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Memory aids in reality orientation: a single-case study
Behar. Res. Ther. Vol. 22, No. 6. pp. 709-712.
1984
Printed in Great Britain.
Copyright
CASE HISTORIES Memory
AND SHORTER
aids in Reality
Orientation:
I
0005-7967 h4 53 w-t o.tb!l 1’184 Pcrgamon Prc\, Ltd
COMMUNICATIONS a single-case
study
IAN G. HANLEY Department of Psychological Services
and Research. Crichron Royal Hospital, Dutnfries. Sro:lund
KEITH LUSTY Nursing Services, Si Mar!, ‘s Hospilal. Hereford, England (Received 7 March 1984)
Summary-A single-case study of retraining both verbal and behavioural orientation in an 84-yr-old patient with senile dementia is described. In contrast to the traditional approach of employing RO sessions in which verbal learning and subsequent free recall is employed, the patient was provided with a watch and a diary containing personalized information and a daily behavioural itinerary. Results suggest that such memory aids can increase orientation and when effective use of these aids becomes the target of a specific behavioural training then purposive behaviour can be engineered.
INTRODUCTlON Reality Orientation (RO) is extensively used with psychogeriatric patients, many of whom are confused. disorientated and suffering from organically based memory disorders. There are a number of components in the RO approach, many of which have been relatively neglected in the attempts that have been made to evaluate RO and measure its effectiveness. Mosp studies have looked only at formal RO sessions which have a major element of memory retraining and involve the patient learning or relearning information relating to time, place and person (Woods. 1979, 1983; Brook, Degun and Mather. 197.5. Hanley, McGuire and Boyd, 1981; Johnson, McLaren and McPherson. 1981). Small significant increases in verbal orientation have been demonstrated, as has a specific retraining effect for RO sessions (Woods. 1983). Some evidence has also emerged for RO having a beneficial effect on the mood of patients and subsequently their caregivers (Greene. Timbury. Smith and Gardiner, 1984). The impact of such RO sessions, however, is by no means dramatic. Both Johnson er al. (198 1) and Zepelin, Wolfe and Kleinplatz (1981) have commented that the effects produced are small in comparison to the effort required to attain them. Moreover the gains during therapy are not maintained for long (Greene, Nicol and Jamieson, 1979). Perhaps this is because investigators have employed an RO session technique based primarily on having patients learn new mformation and then recall it later by free recall. For patients with dementia this poses the greatest possible demand and emphasizes unnecessaril! the primary neuropsychological deficits of the condition. It is also a technique fundamentally at odds with one of the basic premises of RO, namely that patients should be helped to succeed. Success for the patient is made more likely by providing memory aids in the patient’s environment, encouraging their use and where recall of verbal information is requ,;ed by providing a recognition format or cued-recall format to solicit a successful response (Woods, 1983). Hanley (196i ) m one of the few studies that has demonstrated a behavioural effect for RO-based procedures showed that a combination of signposts and behavioural training produced a sizeable and relatively durable improvement in the ability of patients to find places in the ward environment. This specific behavioural change was not evidenced by patients receiving cognitive class RO (Hanley, McGuire and Boyd, 1981). The present study represents an attempt to improve verbal orientation and behavioural functioning in a patient with organic dementia, by providing two simple prosthetic aids to memory (watch and diary) and training the patient to use these aids effectively. METHOD Subject The S was an 84-yr-old female patient who had been admitted a 5 yr history of being increasingly forgetful, isolated and unable
to a psychiatric hospital 9 months to look after herself. The diagnosis
previously. supported
She had by EEG
examination and neuropsychological investigation was of senile dementia. This was moderately advanced according to the criteria of the Clifton Assessment Procedures for the Elderly (CAPE) on which the patient scored C on the scale A-E. Measuremenf A 30-item personalized memory and orientation test was constructed from the patient’s records, Information from relatives etc. This was used as the major assessment measure throughout, administered by the experimenter (K.L.) in a conversational manner. It contained items of personal current and personal past information together with items of current non-personal orientation. In addition a list of daily behaviour targets was compiled. These were written in the form of appointments to be kept with either the experimenter or other staff on the ward. Times of the appointments were varied. but kept to even times in the hour, such as 10.15 a.m., 10.30 a.m.. 10.45 a.m. etc. The appointments were for activities relevant to the patient’s interests, e.g. collecting the daily paper. having her hair done (she had managed her own hairdressing shop for many years), having a ‘chat’ with the experimenter etc. To avoid contamination effects the target times were restricted to periods of the day when no other activity was scheduled. e.g. meals. The patient’s success at
