and Related Disorders & Research, July/August 1991

Author, SharonM.Arkin(right),with her mother,Beatrice Shultz, an Alzhemner's disease patient.Sharon M. Arkin, MEd, is a certified clinicalmental health counselor in Ft. Wayne, IN.

17



evidence that memory stimulation andcognitive training improved thinkingor memory function. The articles citedto support the conclusion of "no im-provement"7-9 were acknowledged asdemonstrating the importance ofstimulation and cognitive training incombating depression and increasing asense of mastery. It is this fact which,in my view, makes the case for suchintervention so compelling. Whetherornot significant or permanent memoryimprovement is achieved, thetherapeutic benefit of patient andcaregiver involving themselves witheach other in an effortful task that ad-dresses one of the patient's most dis-tressing and noticeable problems hasenormous face validity.

Nancy Mace, co-author ofthe wide-ly-used AD caregiver's handbook, The36-Hour Day,'0 in a 1985 speech,called for less dwelling on the sufferingand despair that are the inevitable con-comitants of Alzheimer's disease, in-creased attention to the rare successstories, and for increased commitmentto rehabilitation. Mace stated that:

I believe that our charge for thecoming decade is to learn whatwe can do to rehabilitate patients,to enable them to live WITH theirillness, to improve their function,to remove excess disability, andto improve their quality of life."

Americans are broughtup with slogans like"use it or lose it" and

"practice makesperfect. "

Increasingly, researchers andclinicians are calling formore attentionto cognitive training of the early andmoderate dementia patient.'2"13

In the 1981 book,'0 Mace andRabins stated that "families often ask if

retraining, reality orientation, or keep-ing active will slow down or stop thecourse of the disease."

The fact that the authors' answerwas equivocal about the benefits ofsuch retraining and activity stimulationis less important than the fact that, byasking the question, family members ofAD patients have demonstrated thatthey want to actively fight cognitivedecline in their loved ones. Americansare brought up with slogans like "use itorlose it" and "practice makes perfect."The positive feeling one gets from do-ing something pro-active with and fora memory-impaired person and thefeeling ofpurpose and involvement the

it is too early toconclude that early

stage ADpatients areunsuitable candidates

for cognitiveintervention.

impaired person experiences from en-gaging in an efforfful cooperative taskmake the effort worthwhile in and ofitself. And if, as the programs describedin this review seem to indicate, somepatients get some cognitive benefitfrom some interventions, so much thebetter.

Early Alzheimer patients mayprofit from standard memory

techniquesMost memory training methods that

work with nornal elderly and/or withpatients with amnesia caused by otherillnesses or head injuries are generallythought not to work with dementia pa-tients. These methods include visualimagery, organizational or categoriza-tion schemes, peg and loci strategies,and various exercises based on repeti-tion.14-16

Karlsson and his associates14 sug-gest that the reason for the failure of

these methods to work with Alz-heimer's disease and other dementiapatients may be the presence of other

It may be that many ofthe systematic

behavioral methodsdescribed in the

cognitive rehabilitationliterature would workwith early stageAD

patients.

deficits, such as agnosia and aphasia,attentional problems, and losses inpremorbid knowledge, autobiographicmemories, and visuo-spatial abilities.Because these conditions tend to bepresent more frequently and to agreater degree among more advancedAD patients, that theory may be lessapplicable to the early stage patient.Since research tends to be conductedmore frequently with more advancedinstitutionalized patients than withnon-institutionalized patients and sincemost early stage patients have neverbeen given an opportunity to work atmemory therapy, it is too early to con-clude that early stage AD patients areunsuitable candidates for cognitive in-tervention.

The literature of the emerging fieldof cognitive rehabilitation'7'l9 de-scribes many head-injured and otheramnesic patients who, in theirsymptompresentation and the intactness of otherabilities, are very similar to early stageAlzheimer patients, whose noticeableimpairment is limited to memory loss.

