Relearning face-name associations in early Alzheimer's ...

Relearning face-name associations in early Alzheimer's disease

Preliminary evidence for the effectiveness of cognitive rehabilitation interventions based on errorless learning principles in early-stage Alzheimer's disease (AD) was provided by Clare et al. (1999, 2000, 2001). The present study extends these findings in a controlled trial. Twelve participants meeting criteria for probable AD, with Mini-Mental State Examination scores of 18 or above, were trained in face–name associations using an errorless learning paradigm. Training produced a significant group improvement in recall of trained, but not control, items. Gains were largely maintained 6 months later, in the absence of practice. There were differences in individual response to intervention. Results did not differ according to medication status, and the intervention had no adverse effects on self-reported well-being, but participants who were more aware of their memory difficulties achieved better outcomes.

Clare L, Wilson BA, Carter G, Roth I, Hodges JR. Relearning face-name associations in early Alzheimer's disease. Neuropsychology 2002; 16(4): 538-547.

There is a strong rationale for the development of inter-
ventions to assist with memory problems in early-stage
Alzheimer’s disease (AD). Despite severe episodic memory
impairment, some components of memory are relatively
preserved (Brandt & Rich, 1995), and a continued capacity
for learning means that, given appropriate cognitive support
(Bäckman, 1992), memory performance can be facilitated.
This effect is evident both in relation to procedural (Zanetti
et al., 1997; 2001) and verbal (Camp, Bird, & Cherry, 2000)
memory tasks. A recent review of empirically validated
treatments for older people (Gatz et al., 1998) classified
“memory therapy” as “probably efficacious,” indicating that
it has some promise and that further research is warranted to
extend the evidence base and clarify outstanding questions.

A series of single case evaluations of individually tailored
cognitive rehabilitation interventions designed to address
everyday memory problems in early-stage AD (Clare, Wil-
son, Breen, & Hodges, 1999; Clare et al., 2000) produced
positive outcomes in five out of six cases, and there was
evidence of long-term maintenance of treatment gains
(Clare et al., 2001). The improvements could not be attrib-
uted to generalized changes in cognitive functioning or
behavior. Targets for intervention were chosen by the par-
ticipants and their partners to maximize clinical relevance.
The interventions were based on errorless learning princi-
ples (Wilson, Baddeley, Evans, & Shiel, 1994) and involved
adaptation of learning methods for which there was prior
evidence of potential usefulness (Camp & Stevens, 1990;
Hill, Evankovich, Sheikh, & Yesavage, 1987; Thoene &
Glisky, 1995; Zanetti, Magni, Binetti, Bianchetti, & Tra-
bucchi, 1994). The results suggested that this approach may
be beneficial for a proportion of people with early-stage AD,
showed that it can be applied to individually selected and
clinically relevant tasks, and countered some of the criti-
cisms that have been leveled at “memory training” (Rabins,
1996; Small et al., 1997) by demonstrating that gains can be
maintained for significant periods and by failing to find
evidence for any clinically significant negative effect on
well-being.

These results were promising, but a number of questions
remain unanswered. In considering whether this approach
can usefully be applied in clinical practice, it will be nec-
essary to assess what proportion of people with early-stage
dementia might benefit, and to establish what factors might
help to predict outcome. Therefore, one important next step
is to explore the feasibility of applying the techniques in a
more standardized way that facilitates comparison between
individuals but nevertheless allows some scope for ensuring
personal relevance, while also evaluating factors that might
help clinicians to determine whether a given individual
would be likely to benefit.

The present study represents an initial attempt to evaluate
the efficacy of a memory rehabilitation intervention based
on errorless learning principles in a standardized, controlled
design, and to address the following research questions:
1. To what extent are the positive results achieved in the
previously reported single-case series generalizable to a
wider group of people with early-stage AD?
2. Is there evidence for long-term maintenance of treat-
ment gains?
3. Is there evidence for negative effects on the well-being
of participants or carers?
4. Do participants receiving acetylcholinesterase-inhibit-
ing medication achieve better learning outcomes than those
not receiving medication?
5. Is outcome related to participants’ awareness of their
memory difficulties?