710
CASE
Phase A
I
Phase
HISTORIES
AND
SHORTER
C~~MUNtCATiONS
0
Phase C
Phase 8
Phase A
I
Week 1
Weeks 2 and 3
Weeks 4 and 5
Week 6
Week 7
Fig. 1. Ss daily POQ scores during baseline and experimental phases, attending these appointments, without reminding from staff, was the other major assessment measure throughout. Two points were awarded when the patient kept an appointment within tOmin of the specified time, One point was awarded if the patient turned up for the appointment outside this period. Design
A quasi-experimental design of the ABCBA type using repeated measurements of the Personal Orientation Questionnaire (POQ) and daily Appointment scores was employed (Hersen and Barlow, 1976). The phases of the experiment are shown in Table I. Each phase lasted 7-14 days. Throughout the period of the study the experimenter met with the patient each day (except Sunday) and the POQ was administered. Correct answers were not provided by the experimenter. Before the commencement of Phase B the patient was provided with her watch (kept in the patient’s belongings, but previously unused) and a large diary containing all relevant personal information. The patient was shown this information once only before Phase B commenced and after this it was not referred to at all by the experimenter. During Phase A three ‘appointments’ for the patient on the following day were presented verbally by the experimenter after each administration of the POQ. During Phase B these appointments were written in the diary by the S with the assistance of the experimenter. The S was actively trained to use the diary to answer the questions on the POQ during Phase C. This involved a 5 min training period at the end of each day’s session. The patient was asked to look at the diary and answer each question not correctly answered during the session, e.g. “Mrs Smith, the answer to the question about your brother’s name is on page 2 of your diary, Look at page 2 and tell me the answer.7“ During Phase C the patient was also trained to use the watch and diary to keep the ap~~n~ents written in the diary. This involved reminding the patient about each failed appointment after 10 min had elapsed and asking her to look at her watch and diary. The activity was then carried out. Throughout all phases of the experiment the patient was praised for keeping appointments and the activity involved carried out as scheduled. Baseline (A)
Table 1. Design of single-case study --no diary, watch or training.
Phase
-watch
B
and
diary
appointments Phase
C
Phase B Baseline (A)
-watch,
containing
provided;
diary
and
Information
and
daily
traming.
-watch and
diary
only;
-watch
diary
withdrawn.
and
personal
no training. training
withdrawn.
RESULTS Figure 1 shows the patient’s score on the POQ during the experimental intervention. The final plateau of 30 in Phase C is the test ceiling and represents an increase of 23 points over the baseline level. Although some improvement is noticeable in Phase B this is small and irregular compared with the cumulative increase in score evident through Phase C. A rapid reversal effect is seen on return to Phase B and scores on second baseline have returned to the level recorded at the start of the intervention. Figure 2 shows the daily Appointments scores (maximum 3 appointments x 2 points = 6 points) over the period of the study. ~roughout Phase A the patient consistently failed to respond. During Phase B (diary and watch) only I;36 appointments was kept. When training was introduced in Phase C 12/36 appointments were kept. This improvement in performance was not maintained when training was withdrawn and scores returned rapidly to initial baseline level for the remainder of the study. DLSXJSSION The results of this study suggest that elderly memory-disordered patients can be trained to use a prosthetic memory aid (diary) to successfully respond to demands on their orientation and memory for relevant personal information. The ability
CASE
HISTORIES
AND
SHORTER
711
COMMUNICATlONS
I
Phase A
Phase B
I
Phase C
Phase B
I
oo I .-. ’ AM A.-.1AI\i -.-.-.-.-.-. .A.-.-.-.-.-.-. /
t
l
I
t
o-0-0
,
II
I 1
I
I
I
I
Week 1
Weeks
2 and 3
Fig. 2. Ss daily Appointments
I 1 Phase A
.
.
.
Weeks 4 and 5
’
.-.-.-e.-.