Itmay be thatmany ofthe systematicbehavioral methods described in thecognitive rehabilitation literature wouldwork with early stage AD patients.

Encouraging studiesOne encouraging report in the litera-

ture is of an eight-month experimental




cognitive stimulation program involv-ing 10 early Alzheimer patients andtheir spouses and six control couplesthat was sponsored by the University of

... they feltpositiveabout concretely

helping their spouse;they gained an

appreciation for theintact abilities ofthe

patient and learned newways of coping.

San Diego."3 The caregivers weretrained to provide one hour a day ofactivities from three differentcategories: conversation, memory-stimulating exercises, and problem-solving techniques. Monthly "booster"sessions were provided by project staffat the couples' homes.

Patient participants and controlswere assessed at the beginning, middle,and end oftreatment as to cognitive andbehavioral functioning. Caregivingparticipants and controls were assessedatthe same intervals as to their physicaland mental health status and feelings ofburden.

Results showed that patients in theprogram maintained theirlevels ofcog-nitive and behavioral functioning,while the control patients deteriorated.Seven out of ten of the caregiversreported that there had been positiveemotional outcomes for the patient as aresult of participating in the program.Participating caregivers remainedstable in terms of emotional well-being, while the control caregivers ex-perienced an increase in mental healthsymptoms.

Qualitative reports from participat-ing caregivers indicated that spousalrelations improved as a result of thecommunication fostered by the jointtraining endeavor; they felt positive

about concretely helping their spouse;they gained an appreciation for the in-tact abilities of the patient and learnednew ways of coping. One caregiverwrote, "A feeling of care has replacedthe no-hope, impersonal concept of thedisease."13

McEvoy and Patterson2o providedcognitive-behavioral training to 15 de-mented and 15 non-demented adults inan institutional setting. The dementedimproved as much as the non-de-mented in communications skills (ap-propriate expression of pleasure anddispleasure) and in personal hygiene,actually achieving the same level ofskill in the latter area. On personal in-formation and spatial orientation, the

Only in morecomplicated activities of

daily living, such aslaundry, meal

preparation, and moneymanagement did thedemented show no

improvement.

demented showed moderate improve-ment, while the non-demented requiredlittle or no training in these areas. Onlyin more complicated activities of dailyliving, such as laundry, meal prepara-tion, and money management did thedemented show no improvement.

The personal information com-ponent consisted of six basic items,such as name, address, and phone num-ber. The information was presented tothe subjects on index cards during thefirst week of training and knowledgeassessed afterone week. Staffasked thequestions of the patient at frequent in-tervals and provided visual and verbalprompts for the information notknown. Patients increased theirknowledge from an average of 2.17 to3.83 items correct; most of the gains

were made during the firstmonth ofthe20 weekprogram. The authors note thatthe AD patients showed the most im-provement in areas with the least cog-nitive involvement and where physicalpractice was part of the training andmulti-sensory feedback was received.

McEvoy and her present and pastassociates at the Florida Mental HealthInstitute inTampahave used cognitive-behavioral techniques to improve thebehavior, communication, and overallfunctioning of memory-impaired out-patients and their family members2 2=and in a geriatric day program.23 Unfor-tunately, budget cuts have resulted intermination of all outpatient programsand a de-emphasis on work withAlzheimer patients.2A

Several studies were found thatreported on memory experimentsrather than memory training involvingAlzheimer patients.

Karlsson et al14 in Stockholmhypothesized that presenting informa-tion whose encoding could be assistedvia a motor act would enhance learningin AD patients. They based theirhypothesis on Lawson and Barker'sobservatione thatdemented persons dobetter on object naming tasks ifthey areallowed to demonstrate the use of anobject prior to naming it. Alzheimer

With cueing, theADpatients were able to

increase theirperformancefivefold

over baseline.

patients at the mild, moderate, andsevere levels of the illness and healthyelderly controls were tested on free andcued recall of subject-performed tasks(SPFs), such as "lift the cup; put on theglove," etc. and on verbally presentedsentences containing the same infor-mation.