METHOD

Participants

Criteria for inclusion in the study were as follows: medical
diagnosis of probable AD according to National Institute of Neu-
rological and Communications Disorder and Stroke and Alzhei-
mer’s Disease and Related Disorders Association criteria (Mc-
Khann et al., 1984), with supporting evidence from neuropsycho-
logical tests and scans; minimal or mild AD in keeping with
previous studies based on the Addenbrooke’s Memory Clinic
cohort (Hodges & Patterson, 1995), where minimal corresponds to
a Mini-Mental State Examination (MMSE; Folstein, Folstein &
McHugh, 1975) score of 24 or above and mild corresponds to a
MMSE score of 18–23; impairments predominantly in memory,
without widespread general intellectual impairment; absence of
major psychiatric disorder; living with a spouse or other relative
who was willing to participate; English spoken fluently; and able
to give informed consent.

Memory clinic records were reviewed to identify all potentially
suitable participants, and new referrals were scrutinized through-
out the recruitment period. Referrals were also solicited from local
clinical geropsychologists and from the Alzheimer’s Society out-
reach worker. This produced a pool of 18 possible participants of
whom 14 agreed to participate; one dropped out and one died,
leaving a total of 12 participants who completed all parts of the
study.

The participants were nine men and three women aged 57–83
years (mean 71). MMSE scores on entry to the study ranged from
19–29 (mean 23). At 12-month follow-up, MMSE scores ranged
from 12–26 (mean 20.9). Half the participants had professional or
managerial backgrounds, whereas the remainder had pursued tech-
nical, clerical, or caring occupations. Five of the participants were
taking either donepezil or rivastigmine, two had discontinued
rivastigmine prior to entering the study, and five had never taken
acetylcholinesterase-inhibiting medication. One of these began
taking donepezil shortly after the one-month follow-up. The car-
ers, all partners, were three men and nine women aged 52–78 years
(mean 67.5). Details of participants are summarized in Table 1.

Design

A quasi-experimental pretest posttest design (Cook & Campbell,
1979) was adopted. Participants served as their own controls,
receiving training on one set of items and no training on a second
matched control set which was presented an equivalent number of
times. Level of prior familiarity with the items was established
through an initial assessment of visual and verbal recognition
memory for the items. All participants performed at ceiling on
visual and verbal recognition, indicating that the items represented
previously known associations.

This design yielded group data allowing a comparison of per-
formance on free-recall and cued-recall trials at baseline, post-
intervention, and follow-up assessments for both training and
control items. The data could equally be considered as a series of
single-case experimental designs involving direct replication. In
this regard the design approximated accepted quality standards for
empirical validation of treatments using single-case designs, as
described by Gatz et al. (1998).

Individual results were reviewed by visual inspection of graphs
showing free-recall scores. Analysis of aggregated group data
involved comparisons of initial and postintervention free- and
cued-recall scores on training and control items, and of initial and
postintervention scores on specified questionnaire measures, using
repeated measures t tests. In addition, postintervention perfor-
mance on trained items for the currently medicated and never-
medicated participants was compared using an independent groups
t test (Howell, 1997), along with other selected variables.

Pre- and postintervention assessments covered relevant vari-
ables, including cognitive functioning, participants’ awareness of
memory difficulties, participant and carer mood, and carer strain.
These allowed for selected within-participant comparisons using
repeated measures t tests (Howell, 1997) to establish whether there
had been any changes on key measures following intervention.
Relationship of mean awareness scores and learning outcomes was
analyzed using Pearson’s product-moment correlation coefficient
and controlling for severity of impairment.

Neuropsychological Assessment

As part of the initial assessment, participants completed a bat-
tery of neuropsychological tests assessing general intellectual abil-
ity, memory, naming, visuospatial perception, attention, and exec-
utive function. The tests used were as follows: (a) National Adult
Reading Test (Nelson, 1982; Nelson & Willison, 1991); (b)
Raven’s Coloured Progressive Matrices (CPM; Raven, Court, &
Raven, 1984); (c) Visual Object and Space Perception Battery
(Warrington & James, 1991)—Screening, Object Decision, and
Position Discrimination subtests; (d) Facial Recognition Test
(Benton, Hamsher, Varney, & Spreen, 1983); (e) Graded Naming
Test (McKenna & Warrington, 1983; Warrington, 1997); (f) Doors
& People Test (Baddeley, Emslie, & Nimmo-Smith, 1994); (g)
Digit Span subtest of the Wechsler Adult Intelligence Scale—
Revised (Wechsler, 1981); (h) Test of Everyday Attention (TEA;
Robertson, Ward, Ridgeway, & Nimmo-Smith, 1994)—Map
Search, Elevator Counting and Elevator Counting with Distraction
subtests; (i) Dual Performance Task (Baddeley, Bressi, Della Sala,
Logie, & Spinnler, 1991); (j) Stroop Test (Trenerry, Crosson,
DeBoe, & Leber, 1989); (k) Behavioural Assessment of the Dys-
executive Syndrome (BADS; Wilson, Alderman, Burgess, Emslie,
& Evans, 1996)—Key Search and Zoo Map subtests; (l) Hayling
and Brixton Tests (Burgess & Shallice, 1997); and (m) verbal
fluency (Spreen & Strauss, 1998).

