Journal of Communication Disorders

36 (2003) 361–378

A comparison of training strategies to

enhance use of external aids by
persons with dementia
Michelle S. Bourgeoisa,*, Cameron Campb,
Miriam Roseb, Blanche Whitea, Megan Maloneb,
Jaime Carrb, Michael Rovinec
a
Department of Communication Disorders, Florida State University,
302 Rehabilitation Center, Tallahassee, FL 32306-1200, USA
b
Myers Research Institute, Beachwood, OH, USA
c
Department of Human Development and Family Studies, Pennsylvania State University,
University Park, PA, USA
Received 15 March 2003; received in revised form 15 May 2003; accepted 15 May 2003

Abstract

The purpose of this study was to compare the effectiveness of two training approaches,
Spaced Retrieval (SR) and a modified Cueing Hierarchy (CH), for teaching persons with
dementia a strategy goal involving an external memory aid. Twenty-five persons with
dementia living in either community or nursing home settings received training on two
individual-specific strategy goals, one with each training approach. Results revealed that
significantly more goals were attained using SR procedures than CH, but that a majority of
participants learned to use external aids using both strategies. There were no significant
differences in the number of sessions required to master goals in either condition; however,
significantly more SR goals were maintained at both 1-week and 4-months post-training
compared to CH goals. Mental status was not significantly correlated with goal mastery,
suggesting the potential benefits of strategy training beyond the early stages of dementia.
Learning outcomes: As a result of this activity, the reader will be able to (1) identify
ways to enable persons with dementia to make effective use of external memory aids;
(2) describe a method, Spaced Retrieval, by which persons with dementia can learn and

*
Corresponding author. Tel.: þ1-850-644-2238; fax: þ1-850-644-8994.
E-mail address: Michelle.Bourgeois@comm.fsu.edu (M.S. Bourgeois).

0021-9924/$ – see front matter # 2003 Elsevier Inc. All rights reserved.
doi:10.1016/S0021-9924(03)00051-0
362 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

retain information; and (3) describe two approaches to working with persons with dementia
to train a strategy learning goal.
# 2003 Elsevier Inc. All rights reserved.

Keywords: Dementia; External aids; Strategy learning; Cueing Hierarchy; Spaced Retrieval

1. Introduction

Since the mid-1990s, the number of published studies documenting effective

interventions for individuals with dementia has grown phenomenally. The clinical
practice of speech-language pathologists in long-term care and community
settings is changing, as a result. Long-held beliefs about learning limitations
due to cognitive deficits are being re-examined. Third party payers are satisfied
that clinical outcomes with this population deserve reimbursement. This reversal
of thinking and practice has evolved with repeated demonstrations that indivi-
duals with dementia can be prompted with a variety of cues to perform desired
behaviors such as on-topic conversation (Bourgeois, 1990, 1992a) and to decrease
undesirable behaviors such as repetitive verbalizations (Bourgeois, Burgio,
Schulz, Beach, & Palmer, 1997). Concurrently, Camp and his colleagues have
shown repeatedly that new learning is not only possible in individuals with
dementia, but is maintained over long periods of time and generalizes when
trained using Spaced Retrieval (SR) techniques (Abrahams & Camp, 1993; Brush
& Camp, 1998a, 1998b, 1999; Camp, Bird, & Cherry, 2000; Camp et al., 1996a,
1996b; Lee & Camp, 2001; Camp et al., 2001; McKitrick, Camp, & Black, 1992;
Stevens, O’Hanlon, & Camp, 1993).
Teaching a client with dementia to use a cueing strategy for achieving desired
target behaviors is the natural extension of these two lines of research. For
example, while it may be satisfying to demonstrate improved memory for
personal information with a memory book, unless the person remembers to
use the memory book when needed, in a variety of contexts, the outcomes of a
memory book intervention alone would be limited. Individuals may need direct
training to recognize when the memory book could be helpful and practice using it
in those situations. Camp and Bourgeois have combined these two intervention
approaches and have been systematically exploring the efficacy of training
individuals with dementia to use cues in the form of external memory aids
(Bourgeois et al., 2001; Camp et al., 2001).

1.1. External memory aids as intervention

Memory wallets and memory books were first proposed for the memory
problems of persons with dementia who demonstrated relatively preserved and
effortless oral reading and fact retrieval abilities in the presence of written
sentence stimuli accompanied by relevant illustrations (Bourgeois, 1990).
 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378 363

