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Memory enhancement training for older

adults with mild cognitive impairment: A
preliminary study
a a b
S. Rapp , G. Brenes & A. P. Marsh
a
Department of Psychiatry and Behavioral Medicine, Wake Forest University
School of Medicine , Wake Forest University , USA
b
Department of Health and Exercise Science , Wake Forest University , USA
Published online: 09 Jun 2010.

To cite this article: S. Rapp , G. Brenes & A. P. Marsh (2002) Memory enhancement training for older
adults with mild cognitive impairment: A preliminary study, Aging & Mental Health, 6:1, 5-11, DOI:
10.1080/13607860120101077

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 Aging & Mental Health 2002; 6(1): 5–11

ORIGINAL ARTICLE

Memory enhancement training for older adults with mild cognitive

impairment: a preliminary study

S. RAPP1, G. BRENES1 & A. P. MARSH2

1Department of Psychiatry and Behavioral Medicine, Wake Forest University School of Medicine & 2Department of
Health and Exercise Science, Wake Forest University, USA

Abstract
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‘Mild cognitive impairment’ (MCI) in older adults refers to a significant decline in memory function but not other cognitive
functions. Pharmacological and non-pharmacological treatments for MCI are needed. The present randomized clinical trial
tests the efficacy of a cognitive and behavioral treatment to improve memory performance and participants’ attitudes about
their memory. A multi-faceted intervention that included education about memory loss, relaxation training, memory skills
training, and cognitive restructuring for memory-related beliefs was compared to a no-treatment control condition.
Outcomes included memory performance and appraisals of memory function and control. Results indicate that the treated
group had significantly better memory appraisals than controls at the end of treatment and at a six-month follow-up. There
were no differences between groups on memory performance at post-test but at follow-up the trained individuals showed a
trend toward better word list recall than controls. Findings suggest that individuals with MCI can benefit from multi-
component memory enhancement training. Further development of such training programs and tests of their efficacy alone
and in combination with medications are needed.

Introduction et al., 1992) and subjective memory (Floyd &

The term ‘mild cognitive impairment’ (MCI) has
been used to describe an isolated memory deficit in
older adults in the context of otherwise normal
cognitive functioning. A classification of MCI typi-
cally requires a memory complaint and abnormal
memory function (e.g., >1.5 standard deviations
below expected performance for age on neuropsy-
chological tests) but unimpaired activities of daily
living and normal global cognitive function
(Petersen, 1995; Petersen et al., 1997; Petersen et al.,
1999). Research suggests that this population is at
high risk for developing dementia with 10%–15% per
year converting to Alzheimer’s dementia (AD)
compared to 1%–2% of unimpaired older adults
(Petersen et al., 1999).
Identifying and treating this at-risk group of
older adults is important as treatment may prevent
or delay the progression to AD and reduce func-
tional impairment (Petersen et al., 1997). In
addition to pharmacological treatments, meta-
analytic studies of memory skills training
interventions in the elderly have revealed that
training can improve both objective (Verhaeghen
Scogin, 1997). Most studies, however, have trained
healthy older adults who do not have existing
memory impairment.
It is also important to modify how they appraise
their memory function and to enhance their sense
of control over their memory abilities (Verhaeghen,
2000) because one’s sense of control can influence
motivation and memory performance (West et al.,
2000; Lachman, 2000). Lachman et al., (1992)
demonstrated significant improvement in memory
control beliefs following a skills training plus
appraisal modifying intervention in healthy older
adults. West & colleagues (1992) compared a
memory skills training with practice to memory
skills training plus memory control beliefs enhance-
ment condition and found that both groups
improved on measures of memory control beliefs
and on at least one memory performance task.
Caprio-Prevette & Fry (1996) compared a cogni-
tive restructuring (CR) intervention aimed at
modifying participants’ control beliefs regarding
their memory to the traditional memory skills
(TMS) training in healthy older adults. By follow-
up nine weeks later the CR group outperformed the

