The Spaced-Retrieval Technique: Research Findings & Clinical Implications

1. The Spaced-Retrieval Technique: Research Findings & Clinical Implications Megan L. Malone, M.A. CCC-SLP Myers Research Institute, Beachwood, OH Jenny Loehr, M.A. CCC-SLP Arden Courts, Austin, Texas

2. About Myers Research Institute… • Fourteen full-time research staff • Three Ph.D. researchers • Multiple part-time staff • Funding provided by both federal and private sources • NIA, NIMH, National Alzheimer’s Association, Retirement Research Foundation, HCR Manor Care Foundation, etc. Mission To developing practical interventions for dementia and other disabling conditions associated with aging

3. About Arden Courts… • HCR Manor Care • Alzheimer’s assisted living facility • 60 residents (Min. to moderately independent) • ST, OT and PT offered five days per week Mission: To assist each resident in maintaining the highest possible level of functional independence appropriate for the assisted living environment.

4. Seminar Objectives • Define the Spaced-Retrieval (SR) technique and its application to cognitively-impaired individuals. • Provide 2 examples of how SR can be applied to patients with cognitive impairment. • Identify 2 current research findings on the use of SR in rehabilitative settings.

5. The Spaced-Retrieval Technique • Spaced-Retrieval is a memory intervention that gives individuals practice at successfully recalling information over progressively longer intervals of time. • The goal of SR: To enable individuals to remember information for long periods (days, weeks, months, years) so that they can achieve long-term treatment goals. • Therapists teach clients strategies that compensate for memory impairments, using procedural memory, including reading and repetitive priming. • In addition, SR uses external aids to compensate for memory

6. The Spaced-Retrieval Technique • Capitalizes upon the strengths of an individual with dementia • PROCEDURAL MEMORY • READING SKILLS

7. Memory(Squire, 1994) Declarative Memory Procedural Memory Facts Events Skills Habits World Knowledge Vocabulary Simple Classical Conditioning Priming

8. The Spaced-Retrieval Technique • Begin with a prompt question for the target behavior and train the client to recall the correct answer • When retrieval is successful, the interval preceding the next recall test is increased. • If a recall failure occurs, the participant is told the correct response and asked to repeat it • The following interval length returns to the last one at which recall was successful.

9. SR Example • SR Goal: ‘R’ will learn location of room to decrease wandering into unsafe areas by correctly recalling room number at the beginning of 3 consecutive therapy sessions using SR. • Information to be : Facility room number • SR Prompt : What is your room number? • SR Response: 208

10. SR Example • Trial 1 (0 Seconds): Client Responds CORRECTLY • Trial 2 (10 Seconds): Client Responds CORRECTLY • Trial 3 (30 Seconds): Client Responds CORRECTLY • Trial 4 (60 Seconds): Client Responds INCORRECTLY • Therapist provides client with correct response (“208”), asks the client the prompt question again, allows the client to respond, and returns to the interval at which the client was last successful. • Trial 5 (30 Seconds): Client Responds CORRECTLY • Trial 6 (60 Seconds): Client Responds CORRECTLY

11. SR Case Studies • 90 year-old female; Diagnosis: dementia; residing on SCU • MMSE: 12/30 • Anomia, disengagement, executive dysfunction • SR Goal: ‘R’ will recall and demonstrate strategy of describing items in order to better communicate wants & needs during 80% of trials. • Prompt Question:“If you don’t know the name of something, what should you do?” • Target Answer:“Describe it.”

12. SR Session Video Example

13. SR Case Study • 82 year-old male; Diagnosis: dementia; residing on a sub-acute unit of a LTC facility • MMSE: 8/30 • Loss of ability to perform ADLs independently • SR Goal: ‘R’ will consistently respond to cue during meals in order to maintain focus on self-feeding during 80% of trials. • SR Prompt :“E., your food is here.” • SR Response: E. looking down at tray of food and independently feeding himself

14. SR Session Video Example

15. SR Screen • The SR screen evaluates client’s ability to correctly recall a target name for a person in a photograph over 3 different time intervals or Steps (Step 1 - immediately after presentation; Step 2 - after a 10 second interval; and Step 3 - after a 15 to 20 second interval). • At each Step the client is offered three trials. • Three trials per step. • Only advance to next step if successful at previous step. • Exit if not successful at Trial 3 of Step 1 or Step 2. • Consider offering the client a visual cue.

