Caring for older people with dementia is among the most challenging clinical endeavors in health care. Patients with cognitive impairments can be confused, forgetful and combative. It is incumbent on rehabilitation facilities that strive for clinical excellence to provide focused care for this population. Recent innovations are allowing therapists to make a difference in the lives of these unique clients.

Spaced retrieval is one such development. This memory intervention helps people with cognitive impairment retain important information for future recall. Therapists use written and visual cues and verbal prompts in working with clients on strategies to retain information and strive to increase the time interval for recalling meaningful facts.

Better memory means greater independence. By increasing recall time through spaced retrieval training, clients with cognitive challenges learn to retain important information regarding adaptive devices, activities of daily living, and the use of memory aids such as schedules and calendars. Clinicians also can employ compensatory techniques for swallowing difficulty and word-finding problems.

Launching a spaced retrieval program is fairly straightforward. A two-year project funded by the New York State Department of Health identified a structured nine-step program to ensure successful integration. These steps help identify and respond to common challenges that facilities can face when implementing a spaced retrieval protocol: gather information, foster administrative buy-in, train staff, set up a spaced retrieval-friendly environment, identify appropriate clients, identify spaced retrieval "champions," troubleshoot clinical issues, address therapist resistance, and transfer skills to home.

Clinicians can proactively address potential barriers before they arise and tailor the program to the specific needs of their rehab department by gathering baseline data about the department. This initial step also lets them know how successfully their program is performing after it's up and running. Begin with basic demographic and clinical information and a fundamental understanding of how the department functions. How many people with dementia are being served? Is there a desire to increase therapist caseload or expand the department? How knowledgeable are staff members regarding dementia care?

Look for barriers that may be affecting therapist success. Are staff members open to trying new strategies? Do they feel that people with dementia have rehab potential? Therapist attitudes are an integral part of the success of a spaced retrieval program.

In addition, look at the context of care provided. Are services provided within a long-term care or subacute setting? Do therapists see patients individually or juggle multiple patients simultaneously? Is there a separate rehab area, or does treatment generally take place in the person's living area? It's important to ask these questions in the foundational phase since they combine to form a picture of the feasibility of successful spaced retrieval implementation.

Administrative support is needed for a new program to succeed. Administrators will want to know the redeeming qualities of a program and see how their support can lead to positive outcomes for clients and the organization. It's important to explain the financial benefits of implementing spaced retrieval, such as generating referrals, maintaining clients in therapy longer due to demonstrated progress, and marketing rehab services that respond to the dementia population.

When clinicians approach administration, they should outline the clinical benefits of implementing spaced retrieval. These include improving staff competence in dementia care and helping people with dementia achieve success in therapy. When we began our spaced retrieval program, we highlighted the role of administration in implementing the program, especially in approving time commitments for staff training and overseeing staff implementation.

Staff training should provide an overview of spaced retrieval and troubleshooting for specific clinical issues and general information about treating people with dementia. We addressed time management, such as incorporating spaced retrieval along with other therapeutic goals, and billing for reimbursement.

Staff should receive both didactic and hands-on practice during training. In addition, group activities should address writing functional goals and implementing spaced retrieval treatment. We also selected staff members with an interest in acquiring new skills to serve as lead trainers to other staff.

An essential component of training is periodic technical assistance to help therapists implement spaced retrieval. This can take the form of lead trainers discussing clients and goals, troubleshooting problems, and discussing clinical successes and failures. This helps therapists feel validated in their choices and reduces frustration when things don't go smoothly.

No matter what program you implement, it's important to provide staff with the tools they need to succeed. We supplied binders for treatment forms, screening tools and other paperwork, index cards, markers, and laminating film for creating external aids. We also provided elastic fasteners for placing written signs on walkers or wheelchairs and colored duct tape for visual cueing, such as marking hand placement on walkers. These materials were kept in an organized location with easy access.

Determining which clients can benefit from spaced retrieval intervention is critical. Published spaced retrieval screening tools can help ensure that clients will be willing to address impairments and work to achieve goals.

We recommended that therapists administer this screen to all patients with diagnosed dementia at the outset of therapy and involve key people in the client's life during therapy. In some cases direct care staff can help generate new referrals by identifying people who potentially could function more independently if they could retain specific information.

Clinicians should identify staff in their department who demonstrate initiative, enthusiasm, natural leadership and competence delivering spaced retrieval. They should be encouraged to mentor other therapists and provide technical assistance to those getting started.

Despite the best efforts of setting up a spaced retrieval-friendly environment, challenges still may occur when a new treatment paradigm is introduced, including the resistance of clients and therapists. It helps to troubleshoot problems early and address them head-on in a collegial, interdisciplinary manner.

Helping therapists refine their skills to meet challenging situations improves outcomes. Working with clients who have ­significant sensory problems, treating people who don't recognize their limitations, and using the right language to elicit a target response are key areas. Encourage staff to use spaced retrieval in combination with other strategies to address sensory limitations, such as graphic and visual cueing; employ an interdisciplinary team to problem-solve with the therapist, such as having a speech-language pathologist assist a physical therapist to identify prompts; and seek the assistance of family and caregivers to encourage participation.

The most challenging obstacle to overcome may be therapeutic skepticism regarding the worth of therapy. This "nihilism" can present a challenge, especially when it's related to a particular disease, such as dementia. Therapists may feel that people with dementia can't learn and that problematic behaviors are an inevitable consequence of the condition. Clinicians also may feel they don't have time for the therapy or that it's no different from what they're already doing.

We encourage clinicians to address these beliefs early. Acknowledge the perspectives as valid while providing current research, case studies and educational materials that demonstrate the benefits of spaced retrieval. If experienced therapists have devised successful strategies for these patients through the years, reinforce the concept that spaced retrieval is not a substitute for what they have learned but builds on existing skills by providing a systematic framework to enhance success.

An ongoing challenge for rehab professionals working in nursing facilities is transferring skills from the care setting to the patient's home. Consistent cueing is necessary across settings to maintain the spaced retrieval goal.

Working closely with nursing staff in the person's living area helps to cultivate buy-in by offering opportunities to demonstrate the technique and the learning potential of people with dementia. Clinicians should encourage strategies that enhance relationships between nursing and rehab professionals to promote carry-over.

Dementia is a growing problem in assisted living and long-term care facilities. Rehab professionals must elevate their understanding of memory and its impact on function and develop appropriate treatment skills. Spaced retrieval can improve ­outcomes and provide ancillary benefits, such as changing therapist attitudes toward dementia care.

Resources

1. Klimas, N. (2002). Maximizing communication in long-term care. ADVANCE for Speech-Language Pathologists, 12: 6-8.

2. Malone, M.L., Skrajner, M.J., Camp, C.J., et al. (2007). Research in practice II: Spaced retrieval, a memory intervention. Alzheimer's Care Quarterly, 8 (1): 65-74.

Ellen Somers is the Alzheimer's services coordinator at St. Camillus Health and Rehabilitation Center in Syracuse, NY; and Kathryn Hawver is director of rehabilitation at Teresian House Center for the Elderly in Albany, NY. Megan Malone is a research associate and Cameron Camp, PhD, is former director and senior research scientist at the Myers Research Institute, Menorah Park Center for Senior Living, in Beachwood, OH. Jessica York is a student at Cleveland State University in Ohio.