All groups, including all levels of

The American Journal of Alzheimer's Care and Related Disorders & Research, July/August 1991 19



AD patients, performed better on theSPTs than on the verbal task. Cueingeffects were greater on the SPN taskthan on the verbal task. The mildlydemented AD patients (Mini-MentalState scores above 20) did only about15 percent as well as the normal elderlyon free recall and 27 percent as well oncued recall of the verbally presentedmaterial; however, on cued recall(semantic categories presented oncards and read aloud), the mildly de-mented achieved 25 percent of theirnormal counterparts scores on freerecall and about 50 percent on cuedrecall.

Several of the least impaired ADpatients did nearly as well as normalson cued recall tasks in an experimentconducted by Cushman, Como, Booth,and Caine,27 though the other ADpatients did not; none of the ADpatients approached normals' level ofperformance on free recall. Withcueing, the AD patients were able toincrease their performance fivefoldover baseline. They demonstrated bet-ter performance on recognition than onrecall tasks and recalled related wordlists better than unrelated ones. Thisstudy contradicted a smaller one byBuschke27 which found similar perfor-mance by AD patients and normals ona cued recall task identical to the one inthe study by Cushman's group.

GAP did acknowledge,however, that such

training and stimulationmay have a positive

effect on mood, senseofmastery, and quality

of life.

Discouraging studiesA recent book on the psychiatric

treatment ofAlzheimer's disease by theGroup for the Advancement of

Psychiatry4 cited three studies to sup-port their conclusion that cognitivetraining and stimulation does not im-prove memory and thinking skills inAD patients.7-9 GAP did acknowledge,however, that such training andstimulation may have a positive effecton mood, sense of mastery, and qualityof life.

Five other studies with discouragingoutcomes were found in the literaturepublished since 1980.

Yesavage'5 provided memory train-ing to 300 outpatient elderly subjectsranging from normal to moderately de-mented in cognitive abilities. Trainingconsisted of relaxation and concentra-tion exercises and mnemonic strat-egies, such as imagery, categorization,

Most patientsappreciate having

their memory problemattended to and arewilling to work hard

on it.

and the use of loci to remember a list ofitems. Goal was to correlate improve-ment on measures of dementia andmemory loss with scores on theFolstein Mini-Mental State.

Results indicated that persons scor-ing over 25 (generally regarded as nor-mal) did quite well and persons scoringunder 18 (moderately demented) didnot benefit at all. Persons scoring in themild range of 18-24 showed some im-provement on test scores, but minimalimprovement in practical functioning.

Zarit and associates 6 used visualimagery in an attempt to improvememory functioning in communitydwelling elderly dementia patients. Ontwo out offour recall tasks, subjects didworse at post-test than on pre-test.Slight, but non-significant improve-ments occurred on the two other recalltests. According to caregivers, none of

the modest improvements had any im-pact on functioning at home.

Concentrate onteaching or reviewinginformation that is

personally significantto the patient.

Individual cognitive skills remedia-tion training was undertaken with 10mild to moderately impaired (Mini-Mental State scores of 15-20) institu-tionalized dementia patients.28 Amatched control group received notraining. Training took place threetimes a week for six weeks and focusedon attention and reading, concentratingon detail, and remembering. Resultsshowed no overall difference betweenthe experimental and control subjectson the cognitive skills pre-test andpost-test used.

In contrast to the experimentalresults of Karlsson and his colleaguesin Sweden described above,14 re-searchers at the University of Califor-nia/Irvine29 found that Alzheimerpatients did no better recalling taskswhich they performed (SPTs) than theydid verbal descriptions of tasksprovided by the experimenter. Youngand non-impaired elderly subjectsshowed significantly higher recall ofthe SF`Ts.