I*.-.-._. I
Week 6
Week 7
scores during baseline and experimental phases.
to read is often one of the last to become impaired in dementia. In addition to learning to make reference to the diary it was evident from this study that the patient also required to be trained to locate the relevant information precisely. Information was arranged in sections across several pages of the diary and the steady improvement across Phase C reflects, in part, an increasing accuracy in finding the relevant section and identifying the particular question asked. The result-100% accurate responding at the end of Phase C-has not been achieved in any study of RO to date. With the exception of Woods (1983) who provided cues (the first two letters of the answer) to facilitate accurate responding, free recall has been the criterion employed. Woods’ data did suggest that the provision of prompts enhances correct responding although a specific learning effect, independent of prompts, is also demonstrated. In the present study no attempt was made to follow the traditional model of having the patient learn a series of training items. Although such specific learning can be achieved there is a definite upper limit to the amount of information dementing patients can successfully retain. Thus the learning of a specific set of skills, i.e. correct use of a diary is more likely to have the potential of giving the patient access to a larger store of information. It would be of interest to establish whether indeed such an approach can be successfully applied with a much larger pool of information than the 30 items employed in this experiment. Woods (1983) used a diary in the final phase of his study and noted that this was particularly useful for time orientation information which changes frequently. The reversal effect noticed on Phase B was not unexpected. Memory-disordered patients are dependent on prompts from their environment in particular from those who care for them. For maintenance to occur consistency of approach is essential. In the institutional setting it is perhaps easier to have staff remind memory-disordered patients to use a diary than it is to have staff remember, and take the time to prompt, each individual answer from each individual patient. One of the major unaddressed issues in RO research is that pertaining to the extent to which staff actually change their interactive style with patients, Hanley (1984)raises doubts as to the extent of change that can be achieved in a 24 hr RO programme. It may be more realistic in some institutional settings to train staff to use a few specific interactional strategies based on the cueing of patients to memory aids in their environment. The efficacy of this focussed approach has been demonstrated when applied to patients finding their way around a ward (Hanley, 1981). Behavioural changes have rarely been demonstrated in RO research and so it is of some interest that the patient in the present study learned to independently keep some 33% of daily scheduled appointments. It would, however, appear that this diary-dependent behaviour was not mastered in the 2-week training phase and perhaps a longer or more intense training phase may have had better results. Staff did report that the patient was frequently seen, sitting in the ward reading her diary. As appointment keeping is dependent on the interrelated use of diary and watch the training could have been improved if more attention had been paid to having the patient cross check the two aids at more frequent intervals. The training in this study only took place a maximum of three times per day after the patient had already missed appointments. There was one particularly pertinent difficulty experienced in this study. The patient quite frequently lost her diary despite generally keeping it in her handbag. A practical solution other than that of having staff find it for her might have been to fix it on a cord attached to her handbag. Despite this problem the results of the study confirm the value of a relatively uninvestigated component of RO, namely the provision of memory aids and the training of patients to use them effectively.
Acknowledgements-The this study.
authors thank the staff of Galloway West. Crichton Royal Hospital, for their co-operation during
REFERENCES Brook P., Degun G. and Mather M. (1975) Reality Orientation, a therapy for psychogeriatric patients; a controlled trial. Br. J. Psychiat.
127, 4245.
Greene J. G.. Nicol R. and Jamieson H. (1979) Reality Orientation with psychogeriatric
patients. Behar. Res. Ther. 17,
615-617.
Greene _I.G., Timbury G. C.. Smith R. and Gardiner M. (1984) Reality Orientation with elderly patients in the community: an empirical evaluation. Age Ageing 12. Hanley I. G. (1981) The use of signposts and active training to modify ward disorientation in elderly patients. J. Behan. Thu.
exp. Psychiat.
12, 241-247.
712
CASE HISTORIES AND
SHORTER COMMUNICATIONS
Hanley I. G. (1984) Theoretical and practical considerations in Reality Orientation therapy with fhe elderly. In Psychological Approaches fo the Care of the EIderIy (Edited by Hanley I. G. and Hodge J.). Croom-Helm. London. Hanley I. G., McGuire R. J. and Boyd W. D. (1981) Reality Orientation and dementia: a controlled trial of two approaches. Br. J. Psychiar. 138, 10-14. Hersen M. and Barlow D. H. (1976) Single Case Experimental Designs: Straregiesfor Studying Behauiour Change. Pergamon Press, Oxford. Johnson C. H., McLaren S. M. and McPherson F. M. (1981) The comparative effectiveness of three versions of ‘classroom‘ reality orientation. Age Ageing 10, 33-35. Woods R. T. (1979) Reality Orientation and staff attention: a controlled study. Br. Jo Psychiat. 134, 502-507. Woods R. T. (1983) Specificity of learning in Reality Orientation sessions: a single-case study. Behau. Res. Ther. 21, 173-175. Zepelin H., Wolfe C. S. and Kleinplatz F. (1981) Evaluation of a year-long Reality Orientation program. J. Geront. 36, 70-77.