Results of the neuropsychological assessment are summarized
in Table 2 (names have been changed to preserve confidentiality).
All participants had estimated premorbid intellectual functioning
in the average, high average, or superior range. Some were im-
paired on current global assessment of functioning. As expected,
all were impaired on at least one of the memory tests, and some
also had impairments on naming and perceptual tasks. Perfor-
mance on tests of attention, working memory, and executive
function was variable, with some showing considerable impair-
ment and others demonstrating preserved functioning.

All participants underwent structural scanning by computerized
tomography or magnetic resonance imaging to exclude other pos-
sible causes of dementia. All were either normal or showed mild
hippocampal atrophy compatible with a diagnosis of AD. Quanti-
tative analyses were not performed.

Standardized Measures

The following standardized measures were used to assess mood,
behavior, awareness, and carer strain before and after the inter-
vention:

1. Hospital Anxiety and Depression Scale (HADS; Snaith &
Zigmond, 1994). Self-ratings were made by both participants and
carers. Separate scores are derived for anxiety and for depres-
sion; possible scores range from 0–21 in each case. Cut-points
of 8, 11, and 15 indicate mild, moderate, or severe disturbance,
respectively.

2. Memory Awareness Rating Scales (MARS; Clare, Wilson,
Carter, Roth, & Hodges, in press). Participants and partners com-
pleted the Memory Functioning Scale and participants completed
the Memory Performance Scale, which is used in conjunction with
the Rivermead Behavioural Memory Test (RBMT; Wilson, Cock-
burn, & Baddeley, 1985). Discrepancy scores were calculated and
a mean awareness score was derived for each participant. Higher
positive numerical scores on this measure reflect lower levels of
awareness. It is possible to achieve negative scores, and these are
taken as indicating higher levels of awareness.

3. Behaviour Problems Checklist of the Clifton Assessment
Procedures for the Elderly (CAPE; Pattie & Gilleard, 1979). Car-
ers rated participants’ behavior and dependency needs using this
scale, providing an indication of the severity of dementia from a
noncognitive perspective. Possible scores range from 0–36, with
higher scores indicating greater severity.

4. Caregiver Strain Index (CSI; Robinson, 1983). Carers rated
their subjective experience of strain on this scale. A score of seven
or above is viewed as indicative of significant levels of strain.

Materials Used in the Learning Task

For each participant, a set of 12 photographs representing people
whom the participant had difficulty in naming was assembled.
They were either photographs of people in the participant’s social
network, photographs of famous people from the Famous Faces
Test (Greene & Hodges, 1996), or photographs of currently fa-
mous people obtained from newspapers and magazines and digi-
tally manipulated to yield a set of images of uniform size. Pairs of
items were matched for gender, nationality, length of name, and
other relevant factors (e.g., occupation) as appropriate. Within
each pair, one item was selected at random to form part of the
training set (n=6) and the remaining item was allocated to the
control set (n=6).

Procedures

During initial assessment, 10 baseline free-recall trials were
given on the chosen set of faces over three sessions, followed in a
subsequent session by one cued recall, one visual recognition, and
one verbal recognition trial. When assessing free recall, the par-
ticipant was shown a photograph and asked for the name of the
person depicted. In the cued-recall condition, a photograph was
shown with the request “This person’s name begins with [initials];
can you tell me the name?” In the visual recognition condition, the
task was to select which photograph matched the name from a set
of three, including two distractors, one taken from the set of
training items, and one taken from the set of control items. Verbal
recognition was assessed by asking the participant to select which
name matched the photograph from a set of three, again including
two distractors, as above.