Cognitive training of amnesicsTwo comprehensive published

works on cognitive rehabilitation ofthehead injured and neurologically im-paired were reviewed for applicabilityto the treatment of early ADpatients.'7'19

Sohlberg and Mateer17 describe twotreatment methods that seem par-ticularly appropriate for use with earlystage AD patients:

* Systematically teaching the




use ofmemory notebooks, and

Teaching prospective memoryskills - remembering to dothings in the future.

Daily orfrequentpractice may slow

down mentaldecline.

The first step in teaching the use ofthe memory notebook is repeated ad-ministration of questions and answersabout the notebook's purpose and con-tents. The second step is role playing ofsituations necessitating notebook use.Finally, notebook use in real situationsis assigned and monitored. Prospectivememory skills are taught by teachingsubjects to perform tasks, such asmaking a phone call, at gradually in-creasing intervals.

Four globally amnesic patients wereimproved in functioning sufficientlyvia the above-described methods thatthey were able to live independentlyand hold jobs.

Wilson and Moffat19 have writtenextensively about their individual andgroup memory training work withbrain-injured individuals. They con-cede that the very mildly dementedmight benefit from traditional memorytherapy techniques and recommend 24hour or classroom reality orientationfor the confused elderly in inpatientsettings. For further information onreality orientation with the elderly, seeHanley and Hodge, 1984.40

Schacter, Rich, and Stampp,18 intheir work with four amnestic patients,demonstrated that memory-impairedpersons could be taught to retrieve in-formation at increasingly longer tem-poral intervals after exposure to thematerial. I accidentally discovered thatthe spaced retrieval technique workedwith an early AD patient (my mother)

while I was on a plane trip with her. Shehad repeatedly askedme where she hadgotten the bracelet she was wearing.Finally, after the fourth inquiry, I gaveher the answer and, rather impatiently,asked, "Do you think you can remem-ber that for 30 seconds?" I asked whereshe'd gotten the bracelet 30 secondslater, then a minute later, then fiveminutes later, and kept it up - everincreasing the time intervals and withlunch and other distractions in betweentill the five hour trip was over. Abouthalf way through the trip, she askedwho was meeting us at the airport. Igave her the answer and started theprocedure all over again with thesecond bit of information. She recalledboth pieces of information consistentlyby the end of the trip and rememberedwho had met the plane the next day,when I asked her the question over thetelephone. She did notknow what I wasreferring to when I asked about thebracelet the next day, probably sinceshe was no longer wearing it.

Memory training: Two personalunpublished reports

In November 1989, I took mymother to the University of Californiain Irvine to participate in the memorytraining class (MEGA) I'd heard abouton television. I arranged to do a clinicalpsychology practicum in Alzheimertreatment under the program's director,Dr. Curt Sandman.

The MEGA program consists offour two-hour training sessions atweekly intervals. Each training class iscomposed of two to four couples, eachcouple consisting of a memory-im-paired early AD patient and a spouse orpartner with normal memory.

The MEGA program presents fourmajor learning activities:

Learning the names of andbasic facts about students andinstructors in the class throughclass drills, home study ofphotographs and class notes,

and weekly quizzes on thematerial;

* Home viewing of a mutuallyagreed upon television show,preparation of quiz questionsabout the program, and takingof a quiz about it;

* Planning and carrying out a"significant event" day,defined as an activity or outingthat is out of the ordinary forthe couple, and then taking aquiz about the day; and

* In-class viewing ofemotional-ly-laden excerpts from thefilm, On Golden Pond, andthen taking a quiz about it.

Sandman's approach is based on hisbelief that a lot of hard work can com-pensate for some of the memoryproblems early AD patients experienceand that they (and theirnormal memorypartners) will remember novel ex-periences more vividly than routineevents.

Sandman's preliminary findingswere that, with a great deal of effort,some AD patients could, in fact, ap-proximate the level of recall achievedby their normal partners without effort.

Unusual experiencesmay be rememberedbetter than routine

ones.

