Putting Spaced-retrieval Into Your Practice The previous chapter provided you with an overview of Spaced-retrieval research and techniques, with a few case examples to clarify concepts. A review is being provided here to ensure the material is clearly reinforced and on its way to retention. Repetition is the roadway to the remembering! This is particularly true when learning new information. If you are familiar with adult learning principals you know that the formula is tell the class what you are going to say, say it, and at the end summarize what you have said. Basically, that is what we are doing. You have just read about Spaced-retrieval and now reading about it again. This chapter is a bit of a repeat of the last chapter, but in more detail. The objective is to provide you with the details that you will require when you decide to adopt Spaced-retrieval techniques as part of your practice. In this chapter you will learn more about each stage of a Spaced-retrieval memory training program. Review of last chapter: To be sure you have grasped the basics! If you have read the previous chapter, test your understanding (and memory). A space is provided for you to put your answer, with the correct answer positioned in the box beside or below the space provided. The Objective of Spaced-retrieval: The objective of SR: Bourgeois (1991) recommends that across the course of Dementia of the Alzheimer’s Type (DAT), “Treatment should focus on activities designed to enhance feeling of control by addressing the most obvious symptom o dementia – the memory deficits”. Camp, et al., 1996 (page 181) Write your answer here:
Transcript
Putting Spaced-retrieval Into Your Practice
The previous chapter provided you with an overview of Spaced-retrieval research and techniques, with a few case examples to clarify concepts. A review is being provided here to ensure the material is clearly reinforced and on its way to retention. Repetition is the roadway to the remembering! This is particularly true when learning new information. If you are familiar with adult learning principals you know that the formula is tell the class what you are going to say, say it, and at the end summarize what you have said. Basically, that is what we are doing. You have just read about Spaced-retrieval and now reading about it again. This chapter is a bit of a repeat of the last chapter, but in more detail. The objective is to provide you with the details that you will require when you decide to adopt Spaced-retrieval techniques as part of your practice. In this chapter you will learn more about each stage of a Spaced-retrieval memory training program.
Review of last chapter: To be sure you have grasped the basics!
If you have read the previous chapter, test your understanding (and memory). A space is provided for you to put your answer, with the correct answer positioned in the box beside or below the space provided.
The Objective of Spaced-retrieval:
The objective of SR:
To assist the person with impaired memory (e.g. – dementia or amnesia) to remember targeted information over longer and longer periods of time.
Bourgeois (1991) recommends that across the course of Dementia of the Alzheimer’s Type (DAT), “Treatment should focus on activities designed to enhance feeling of control
by addressing the most obvious symptom o dementia – the memory deficits”.Camp, et al., 1996 (page 181)
Write your answer here:
How Do You Accomplish This?
Your answer:
The target (information or a behavioural objective) is selected for the cognitively impaired individual and the focus is on helping that individual to remember this information/behaviour over time. A strategic time/interval schedule is developed with the purpose of increasing the retention intervals over longer and longer periods of time (e.g. – weeks or months, with the objective of moving the information/behaviour into long-term memory). You ask the target question, wait for the person’s response (which hopefully is correct), wait the duration of the time interval to ask the question again, and with each successful response, increase the time as per the designated schedule. The session will last about 30 minutes. The next session will begin with the last successful time schedule. If successful, carry on as per the schedule, if not, go back to the last successful interval and begin again. The purpose is to help the person to remember this particular piece of information/behaviour over longer and longer intervals of time.
Why is Spaced-retrieval successful?
Your answer:
Spared memory systems are utilized. The individual will learn/relearn the targeted information (using implicit/procedural memory) but will not remember that learning has taken place (because of the damage to the explicit memory system). Procedural memory and reading skills continue to function in the early and middle stages of dementia and can be used extensively in Spaced-retrieval interventions with great success.
Process, Tools and Techniques
The remainder of this chapter will focus on the practical components of the Spaced-retrieval method of memory intervention, providing you with an overview of the process, tools required at each step and then, in the latter parts of the chapter, you will be introduced to some specific strategies and techniques. This chapter focuses on the things you will need to know before you try these techniques out on your clients. The tools have been developed based on the experiences (and research) of the Myers Research Institute, Menorah Park Centre for Senior Living, in Cleveland, under the direction of Dr. Cameron Camp. For more detailed information contact the Myers Research Institute or visit their website at www.myersri.com.
Preparing for Spaced-retrieval Sessions
Before you begin those sessions you will need a referral to the program and then you will need to collect some important information about the participant.