1984
Printed in Great Britain.
Copyright
CASE HISTORIES Memory
AND SHORTER
aids in Reality
Orientation:
I
0005-7967 h4 53 w-t o.tb!l 1’184 Pcrgamon Prc\, Ltd
COMMUNICATIONS a single-case
study
IAN G. HANLEY Department of Psychological Services
and Research. Crichron Royal Hospital, Dutnfries. Sro:lund
KEITH LUSTY Nursing Services, Si Mar!, ‘s Hospilal. Hereford, England (Received 7 March 1984)
Summary-A single-case study of retraining both verbal and behavioural orientation in an 84-yr-old patient with senile dementia is described. In contrast to the traditional approach of employing RO sessions in which verbal learning and subsequent free recall is employed, the patient was provided with a watch and a diary containing personalized information and a daily behavioural itinerary. Results suggest that such memory aids can increase orientation and when effective use of these aids becomes the target of a specific behavioural training then purposive behaviour can be engineered.
INTRODUCTlON Reality Orientation (RO) is extensively used with psychogeriatric patients, many of whom are confused. disorientated and suffering from organically based memory disorders. There are a number of components in the RO approach, many of which have been relatively neglected in the attempts that have been made to evaluate RO and measure its effectiveness. Mosp studies have looked only at formal RO sessions which have a major element of memory retraining and involve the patient learning or relearning information relating to time, place and person (Woods. 1979, 1983; Brook, Degun and Mather. 197.5. Hanley, McGuire and Boyd, 1981; Johnson, McLaren and McPherson. 1981). Small significant increases in verbal orientation have been demonstrated, as has a specific retraining effect for RO sessions (Woods. 1983). Some evidence has also emerged for RO having a beneficial effect on the mood of patients and subsequently their caregivers (Greene. Timbury. Smith and Gardiner, 1984). The impact of such RO sessions, however, is by no means dramatic. Both Johnson er al. (198 1) and Zepelin, Wolfe and Kleinplatz (1981) have commented that the effects produced are small in comparison to the effort required to attain them. Moreover the gains during therapy are not maintained for long (Greene, Nicol and Jamieson, 1979). Perhaps this is because investigators have employed an RO session technique based primarily on having patients learn new mformation and then recall it later by free recall. For patients with dementia this poses the greatest possible demand and emphasizes unnecessaril! the primary neuropsychological deficits of the condition. It is also a technique fundamentally at odds with one of the basic premises of RO, namely that patients should be helped to succeed. Success for the patient is made more likely by providing memory aids in the patient’s environment, encouraging their use and where recall of verbal information is requ,;ed by providing a recognition format or cued-recall format to solicit a successful response (Woods, 1983). Hanley (196i ) m one of the few studies that has demonstrated a behavioural effect for RO-based procedures showed that a combination of signposts and behavioural training produced a sizeable and relatively durable improvement in the ability of patients to find places in the ward environment. This specific behavioural change was not evidenced by patients receiving cognitive class RO (Hanley, McGuire and Boyd, 1981). The present study represents an attempt to improve verbal orientation and behavioural functioning in a patient with organic dementia, by providing two simple prosthetic aids to memory (watch and diary) and training the patient to use these aids effectively. METHOD Subject The S was an 84-yr-old female patient who had been admitted a 5 yr history of being increasingly forgetful, isolated and unable
to a psychiatric hospital 9 months to look after herself. The diagnosis
previously. supported
She had by EEG
examination and neuropsychological investigation was of senile dementia. This was moderately advanced according to the criteria of the Clifton Assessment Procedures for the Elderly (CAPE) on which the patient scored C on the scale A-E. Measuremenf A 30-item personalized memory and orientation test was constructed from the patient’s records, Information from relatives etc. This was used as the major assessment measure throughout, administered by the experimenter (K.L.) in a conversational manner. It contained items of personal current and personal past information together with items of current non-personal orientation. In addition a list of daily behaviour targets was compiled. These were written in the form of appointments to be kept with either the experimenter or other staff on the ward. Times of the appointments were varied. but kept to even times in the hour, such as 10.15 a.m., 10.30 a.m.. 10.45 a.m. etc. The appointments were for activities relevant to the patient’s interests, e.g. collecting the daily paper. having her hair done (she had managed her own hairdressing shop for many years), having a ‘chat’ with the experimenter etc. To avoid contamination effects the target times were restricted to periods of the day when no other activity was scheduled. e.g. meals. The patient’s success at
