It is important to consider how research findings may be incorporated into interventions for people with dementia. One may question the value of using group data, as averaging scores across all participants extinguishes the ability to identify differences in learning patterns for each individual. One should consider the use of single case analyses to determine which methods are more efficacious for each individual. The disadvantages of using group data, to hypothesise factors that would benefit group training in dementia, and advantages in exploring single cases, to establish individually designed interventions, are also reflected in two strands o f interventions. Interventions in early- stage dementia have typically followed cognition-focussed approaches that involve either cognitive training or cognitive rehabilitation. Cognitive training involves guided practice on a set of standardized tasks that vary in difficulty according to severity of cognitive impairment. These training tasks aim to address specific aspects of cognition.
such as memory, language, attention or executive function. In contrast cognitive rehabilitation involves individually-designed interventions which address everyday practical difficulties identified by the person with dementia and/or their caregiver (Clare, 2003).
To date, the main emphasis has been on cognitive training, but recent reviews (Clare, in press; Clare, Woods, Moniz-Cook, Orrell, & Spector, in press) demonstrate that evidence for the benefits o f such approaches, compared to individually-based interventions, is weak, and any gains do not generalise well. Clare et al. (in press) carried out a systematical review o f random controlled trials (RCTs) of cognitive training for people with early-stage dementia, which also identified a number of methodological limitations that apply to the group analysis in this present study. One limitation may be that o f low statistical power due to small sample sizes, and thus it would be advisable to replicate studies with larger sample sizes. Insufficient duration and intensity o f intervention may also be a limitation. One confounding variable that may have influenced the efficacy of forward cues and target selection may have been the greater time taken to complete these training methods. However, factors such as these may be difficult to overcome from a practical perspective, as increasing the number of participants and time involved in learning, pose practical difficulties. The present study required a substantial investment in time to complete, considering that about eighty one- to-one contacts were required, each taking approximately two hours and most being home visits to ensure regularity. In clinical practice, implementing such an approach
their busy clinical schedules. Time must also be given to deal with any emotional reactions that may arise in the course o f rehabilitation interventions (Prigatano, 1999). Furthermore, if learning approaches are not individually tailored to the person then motivation to complete the training by the participant may also falter.
When considering how to overcome some of these difficulties, there appear to be two main components that need to be incorporated into peoples’ care: firstly, there is the need to explore which learning method is most efficacious for the individual, and secondly, to incorporate those methods into everyday situations to help with daily memory difficulties. The present study highlighted the fact that it is the first stage in this process that takes considerable time for both professionals and participants. However, at this stage each participant is using all the learning methods, in an attempt to find which factors facilitate them most, so this stage could be manualised (or even computerised). Some professionals may be reluctant to incorporate this stage of cognitive rehabilitation into their busy schedules, but staff at the day Hospital (e.g. nurses) did state an interest in learning new ways to approach cognitive rehabilitation. Carers also seemed to be very keen in finding ways to help. Staff and carers could be trained to follow a manualised approach to using the learning methods and explore the factors that facilitate learning for the person with dementia. Once these factors have been identified, individually-tailored methods o f learning could be taught with the person with dementia, who could practice these using personally chosen items at home on their own, or supported by a carer. Progress in learning, and any change in affect, could be monitored at the day hospital throughout this process.
Group analysis in the present study was useful in determining some factors that may facilitate learning in dementia. However, multiple single case analyses highlighted the heterogeneity in learning patterns for all participants and the need to consider the social and interpersonal context for effective rehabilitation. High MMSE scores appeared to facilitate recall, but other social and interpersonal factors that seemed to aid recall were also observed, namely: awareness of memory difficulties and implementing strategies to overcome them, living with a supportive carer, good affect and motivation. Although awareness seemed to facilitate learning, this appeared to be negated if coping strategies had not been implemented, and quality o f life had reduced. Another important variable for effective cognitive rehabilitation in future work may thus be to use a measure of awareness (e.g. MARS: Clare, Wilson, Carter & Hodges, 2002a), in conjunction with some measure o f the impact o f dementia on quality of life. Outcome measures should also include social functioning and positive affect.