The conversations of persons using a memory book showed more factual and
elaborated statements and fewer ambiguous and repetitive utterances than con-
versations without an external aid. It was noted that persons did not require
training to use the memory book; changes in their conversational behavior were
evident immediately upon presentation of the book and a brief explanation of its
potential use. This suggested that the visual and written stimuli in the book served
as external sensory/environmental cues that did not require conscious cognitive
effort in order to trigger associated behavior (in this case, recognition of
personally relevant stimuli and retrieval from memory storage of related semantic
information). Repeated demonstrations of the effectiveness of memory books to
effect positive changes in the conversational behaviors of persons with a wide
range of severity of cognitive impairment support the use of external cues as
intervention in dementia (Bourgeois, 1992a).
Beyond conversational behavior, memory books have been shown to effect
changes in other memory-related problem behaviors, such as repetitive questions
and demands. Bourgeois et al. (1997) demonstrated decreased frequency of
repeated verbalizations when caregivers were trained to direct patients with
dementia to read a memory book page (or written message on a memo board
or index card) when they asked a question repeatedly. Caregivers expressed
satisfaction with both their ability to redirect the person to an external stimulus
that answered the question and the speed with which the person learned to use
this stimulus independently. Anecdotal reports of persons with dementia stopping
to read information on a memo board on the refrigerator as they paced, or asking
for their index card on which was written the day’s activities, suggest that
written cues can be effective as unconscious, sensory memory triggers, but that
persons with dementia can also learn to use these cues in a conscious, determined
manner.
Many types of external aids have been suggested to compensate for memory
loss, including cue cards, written schedules, diaries, log books, visitor sign-in
books, daily or weekly planners, and other calendars (Bourgeois, 2002;
Sohlberg & Mateer, 2001). Assistive devices such as timers, watch alarms,
medication/pill organizers, and vibrating signaling and electronic devices have
also supported daily functioning (Garrett & Yorkston, 1997; Hersch & Tread-
gold, 1994; Weinstein, 1991). Written cues in the form of signs and orientation
boards have long been used as cues (Hanley, 1981; Hanley & Lusty, 1984;
Zeisel, Hyde, & Shi, 1999). As potentially useful as these aids may seem, there
are many barriers that prevent their routine use and discourage clinicians from
incorporating them into standard practice. The most obvious problems are when
the client forgets that the external aid exists, forgets its location, or does not
use it at appropriate times. Clients may be dependent on others to prompt them
to look at or otherwise use the aid. Unless independent use of a compensatory
strategy, such as using an external memory aid, is possible, many clinicians
and families will not want to waste their time and efforts in creating such
aids.
364 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

1.2. Learning in dementia: Spaced Retrieval

Spaced Retrieval is a method of learning and retaining information by recalling

that information over increasingly longer periods of time. It is, in essence, a
shaping paradigm applied to memory (Bjork, 1988; Camp & McKitrick, 1992;
Landauer & Bjork, 1978). When a 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. Then the following interval length returns
to the last one at which retrieval was successful.
SR takes advantage of a neuropsychological rehabilitation principle called
‘‘errorless learning’’ (Baddeley, 1992; Wilson, Baddeley, Evans, & Shiel, 1994).
Errorless learning is based on the premise that there are two types of learning/
memory systems. The first, called declarative (or explicit) memory (Squire, 1992,
1994), involves conscious learning and retrieval. It is what most persons refer to
when they use the term ‘‘memory,’’ and this system is impaired from the earliest
stages of AD. The ability to learn and remember information from personal or
autobiographic memory, such as what you were doing 10 min ago or what you ate
for breakfast, is part of this system. This memory system is devastated early in the
course of dementia.
To learn and retain information, persons with memory deficits should engage in
‘‘errorless’’ practice with the new information. Since they cannot recall personal
episodes (a function of declines in declarative memory), they cannot use the past
as a basis for correcting themselves. Only if they are not allowed to make errors
will they learn new information accurately; otherwise, inaccurate learning will
take place. Because it is important to inhibit generation of errors during training,
the use of cueing during SR training is discouraged as such cueing could lead to
generation of incorrect responses. This is why it is so important for persons with
Alzheimer’s Disease (AD) and related dementias to have success when recalling
information in the SR procedure, and why each trial must end with a correct recall.
Appropriately structured successful practice can allow new information to enter
memory through a second, very different memory system.
In Squire’s model, the second memory system is referred to as nondeclarative
(or procedural or implicit) memory. It involves the use of well-learned processes
and the unconscious, relatively effortless acquisition and retrieval of new infor-
mation. It is believed that much if not most new learning found in persons with
memory loss due to dementia takes advantage of unconscious or effortless
learning. SR training appears to require little cognitive effort (Camp & Stevens,
1990; Schacter, Rich, & Stampp, 1985). There is evidence that SR can be used by
persons with AD because this intervention accesses nondeclarative memory
(Camp et al., 1996a, 1996b; Cherry, Simmons, & Camp, 1999; Vanhalle, Van
der Linden, Belleville, & Gilbert, 1998) and circumvents declarative memory.
SR has been shown in previous case studies to be effective across a variety of
dementing conditions, including AD (Camp et al., 1996a, 1996b; McKitrick et al.,
1992), dementia associated with Parkinson’s Disease (PD; Hayden & Camp, 1995),
 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378 365

dementia associated with Korsakoff’s syndrome (Camp & Schaller, 1989);