My mother was not able to do this.Despite enthusiastic participationduring the class sessions and manyhours spent on homework, she couldnot remember that the class existed be-tween sessions or remember people orevents that were the subject ofclass andhomework assignments.

However, one of my practicum ex-periences with an earlyAD patient whohad been successful in the MEGA




program led to my discovery of an in-tervention that did work with mymother. The idea for this interventionwas discovered quite by chance.

Dr. Sandman asked me to observe aparticular patient, a 58-year old man,and his wife during a "significantevent" day and then, later, to quiz thepatient on his recall ofthe day's events.It had been agreed that I wouldvideotape the patient during the quiz.

As the quiz proceeded, it was ob-vious he was having a terrible timerecalling details ofthe day. After aboutthe third incorrectly answered ques-tion, I came upon the idea of supplyinghim the correct answer for each un-known question and leaving thevideotape with the correct answers forhim to review over the week. The resultwas most encouraging. On the originalquiz, the subject answered eight out of19 questions correctly, most of themwith prompting. On a re-take of thequiz, after four viewings of thevideotape, the subject answered all 19questions correctly, with only oneprompt.

Involvement ofmotor activity

sometimes facilitateslearning in someAD patients.

I later adapted the question andanswer format that had worked withthis subject to my mother's situationa need to prepare for my forthcomingmove out oftown and forherforthcom-ing move to a retirement building.Since she did not own a VCR, I decidedto use an audio cassette recorder in-stead. In her case, I prepared brief in-formational narratives followed bypertinent questions; each question wasfollowed by a pause for her to answer,if able, and then the correct answer wassupplied.

My mother learned the material ontwo subject matter tapes to near 100percent accuracy after six to eight prac-tice sessions. The material on the tapesgreatly facilitated her adjustment to ourchange in residence and was observedbeing used by her in social conversa-tion many months after the trainingtook place. Two single subject replica-tions ofthe above-described methodol-ogy became the subject ofmy doctoraldissertation (in progress) and had high-ly significant results.

Treatment implications andrecommendations

None of the studies cited in theabove literature review on memorytraining and research with earlyAlzheimer patients demonstrated sig-nificant global cognitive improvementas a result of training. However, the SanDiego study13 suggested that cognitivestimulation could temporarily halt orslow down the inevitable cognitivedecline that is associated withAlzheimer's disease and, when familymembers are involved in providing thestimulation, patient and caregivermood and relationship tends to im-prove.

The McEvoy and Patterson study20as well as Sandman's and my experi-ence indicated that limited amounts ofspecific and personally significant in-formation could be taught, using avariety of face-to-face drills and audioor video-assisted quizzing methods.

The type oftraining and stimulationdescribed by the San Diego study neednot be done by a family member or byexpensive professional therapists. Ihave trained two college students tocoach my mother, using audio andvideo materials I developed, and toplay word fluency games with her. Theaudio tape contains important personaland family information and remainsconstant; on the flip side is more cur-rent information that I keep updated,e.g., recent and upcoming vacations,

deaths, weddings, etc. Each brief fac-tual narrative is followed by a quiz,with each question stated twice and thecorrect answer given after a pause. Aspreviously stressed, it is the questionand answer portion of the tape thatseems to have therapeutic value.

Figuring out thereasonfor or goal

ofa person'stroublesome behavior

is an importantfirst step incorrecting it.

The primary videotape contains aseries of thirty second segments of 25important people in my mother's life;the student asks her to name each per-son as his or her image is on the screen.The student shows her other videotapesof her participation in family events,vacations, etc., to jog her memory,stimulate conversation, and to maintainher self-confidence. (Many of thevideotapes show her doing skillful andactive things, such as singing, dancing,playing the piano, and swimming.) Mymother has shown no significantdecline in social skills or self care or onformal neuropsychological and lan-guage testing in three years, though hermemory deficit was and continues to besevere.