Correspondence to: Stephen R. Rapp, PhD., Department of Psychiatry and Behavioral Medicine, Wake Forest University
School of Medicine, 1 Medical Center Boulevard, Winston-Salem, NC 27157. Tel: (336) 716 6995. Fax: (336) 716 6830.
E-mail: srapp@wfubmc.edu

Received for publication 12th March 2000. Accepted 17th April 2001.
ISSN 1360–7863 print/ISSN 1364–6915 online/02/010005–07 © Taylor & Francis Ltd
DOI: 10.1080/1360786012010107 7
 6 S. Rapp et al.
TMS group on several memory measures and
perceived greater control over their memory.
The present study tests a multifaceted interven-
tion for older adults with MCI. The training
package includes education on memory, relaxation
skills training, mnemonic strategies, and cognitive
restructuring to change beliefs about memory
control. It was expected that compared with the no
treatment control condition, the intervention group
would improve in memory performance and have
stronger and more positive attitudes regarding their
memory.
Methods
Sample
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Participants for this study were community
dwelling, older adults meeting criteria for MCI
(Petersen et al., 1999) including (1) a self-reported
memory complaint, (2) a score on a standardized
memory test at or below the 10th percentile, (3)
scores on tests of all other cognitive functions
greater than the 10th percentile, (4) normal global
cognitive functioning, (5) no ADL or IADL defi-
cits, and (6) the absence of dementia.
Measures
Cognitive function. The Consortium for the Registry
of Alzheimer’s Disease (CERAD) (Morris et al.,
1989) neuropsychological battery (Welsh et al.,
1991) was used in assessing cognitive functions
(verbal fluency, naming, constructional praxis,
attention and concentration, executive function and
memory).
Global cognitive function. This was assessed with the
Mini-Mental State Exam (Folstein et al., 1975).
Memory performance. Outcome measures included
four memory tasks, each with immediate and
delayed recall parts (Scogin et al., 1998). A word list
task involved a visual presentation of a list of 20
high-imagery, concrete nouns. The grocery list task
is an oral presentation of a 20-item grocery-shopping
list presented one at a time. The names and faces
task is a self-paced presentation of 15 facial photo-
graphs each with a unique surname. The paragraph
recall task is an oral presentation of a brief story
(Wechsler, 1981). The scores for both immediate
and delayed recall were the total number of elements
recalled. Higher scores indicate better memory
performance.
Perceptions of memory impairment. This was assessed
with the Memory Functioning Questionnaire
(MFQ) (Zelinski et al., 1990; Gilewski et al., 1990).
The MFQ consists of 64 items, all rated by the
respondent on a seven-point Likert scale. Subscales
include general frequency of forgetting (Freq.),
change relative to retrospective functioning (Retro-
spective), seriousness of forgetting problems
(Seriousness), and mnemonics usage (Mnemonics).
Mean item scores were used. Higher scores indicate
less memory problem and less mnemonic usage.
Perceived control over memory. This was measured
using the Memory Controllability Inventory
(Lachman et al., 1995), which consists of 12 items
forming four subscales (present ability, potential
improvement, inevitable decrement, effort utility) of
three items each. Respondents rate each item on a
seven-point Likert scale to reflect their agreement or
disagreement.
Mood. To control for the influence of mood states on
memory performance and appraisals (Smith et al.,
1996), the Profile of Mood States (McNair et al.,
1992) was administered at each assessment.
Procedures
Prospective participants were screened by tele-
phone and were excluded from the study if they
reported a diagnosis of dementia or other cognitive
disorder reported any ADL/IADL impairments;
were currently being treated for major psychiatric
disorders, cancer, myocardial infarction or other
heart diseases; if they were taking medications
(e.g., donepezil, antidepressants) or herbal
mixtures (e.g. gingko biloba) likely to affect cogni-
tive function; or if they had received memory
training previously. Prospective participants signed
a written informed consent in accordance with the
WFUSM institutional review board procedures
and were administered the CERAD battery by a
trained technician. Informants verified questions
regarding ADLs/IADLs. Individuals meeting the
criteria for MCI were then administered the four
memory performance study measures. Persons
meeting all study criteria were then randomized to
either the treatment or the control group.
Treatment condition. The treatment consisted of six,
weekly group meetings lasting two hours each
administered by two clinical geropsychologists (SR,
GB). The first session included a presentation on
dementia, memory and the factors that can influence
memory performance (e.g., fatigue, anxiety, motiva-
tion, appraised importance). Participants were
taught a relaxation skill (systematic breathing) and
encouraged to use it to reduce tension, especially
associated with remembering. Each participant also
received a copy of Improving Your Memory (Folger
& Stern, 1994) with chapter assignments. There was
general discussion of the memory problems
 Memory training and MCI 7