vascular and mixed dementia (e.g., Abrahams & Camp, 1993; Bird, Alexopoulos,
& Adamowitz, 1995); post-anoxia dementia (Bird et al., 1995); and dementia
associated with HIV (Lee & Camp, 2001; Neundorfer et al., 2002). For example,
Hayden and Camp (1995) demonstrated that persons with dementia associated
with PD could learn new motor activities through SR when, under ordinary
conditions, they could not. Exploratory research with HIVþ older adults dis-
playing cognitive deficits, including dementia, indicates that these persons can
substantially benefit from SR training in the use of external aids (Lee & Camp,
2001; Neundorfer et al., 2002).
Camp et al. (1996b) described a study in which 23 persons with AD were
trained to used an external aid (a calendar). Results from the calendar training
procedures confirmed that persons with AD who had severe memory deficits for
newly encountered information could learn a strategy though SR training. The
number of training sessions required to achieve 1-week retention of the strategy
varied across participants. The majority (61%) learned the strategy in two to three
training sessions, while another 26% learned the strategy after four to seven
training sessions.
McKitrick and Camp (1993) extended this line of research by having family
caregivers implement the training. Other researchers likewise trained caregivers to
implement SR as an intervention for persons with dementia (Arkin, 1991; Riley,
1992). Riley (1992) also reported a case study in which a man in the initial stages of
dementia was able to train himself to remember new information utilizing SR.
Brush and Camp (1998a) reported the use of SR by speech-language pathologists
to reach clinical goals involving strategies in seven persons with dementia, most of
whom were living in a long-term care facility. Goals included teaching the client to
use a schedule or date book, teaching the client to use a voice amplifier and make eye
contact when speaking, and training the client to describe an item or use a synonym
when experiencing anomia. Five clients with dementia learned their compensatory
techniques and exhibited appropriate use of the technique at a 4-week follow-
up. Two individuals with dementia did not complete the study. One became
uncooperative during speech and physical therapy sessions, exhibiting behavior
such as screaming and striking out, which also was seen on the unit where the client
lived. The second client stopped therapy after a rapid deterioration in health.
In a case study, Brush and Camp (1998b) used SR to train a person with
dementia a strategy for remembering to take a sip of liquid after each bite of solid
food as a treatment for dysphagia. This was accomplished by pairing the strategy
training with the use of an external aid.

1.3. Teaching strategies in speech pathology: Cueing Hierarchies

Speech-language pathologists have a long history of teaching individuals with

language and memory impairments due to neurological damage, particularly
aphasia, using cues to elicit desired language behaviors, such as word retrieval
366 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

(for a review, see Patterson, 2001). Cueing hierarchies (CH), a systematic and
graded sequence of cues of increasing power, have guided the selection and
sequencing of cues in treatment protocols. Clinicians evaluate an individual’s
response to each cue type and design a unique training hierarchy based on the
relative strength or power of each cue to elicit the desired response. Bollinger and
Stout (1976) described this procedure as response-contingent small-step treat-
ment that can be accomplished in an ascending or descending sequence in order to
elicit the desired response with the least powerful cue. In her review of CHs in
word retrieval studies, Patterson (2001) found two common ways to implement
this technique: traditional CHs using descending and ascending movement and
modified CHs using descending cues only. To date, there have been no published
accounts of applying the cueing hierarchy training approach to targeted treatment
goals for persons with dementia.
The purpose of this study was to compare the efficacy of two training
approaches, SR and a modified CH, for teaching persons with dementia to use
an external memory aid for a specific purpose. We were interested in addressing a
number of questions salient to practicing clinicians: Are there differences in the
mastery of strategy learning goals trained with SR and CH procedures? Are goals
mastered within fewer sessions or with fewer trials in either condition? Does goal
mastery and/or maintenance differ as a function of training procedure? Is there a
relationship between cognitive status and goal mastery in either condition?

2. Methods

2.1. Participants

Twenty-five individuals with dementia were recruited from long-term care and
adult day care facilities in Beachwood, Ohio, and Tallahassee, Florida. Seven
participants were assessed and trained in Ohio; 18 were trained in Florida. Single
training sites in each were used. Twenty-four percent of the sample was trained in
a quiet room in a nursing home; 28% were assisted living residents; and 48% of
participants attended adult day care. The participants were drawn from a larger
study of goal attainment in speech pathology involving additional goals, including
fact retrieval (Bourgeois et al., 2001; Camp et al., 2001). Table 1 presents des-
criptive data on age, gender, race, educational attainment, and dementia diagnosis
found in the medical records of these participants, each of whom received training
on two strategy learning goals.

2.2. Trainers

A total of 18 trainers (SLPs and supervised student clinicians) administered all

assessment and training protocols. All trainers received a minimum of 2 h of
training on study procedures and protocols. All student clinicians were observed
 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378 367

Table 1
Participant characteristics (N ¼ 25)

Mean (S.D.)

Age (in years) 83.8 (7.6)

Race (%) Black 16
White 84
Gender (%) Male 36
Female 64
Education (%) <High school 4
High school 40
Tech/trade 8
College 20
Graduate 8
Missing 20
Type of Dementia in Medical Records (%) Organic 4
Alzheimer Disease 38
Senile 4
Not specified 42
No diagnosis of dementia 12

Mean/total possible (S.D.)

Expressive language 5.24/6 (1.0)

MMSE 14.76/30 (6.6)
WRAT3 word and letter reading 41.40/57 (9.4)
WRAT3 grade level 7.54/10 (3.0)
Oral reading 22.40/24 (3.3)
Boston Naming Test 5.92/15 (3.6)
MMSE: Mini Mental Status Exam (Folstein, Folstein, & McHugh, 1975); WRAT3: Wide Range
Achievement Test-Revision 3 (Wilkinson, 1993).

during 100% of their interactions with participants and received immediate

feedback for any deviations from the protocol. Videotapes of individual assess-
ment and training sessions at both sites were viewed and scored for cross-site
reliability purposes throughout the study.