The intervention was then carried out over six sessions, with one
item trained in each session. Order of training was randomly
determined. The training method was a replication of that de-
scribed by Clare et al. (1999). This involved selecting a mnemonic,
learning the name using vanishing cues, and rehearsing the name
using spaced retrieval (expanding rehearsal), for which a criterion
of correct recall after 10 min was established—the predetermined
time intervals were 30 s, 1, 2, 5, and 10 min. Should the name not
be recalled on a given trial, the procedure was to halve the time
interval until correct recall was achieved; in such cases a criterion
of a total of eight trials was to be adopted. At the end of each
training session, a test trial for the whole set of faces was given.
Following each training session, participants were given a copy of
the item that had been trained, with the name and mnemonic
written on the reverse, and were asked to practice the face–name
association during the week. It was suggested that practice be
continued until the one-month follow-up trials; after this, practice
was discontinued.

Ten postintervention free-recall trials for all trained and un-
trained faces were given over three sessions. The cued-recall trial
was given at the next session. A follow-up assessment of the
name-learning task was carried out 1, 3, and 6 months after the end
of the postintervention baseline trials. A further follow-up was
completed 12 months after the end of the intervention, involving a
single visit during which five free-recall trials were followed by
one cued-recall trial.


RESULTS

Mean free-recall scores on training and control items for
all participants at baseline and postintervention, and at 1-,
3-, 6-, and 12-month follow-up, are shown in Figure 1. The
marked improvement in performance on trained items from
baseline to postintervention phases was statistically signif-
icant, t(11) = -4.408, p < .001, two-tailed. Although
practice was discontinued after the 1-month follow-up,
gains were largely maintained over the first 6 months of
follow-up. A further slight decline observed at 12-month
follow-up brought scores on the trained items into line with
scores on control items, but performance still remained
above baseline levels. For the control items, there was a
slight, nonsignificant improvement in performance between
baseline and postintervention assessment, t(11) = -1.639,
ns. The trend to slight improvement on control items con-
tinued over the first 6 months of follow-up, after which
performance began to decline.

Scores for cued recall of trained and untrained items are
shown in Figure 2 (the analysis is based on data from 11
participants, as scores were not available for Roy). Cued
recall scores followed a similar pattern to that for free recall,
but were slightly higher, indicating that cueing provided a
small degree of assistance. There was a significant improve-
ment in cued recall for trained, t(10) = -4.665, p < .001,
two-tailed, but not control items, t(10) = -1.701, p > .05,
two-tailed.

Free-recall scores (maximum six) for each participant on
training and control items across all baseline, postinterven-
tion and 1-month follow-up trials, and mean free-recall
scores achieved on 3-, 6-, and 12-month follow-up trials, are
shown in Figure 3. With regard to the trained items, 10 of
the participants showed at least some improvement in
scores; only 2 participants, Heather and Louis, showed no
learning. Seven participants, Iain, Kathleen, Martin, Neil,
Paula, Roy, and Steve, showed considerable improvements
in performance that were well maintained. Slight improve-
ment, with some maintenance, was shown by George and
Joel. Oliver showed a slight improvement in performance at
postintervention assessment, but this was not maintained at
1-month follow-up. In summary, just over half of the par-
ticipants showed clear beneficial effects of the intervention,
whereas others showed slight improvement and two showed
no learning.

Mean initial and postintervention scores on the HADS,
CAPE, and CSI are shown in Table 3. There was very little
change in mean score on any measure.

Results for the 5 participants who were taking acetylcho-
linesterase-inhibiting medication were compared with the
results for the 5 participants who had never taken such
medication; results for the two groups are summarized in
Table 4. Mean free-recall scores at postintervention assess-
ment were almost identical for the currently medicated and
never-medicated groups, and there was no statistically sig-
nificant difference. The two groups did not differ signifi-
cantly in age, awareness score, initial MMSE score, or
current memory ability as indicated by the RBMT Standard-
ized Profile Score, and mean scores on these variables were
very similar.

For the whole group of participants, the relationship
between learning (postintervention free-recall score) and
awareness of memory difficulties (mean MARS discrepancy
score) was explored. Mean discrepancy score was inversely
correlated with performance on the trained items (r =
-.623, p < .05), showing that a higher level of awareness,
as reflected in a low discrepancy score, was related to better
learning performance. Mean discrepancy scores showed no
relationship with postintervention performance on the un-
trained control items (r = .091, ns). Learning outcome was
also significantly correlated with MMSE score (r = .639,
p < .05), and there was a significant inverse association
between learning outcome and CAPE behavior score (r =
.668, p < .05), but there was no significant association
between learning outcome and age, premorbid IQ, or any
other measure.