_____ Diagnosis: □ Dementia: □ DAT □ FL □ LB □ Other
□ CVA □ TBI □ Other_____ Medically stable_____ Alert and awake_____ New admission to facility/program
Resident is demonstrating one or more of the following behaviours:
_____ Repetitive questioning
_____ Decline in independent ADL’s
_____ Disorientation and anxiety
_____ Attempts to leave
_____ Not recognizing family members
_____ Fearful of staff or unfamiliar people
_____ Lack of engagement in available activities
_____ Anger toward self or others (has been screened by psych)
_____ Lack of socialization
_____ Overall decline since hospitalization
If you have marked any of the above areas or have any questions, please contact __________________________at _________________for a full Spaced-retrieval evaluation.
Assessment Procedure
If you are working with individuals who reside in a long-term care facility you could begin by checking their files for information pertaining to diagnosis. You may find the person has been assessed by a physician, a geriatrician or a psychiatrist and the diagnosis has already been stated (e.g. – Dementia of the Alzheimer’s Type, Vascular Dementia, Lewy-body Dementia, Frontal Lobe Dementia or Mixed Dementia). Any of these findings would suggest that the individual being considered for this programming would be eligible. If, however, there is no such information in the file (and this might pertain to individuals in a Day Program or those who are in the community), a complete assessment should be conducted prior to using the Spaced-Retrieval Screening Tool. The Mini-Mental State assessment tool (Folstein, 1975) is often used in the process of assessing for dementia. The test is easy to administer (note: it is recommended that trained individuals score the results). The MMSE is scored on a scale of 0 – 30, with the lower the scores being an indication of more severe forms of dementia. The MMSE can be thought of as a screening tool. Moreover, it can help you to monitor change in each of the domains over time (e.g. – time orientation, place orientation, registration, attention and calculation, etc.) However, the MMSE has not proven to be culturally sensitive (Mast, et al., 2001) and can create false positives (meaning that a dementia may be suspected when in fact it may be a language or cultural barrier that has contributed to the low score). While there are more sophisticated cognitive and neuropsychological methods of assessing for dementia (Mast, MacNeill & Lichtenberg, 2002), the MMSE will provide you with some baseline information. If you suspect that a more in-depth assessment is required you should make arrangements (with facility or family) for this person to see his/her medical specialist.
Screening
The Spaced-retrieval Screening Tool is used next. Follow the steps, which are clearly laid out, to determine whether a particular individual is capable of participating in Spaced-retrieval memory training. As you will see after reviewing, and actually using the form, the directions and dialogue are straight forward.
CAMERON – is there a getting to know you tool that you use??? That would help with the prompt question –
Screening Form
This screening tool has been developed by the Myers Research Institute (Brush and Camp, 1998) to help you determine whether an individual who is cognitively impaired will be a candidate for Spaced-retrieval (SR) memory training. If the participant makes three errors at any of the screening levels described below (No Delay; Short Delay; Long Delay) STOP the SR training. You will notice that the form is laid out with the intention of relaying a very relaxed message that communicates, “I am here to help”. The feedback the participant receives is friendly, positive encouragement. If the individual’s answer is correct he/she is told, “That’s right. I’m glad you remembered.” If the answer was incorrect he/she is not told the answer is wrong. The screener simply says, “Actually, my name is ________________”. You never use statements that overtly state, “No, you are very wrong”.
The example below targets the name of the SR trainer as the information to be retained by the participant. This is just an example. You may use something different if there is obvious target information that you would like this person to retain (e.g. - name of daughter, where he/she lives, who visits daily, etc.)
TIMING: NO DELAY
Place an X here for each error made at this level: ________ _______ ________
STEP 1: Begin by saying:
“Today we are going to practice remembering my name.My name is _______________________. What is my name?
Step 2: If the client’s response is correct, say:
“That’s right. I am glad that you remembered.”Proceed to Short Delay Step 1.
Step 3: If the client is incorrect, repeat Step 1 again, exactly as stated above.
Step 4: If the client is correct on the second try, proceed to the Short Delay. If the client is incorrect on the second try, repeat Step 1 one more time.
Step 5: If the client’s response is correct on the third try, proceed to Short Delay Step 1. If the client responds incorrectly three times, STOP. This client is not appropriate for SR training. Proceed to the Exit Line.
Timing: Short Delay (following a correct response in “no delay”)
Mark here for each error made at this level: ________ ________ _______
Step 1: Create a short delay (approximately 10 -15 seconds) between requests for recall by saying:
“Good. I will give you more opportunities to practice as I am working with you today. Let’s try again. What is my name?”
Step 2: If the client’s response I correct, say:
“That’s right, I am glad that you remembered.”Proceed to the Long Delay Step 1.
Step 3: If the client’s response is incorrect, say:
“Actually, my name is _________________________. What is my name?”This provides the client with the correct information, then asks for immediate recall. Go back to No Delay Step 2 and follow directions.
After the third incorrect response after the short delay, STOP. The client is not appropriate for SR training. Proceed to the exit line.