2.3. Procedures

2.3.1. Consent, eligibility screening and pre-test procedures

At each training site, program staff identified potential participants with
dementia who exhibited a variety of memory and other problem behaviors. Family
was contacted for consent. Clients were then administered the SR screen (Brush &
Camp, 1998c). Eligible clients were administered the Mini Mental Status Exam
(Folstein, Folstein, & McHugh, 1975), Expressive Language screen (Bourgeois,
1992a), the word reading subtest of the Wide Range Achievement Test (WRAT3;
Wilkinson, 1993), Oral Reading Test (Bourgeois, 1992b), and a short form of the
368 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

Table 2
Frequency and types of goals and external aids

Goals External aids Frequency

SR CH

Increase conversation/social interaction Memory book 5 10

Increase ADLs (safe swallowing, toileting, Written steps 5 4
hairbrushing, etc.)
Increase activity participation Activity reminder card 4 5
Decrease specific repetitive questions Reminder card 5 1
Increase specific behavior (use of names, Physical cue (name tag, 6 5
call button, telephone directory, name board, etc.) specific object, person)
ADL: activities of daily living.

Boston Naming Test (Fastenau, Denberg, & Mauer, 1998). Descriptive data on
various cognitive and language measures for participants may be found in Table 1.
Program staff and family were interviewed to identify a comprehensive list of
problem behaviors for potential remediation. Research staff, consisting of project
clinicians and student clinicians at each site, met to prioritize identified problem
behaviors, select goals, and assign goals to SR and CH procedures. Verbal prompts,
external aids, and other cues were selected for each goal according to the assigned
strategy. Table 2 lists the frequency and types of strategy goals and externals aids
used by participants in both training conditions for this analysis. External aids were
developed by clinicians for each individual client and goal and ranged from
memory books, reminder cards, activity lists, and ADL task analyses, to name tags
and other visual/physical objects in the environment (e.g., call button, sweater,
plant). Most external aids included written text in the form of words, phrases or
short sentences; the results of the Oral Reading Test (Bourgeois, 1992b) guided
clinician selection of the appropriate font size for each client’s external aid.
Appendix A provides examples of a variety of external aids used in this study.

2.3.2. Treatment sessions

Treatment began with one of the identified goals. Each 30-min treatment session
consisted of as many training trials as necessary to demonstrate progress towards
the goal or goal mastery, according to the mastery criterion specified for each
training procedure. Subsequent goal training was initiated in a counterbalanced
fashion as goals were mastered and until all goals were mastered or training was
discontinued for lack of progress or other reasons (e.g., client died or moved).

2.3.3. SR training
Using the SR data sheet to record responses (see Appendix B), clinicians
initiated training with an introduction to the goal and procedures: ‘‘I understand
that sometimes you have trouble remembering what activities there are to do
here. If you want to know what activity you should do today, you can look at
this list of activities. What can you do to know what activity you should do?’’
 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378 369

Expected response: ‘‘I look at my activity list.’’ If the correct response was given
immediately, the clinician replied, ‘‘That’s right. And I’ll be asking you to
remember that in a little while,’’ and continued to talk about an unrelated topic
for the designated interval (i.e., 30 s, 1 and 2 min, etc.). The clinician continued to
prompt the client at increasing intervals as long as the correct response was given
immediately. If the client did not respond or responded incorrectly, the clinician
modeled the correct response for the client to imitate, and the next prompt was
given after an interval of the length of the last successful response. Prompted trials
continued for the 30-min session. As the interval between prompts became longer
(i.e., 4 and 8 min, etc.), the clinician used this time for training other goals
unrelated to the SR target goal or for engaging the client in activities designed to
maintain the client’s interest. For example, these might have included activities
such as category sorting based on Montessori educational principles and adapted
to enable active engagement with persons with dementia (Brush & Camp, 1999).
The goal was mastered when the correct response was given to the first prompt of
the next three sessions, with a minimum of a 24-h interval between each of them.

2.4. CH training

Using the CH data sheet to record responses (see Appendix C), clinicians
initiated training with the same introduction and expected response as in SR
training above, but if the client did not respond immediately or responded
incorrectly, the clinician provided a hierarchy of cues in the following order until
the targeted response was obtained: Semantic (‘‘Something to look at’’), Phonemic
(‘‘/qk/’’ first syllable of Activity List), Visual (point to list), Tactile (touch/hold list),
Imitation (‘‘I look at my activity list.’’). Training continued for the 30-min session
and the goal was considered mastered when the correct response was given to the
first prompt of the next three sessions, a minimum 24-h interval between each
session. The average number of cues given for CH goals varied across cue type.
These were: M ¼ 21 (S:D: ¼ 22) for semantic cues, M ¼ 6 (S:D: ¼ 14) for
phonemic cues, M ¼ 17 (S:D: ¼ 19) for visual cues, M ¼ 2 (S:D: ¼ 5) for tactile
cues, and M ¼ 3 (S:D: ¼ 4) for imitation cues. (Note that cues were not given
during SR training.)