710
CASE
Phase A
I
Phase
HISTORIES
AND
SHORTER
C~~MUNtCATiONS
0
Phase C
Phase 8
Phase A
I
Week 1
Weeks 2 and 3
Weeks 4 and 5
Week 6
Week 7
Fig. 1. Ss daily POQ scores during baseline and experimental phases, attending these appointments, without reminding from staff, was the other major assessment measure throughout. Two points were awarded when the patient kept an appointment within tOmin of the specified time, One point was awarded if the patient turned up for the appointment outside this period. Design
A quasi-experimental design of the ABCBA type using repeated measurements of the Personal Orientation Questionnaire (POQ) and daily Appointment scores was employed (Hersen and Barlow, 1976). The phases of the experiment are shown in Table I. Each phase lasted 7-14 days. Throughout the period of the study the experimenter met with the patient each day (except Sunday) and the POQ was administered. Correct answers were not provided by the experimenter. Before the commencement of Phase B the patient was provided with her watch (kept in the patient’s belongings, but previously unused) and a large diary containing all relevant personal information. The patient was shown this information once only before Phase B commenced and after this it was not referred to at all by the experimenter. During Phase A three ‘appointments’ for the patient on the following day were presented verbally by the experimenter after each administration of the POQ. During Phase B these appointments were written in the diary by the S with the assistance of the experimenter. The S was actively trained to use the diary to answer the questions on the POQ during Phase C. This involved a 5 min training period at the end of each day’s session. The patient was asked to look at the diary and answer each question not correctly answered during the session, e.g. “Mrs Smith, the answer to the question about your brother’s name is on page 2 of your diary, Look at page 2 and tell me the answer.7“ During Phase C the patient was also trained to use the watch and diary to keep the ap~~n~ents written in the diary. This involved reminding the patient about each failed appointment after 10 min had elapsed and asking her to look at her watch and diary. The activity was then carried out. Throughout all phases of the experiment the patient was praised for keeping appointments and the activity involved carried out as scheduled. Baseline (A)
Table 1. Design of single-case study --no diary, watch or training.
Phase
-watch
B
and
diary
appointments Phase
C
Phase B Baseline (A)
-watch,
containing
provided;
diary
and
Information
and
daily
traming.
-watch and
diary
only;
-watch
diary
withdrawn.
and
personal
no training. training
withdrawn.
RESULTS Figure 1 shows the patient’s score on the POQ during the experimental intervention. The final plateau of 30 in Phase C is the test ceiling and represents an increase of 23 points over the baseline level. Although some improvement is noticeable in Phase B this is small and irregular compared with the cumulative increase in score evident through Phase C. A rapid reversal effect is seen on return to Phase B and scores on second baseline have returned to the level recorded at the start of the intervention. Figure 2 shows the daily Appointments scores (maximum 3 appointments x 2 points = 6 points) over the period of the study. ~roughout Phase A the patient consistently failed to respond. During Phase B (diary and watch) only I;36 appointments was kept. When training was introduced in Phase C 12/36 appointments were kept. This improvement in performance was not maintained when training was withdrawn and scores returned rapidly to initial baseline level for the remainder of the study. DLSXJSSION The results of this study suggest that elderly memory-disordered patients can be trained to use a prosthetic memory aid (diary) to successfully respond to demands on their orientation and memory for relevant personal information. The ability
CASE
HISTORIES
AND
SHORTER
711
COMMUNICATlONS
I
Phase A
Phase B
I
Phase C
Phase B
I
oo I .-. ’ AM A.-.1AI\i -.-.-.-.-.-. .A.-.-.-.-.-.-. /
t
l
I
t
o-0-0
,
II
I 1
I
I
I
I
Week 1
Weeks
2 and 3
Fig. 2. Ss daily Appointments
I 1 Phase A
.
.
.
Weeks 4 and 5
’
.-.-.-e.-.