Long Delay
Mark here for each error made at this level: ________ ________ _______
Step 1: Create a longer delay (20 – 30 seconds) between requests for recall by saying:
“You are doing well remembering my name for a longer period of time, and that’s the idea. I would like you to always remember my name. I will be practicing this with you during each session by asking you often. What is my name?”
Step 2: If the client responds correctly say:
“That’s right, you are remembering for a longer period of time.”Proceed to Continuation Line below:
Step 3: If the client responds incorrectly say:
“Actually, my name is _________________. What is my name?”Return to the Short Delay Step 1 and follow the directions. If the client responds incorrectly three times after the long delay interval, STOP. This client is not appropriate for SR training. Proceed to the Exit Line.
Continuation Line: If the client passes the screening say:
”You did a great job remembering my name. We are going to continue practising this during memory training.” Follow the directions provided on the recommended dialogues.
Exit Line: If the client did not pass the screening say:
“Thanks for trying so hard. Let’s work on something else now.”NOTE: This screening tool has been developed by the Myers Research Institute (Brush and Camp, 1998, pg 27).
Prompt questions/target information need to be considered next. You need to do consult with those who know this person best to find out what questions might be most useful. In fact, you can ask the person with dementia if there is something they would like to remember. You can decide to focus on a piece of information (e.g. – someone’s name), a problem behaviour (e.g. – repetitive questioning) or behavioural change (e.g. – where to look to find out about today’s activities). The Spaced-retrieval Process Model outlines the next steps that must be followed in the process of implementing SR techniques.
The Spaced-retrieval Process Model
A model outlining each step of the Spaced-retrieval intervention is presented below. This model provides an overview of the process, beginning with identification of a problem situation. Please note that we have skipped the stage of assessing to determine eligibility for Spaced-retrieval training. We are assuming the person has been screened and recommended for the program. The person who qualifies for Space-retrieval intervention experiences memory difficulties that interfere with daily functioning. For example, anyone who has been diagnosed with dementia or amnesia, and thus has difficulty with memory, is suitable for Spaced-retrieval training. If you work with people who engage in repetitive questioning or repetitive behaviours you know the challenges encountered by both the person who questions and those who are trapped in the cycle of ongoing response. (Note: The word “trapped” may seem to be a bit harsh, but if you ask those who work directly with individuals who are repetitively engaged in seeking orienting information, they feel frustrated and often helpless, as they search for ways to help the person in their care.) This is a perfect candidate for Spaced-retrieval.
The Spaced-retrieval Process Model
Identify a problem (e.g. – participant does not remember caregiver’s name)
Develop a suitable prompt question (e.g. – What is your room number?)
Begin by providing the answer to the prompt question.
Develop strategy for spacing of intervals between exchanges (question to be asked by you and retrieval of the information from participant).
Train the participant to recall the answer (consider using cue cards, thus combinng motor movement, via turning the card over, with verbal
response).
With each successful retrieval/answer the space between intervals is
increased.
If the answer is incorrect, provide the
correct answer and return to the last
successful interval.Continue for 30 minutes.
Once you are comfortable using these techniques, incorporate other activities into the
training session (such as cards, chatting or something else this person would enjoy).
If the answer is correct, increase the timing of the next interval to the
nextdesignated time.
When you say good-bye, thank the participant for meeting with you today.
Session 2 (and subsequent sessions)
Begin with the question/target information and the timing of the last successful interval.
If the information is retrieved successfully, no need to hold the session –
retention has been successful.
If the answer is not correct, begin with the last successful
time interval from the last session.
Fade cue cards when no longer needed
Decisions about what to target (learn/relearn) first
Each person you work with is different, with different interests and memory capabilities. Some people are in the earlier stages of neurological decline, therefore not experiencing the same degree of memory impairment as those who in the middle or later stages. There are some people that present with obvious first questions (e.g. – they engage in repetitive questioning all day long and you are very familiar with the question you want them to be able to answer!) If you do not already know the person you are about to work with there are a number of ways to determine your first target question. Staff who work closely with a resident will already know what information is chronically being sought or behaviour(s) is/are problematic. For example, the staff who are assigned to work with individuals who engage in repetitive vocalizations would likely recommend that you begin with the question that is asked most frequently. Others might be working with residents who are disoriented, and thus in need of orienting information. Others might be “exit seeking” and in need of information that will help them to relax and remember where they are and why they are here.
It is important to point out here that the individual with impaired memory might tell you what he/she would like to remember. Don’t overlook the spared capacity, and awareness of his/her own frustrations that result from impaired memory. You might be surprised to hear them list off a few key pieces of information that would assist him/her with feeling less agitated and more oriented.
Getting Started
Remember, you always begin with a concrete question, never abstract. You provide the answer at first and then you ask the question and set the objective for your client to recall the answer over time. There are generally three categorical options to choose from when making your decision about your first targeted information for recall and retention. Consider starting with something simple, such as, “What is my name?”, the first time you try out this technique. As stated in the previous chapter, you can print your name in large letters on a cue card and the participant can use this as a prompt. When you ask for the response, you can tell the participant to look at the card. As the time intervals increase and retention improves you can work toward extinguishing reliance on the card and focus on remembering without a prop.