2.4.1. Maintenance
One week and four months post-goal mastery participants were given the goal
prompt to assess goal maintenance. Clinicians insured ahead of time that the
relevant external aid was available and present prior to providing the verbal prompt.

3. Results

Results related to our primary questions of interest are shown in Table 3.

Results are discussed as they related to these questions.
370 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

Table 3
Goal outcomes by type of training

Goal outcomes Type of training

SR CH

No. of goals attempted 25 25

No. of goals mastered 23 18
Sessions to goal mastery
Mean (S.D.) 10.26 (6.47) 11.0 (5.05)
Range 4–24 4–23
Trials to goal mastery
Mean (S.D.) 46.5 (37.1) 50.2 (33.7)
Range 9–114 7–113
No. of goals maintained
1 week 16/23 9/18
4 months 5/11 1/11

3.1. Are there differences in the mastery of strategy learning goals

trained with SR and CH procedures?

Overall, participants generally were successful in achieving their goals, though

SR did provide some advantage over CH. In our sample, 18 participants mastered
their goals, successfully using an external cue in both the SR and CH conditions.
No participants mastered a CH goal without also mastering a SR goal. However,
five participants mastered a SR goal without mastering a CH goal. Thus, 23 of our
25 participants mastered a SR goal, while 18 participants mastered a CH goal.
This difference reached statistical significance, Fð1; 24Þ ¼ 4:99, P < 0:035. Only
two participants did not master either of their strategy goals. One of these
participants showed a precipitous drop in cognitive status from initiation of
training (MMSE ¼ 19) to termination of training (MMSE ¼ 4), along with
exacerbation of other co-morbid medical conditions that required hospitalization.
The other participant who did not master either goal left the adult day center
shortly after initiation of training, and had only eight sessions of CH training and
three sessions of SR training, which is fewer than the average number of sessions
required to master goals for this sample.

3.2. Are goals mastered within fewer sessions or with fewer trials
in either condition?

The average number of sessions required to achieve goal mastery was

M ¼ 10:3 (S:D: ¼ 6:5) for SR goals and M ¼ 11:0 (S:D: ¼ 5:1) for CH goals,
respectively. This difference was not statistically significant. Similarly, the
average number of trials across sessions was M ¼ 46:5 (S:D: ¼ 37:1) for SR
goals and M ¼ 50:2 (S:D: ¼ 33:7) for CH goals, which also was not significantly
 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378 371

different. Thus, when a goal was mastered, the number of sessions and trials
across sessions required to do so was not affected by the use of SR versus CH.

3.3. Does goal maintenance differ as a function of training procedure?

At 1-week post-test, we examined whether there was a significant difference in

the number of goals maintained in the SR versus the CH training conditions.
Using a Wilcoxon Signed Ranks Test, the outcome was significant (Z ¼ 2:33,
P < 0:02). In all, 16 goals were maintained in the SR condition, while 9 goals
were maintained in the CH condition. This represents maintenance of 70% (16/
23) of the goals originally mastered in the SR condition, and maintenance of 50%
(9/18) of the goals originally mastered in the CH condition.
Four months after the last treatment session, 11 of the participants in our
sample were available for long-term post-testing. All of these participants had
mastered goals in both the SR and CH conditions. Again, there was a significant
difference in the number of goals for which mastery was maintained in the SR
versus CH training conditions (Z ¼ 0:20, P < 0:05). For these individuals,
maintenance was demonstrated for 45% (5/11) of SR goals, while 9% (1/11) of
CH goals continued to be maintained. Thus, goal maintenance was best demon-
strated when goal mastery was achieved using SR in this sample.

3.4. Is there a relationship between cognition and goal mastery in either

condition?

Cognition at baseline as measured by the MMSE was examined in relation to

the number of goals mastered and the number of trials necessary to reach goal
mastery for each participant. Correlations were r ¼ 0:10 and r ¼ 0:15, respec-
tively, neither of which reached statistical significance. MMSE scores remained
relatively stable across the course of the study. We were able to obtain MMSE
scores for eight respondents at both post-test occasions. For this subsample,
average MMSE scores were M ¼ 16:8 (S:D: ¼ 6:6) and M ¼ 16:0 (S:D: ¼ 5:2),
respectively; this difference was not significantly different.

4. Discussion

The comparison of two training approaches, SR and CH, to teach strategy goals
involving an external memory aid demonstrated one primary and clear outcome;
that persons with dementia can indeed acquire new information using both SR and
CH procedures. The majority of our sample mastered both goals involving the use
of external aids and required approximately the same number of training sessions
to do so. While these findings corroborate earlier studies showing that SR can be
used to train persons with dementia to use strategies involving external aids, to our
knowledge, there have been no published accounts of teaching strategy use with
CH in dementia.
372 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