participants found most disturbing. During the
remaining sessions, the trainers described and
demonstrated specific memory skills (cueing, cate-
gorization, chunking, method of loci) and led group
exercises using them. Homework employing the
trained skill was assigned.
No-treatment control condition. Participants in this
group received no memory education or training. At
the end of the study, each person was given a copy of
the book and other printed materials distributed to
the trained participants.
Within two weeks following completion of the
training, participants in both groups were retested
by the research technician, who was blinded to
group assignment. Six-months following post-
testing participants were retested.
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memory skills training. The change in R2 indicates
the relative effect size of the intervention.
Results
Of the one hundred and sixty-eight persons
interested in the study, 77 were eligible for initial
testing. Forty-three individuals had memory func-
tion above the threshold for inclusion. Of the 25
remaining persons with MCI, 19 agreed to partici-
pate and were randomized to either the treatment
group (n = 9) or the control group (n = 10). The
overall sample had slightly more females (58%) and
had a mean age of 75.1 (7.0) years. The sample was
predominantly Caucasian (95%) and well educated
(74% having more than 12 years of education).

Approximately half (47%) of the sample was

Statistical analyses
T-test and chi-square analyses are used to compare
groups at baseline on demographic variables.
Variables with significant pre-treatment group
differences were retained as covariates in all
analyses. To prevent the loss of participant data due
to missing data at follow-up for three subjects (two
experimental, one control), multivariate regression
analyses were used instead of repeated measures
MANOVA to examine the effects of the memory
skills training on the outcomes after controlling for
any groups differences at baseline. To test for
training effects between pre- and post-test, pre-
intervention scores for the dependent variable (post-
training score) and covariates were entered in the
first step followed in the second step by a group
variable (intervention group = 1, control group = 0).
In separate analyses of pre- to follow-up changes,
the pre-training score was entered in step 1 to
predict follow-up scores. A significant change in the
F for the second step indicates a significant effect of
married. The mean MMSE scores were all within
the normal range (i.e., > 24). Table 1 shows sample
characteristics by group.
There were no statistically significant differences
between the treatment and control groups with
respect to age, race, marital status, education,
income, global cognitive function or mood at base-
line or medication use at any time point (all ps >
0.10). There was a significantly greater number of
males in the control group (p = 0.02); hence,
gender was entered as a covariate in all analyses.
Between post-treatment and follow-up assess-
ments, three participants (two treatment, one
control) dropped out of the study (2) or could not
tested (1).
Memory task performance
Table 2 presents the group means and standard
deviations for dependent variables at pre-test, post-
test and follow-up. Regression analyses revealed that
following treatment there were no significant

TABLE 1. Sample demographic characteristics by group

Variable Trained group (n = 9) Control group (n = 10)
Mean SD % Mean SD %
Age 73.33 6.61 75.10 7.03
Gender
Male 11 70
Female 89 30
Marital status
Married 44 50
Widowed 33 30
Divorced 22 20
Education
High School graduate 33 20
Some college 22 50
College graduate 11 10
>16 years 33 20
Race (White) 100 90
MMSE 28.0 1.5 27.3 1.88
 8 S. Rapp et al.