A significant relationship between learning and aware-
ness remained when MMSE score, representing severity of
dementia, and CAPE score, representing caregiver’s report
of behavior, were partialed out (r = .764, p < .01). The
significant inverse relationship between learning and aware-
ness was maintained in a further analysis controlling for
severity of memory impairment (RBMT standardized pro-
file score) as well as CAPE score and MMSE score (r =
-.75, p < .05).


DISCUSSION

Twelve people with early stage AD participated in a
standardized, controlled cognitive rehabilitation interven-
tion involving training in face–name associations based on
errorless learning principles. Explicit recall was assessed,
and maintenance of gains up to 12 months after the inter-
vention was evaluated. Performance of medicated and
never-medicated participants was compared. The relation-
ship between awareness of memory functioning and out-
come of the intervention was also explored. Mood, behav-
ior, and carer strain were assessed initially and following
intervention.

The intervention produced a statistically significant
change in group performance on free recall of trained items
and a slight, nonsignificant improvement for control items.
Gains were well maintained at 6-month follow-up and
scores remained above baseline levels 12 months after the
end of the intervention in the absence of further practice.
The results provide further support for the efficacy of the
errorless learning procedures used in earlier single case
studies. These case studies demonstrated that the procedures
can be adapted to address individual goals in the real-life
context, and thus showed that they have the potential for
clinical relevance. Here, the procedures were implemented
in a standardized, controlled way to produce a brief, cir-
cumscribed intervention that would provide a more strin-
gent test of efficacy. Use of a standard procedure with a
fixed number of sessions meant that the learning was not
individually paced as in the earlier studies, which may have
reduced effectiveness for some participants. Furthermore, it
precluded the adaptation of learning strategies to suit indi-
vidual preferences. Another aspect of the study design that
needs to be borne in mind when interpreting the results is
that practice was stopped after the 1-month follow-up. Al-
though this provides a useful indication that gains were
reasonably well maintained at 6-month follow-up in the
absence of practice, clinical interventions need to be de-
signed to support maintenance of gains through continued
use of new learning (Bäckman, 1992). Future work will
need to return to the real-life setting and continue adapting
these procedures, now with demonstrated efficacy, to meet
the challenge posed by selecting individual goals, devising
appropriate interventions, and conducting these in a thera-
peutic manner that offers the possibility of more wide-
ranging clinical benefits.

It is important to try to understand in what way these
cognitive rehabilitation interventions are exerting their ben-
eficial effects. The areas of the brain most affected in the
early stages of AD are the medial temporal lobe structures,
notably the entorhinal cortex and hippocampus (Braak &
Braak, 1991). According to standard views of memory
processing, the hippocampal complex plays a critical role in
the establishment of new episodic and semantic memories
by linking together cortical representations (McClelland,
McNaughton, & O’Reilly, 1995; Murre, Graham, &
Hodges, 2001). Over time, by rehearsal or reinstatement,
connections are established within the cortex which become
independent of the hippocampus—so-called long-term con-
solidation. There is, however, accruing evidence that
slower, nonhippocampally dependent processes can support
learning of new semantic facts and vocabulary (Kitchener,
Hodges, & McCarthy, 1998; Vargha-Khadem et al., 1997).
In AD, the earliest pathological changes occur in the medial
temporal lobe, notably the entorhinal cortex and hippocam-
pus proper, thus explaining the profound episodic memory
deficit found in AD (Hodges, 2000). Because normal hip-
pocampally dependent learning (or relearning) is essentially
abolished in AD, one possible hypothesis is that the reha-
bilitation strategy used here may have operated by slowly
reestablishing links between phonological (name) and se-
mantic (person-specific) representations in neocortical re-
gions that are less damaged in early AD. If this hypothesis
were found to be correct, it is possible that a similar ap-
proach would also be effective for learning new semantic
information, although clearly the learning or relearning
would be expected to occur more reliably where the demen-
tia is less advanced and pathology is confined mainly to the
medial temporal areas. However, the results for individual
participants in the present study demonstrate that not all
benefited equally, and some showed no improvement. Fur-
thermore, although all had significant memory impairments,
their neuropsychological profiles differed in other ways.
Therefore, different mechanisms might be operating for
different individuals. Future studies incorporating neuroim-
aging data are required to explore further the mechanisms
involved in successful relearning.