The use of SR as the training method showed some advantage over CH in terms
of goal mastery. Persons with dementia demonstrated the ability to master goals,
indicating that the training is effective. The fact that some goals involving use of
external aids can be maintained in persons with dementia 4 months after the end of
SR treatment without attempts to implement ‘‘booster’’ sessions or other similar
intermediate interventions is also encouraging. Assessment of long-term goal
maintenance was hampered by the small number left in the sample at the 4-month
post-test, however, and it is possible that periodic booster training sessions could
improve the long-term retention rate even more. Camp et al. (1996a, 1996b)
reported that persons with AD trained in the use of an external memory aid (a
calendar used to keep appointments and do activities each day) could effectively
continue to use the aid in spite of declining mental status, evidenced by declines in
MMSE scores over time. Furthermore, they reported some evidence of main-
tenance of the strategy at 6-month follow-ups. In exploratory research with HIVþ
older adults displaying cognitive deficits, including dementia, Neundorfer et al.
(2002) found substantial retention of correct responses to prompts 2 months after
SR treatment. As these studies employed different lengths of time for measuring
long-term outcomes, perhaps some thought should be given to determining which
is most clinically meaningful. Clearly, more research is also needed to determine
means for optimizing maintenance (e.g., how and when to administer ‘‘booster’’
sessions).
Finally, our results clearly demonstrate that external aids can be successfully
utilized by persons with dementia if strategy training in the use of such aids is
included in the training regimen. In other words, in persons with cognitive
impairment, it is not enough just to provide aids such as pill organizers and
expect that these aids will be used appropriately. This has important implications.
For example, given that many HIVþ older adults exhibit executive dysfunction
and/or memory deficits, their complex medication regimens for treatment of HIV
pose a severe challenge to their compromised cognitive systems. When adherence
to appropriate medication regimens is sporadic, it can result in the development of
drug-resistant strains of HIV. In addition, these persons may have difficulties in
planning, problem solving, and abstract thinking, and may therefore be likely to
engage in unsafe behaviors. In this situation, successful use of external aids that
result in adherence to drug regimens could help prevent the development of drug-
resistant strains of a disease such as HIV from entering into the general
population. Initial findings indicate that SR has promise as a means of teaching
these persons strategies to successfully use aids that allow better adherence to
their medical regimens (Lee & Camp, 2001; Neundorfer et al., 2002).
These findings justify the contention that persons with dementia have the
potential to benefit from rehabilitation services. Our examination of the correla-
tion between MMSE scores and the two primary outcomes revealed that, across a
relatively wide range of MMSE scores, mental status did not correlate with
measures related to the ability to benefit from treatment. The idea that rehabilita-
tion for persons with dementia is only effective in early stages of dementia is also
 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378 373

not supported by our data. This outcome parallels similar outcomes in persons
with AD regarding the relationship of MMSE scores and other intervention
outcomes using SR (Camp et al., 1996a, 1996b).
Therefore, we see a continuing and growing need for rehabilitation profes-
sionals to become involved in training persons with dementia and other cognitive
impairments to use external aids successfully. It is our hope that results from our
initial studies, and research to follow, will begin to provide tools that will enable
this vision to be realized.

Acknowledgments

This study was funded by a grant from the National Institute on Aging to
Menorah Park Center for Senior Living (R01 AG17908 to C. Camp, PI). We wish
to thank the clients, families, residents, and administrators of Menorah Park
Center for Senior Living, the Tallahassee Memorial HealthCare Adult Day Care
program, and Alterra Memory Care residence; and the student clinicians from
Florida State University for participating in this study.

Appendix A. Sample External Aids

Goal: Use Nametag to say person’s name Goal: Look at list of activities

Activities I can do Today:

My name is 9:00 Exercise
Michelle 10:00
12:00
Bible study
Lunch
3:00 Beauty Parlor
5:00 Dinner
Goal: Read card before transfer
7:00 Watch TV

Before I sit down in my

Goal: Read card before eating.
wheelchair, I will:
Safe Swallowing Card
1. Feel for the chair
1. Take small bites,
with my legs. chew, and swallow.

2. Reach back for the 2. Take tiny sips.

arm rests.
3. Tuck my chin.

4. Double swallow after

each sip.
374 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

Appendix B. S-R DATA SHEET (STRATEGY LEARNING)

Client ID# : __ - __ __ - __ __ __ Therapist ID# : ___________

(Site) (Location) (Subject #)
Date: ________________ Session #: ______________ Start Time: ______ : ______
End Time: ______ : ______
Type of Strategy: ______________________________________________________________

Prompt Used: _________________________________________________________________

Correct Response: _____________________________________________________________

Longest interval retained previously: sec/min

Able to carry out strategy at previous session: yes / no

Trial 1 Trial 2 Trial 3 Trial 4 Trial 5

sec/min sec/min sec/min Sec/min sec/min
+ / - + / - + / - + / - + / -
Optional:
yes / no yes / no yes / no yes / no yes / no
Verbal response card used.
Last trial of the session only:
Client carries out strategy (to
extent possible).

Trial 6 Trial 7 Trial 8 Trial 9 Trial 10

sec/min sec/min sec/min Sec/min sec/min
+ / - + / - + / - + / - + / -
Optional:
yes / no yes / no yes / no yes / no yes / no
Verbal response card used.
Last trial of the session only:
Client carries out strategy (to
extent possible).