16. SR Screen

17. SR Goal Examples • Disorientation • “Where do you live?” (Answer: Name of Facility) • “What is your room number?” (Answer: Room #) • “What is your address?” (Answer: Client’s address) • Repetitive Questioning • Dependent upon question being asked

18. SR Goal Examples • Naming • “If you don’t know the name of something, what should you do?” (Answer: “Describe It”) • What is your husband/wife/son’s name? (Answer: Target name) • Who runs the activities here? (Answer: Staff member’s name) • Disengagement • What can you read to remind you of your family? (Answer: “Read my memory book”) • What can you check to see what is planned for the day? (Answer: “Activity Schedule”) • What can you look at to find something to do? (Answer: “My list of activities”)

19. National Institute on Aging SR Study Funded by the National Institute on Aging • R01 AG17908 • R01 AG17908S1 Cameron J. Camp, Ph.D.Principal Investigator Michelle S. Bourgeois, Ph.D.Collaborative Researcher

20. SR Research: R01 AG17908 • To determine to what extent use of Spaced-Retrieval (SR) increases the effectiveness of treatment for communication problems in persons with dementia during the course of standard speech therapy sessions • To assess to what extent use of SR enhances the effectiveness of goals achieved during therapy • Data taken at 2 different sites (Ohio & Florida)

21. SR Research • Screen for appropriateness of SR as a treatment modality for each client • Client assessment, collection of medical information, interview of a caregiver • Baseline • One week after therapy has concluded • Four months after therapy has concluded • Selection of goals for therapy • Data taken on each therapy session

22. SR Research Results • Persons with dementia can master a wide variety of clinically relevant goals in therapy delivered by Speech-Language Pathologists. • In this study, SR was more effective in allowing persons with dementia to master goals than BP (67% of goals attempted were mastered for SR vs. 57% for BP; BP=Best Practice) • Training materials and protocols for implementing SR have been developed that can allow dissemination of this therapy technique on a large scale.

23. SR Research: R01 AG17908S1 A 1-year research project designed to: • Train staff at HCR centers in the application of Spaced Retrieval (SR) using the train-the-trainer model • Assess the effects that the training has on various outcome measures for dementia residents at each center • Examine the impact that SR training has on the existing system/infrastructure of participating centers.

24. SR Research • Baseline data was collected from each facility examining the speech therapy caseload over a 6 month period. • Data collected for baseline included demographic information (age, diagnoses, medications), and MDS information. • Outcome data was collected from each facility examining possible changes in the speech therapy caseload over a six-month period as a result of SR training • Data collected included demographic information, therapy goals attempted using SR, if the SR goals attempted were mastered, and if SR goals were maintained at a one-month post-test. Number of Participants: 14 Mean Age of Participants: 75.93

25. SR Research • After implementation of the SR training, ST caseload included residents with more cognitive impairment than those seen prior to implementation. • 42 goals were attempted and 32 (76%) were mastered; at one-month posttest, mastery was maintained for 71% of goals mastered previously. • Data from two facilities over a six-month period indicated that the number of long-term residents receiving speech therapy increased after implementation of the program • Speech therapy caseload included a higher percentage of long-term residents with dementia. • At one facility, MDS-based Cognitive Performance Scale scores of speech therapy clients were significantly lower after implementation of the program, indicating therapy was now being provided to residents with more severe impairment. • We also found therapists starting to use SR successfully for clients who did not have dementia.

26. Arden Courts Short Term Study • Data collection from April 2004 to April 2005 • 20 residents selected who received therapy services • 13/20 residents received SR training • All 13 residents increased overall LOS (from 2 weeks to 12 months) • Of the residents that no longer met AL requirements, the LOS increased by an average of 5 months.

27. SR Case Study • 84 year old male; Diagnosis: Alzheimer’s dementia. Residing in AL facility. • Needs assistive device to ambulate (i.e. rolling walker) • SR Goal: Teach Mr. L. to remember to use the walker • SR Prompt: “When you walk, what should you take with you?” • SR Response: “My walker-talker”

28. SR Case Study • 89 year old male; Diagnosis: Alzheimer’s disease, Parkinson’s disease, and mild to moderate pharyngeal dysphagia (etiology unknown). • MBS indicated need for resident to use chin tuck as a safe swallow strategy • SR Goal: Dr. M. needs to learn to use a chin tuck • SR Prompt: “When you swallow, what should you do?” • SR Response: “Look at my lap”.

29. SR Case Study • 80 year old male; Diagnosis: Alzheimer’s dementia. • Loss of ability to remember certain appropriate social behaviors • SR Goal: Eliminate excessive spitting in common areas • SR Prompt: “When you feel you need t spit, what should you use?” • SR Response: “My hankie”.

30. SR & Documentation • Goal possibilities are endless • SR goals are NOT written any differently than other goals. FUNCTIONAL GOAL = SR GOAL

31. SR & Documentation • Measurement of goal attainment can be by percentage (“80% of time”) or by recalling and demonstrating target response for a set number of sessions (3 sessions recommended) depending on the type of goal. • “Client will recall strategy of inhaling prior to speaking in order to demonstrate appropriate vocal volume during 80% of structured sentence production” OR • “Client will demonstrate strategy of locking wheel chair brakes prior to standing to increase safety at the beginning of 3 consecutive therapy sessions using SR”

32. SR & Documentation • SR is considered to be a MODALITY or APPROACH that therapists may use to help clients reach their goals. • SR does not fit one particular diagnosis category • Use the ICD 9 Code that corresponds to the goal area you are addressing Use SR to teach compensatory swallowing strategies = Use the ICD 9 code for Dysphagia