Memory Problem Categories for Spaced-Retrieval Target Question Development
Generally, there are five broad areas that capture the memory problems you will want to tackle. These include:
Disorientation Naming and other important personal information Repetitive questioning Disengagement Behavioural change Executing prospective task
DISORIENTATION – The Quest for Important Personal Information
The underlying problem for many who challenged by the consequences of memory loss is that of finding the answer to personal information that, in the past, was always so easily accessed. Imagine how disoriented you would feel if you could not remember the name of a loved one (e.g. – spouse of 50 years – and you can’t even recall how long you have been with this stranger. In fact, at times you are quite certain that this is not your spouse!) Can you imagine how frustrating and depressing it would be to wander the halls wondering where you are and how you are going to find your way home? These are the types of questions that are suitable for Spaced-retrieval memory training. If we can put the “person” in the equation by thinking about how difficult this must be for anyone of any age, we can more easily connect to the person and the problem. All too often, when people become frustrated with problem behaviours they lose sight of the fact that this is a normal person who just happens to have been diagnosed with dementia. When you make that “personal connection” you will find the person who has been lost behind the problematic behaviours and the repetitive vocalizations.
Sample Spaced-retrieval questions and answers, related to the disorientation category, follow. Answers may be printed and available on a prompt/cue card for the participant to read. In future, after the SR techniques have lead to retention, the answer to the question will be available on their cue card for them to read only when required.
“What does this person REALLY need to remember?”
Where do you live? (Answer: If living at home, the answer could be the street address. If living in a long-term care facility, the name of the facility can be used. If the individual is always wanting to know the name of the town, that would be the answer you would have this person learn/relearn.)
What is your room number? (Answer: Correct room number.)
What floor are you on? (Answer: Floor number. This is an important piece of information for those who regularly use the elevator to go to meals and/or recreational activities.)
Who looks after you? (Answer: The name of the caregiver that provides most, if not all, of the care. This is particularly important for the person at home who has a “stranger in my home” on a daily basis.) Note: This question fits with “naming” as well but since caregiving is so very personal it has been included here.
Where can you find information about what will be going on today? (Answer: Depends on the situation. Sometimes the schedule will be posted in a central location, while others will have a personal schedule available on the wall in their room, in a book that contains information about today’s activities or on a single sheet that is easily accessible.)
Obviously there are many other questions to add to this list but the main consideration in formulating your target question is, “What does this person REALLY need to remember?” It might be useful for this person to remember his/her birth date, where he/she worked, how many children/grandchildren he/she has, etc., but are these the most important pieces of information that will provide the most benefit in everyday activities? If they are, then start there. Input from the individual and family and staff will help you make good decisions about where to begin.
NAMING: More than just a memory slip
Each of us struggles from time to time to find the word we want to use in a sentence. Unfortunately, this is an ongoing, relentless problem for those diagnosed with various forms of cognitive impairment. There are a variety of questions you can develop to address this problem.
A universal feature of dementia is disorientation to:
Time Place Person
Spaced-retrieval training can be used to help the person remember the answers to questions that provide orienting information.
What is your caregiver’s/daughter’s/son’s/wife’s/husband’s name? (Answer: Provide the name.)
If you don’t know the name of something, what should you do? (Answer: Describe it.)
Who looks after you here? Or Who runs the social activities here? (Answer: Provide name of the person targeted. (CAMERON – What is the final word on using a picture of this person – does that help?)
Where do you keep your clothes? (Answer: In the blue closet. (Note: sometimes lockers are colour coded and it is important to learn which location is for “me”.)
Repetitive Questioning: Difficult for staff, more difficult for cognitively impaired!
If you work with individuals who ask the same question over and over and over, you may think you will soon go crazy. This is only one side of the equation. What would you do if you were on a trip and couldn’t find your hotel? Would you keep asking for help until you found your destination? Or would you just sleep in your car for the extent of the vacation so you wouldn’t bother anyone with your questions? Not knowing the answers to important questions is not only bothersome, it is quite anxiety producing! We just can’t imagine how difficult it must be to always be searching for simple answers and then immediately forgetting that vitally important, sought after information. Spaced-retrieval techniques are perfect memory interventions for this problem. Not only do they provide relief for the individual who is in constant search of information, they also take some of the burden away from staff who become frustrated with “same old, same old” questions. The target question is totally dependent on the individual’s quest for information.
Repetitive Questioning: The target question will reflect the repetitive
question of the participant.
In the space below, identify 5 questions that you have encountered in your work with those who are challenged by memory loss.