I*.-.-._. I
Week 6
Week 7
scores during baseline and experimental phases.
to read is often one of the last to become impaired in dementia. In addition to learning to make reference to the diary it was evident from this study that the patient also required to be trained to locate the relevant information precisely. Information was arranged in sections across several pages of the diary and the steady improvement across Phase C reflects, in part, an increasing accuracy in finding the relevant section and identifying the particular question asked. The result-100% accurate responding at the end of Phase C-has not been achieved in any study of RO to date. With the exception of Woods (1983) who provided cues (the first two letters of the answer) to facilitate accurate responding, free recall has been the criterion employed. Woods’ data did suggest that the provision of prompts enhances correct responding although a specific learning effect, independent of prompts, is also demonstrated. In the present study no attempt was made to follow the traditional model of having the patient learn a series of training items. Although such specific learning can be achieved there is a definite upper limit to the amount of information dementing patients can successfully retain. Thus the learning of a specific set of skills, i.e. correct use of a diary is more likely to have the potential of giving the patient access to a larger store of information. It would be of interest to establish whether indeed such an approach can be successfully applied with a much larger pool of information than the 30 items employed in this experiment. Woods (1983) used a diary in the final phase of his study and noted that this was particularly useful for time orientation information which changes frequently. The reversal effect noticed on Phase B was not unexpected. Memory-disordered patients are dependent on prompts from their environment in particular from those who care for them. For maintenance to occur consistency of approach is essential. In the institutional setting it is perhaps easier to have staff remind memory-disordered patients to use a diary than it is to have staff remember, and take the time to prompt, each individual answer from each individual patient. One of the major unaddressed issues in RO research is that pertaining to the extent to which staff actually change their interactive style with patients, Hanley (1984)raises doubts as to the extent of change that can be achieved in a 24 hr RO programme. It may be more realistic in some institutional settings to train staff to use a few specific interactional strategies based on the cueing of patients to memory aids in their environment. The efficacy of this focussed approach has been demonstrated when applied to patients finding their way around a ward (Hanley, 1981). Behavioural changes have rarely been demonstrated in RO research and so it is of some interest that the patient in the present study learned to independently keep some 33% of daily scheduled appointments. It would, however, appear that this diary-dependent behaviour was not mastered in the 2-week training phase and perhaps a longer or more intense training phase may have had better results. Staff did report that the patient was frequently seen, sitting in the ward reading her diary. As appointment keeping is dependent on the interrelated use of diary and watch the training could have been improved if more attention had been paid to having the patient cross check the two aids at more frequent intervals. The training in this study only took place a maximum of three times per day after the patient had already missed appointments. There was one particularly pertinent difficulty experienced in this study. The patient quite frequently lost her diary despite generally keeping it in her handbag. A practical solution other than that of having staff find it for her might have been to fix it on a cord attached to her handbag. Despite this problem the results of the study confirm the value of a relatively uninvestigated component of RO, namely the provision of memory aids and the training of patients to use them effectively.
Acknowledgements-The this study.
authors thank the staff of Galloway West. Crichton Royal Hospital, for their co-operation during
REFERENCES Brook P., Degun G. and Mather M. (1975) Reality Orientation, a therapy for psychogeriatric patients; a controlled trial. Br. J. Psychiat.
127, 4245.
Greene J. G.. Nicol R. and Jamieson H. (1979) Reality Orientation with psychogeriatric
patients. Behar. Res. Ther. 17,
615-617.
Greene _I.G., Timbury G. C.. Smith R. and Gardiner M. (1984) Reality Orientation with elderly patients in the community: an empirical evaluation. Age Ageing 12. Hanley I. G. (1981) The use of signposts and active training to modify ward disorientation in elderly patients. J. Behan. Thu.
exp. Psychiat.
12, 241-247.
712
CASE HISTORIES AND
SHORTER COMMUNICATIONS
Hanley I. G. (1984) Theoretical and practical considerations in Reality Orientation therapy with fhe elderly. In Psychological Approaches fo the Care of the EIderIy (Edited by Hanley I. G. and Hodge J.). Croom-Helm. London. Hanley I. G., McGuire R. J. and Boyd W. D. (1981) Reality Orientation and dementia: a controlled trial of two approaches. Br. J. Psychiar. 138, 10-14. Hersen M. and Barlow D. H. (1976) Single Case Experimental Designs: Straregiesfor Studying Behauiour Change. Pergamon Press, Oxford. Johnson C. H., McLaren S. M. and McPherson F. M. (1981) The comparative effectiveness of three versions of ‘classroom‘ reality orientation. Age Ageing 10, 33-35. Woods R. T. (1979) Reality Orientation and staff attention: a controlled study. Br. Jo Psychiat. 134, 502-507. Woods R. T. (1983) Specificity of learning in Reality Orientation sessions: a single-case study. Behau. Res. Ther. 21, 173-175. Zepelin H., Wolfe C. S. and Kleinplatz F. (1981) Evaluation of a year-long Reality Orientation program. J. Geront. 36, 70-77.