TABLE 2. Means and standard deviations for memory performance by treatment condition
Treatment Pre-test M (SD) Post-test M (SD) Follow-up M (SD)
Word list-immediate
Training 8.11 (3.02) 11.56 (2.83) 8.71 (3.35)
Control 5.10 (0.99) 7.80 (3.22) 8.33 (2.18)
Word list-delayed
Training 3.56 (2.92) 8.44 (4.22) 6.71 (3.99)*
Control 1.90 (1.45) 4.70 (3.62) 5.89 (3.22)
Shopping list-immediate
Training 7.89 (2.03) 6.33 (1.58) 7.14 (1.77)
Control 7.60 (2.59) 6.10 (1.45) 5.78 (3.11)
Shopping list-delayed
Training 5.44 (1.94) 4.11 (2.37) 5.86 (3.53)
Control 5.40 (2.01) 5.40 (2.22) 5.89 (2.85)
Names and faces-immediate
Training 5.78 (3.35) 4.33 (2.50) 5.43 (3.69)
Control 3.90 (3.70) 2.60 (2.80) 3.89 (3.41)
Names and faces-delayed
Training 4.33 (3.12) 3.22 (2.44) 4.14 (3.85)
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Control 2.70 (3.23) 1.60 (2.50) 3.33 (3.87)

Paragraph-immediate
Training 10.11 (3.72) 12.11 (4.04) 11.86 (4.06)
Control 9.90 (3.76) 12.00 (2.90) 13.78 (2.49)
Paragraph-delayed
Training 8.56 (4.28) 11.11 (4.17) 11.14 (5.49)
Control 8.30 (4.92) 9.00 (3.59) 11.56 (2.96)
*= p < 0.07. At pre-and post-treatment assessments the Training group had 9 participants and the Control group had 10
participants. At follow-up the ns were 7 and 9, respectively.

differences between groups on the measures of
memory performance after adjusting for gender (all
ps > 0.25). There was a statistical trend at follow-up,
however. The trained group had higher scores on the
word list task delayed recall than the control group
(p = 0.08, R2 = 0.11). There was evidence of a
practice effect on the word list and paragraph tasks
with scores in both groups improving at each admin-
istration, but not on the shopping list or names and
faces tasks.
had stronger beliefs in the potential for improvement
(MCI-Potential Improvement: p = 0.005, R2 = 0.20)
and there was a trend toward expecting less inevitable
decline in memory (MCI Inevitable decline: p = 0.06,
R2 = 0.12). By follow-up, however, there were no
differences between trained participants and untrained
participants. Examination of the means over time
suggests that trained participants’ ratings of control
returned to baseline levels by follow-up while
untrained participants ratings at follow-up were lower
than baseline levels.

Perceived memory ability

There were significant pre-to-post training effects
on participants’ perceptions of their memory
ability. The trained group perceived their current
memory ability to be better than controls on the
MCI-Present Ability scale (p = 0.008, R2 = 0.23)
and there was a trend their memory was better than
it was in the past (MFQ-Retrospective Func-
tioning, p = 0.07, R2 = 0.20). Training appeared to
have no differential effect on frequency of forgetting
(p = 0.23). By follow-up, the trained group still
reported significantly better current memory ability
than the control group (MCI-Present Ability:
p = 0.05, R2 = 0.17). There were no other group
differences in perceived ability at follow-up.
Memory skill development
The two groups did not differ in their reported use of
mnemonics at the end of treatment (p = 0.48). By
follow-up, the control group was reporting greater use
of mnemonics than the trained group (MFQ-
Mnemonics: p = 0.008, R2 = 0.30). Untrained partici-
pants were using ‘to-do’ lists more (p = 0.02) and
planning their daily schedule more (p = 0.03) than
trained participants. Trained individuals were using
grocery lists more than untrained participants
(p = 0.06). There were no differences in their use of
appointment books, written reminders, mental repeti-
tion, associations with other things, or keeping things in
prominent places (all ps > 0.10). See Table 3.