Changing Behaviour : A key feature of health and safety
Spaced-retrieval can benefit those with memory dysfunction by teaching them to do something before doing something else. For example, they may not remember that it is important to grasp the grab bars before sitting on a toilet. Corkin (1968) and Damasio et al. (1990) report that people who have been diagnosed with severe memory deficits, including Dementia of the Alzheimer Type, can learn/relearn motor skills. Motor learning, as noted earlier, is a spared ability in dementia. Therefore we can pair motor learning abilities with verbal information for positive outcomes related to health and safety. For example, the target information that is to be learned can relate to some element of safety such as gripping grab bars, locking brakes on a walker or wheelchair or chewing before swallowing.
“Hayden and Camp (1995) used SR to teach persons with dementia associated with Parkinson’s Disease a two-step motor task, a two-step verbal task, and a combined motor-verbal task. Brush and Camp (1998b) taught a man with dementia both to verbalize and follow through with a compensatory swallow technique during dysphagia therapy.”
Brush & Camp (1998), pg 62
Although there are many examples that could be applied to those who are cognitively impaired, there will be very specific examples that can be developed to suit individual circumstances. Staff and family tend to know what the problem issues are and will be able to assist in making decisions about what needs to be learned first.
Adamowicz (1995) successfully used Spaced-retrieval to teach associations between environmental cues and identifiable behaviours that were regarded as problematic, particularly for staff. For example, “a man confused about where to urinate was trained using Spaced-retrieval to associate a large coloured sign with the location of the toilet. This decreased his confusion about where the toilet was located, and inappropriate voiding ceased” (Camp, et al., 1996, page 208).
Questions and Answers Used for Creating Behavioural Change: What should you do before you sit in your
chair? (Answer: Grab the arms of the chair.)
What should you do before you take a bite of food? (Answer: Take a drink and swallow.)
What should you do before you get out of bed? (Answer: Put my glasses on.)
What should you do before you eat? (Answer: Put my teeth in.)
What should you do before you sit in your wheelchair? (Answer: Put the brakes on.)
What should you do before you use your walker? (Answer: Make sure the brakes are on/off, depending what the problem is for this person.)
Where should you go to the toilet? (Answer: Where there is a sign that looks like this [a picture of the toilet that is exactly like the one in the men’s or ladies’ room would be provided].
DISENGAGEMENT: Who really wants to be bothered?
Life can seem overwhelmingly futile when one struggles to remember even the most simple facts of life. If you can’t remember where you are, you might not really care about what you might be doing today. A favourite expression that applies here is: You need someone to love, a reason to get up in the morning and something to look forward to. If we can help the person who is challenged by memory loss remember who it is that loves them the first part of the expression will be addressed. If we can teach the individual to remember to look at the schedule the following two will also be attended to before he/she begins the day.
Disengagement: Where can you look to find the schedule of
activities for today? (Answer: The activities board in the main hall. In my book.)
Where can you find a list of things to do today? (Answer: In my book of “things to do today”. The answer would obviously be individualized for each person.)
What can you write in every day? (Answer: My diary.)
What can you do when you want to be reminded of your family? (Answer: Look through my Memory Book.)
What can you do when you want to remember details about your life? (Answer:
Look through my Memory Book. Note: Each memory book can be set up differently.)
What do you do every morning? (Answer: I go for a walk with my daughter.)
Who calls you on the phone every afternoon? (Answer: My son/daughter/granddaughter/husband/wife.)
Prospective Memory Tasks
Camp, Foss, Stevens and O’Hanlon (1995) discovered that Spaced-retrieval techniques can be used to assist a person with dementia complete a prospective memory task. In other words, they were able to teach memory impaired individuals to remember to do something in the future. Notably, the people with dementia were experiencing severe memory loss, and under normal circumstances were incapable of remembering new information for more than a few minutes (and in some cases, could not retain information for more than a few seconds). A pilot study conducted by McKitrick, et al. (1992) revealed that individuals who had received Spaced-retrieval interventions were able to perform a prospective memory task over a 1-week time delay. Camp, et al. (1995) found that 61% of the calendar study participants were able to carry out the strategy in two to three training sessions. The strategy included the following elements:
Answering the question, “How are you going to remember what to do each day?” correctly. The correct answer was, “Look at my calendar”.
Each page of the daily calendar had two tasks for the participant to complete:
o The participant was required to sign his/her name on the page for that day, and
o Read the instructions for the task to be completed that day, and then,
o Complete the task.
When developing an intervention such as this you need to take into account the likes and dislikes of the participant. Camp, et al. (ibid) chuckled to find that at times the task was not completed because the individual simply did not like that activity (e.g. – the task labeled ‘take out the garbage’) and thus did not follow through to complete the task. It might have been concluded that the person could not remember to perform the task. However, conversations with participants followed, pointing
“Successful use of calendars [using Spaced-retrieval techniques] may occur in spite of concurrent decline in other memory measures (perhaps indicative of continued decline in explicit memory).”