Number of correct trials without verbal response card: _____ = _____%

Total number of trials _____

Number of trials with verbal response card: _____ = _____%

Total number of trials _____

Comments (note anxiety or agitation):

 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378 375

Appendix C. Cueing Hierarchy Data Sheet (Strategy Learning)

Appendix D. Continuing education

1. Individuals with dementia are

a. Poor treatment candidates because of their inability to learn new
information
b. Poor treatment candidates because trained goals do not generalize or
maintain for long periods of time
c. Potential treatment candidates for interventions that systematically
train them to use a strategy to achieve a target behavior
376 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

2. Spaced Retrieval
a. Requires the client to successfully recall information over increasingly
longer periods of time
b. Is successful as a training technique when the client is encouraged to
use a variety of cues to prompt the target behavior
c. Improves a person’s declarative memory
3. The Cueing Hierarchy strategy
a. Allows the client to use a variety of cues to elicit the target goal
b. Has primarily been used in prior training studies with persons with
dementia to teach strategies
c. Is less structured and more natural than Spaced Retrieval
4. In SR training the client
a. Is prompted to remember the expected response using a variety of cues
b. Is considered to have mastered the task at the end of a successful
training session
c. Should experience ‘‘errorless’’ learning and end each trial with a
correct recall
5. Participants in this study
a. Required significantly fewer sessions to achieve goal mastery using SR
b. Mastered significantly more goals using SR than CH
c. Required significantly fewer trials across sessions to achieve goal
mastery in CH

References

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.
Arkin, S. M. (1991). Memory training in early Alzheimer’s disease: An optimistic look at the field.
American Journal of Alzheimer’s and Related Disorders Care and Research, 6, 17–25.
Baddeley, A. D. (1992). Implicit memory and errorless learning: A link between cognitive theory and
neuropsychological rehabilitation? In L. R. Squire & N. Butters (Eds.), Neuropsychology of
memory (2nd ed., pp. 309–314). New York: The Guillford Press.
Bird, M., Alexopoulos, P., & Adamowicz, J. (1995). Success and failure in five case studies: Use of
cued recall to ameliorate behaviour problems in senile dementia. International Journal of
Geriatric Psychiatry, 10, 305–311.
Bjork, R. A. (1988). Retrieval practice and the maintenance of knowledge. In M. M. Gruneberg, P.
Morris, & R. Sykes (Eds.), Practical aspects of memory (vol. 2, pp. 396–401). London: Academic
Press.
Bollinger, R. L., & Stout, C. E. (1976). Response-contingent small-step treatment: Performance-
based communication intervention. Journal of Speech and Hearing Disorders, 41, 40–51.
Bourgeois, M. (1990). Enhancing conversation skills in Alzheimer’s Disease using a prosthetic
memory aid. Journal of Applied Behavior Analysis, 23, 29–42.
Bourgeois, M. (1992a). Evaluating memory wallets in conversations with patients with dementia.
Journal of Speech and Hearing Research, 35, 1344–1357.
 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378 377

Bourgeois, M. (1992b). Enhancing the conversations of memory-impaired persons: A memory aid

workbook. Gaylord, MI: Northern Speech Services, Inc.
Bourgeois, M. (2002). Where is my wife and when am I going home? The challenge of
communicating with persons with dementia. Alzheimer Care Quarterly, 3, 132–144.
Bourgeois, M., Burgio, L., Schulz, R., Beach, S., & Palmer, B. (1997). Modifying repetitive
verbalization of community dwelling patients with AD. The Gerontologist, 37, 30–39.
Bourgeois, M., Camp, C., White, B., Malone, M., McClelland, A., & Rose, M. (November, 2001).
Spaced retrieval protocol development: Fact retrieval and strategy learning. Presented at the
American Speech Language Hearing Association Conference, New Orleans, LA.
Brush, J. A., & Camp, C. J. (1998a). Using spaced retrieval as an intervention during speech-
language therapy. Clinical Gerontologist, 19, 51–64.
Brush, J. A., & Camp, C. J. (1998b). Using spaced retrieval to treat dysphagia in a long-term care
resident with dementia. Clinical Gerontologist, 19(2), 96–99.
Brush, J. A., & Camp, C. J. (1998c). A therapy technique for improving memory: Spaced retrieval.
Beachwood, OH: Menorah Park Center for the Aging.
Brush, J. A., & Camp, C. J. (1999). Effective interventions for persons with dementia: Using spaced
retrieval and Montessori techniques. Neurophysiology and Neurogenic Speech and Language
Disorders, 9(4), 27–32.
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.), Cognitive
rehabilitation in old age (pp. 224–248). New York: Oxford University Press.
Camp, C. J., Foss, J. W., O’Hanlon, A. M., & Stevens, A. B. (1996a). Memory interventions for
persons with dementia. Applied Cognitive Psychology, 10, 193–210.
Camp, C. J., Foss, J. W., Stevens, A. B., & O’Hanlon, A. M. (1996b). 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 & Associates.
Camp, C. J., & McKitrick, L. A. (1992). Memory interventions in Alzheimer’s-type dementia
populations: Methodological and theoretical issues. In R. L. West & J. D. Sinnott (Eds.),
Everyday memory and aging: Current research and methodology (pp. 155–172). New York:
Springer-Verlag.
Camp, C., Rose, M., Orsulic-Jeras, S., McClelland, A., Malone, M., Bourgeois, M., & White, B.
(November, 2001). Effective interventions for persons with dementia: The Spaced-Retrieval
technique and Montessori methods. Pre-conference Workshop, Gerontological Society of
America, Chicago, IL.
Camp, C. J., & Schaller, J. R. (1989). Epilogue: Spaced-retrieval memory training in an adult day-
care center. Educational Gerontology, 15, 641–648.
Camp, C. J., & Stevens, A. B. (1990). Spaced-retrieval: A memory intervention for dementia of the
Alzheimer’s type (DAT). Clinical Gerontologist, 10, 58–60.
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.
Fastenau, P. S., Denburg, N. L., & Mauer, B. A. (1998). Parallel short forms for the Boston Naming
Test: Psychometric properties and norms for older adults. Journal of Clinical and Experimental
Neuropsychology, 20, 828–834.
Folstein, M., Folstein, S., & McHugh, P. (1975). ‘Mini-Mental State.’ A practical method for
grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12,
189–198.
Garrett, K., & Yorkston, K. (1997). Assistive communication technology for elders with cognitive
and language disabilities. In R. Lubinski, & D. J. Higginbotham (Eds.), Communication
technologies for the elderly (pp. 203–234). San Diego, CA: Singular Press.
Hanley, I. G. (1981). The use of signposts and active training to modify ward disorientation in elderly
patients. Journal of Behavior Therapy and Experimental Psychiatry, 12, 241–247.
378 M.S. Bourgeois et al. / Journal of Communication Disorders 36 (2003) 361–378