Perceived control over memory Perceived impact of memory problems

The intervention also improved participants’ beliefs in Both groups characterized their memory problems
their ability to control their memory. The trained group as somewhat serious and causing problems for them
 Memory training and MCI 9

TABLE 3. Means and standard deviations for perceived memory and mnemonics use
Treatment Pre-test M (SD) Post-test M (SD) Follow-up M (SD)
Perceived memory ability
MCI-Present ability
Training 3.94 (1.46) 5.36 (0.93)*** 4.86 (0.83)**
Control 3.85 (1.14) 3.98 (0.52) 3.81 (1.08)
MFQ-Frequency of forgetting
Training 4.51 (0.86) 4.55 (0.68) 4.44 (1.39)
Control 4.17 (0.98) 4.04 (0.59) 4.02 (0.82)
MFQ-Retrospective functioning
Training 3.61 (1.21) 4.17 (0.91) 3.46 (0.98)
Control 3.80 (0.85) 3.55 (0.50) 3.33 (0.77)
Perceived impact of memory functioning
MFQ-General functioning
Training 3.83 (0.98) 3.78 (0.97) 3.67 (1.03)
Control 3.88 (1.13) 3.30 (0.82) 3.44 (0.88)
MFQ-Seriousness
Training 4.34 (1.65) 4.52 (1.19) 3.60 (1.34)
Control 3.78 (1.04) 4.20 (0.90) 3.20 (1.16)
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Memory skill use

MFQ-Mnemonic use
Training 2.19 (0.72) 2.15 (0.71) 2.32 (0.62)***
Control 2.48 (0.94) 2.93 (0.74) 2.18 (0.60)
Perceived control over memory
MCI-Potential improvement
Training 5.15 (0.88) 6.00 (0.65)*** 5.14 (0.69)
Control 4.77 (1.14) 4.37 (0.88) 4.19 (1.03)
MCI-Inevitable decline
Training 3.52 (1.28) 2.70 (1.12)* 3.57 (1.08)
Control 3.67 (1.50) 4.00 (0.63) 3.93 (0.70)
MCI-Effort utility
Training 5.33 (1.15) 5.96 (0.99) 5.29 (0.78)
Control 5.23 (1.57) 5.57 (0.52) 5.11 (1.07)
* = p < 0.07, **= p < 0.05, ***= p < 0.01. At pre-and post-treatment assessments the Training group had 9 participants
and the Control group had 10 participants. At follow-up the ns were 7 and 9, respectively.