Camp, Foss, O’Hanlon and
Stevens (1996),pg 205
to the fact that some tasks are not enjoyable and will therefore not be completed by certain individuals. This was a particularly important observation in that it may be the type of task that is the culprit, not the memory impairment. Decisions about the task to be completed should therefore be made in consultation with the person with the memory impairment, family and staff who really know the participant.
These research findings have proven to be useful for those who are searching for information about today’s activities. The participant can be taught to look at his/her calendar, record notes that outline an activity that he/she needs to complete today and then follow through to complete the task. Considering that people with dementia suffer dramatic short-term memory loss these findings present an exciting contribution to memory rehabilitation.
Questions for the spaced-retrieval training:
“How are you going to remember what to do each day?” (Answer: “Look at my calendar.”)
Types of tasks to include on the calendar (Camp, et al., 1996): Water the plants. Take out the garbage. Save an article from the newspaper. Dust the furniture. Fold the towels. Sweep the floor.
It is interesting to note that caregivers report numerous benefits from this particular intervention. Note that the caregivers can be also trained to use these approaches. Caregivers “described perceptions of reduced stress, increased optimism and increased perceived control after implementation of the intervention” (Camp, et al., 1996, page 206).
To Summarize . . .
Focus on one target (learning/relearning) that you want the person with cognitive impairment to remember over longer and longer intervals of time. Consult with family and staff in the process of making the decision about where to begin (the first piece of information you want this person to remember). Once you are
successful with the first piece of information being retained over time, you can introduce a new question and answer.
The Specifics of Spacing in Spaced-Retrieval
Spacing the intervals between the trainer/participant exchange requires a bit of homework. You will need to know the degree of impairment as a starting point. Those who are in the later stages of dementia will have suffered devastating consequences of memory loss and will need shorter intervals when the training begins.
Landauer ang Bjork (1978) have used a variety of recall schedules to determine whether a fixed schedule would lead to memory retention. Shaughness and Zechmeister (1992), as cited in Camp, et al. (1996), replicated Launauer’s and Bjork’s work with the cognitively impaired and indeed found that fixed interval schedule is “clearly within the general spaced-retrieval experimental paradigm” (page 198).Cameron I need your help here. What is the ideal interval schedule? Do you have any recommendations established? Eg – Mild memory problems 1, 3, 5, min intervals? Moderate. . . . . . Moderate severe . .. . . . Some of the research used seconds so I’m not sure what to put here. Do your have guidelines for the novice????I’ve created a chart because I think that would be useful for those who are learning. Maybe it isn’t that simple but could we use something like this to help people get started? How do you decide length of time between intervals? Is there a formula? Are you doubling with minutes? I’m guessing that may be too much in seconds so made up the timing below
Note: Numerical value provides a guideline re the individual’s MMSE score (Folstein, 1975). Should we include these scores beside labels (mild, etc)
Errorless learning is an important component of memory training (Baddeley, 1992; Wilson, Baddeley, Evans & Sheil, 1994). When the participant provides an answer that is close - but not exactly correct - it is important to provide the accurate response, thus providing an opportunity for the individual to immediately recall the correct information. If incorrect information is repeated, and not corrected, it seems quite obvious that their revised answer will soon replace the correct one. For example, Mrs. Right likes to go to the dining room on her own. She needs to take the elevator to the second floor, but tends to forget which floor she needs to go to for meals. The SR session is set up to ask, “What floor do you go to for meals?” The response is, “The second floor.” If she says she needs to go to the third floor the correct response must be provided, while saying she was close but not quite right. If she says this more than once you can adjust the technique by clearly printing the floor number on a
Severity ofMemory Loss Spacing of intervals
Minutes SecondsMild (28) 1 2 4 8 1
632
Mild-moderate (25)
1 2 4 8 16
32
Moderate (19) 1 2 4 8 16
32
30
60
120
180
140
Moderate-severe (14)
30
60
120
180
140
Severe but not end stage (5)
30
60
120
180
140
Errorless learning “represents a behavioural technology applied to cognitive rehabilitation. . . . [It is the] eclectic fusion of research and theoretical perspectives …[and is] … critically necessary in the development of effective memory interventions for persons with dementia and other memory-impaired populations . . . This method is likely to increase the robustness and durability of learning.”
Camp, Foss, O-Hanlon and Stevens (1996), pg 200
Errorless Learning
prompt card and asking her to read the answer. This is an example now of combining motor movement with reading and verbal response. The card can then be left with her to use if she should need it when she gets on the elevator. The outcome is that she continues to maintain a level of independence (an important element in this very independent woman’s quality of life) with the reassurance that information is available on her card if she should become confused in the elevator.