Hanley, I. G., & Lusty, K. (1984). Memory aids in reality orientation: A single-case study. Behavior
Research Therapy, 22, 709–712.
Hayden, C. M., & Camp, C. J. (1995). Spaced-retrieval: A memory intervention for dementia in
Parkinson’s disease. Clinical Gerontologist, 16(3), 80–82.
Hersch, N., & Treadgold, L. (1994). NeuroPage: The rehabilitation of memory dysfunction by
prosthetic memory and cueing. Neuropsychological Rehabilitation, 4, 187–197.
Landauer, T. K., & Bjork, R. A. (1978). Optimal rehearsal patterns and name learning. In M. M.
Gruneberg, P. Morris, & R. Sykes (Eds.), Practical aspects of memory (pp. 625–632). London:
Academic Press.
Lee, M. M., & Camp, C. J. (2001). Spaced-retrieval: A memory intervention for HIVþ older adults.
Clinical Gerontologist, 22(3/4), 131–135.
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.
McKitrick, L. A., & Camp, C. J. (1993). Relearning the names of things: The spaced-retrieval
intervention implemented by caregivers. Clinical Gerontologist, 14, 60–62.
Neundorfer, M. M., Camp, C. J., Lee, M. M., Malone, M. L., Carr, J. R., & Skrajner, M. J.
(November, 2002). A cognitive intervention for persons age 50 and over with HIV: Pilot results
on dementia screening and treatment effects. Paper presented at the Annual Meeting of the
Gerontological Society of America, Boston, MA.
Patterson, J. P. (2001). The effectiveness of cueing hierarchies as a treatment for word retrieval
impairment. American Speech-Language-Hearing Association, Division 2, Neurophysiology and
Neurogenic Communication Disorders, 11(2), 11–18.
Riley, K. P. (1992). Bridging the gap between researchers and clinicians: Methodological
perspectives and choices. In R. L. West & J. D. Sinnott (Eds.), Everyday memory and aging:
Current research and methodology (pp. 182–189). New York: Springer-Verlag.
Schacter, D. L., Rich, S. A., & Stampp, M. S. (1985). Remediation of memory disorders:
Experimental evaluation of the spaced-retrieval technique. Journal of Clinical and Experimental
Neuropsychology, 7, 79–96.
Sohlberg, M., & Mateer, C. (2001). Cognitive rehabilitation: An integrative neuropsychological
approach (pp. 194–229). New York, NY: Guilford Press.
Squire, L. R. (1992). Memory and the hippocampus: A synthesis from findings with rats, monkeys,
and humans. Psychological Review, 99, 195–231.
Squire, L. R. (1994). Declarative and nondeclarative memory: Multiple brain system supporting
learning and memory. In D. L. Schacter & E. Tulving (Eds.), Memory systems (pp. 203–232).
Cambridge, MA: The MIT Press.
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.
Vanhalle, C., Van der Linden, M., Belleville, S., & Gilbert, B. (1998, December). Putting names on
faces: Use of a spaced retrieval strategy in a patient with dementia of the Alzheimer’s type.
Neuorphysiology and neurogenic speech and language disorders, 17–21.
Weinstein, B. E. (1991). Auditory testing and rehabilitation of the hearing impaired. In R. Lubinski
(Ed.). Dementia and communication (pp. 223–237). Philadelphia: B. C. Decker, Inc.
Wilkinson, G. (1993). Wide Range Achievement Test (WRAT3). Wilmington, DE: Jastak Associates.
Wilson, B. A., Baddeley, A., Evans, J., & Sheil, A. (1994). Errorless learning in the rehabilitation of
memory impaired people. Neuropsychological Rehabilitation, 4, 307–326.
Zeisel, J, Hyde, J, & Shi, L. (1999). Environmental design as a treatment for Alzheimer’s disease. In
L. Volicer & L. Bloom-Charette (Eds.), Enhancing the quality of life in advanced dementia
(pp. 206–222). Philadelphia, PA: Bruner/Mazel. Appendix 1.