at baseline. Groups did not differ at the end of treat-
ment or by follow-up in either the perceived impact
of memory problems (MFQ General Functioning,
ps = 0.44, 0.96, respectively) or in the seriousness
of their memory problems (MFQ-Seriousness,
ps = 0.88, 0.41).
Discussion
Individuals with significant memory impairment
represent a highly vulnerable subpopulation of older
adults. This study tested a multi-faceted
intervention that included training in specific
memory skills, education about memory and
dementia, and a component intended to modify
participants’ beliefs about memory control and
performance.
We are encouraged by the impact the intervention
had on participants’ appraisals of their current and
future memory abilities. By the end of treatment,
trained participants rated their memory ability more
favorably than controls. Training also led to stronger
expectations for future improvement and lower
expectations for cognitive decline. By six months
following treatment, trained participants still rated
their present memory ability more favorably than
controls. Thus, it appears that the psychological
component targeting participants’ beliefs about their
memory and their ability to control it was effective.
Lachman et al., (1992) also showed that combining
cognitive training with a cognitive-behavioral inter-
vention targeting control beliefs produced improved
beliefs about memory control and efficacy. Floyd &
Scogin (1997) concluded from their meta-analysis of
the effects of memory training on subjective memory
functioning that the effect size for changes in subjec-
tive memory is greater in studies that include both
training in mnemonics and expectancy modification.
Our finding of no change in laboratory memory
tasks following training is disappointing. In their
meta-analysis of 31 mnemonic training studies of
healthy older adults, Verhaeghen et al., (1992)
found pre-to-post-test gains associated with
training equal to 0.73 standard deviations indi-
cating that training can improve memory
performance. Younger age, pre-training designed
to enhance the learning of mnemonics, training in
groups, and shorter session length were all
associated with training gains. We trained our
participants in groups and pre-trained them by
providing information about dementia and memory
impairment, by teaching them relaxation skills, and
by encouraging them not to view all memory diffi-
culty as catastrophic. The age of our sample (75.1
years), however, was greater than the mean age of
 10 S. Rapp et al.
samples Verhaeghen et al., studied (69 years) and
the duration of our sessions at two hours was lightly
longer than the mean session time (1.49 hours,
range: 0.33 hours to 2.5 hours). These factors may
have made our skills training intervention less
effective. The most important difference between
our study and those reviewed by Verhaeghen et al.,
(1992) however, may be our selection of individ-
uals with documented mild cognitive impairment.
For these individuals, shortening the duration of
sessions, increasing the number of sessions,
including ‘booster’ sessions, and providing more
extensive pre-training might improve memory
performance.
Evidence that participants may have needed
more training sessions came from spontaneous
comments made by them during post-testing.
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Several participants commented to the technician
that they were unsure which mnemonic strategy to
use during memory tasks. This indicates that they
understood when to use mnemonics but they could
not quickly and easily select or apply them. West &
associates (2000) report results similar to ours from
a pilot study of 40 “at risk” older women i.e.,
women who scored one standard deviation below
their peers on a test of object location recall. Their
five-week intervention compared a memory skill
plus memory control belief training program to a
delayed treatment control condition. The trained
group showed improved control beliefs and
reported greater use of the cognitive strategies, but
both groups showed comparable improvement in
memory performance. They concluded that more
practice with memory exercises might have helped
performance.
A curious finding was that trained participants
reported using mnemonics less than untrained
participants, by the six-month follow-up testing.
The difference in scores is due to a slight decrease
in use by trained participants between post-test and
follow-up and a modest increase in use by the
controls during the same period. While we clearly
expected trained participants to increase their use
of mnemonics, some research suggests that
mnemonics is associated particularly with poorer
memory. For example, Small et al., (1995) have
reported greater mnemonic usage measured with
the MFQ predicts lower frontal lobe glucose
metabolism and greater subsequent cognitive
decline (Small et al., 1997). Thus, mnemonics use
may indicate poorer perceived memory function,
not better. We may have unintentionally intervened
in contradictory ways. If our intervention reduced
their appraisals of current and future memory
impairment, participants in the trained group may
have felt less need to use mnemonics. The signifi-
cantly higher perceived memory ability scores for
trained participants supports this interpretation.
Additional research into when memory impaired
persons seek to learn mnemonic strategies would be
helpful.
A significant limitation of our study is the small
number of participants, especially for the follow-up
analysis. Moreover, we did not correct for multiple
comparisons since the study is exploratory and
underpowered. As a result our findings should be
viewed as preliminary and merely suggestive. The
R2s from the regression analyses do suggest that
marginal p-values (0.05 < p < 0.10) were associated
with reasonable effect sizes, however. We used
research diagnostic criteria for MCI developed by
Petersen et al., (1999) but other criteria have been
proposed and might have altered subject selection
and results. Lastly, since we did not track the daily
use of the mnemonic techniques, we cannot say
precisely how much they were used.
In sum, this study has demonstrated that a brief,
cognitive and behavioral group intervention
targeting memory performance and memory
appraisals can be effective at changing perceptions
of memory ability in a high-risk population of older
adults with cognitive impairment. The results
suggest that older adults with cognitive impairment
may need more skills training, however, to achieve
and maintain performance improvements. An
intriguing question in light of these results is
whether combining memory enhancement training
and pharmacological interventions for memory
would provide benefits beyond monotherapy.
Acknowledgments
We wish to express our appreciation to Heather
Uncapher, PhD, for her assistance with the design of
this study and to Stacey Gibson for her help with
data collection, and to Forrest Scogin, PhD, for
permission to use the memory tests.
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