Despite the disappointing lack ofconclusively positive outcomes inmostof the studies reviewed, a number ofobservations and recommendationswere derived from them and other sour-ces that could be of use to family andinstitutional caregivers of AD patientswilling to experiment with mentalstimulation activities. These are sum-marized below:

Alzheimer's disease and in-dividual patients vary consid-erably. Some respond to




memory training under sup-portive conditions. Anythingmight work. Experimentationmay be fruitful.

Most patients appreciatehaving their memory problemattended to and are willing towork hard on it. The effort istherapeutic and gives hopeand sense ofpurpose to patientand coach/caregiver.

* Concentrate on teaching orreviewing information that ispersonally significant to thepatient.

* Coaching sessions can bedone by high school or collegestudents, neighbors, friends,relatives.

* Daily or frequent practice mayslow down mental decline.

* Unusual experiences may beremembered better thanroutine ones.

* Audio and videotapes offamiliar people and familyevents are a tremendous assist.They have reassurance orcomfort value even whentraining effect is no longer evi-dent.

* Involvement of motor activitysometimes facilitates learningin some AD patients.

* AD patients do better onrecognition tasks than on tasksinvolving free recall. Multiplechoice and sentence comple-tion quizzes on past events,public figures, commercials,slogans, and the like are veryuseful. See Brennane for acollection of multiple choicereminiscence exercises.

* Many early AD patients ex-perience verbal fluencyproblems in addition to

memory loss. Word fluencygames, such as naming wordsbeginning with a given letter;naming objects in differentcategories; Scrabble; Hang-man; structured or guided con-versation; and informationreinforced by systematic ques-tion and answer sessions assistlearning. For an excellent col-lection of word fluency exer-cises and games see Stof-fregen.32 For a collection oftheme-based sensory-mentalstimulation programs forgroups, see Ashworth.3

Learning occursmore easily if the

learning environmentis consistentover time.

* Figuring out the reason for orgoal of a person's troublesomebehavior is an important firststep in correcting it.3435

* Teaching or reteaching taskscan be more easily ac-complished by breaking tasksdown into individual com-ponents and teaching themsystematically.

* Learning occurs more easily ifthe learning environment isconsistent over time. This sug-gests it is better for memorytraining to take place in thesubject's home than at atherapist's office.

* AD patients can learn per-sonally significant informa-tion (past and prospective)with frequent and consistentquestioning and prompting.Most such learning takes placewithin the first four weeks oftraining. This prompting can

be done in person or with theaid of audio or video tapes.Only very motivated and highfunctioning subjects an be ex-pected to work with tapes ontheir own. Anecdotal experi-ence suggests that caregiversmay not have the motivation todevelop audio and video mat-erials for their patients. Alz-heimer expert Dr. MarshallFolstein reported that he ex-plained the intervention toseveral caregivers, but thatnone followed through (per-sonal conversation, June 20,1991). It may be that the helpof a therapist is required to getthe ball rolling. I have foundthat I can getmy mother to usethe cassette recorder by meansof step-by-step instructions bytelephone, although she does-n't remember what a cassetterecorder is between sessions.

* Recall can be improved insome early AD patients by theuse of hints or cues.

* AD patients at mild, moderate,and severe stages of impair-ment can be retaught basicself-care skills using be-havioral methods.

* Memory-impaired personsvary from time to time on whatthey know or remember, somultiple assessments are im-portant.

* AD patients mightmake betteruse of external memory aids ifthey were systematicallytaught how to use them.

* For maximum impact on ac-tivities of daily living,memory training for ADpatients should emphasizeprospective memory skills,that is, remembering to dothings in the future.




* Quizzing persons on to-be-learned information is moreeffective than equivalent timespent in re-presenting the in-formation.

* Look for ideas in the literatureof many disciplines, i.e. spe-cial education, nursing,motivational training, etc.

* Speech therapy can improveand prolong communicationsskills of some AD patients.36

Memory-impairedpersons varyfrom timeto time on what theyknow or remember, somultiple assessments

are important.