33. Conclusion • SR can enable many persons with dementia to reach specific therapeutic goals and maintain the goals longer than some traditional therapy methods. • Use of SR in rehab treatment may account for longer length of stay in dementia patients. • After SR training, SLP’s tend to see more lower functioning clients in treatment. • The success of SR depends on many factors, including appropriate screening; selection of appropriate goals; empathy, attitude, and clinical skills of the therapist; and, appropriate application of SR procedures. • It is our hope that this information will enable therapists to think differently about the potential of persons with dementia to learn new information and encourage therapists to use SR for clients with dementia and other forms of memory impairments.

34. References • 1. Abrahams, J. P., & Camp, C. J. (1993). Maintenance and generalization of object naming training in anomia associated with degenerative dementia. Clinical Gerontologist, 12, 57‑72. • 2. Brush, J. A., & Camp, C. J. (1998). Using spaced retrieval as an intervention during speech-language therapy. Clinical Gerontologist, 19, 51-64. • 3. Brush, J. A., & Camp, C. J. (1998). Using spaced retrieval to treat dysphagia in a long-term care resident with dementia. Clinical Gerontologist, 19 (2), 96-99. • 4. Brush, J. A., & Camp, C. J. (1999). A therapy technique for improving memory: Spaced Retrieval. Beachwood, OH: Menorah Park Center for Senior Living. • 5. Squire, L.R. (1994). Declarative and nondeclarative memory: multiple brain system supporting learning in memory. In D.L. Schacter & E. Tulving (Eds.) Memory systems. Cambridge, MA: The MIT Press, 203-232.

35. References • 5. Brush, J. A., & Camp, C. J. (1999). Effective interventions for persons with dementia: Using spaced retrieval and Montessori techniques. Neurophysiology and Neurogenic Speech andLanguage Disorders, 9(4), 27-32. • 6. Camp, C. J. (1989). Facilitation of new learning in Alzheimer's Disease. In G. Gilmore, P. Whitehouse, & M. Wykle (Eds.), Memory, aging, and dementia: Theory, assessment, and treatment (pp. 212-225). N.Y., N.Y.: Springer. • 7. Camp, C. J., Bird, M. J., & Cherry, K. E. (2000). Retrieval strategies as a rehabilitation aid for cognitive loss in pathological aging. In R. D. Hill, L. Bäckman, & A. S. Neely (Eds.), Cognitiverehabilitation in old age (pp. 224-248). New York: Oxford University Press.

36. References • 8. Camp, C. J., Foss, J. W., Stevens, A. B., & O'Hanlon, A. M. (1996). Improving prospective memory task performance in Alzheimer's disease. In M. A. Brandimonte, G. O. Einstein, & M. A. McDaniel (Eds.) Prospective memory: Theory and applications (pp. 351‑367). Mahwah, NJ: Lawrence Erlbaum & Assoc. • 9. Camp, C. J., & Schaller, J. R. (1989). Epilogue: Spaced‑retrieval memory training in an adult day care center. Educational Gerontology, 15, 641-648. • 10. Camp, C. J., & Stevens, A. B. (1990). Spaced retrieval: A memory intervention for Dementia of the Alzheimer’s Type (DAT). Clinical Gerontologist, 10, 58‑61. • 11. Cherry, K. E., Simmons, S. S., & Camp, C. J. (1999). Spaced-retrieval enhances memory in older adults with probable Alzheimer’s disease. Journal of Clinical Geropsychology, 5, 159-175. • 12. Hayden, C. M., & Camp, C. J. (1995). Spaced‑retrieval: A memory intervention for dementia in Parkinson's disease. Clinical Gerontologist, 16(2), 80‑82.

37. References • 13. McKitrick, L. A., Camp, C. J., & Black, W. (1992). Prospective memory intervention in Alzheimer’s Disease. The Journal of Gerontology: Psychological Sciences, 47, P337‑P343. • 14. Stevens, A. B., O'Hanlon, A. M., & Camp, C. J. (1993). Strategy training in Alzheimer’s Disease: A case study. Clinical Gerontologist, 13, 106‑109. • 15. Neundorfer, M.M., Camp, C.J., Lee, M.M., Skrajner, M.J., Malone, M. L., & Carr, J. R, (2004). Compensating for Cognitive Deficits in Persons Aged 50 and Over with HIV/AIDS: A Pilot Study of a Cognitive Intervention. Journal of HIV/AIDS & Social Services, 3, 79-97. • 16. Bourgeois, M., Camp, C., Rose, M., White, B., Malone, M., Carr, J., & Rovine, M. (2003). A Comparison of Training Strategies to Enhance Use of External Aids by Persons with Dementia. Journal of Communication Disorders, 36, 361-379.

38. Thank You! For additional information about SR or its application, please visit www.myersresearch.org