Time Intervals: What do you do when you get “stuck”?
If the participant “gets stuck” at a particular time interval and just doesn’t seem to be able to move on to the expanded interval with success you need to modify your strategy. Camp recommends taking an approach of “over learning”. Since errorless learning is important, and frustration is to be avoided, he suggests that you remain at the successful time interval and remain at that level to provide the participant the opportunity to “over learn” the information. Once this has been accomplished you can then proceed to the next extended interval and aim for success at that level. If you are successful, continue to move on. If not, stop.
Case Examples:
CameronI’d like to include one or two cases and then refer the reader to the Brush and
What do you do when someone gets stuck at a particular time interval?
Repeat the interval over, and over and overObjective: “over learn” the information
Camp (1998) book. I like the layout of the case in your book on SR.
I would also like to include the data sheet for this case so the reader can clearly follow a case with at least two or three of the data sheets filled out so they can see how this progresses.
Protocol for Spaced-Retrieval
The protocol for Spaced-retrieval is presented next. This has been adapted from Brush and Camp’s 1998 guidebook on using Spaced-retrieval techniques. It is recommended that you refer to this book to assist you with improving your understanding and developing your SR skills. The book can be purchased through the Myers Research Institute.
Protocol for Spaced-Retrieval Adapted from: Brush & Camp, 1998
1. The therapy session begins in a normal manner. The client is told that he/she will be given practice remembering things and that the first item to be practiced is ______________________________________.
Today we are going to practice remembering _______________________. (State the target information.) (Now ask the question again.) If the answer is correct, comment on how pleased you are that he/she remembered.
2. There is a brief interval filled by saying: Now let’s practice again. (Repeat the same question.)
3. If the participant remembers the name, proceed to the next and longer interval. If the response is incorrect, repeat the interval again. If the client cannot correctly remember for three consecutive initial intervals, stop and try again at another time (a day or two or a week later).
4. The third interval, lasting about 10 seconds, is filled by saying: Good. I will give you more chances to practice this as I am working with you today. Let’s try again. What is (state your targeted question.)
5. If the correct answer is given, proceed to number 6. If an incorrect response is given, immediately provide the client with the correct information and go back to number 2.
6. The fourth interval, lasting about 20 seconds, is filled by saying,Good. You are remembering _________________ very well and you are remembering after a longer period of time. That is the idea. I want you to remember for longer and longer times so you will always be able to remember this. I’ll be asking you about _____________________ every once in a while, just to give you practice. (Ask the question again.)
7. If the correct answer is given, proceed to step 8. Each time an incorrect response is given, say: Actually, ____________________. Then repeat the question again.
This gives the client the opportunity to finish a trial with a successful recall. Simply telling the client the name will not help them learn it. Then, ask the client for the information after the same amount of time as the last successful recall.
8. Continue to ask the client to recall the therapist’s name after increasingly longer intervals of time such as two minutes, four minutes, eight minutes, sixteen minutes, etc.
Record-Keeping: Oh the pesky paper work!
Charting baseline data, as well as progress across time, is absolutely essential to the success of spaced-retrieval memory training. You will need to keep track of the SR time intervals as well as the client’s responses during each session.
The Data Sheet presented below has been tested and utilized widely by staff and researchers at the Myers Research Institute in Cleveland as well as by many others who have learned from Dr. Cameron Camp’s expertise and adopted the SR techniques. The form was adopted in the United States and therefore has specific criteria included on the form that is required for billing purposes. We do not have this same system in Canada. The information presented here is therefore adapted for the Canadian context. If you are interested in learning more about the billing structure, the form used in the US for Speech Language Pathologists and the required documentation, see Brush & Camp, 1998 or contact the Myers Research Institute in Cleveland, Ohio.
Although you may not need to track progress for billing purposes, the principles of accountability embed the commitment to quality of care and well-documented accurate records that can be used for future reference.
HELPFUL HINTS RECIPE CARDScreen participantsIdentify the target or approach you want to focus onSelect a modality or approach that is meaningful to the participant, and if possible, let the participant choose what they want to rememberDo not select abstract information, focus on learning objectives that are concretePick one target at a time, thus teaching one thing at a timePlan to have fun throughout the sessionDevelop an interval schedule that is consistent with capacity to enable success, rather than failure – the objective is errorless learning! Adapted from: Malone, 2002
CLIENT GOAL AND SPACED-RETRIEVAL DATA SHEET
Client Name:______________________________ Type of Therapy:______________Date: ____________________ Trainer/Position:______________________________Phrase/Question to be asked in Training: __________________________________
Information Client is Learning:____________________________________________Longest Time Between Successful Recalls Achieved Last Session: ______________Successful Recall at the Beginning of This Session? ( ) Yes ( ) No
The numbers below represent the minutes between recall of information. Circle the time interval completed and indicate if the recall was correct or incorrect by placing a plus (+) or minus (-) sign in the last box.