Conclusions andrecommendations

There is something important that Ilearned from my search for memorytraining ideas. That is that one must be"ecumenical," or simply stated, notlimited to one field. If I had maintaineda narrow viewpoint to the literature ofclinical psychology which is my dis-cipline, I would have missed importantand relevant work from the fields ofnursing, neurology, education, neurop-sychology, psychiatry, and the layliterature of the Alzheimer field.

From a tireless and resourcefulcaregiver,36 I learned about the impor-tance of providing speech therapy toAlzheimer patients in order to prolongtheir ability to communicate.

From studying the research andtreatment literature on memory workwith Alzheimer patients, I concludedthat one possible explanation for thedismal results that are so often reportedis the irrelevance of the material beingtaught or that is the subject of testing.What possible motivation could there

be for a memory impaired person towork hard at learning lists of words,number strings, or names and faces ofstrange people? It's about as much funas reading the phone book. Also, itseems that the practice of evaluatingthe effectiveness of a particular cogni-tive intervention by comparing pre-and post-training performance on testsof general cognitive ability is besidethe point. I believe that early Alzheimerpatients should be treated as learningdisabled persons or rehabilitationclients and tested on the materials theyhave been taught. If they are taughtpractical personally significant infor-mation and they learn some of it, thetransfer effect will be readily apparentto family members. In my mind, it isnot important if they remember moreor fewer facts on a Wechsler MemoryTest story or an IQ test.

From observing memory testing attwo leading memory disorders clinics,I came to see the treatment and researchpotential of some of the evaluationmaterials used to periodically assessdementia patients. Difficulty in namingcommon objects when visually con-fronted with them is a commonAlzheimer symptom. The standardizedset of pictures used to test this ability,the Boston Naming Test, could be usedby caregivers and researchers to testand compare the efficacy of variousteaching methods, drawn from the fieldof special education, in improving per-formance on this task. The set ofphotosof famous people from past decades,used to test visual recognition and longterm memory, developed by Dr.Marilyn Albert at MassachusettsGeneral Hospital, could be usedsimilarly. Single subject research is ac-cepted practice with the neurologicallyimpaired.37-39 Alzheimer patients arenotorious for being unpredictable as tosymptom presentation and diseasecourse. The considerable individualdifferences among them are lost ingroup studies. Single subject research

is especially suitable for this popula-tion and is a good method for trackingcognitive performance.

The Boston University MemoryDisorders Clinic, which putmy motherthrough a comprehensive series ofproven and experimental memoryevaluation tests and exercises, uses aninteractive computer program to testAlzheimer and other amnesic patients'ability to learn touch typewriting. Sincemy mother had once been an ac-complished typist, it was not clear thatthe programmed instruction wasresponsible for her success on this task.What was noteworthy was the fact thatshe became increasingly better at fol-lowing written instructions (e.g., "Typethe letter 'p"'), a skill area in which shehad become deficient. If she could beretaught to promptly follow written in-structions, techniques such as attachinga "sticky back" instructional note to apre-set alarm clock, mighthelpprolongher independence. The potential forearly AD patients to recover some lostknowledge and skills through ap-propriate computer programs seemsenormous.

Recall can beimproved in someearlyAD patients

by the use ofhints or cues.

In this article, I have attempted toencourage readers to not "give up" onthe Alzheimer patients in their lives. Ihave also given examples of cognitivestrategies and interventions that haveworked in some cases and might workin others. Most Americans, includingmany early Alzheimer patients, willreadily complete the phrase, "If at firstyou don't succeed" with a resounding"try, try, again." This slogan canmotivate both patients and caregiversas long as they are realistic in their




expectations about results and acceptthis version of another popularAmerican slogan: "Practice makes im-perfect! "OJ

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The American Joumal of Alzheimer's Care and Related Disorders & Research, July/August 1991 25



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