If it is hypothesized, given the substantial cholinergic
inputs to the hippocampus from the basal forebrain cholin-
ergic nuclei via the fornix (Lawrence & Sahakian, 1995),
that acetylcholinesterase-inhibiting medication acts to im-
prove hippocampally dependent memory processes via its
modulating effect on the medial temporal lobe, the present
finding of no difference in learning outcome between the
medicated and never-medicated groups can be taken to
support the view that relearning was independent of hip-
pocampal function. It should be noted, however, that num-
bers were small and the reasons for not taking medication
were varied in this group, including recency of diagnosis or
lack of knowledge of diagnosis, unwillingness to accept the
diagnosis, or having a preexisting medical condition. Once
again, therefore, detailed studies involving larger numbers
and incorporating neuroimaging data would be required to
explore the mechanisms involved.

Learning outcome in the present study was associated
with severity, as assessed by MMSE score and CAPE be-
havior rating score. The association between learning out-
come and severity of dementia is consistent with previous
findings indicating that interventions targeting memory
functioning are likely to be most beneficial early in the
course of dementia, and that as dementia progresses the
amount of cognitive support required to facilitate learning
or relearning increases (e.g., Bäckman, 1992).

Neither individual differences in terms of age or premor-
bid ability, nor current score on any neuropsychological
measure, appeared predictive of outcome, but learning out-
come was significantly associated with awareness of mem-
ory difficulties, and this association remained significant
when severity of dementia was taken into account. This
finding is consistent with previous clinical observations
(e.g., Koltai, Welsh-Bohmer, & Schmechel, 2001), but fu-
ture work could seek to replicate the association in further
prospective studies to establish the extent to which the
association is robust.

As well as being potentially clinically useful, the associ-
ation with awareness raises interesting theoretical issues.
Neuroanatomical models of unawareness emphasize the
role of pathology in right frontal and right parietal areas
(Auchus, Goldstein, Green, & Green, 1994; Mangone et al.,
1991; Starkstein et al., 1995; Vasterling, Seltzer, Foss, &
Vanderbrook, 1995). The participants in the present study
did not undergo functional imaging, so it was not possible to
explore empirically the relationship between awareness
scores and brain pathology. This could be addressed in
future studies.

Cognitive neuropsychological models of unawareness
emphasize the role of disturbances in executive function
(e.g., Schacter, 1989; Stuss, 1991a, 1991b). In the current
study, however, there was no clear association between
awareness and scores on tests of executive function. Indeed,
the participant with the most marked impairment in execu-
tive function (Paula) was also the one with the highest rating
for awareness. Agnew and Morris (1998) proposed three
ways in which unawareness of memory difficulties may
arise in dementia: primary anosognosia, resulting from
damage to the conscious awareness system; executive
anosognosia, resulting from impairment within the execu-
tive system; and mnemonic anosognosia, resulting in a
failure to update the contents of semantic memory. The
ability to update semantic memory may be particularly
significant here. The learning task required participants to
re-activate previously familiar semantic-phonological asso-
ciations, whereas the rating of awareness used may have
tapped into the extent to which participants’ ability to up-
date semantic memory regarding their own situation and
functioning was preserved. Future work on awareness in
dementia might usefully place more emphasis on the pos-
sible role of semantic memory.

The present study aimed to assess the efficacy of the
intervention procedures in a brief, standardized, controlled
intervention, and was not designed to produce wider clinical
benefits. However, because interventions targeting memory
functioning in AD have been criticized for negatively af-
fecting well-being, it was important to assess whether any
adverse effects were observed. In fact, there was a nonsig-
nificant reduction in patient anxiety and depression scores,
and in carer depression scores. The absence of a statistically
significant reduction must be considered in the context of
the small sample size and the low scores on these measures
obtained at initial assessment. The results do not support the
view that cognitive rehabilitation is deleterious to well-
being, but further work is needed to identify whether this
approach can be applied in a way that is beneficial to wider
aspects of well-being. This would require a more clinically
oriented study targeting individual, personally relevant
goals.

The results of the present study must be interpreted in the
context of the methodological constraints outlined above.
Nevertheless, these findings support the view that a propor-
tion of people with early-stage AD may benefit from cog-
nitive rehabilitation interventions, and suggest that careful
assessment of awareness could assist clinicians in determin-
ing the suitability of this form of intervention for individual
patients.


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