Trial
M I N U T E S
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0 2 4 5 6 8 0 2 4 5 6 8 21 2 3 4 5 6 8 1
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Therapy/Training Goals Current Status Date
Functional Progress/Status (important notes from today’s session):
1. Type of therapy: This question will be completed for disciplines such as Physical Therapy, Occupational Therapy or Speech Therapy. This may not apply to many who use the form so may be left blank for filled in with N/A (not applicable).
2. Date: Record today’s date/the date of the training session.3. Trainer/Position: Your name and position or department should be included on the
form.4. Phrase/Question to be asked in Training: Precisely write out the exact phrase or
question that you will ask during training. For example, if your objective is for this person to remember her caregiver’s name your question would be, “What is your caregiver’s name?”
5. Information Client is Learning: Identify the exact details related to the answer to the question. Be sure you know the name of the caregiver targeted. For example, “Your caregiver’s name is Beth.”
6. Longest Time Between Successful Recalls Achieved Last Session: If this is the first session write that in the space provided. For the second and subsequent sessions record the longest amount of time that the client was able to recall the information correctly during the last session. For example, if the participant was successful at 8 minutes, you tried 14 minutes but were not successful, the last successful recall is 8 minutes. You can move towards the 14 minutes in this next session.
7. Successful Recall at the Beginning of the Session: If this is the first training session, mark this N/A (not applicable). If this is the second or subsequent session, ask the client to recall the information before you begin the SR training. Record the outcome (yes or no). If the client correctly recalls the information at the beginning of three treatment sessions you can stop training and consider that retention has been successful. You can then move on to another target question.
8. Chart: The numbers represent minutes. Circle the number that corresponds to the time interval just completed. Each time there is a correct recall place a plus sign (+) in the empty (far right) box, and a minus (-) sign if the response is incorrect. Typically you will be using the numbers 1, 2, 4, 8, 16 and 32. Extra numbers have been provided should you need them
9. Therapy/Training Goals: Identify the client’s therapy goals in the space provided. 10. Progress: Progress in today’s session or since the last session can be recorded here.
You could also include information about what you did, if anything, while conducting the SR training (e.g. – played cards, chatted, etc.) A copy of these notes can be kept in the client’s/resident’s file for other staff to read.
Adapted from: Brush and Camp, 1998
Is Spaced-retrieval a Form of Badgering?
To an outsider or to the person being asked the same question over and over, it might appear that staff are “badgering” this individual. Let’s use physical therapy as a means of comparing the repetition. If you want physical therapy to be effective it is important to “do your exercises”. Sometimes this requires doing the same things over and over, but the outcome may be stronger muscles and the ability to walk again. The objective is to do what is necessary to reach the desired goal (e.g. – walking). Spaced-retrieval is similar. It is the practice (with strategically developed intervals incorporated throughout) that contributes to the successful outcome.
Megan Malone, Speech Language Pathologist at the Myers Research Institute, has used SR techniques successfully for a number of years. While her clients have not said she was badgering them, they have asked why she is asking the same questions over and over. To help the participant understand what she is doing she begins her session by telling the client why she will be asking the same question a number of times during their session. In Megan’s words:
“I've had a few clients who would ask me why I kept asking them the same thing over and over, so I just got into the habit of saying something like this at the beginning(and sometimes) throughout the treatment sessions to combat the problem:
"We are going to be working on __________________ today. I'mgoing to be asking you the question, "_________________" often today. Thiswill help you to remember the answer more easily, so just bear withme."
Often times if the client knows that the frequent asking of a promptquestion is allowing them to remember important information moreeffectively (and as Dr. Camp has said we'd like to see people choosing whatthey would like to remember or have it be information that will affecttheir level of independence, safety, relationships etc. and therefore ismeaningful for them to learn), they are willing to tolerate thestructure of the treatment and aren't as bothered by being asked thesame question over and over.
Most importantly, as with any intervention for dementia, if the individual does not want to be involved in the activity it is vitally important to stop. You simply thank him/her for his/her time and suggest that you could do something together at another time or move on to something you know this person would enjoy.
What Does the Future Hold?
In many ways spaced-retrieval techniques for the cognitively impaired are in their infancy. The full scope of possibilities has yet to be unleashed. As researchers and clinicians continue to explore the untapped potential of these techniques they will consider such questions as: Is there an optimal recall schedule? If yes, what is it? Are there other types of information that can be learned and recalled over time? How much information should be managed at a time? What role does overtraining play and is it beneficial in the short-term and/or long-term? Are there variations to the use of spaced-retrieval that would extend retention intervals longer than weeks or months? All of these questions are new frontiers needing to be explored. In the meantime, there is no question about the amazing benefits of spaced-retrieval as memory intervention for those who suffer from cognitive impairment.
