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Geriatric Nursing 35 (2014) 290e294

Contents lists available at ScienceDirect

Geriatric Nursing
journal homepage: www.gnjournal.com

Feature Article

Face-name memory in Alzheimer’s disease


Sunghee H. Tak, PhD, MPH, RN a, *, Song Hee Hong, PhD b
a
Loewenberg School of Nursing, The University of Memphis, 102 Newport Hall, Memphis, TN 38152, USA
b
The University of Tennessee Health Science Center, 881 Madison Ave., Memphis, TN 38163, USA

a r t i c l e i n f o a b s t r a c t

Article history: Alzheimer’s disease (AD) affects face-name memory, the ability to recognize faces and recall names.
Received 17 February 2012 Remembering face and name requires a sophisticated cognitive process because of the complexity and
Received in revised form similarity among faces and also because of their arbitrary association with names. Assessments of face-
12 March 2014
name memory can measure episodic and semantic memory performance and are useful for early detec-
Accepted 17 March 2014
tion of AD. Improving face-name memory is possible through cognitive interventions targeted to promote
Available online 17 April 2014
procedural memory, which is often preserved until the late stage of AD. This article describes a conceptual
model, assessment tools, and strategies for improving face-name memory in persons with AD.
Keywords:
Memory
Ó 2014 Mosby, Inc. All rights reserved.
Face recognition
Name recall
Assessments
Strategies
Alzheimer’s disease

Introduction Conceptual model of face-name memory

Memory loss, such as forgetting names, is the most common The models of face recognition and name recall were developed
early symptom of Alzheimer’s Disease (AD). Forgetfulness in AD is initially by Bruce and Yong3 and modified by Burton, Bruce, and
different from ordinary forgetfulness that a normal person may Johnston.4 Face-name memory involves the following areas: (a) face
experience. For example, people with ordinary forgetfulness can recognition; (b) name recall; and (c) retrieval of person-related
still remember other facts associated with the thing they have information (see Fig. 1). First, the cognitive process of face recog-
forgotten. They may briefly forget their next-door neighbor’s name nition involves structural encoding of the face. A face is a complex
but they still know the person they are talking to is their next-door and configural representation that requires a perceptual process for
neighbor. A person with AD not only forgets her or his neighbor’s face analysis where individual features (nose, eyes, etc.) are exam-
name but also does not know whom she or he is talking to. This ined in order to discriminate between different faces.5 The analysis
results in embarrassment, loss of self-confidence, and social with- of the structural information of a face takes place initially. Rarely,
drawal among persons with AD. Ability to remember names and visuo-perceptual deficits due to cortical degeneration may interfere
faces decreases as the disease progresses (see Table 1). Human faces with the analysis process and lead to failure of an integration of
are critical socio-emotional signals in everyday life. Family care- facial features. The face analysis includes comparison with previ-
givers experience loss and grief as their loved ones increasingly ously stored structural representations in order to make a familiarity
have difficulties in remembering and recognizing them as daugh- judgment. If the face is a representation of a familiar person, first a
ters or a spouse. They face challenges in interacting with their loved specific area of the brain will be activated so that recognition of face
ones in a meaningful way and in helping engage in everyday may take place. Second, name recall will occur, which involves
activities. Caregiver’s stress is one of the most important factors “name access and generation.” Finally, the retrieval of person-
leading to institutionalization of persons with AD.2 The purpose of related information occurs, which is generated from cognitive pro-
this article is to describe a conceptual model, to review assessment cesses of retrieving the particular knowledge that one has about an
tools, and to explore cognitive strategies for improving face-name individual. The knowledge may include semantic information such
memory in persons with AD. as the person’s occupation (e.g., teacher or politician) or a rela-
tionship with the person. In the course of face-name memory, the
* Corresponding author. Tel.: þ1 901 678 3092; fax: þ1 901 678 3439. retrieval of both name and relevant semantic information associated
E-mail address: shtak@memphis.edu (S.H. Tak). with the face will occur after the successful recognition of the face.

0197-4572/$ e see front matter Ó 2014 Mosby, Inc. All rights reserved.
http://dx.doi.org/10.1016/j.gerinurse.2014.03.004
S.H. Tak, S.H. Hong / Geriatric Nursing 35 (2014) 290e294 291

Table 1
Face name memory according to Alzheimer’s Disease stages.

Stages of AD1 Cognitive loss


Mild cognitive impairment (MCI) or very early-stage Decreased ability to remember names when introduced to new people.
Mild or early-stage Reduced memory of personal history. The affected individual may seem subdued and withdrawn, especially in
socially or mentally challenging situations.
Moderate or mid-stage May retain substantial knowledge about themselves and know their own name and the names of their spouse
or children.
Moderately severe Occasionally forget the name of their spouse or primary caregiver but generally can distinguish familiar from
unfamiliar faces.
Severe or late-stage Lose the ability to respond to their environment and the ability to speak.

For example, recognizing the face of a familiar famous person (e.g., Alzheimer’s disease affects an estimated 5.4 million Americans.
J.F. Kennedy) represented by a photograph would involve the This number has doubled since 1980, and will continue to grow to
following cognitive processes: the encoding of structural informa- an estimated 16 million by 2050.13 Alzheimer’s Disease usually
tion of the face, the activation of the J.F. Kennedy face recognition, begins after age 60 and risk increases with age. Approximately 3
the recall of the name of “J.F. Kennedy,” and the retrieval of semantic percent of Americans between the ages of 54e74, and almost half of
information “President.” those 85 years and older, suffer from AD. Clinical research suggests
that testing face-name memory can provide highly sensitive indices
for early detection of memory deficits, in particular, in initial stages
Assessment tools for face-name memory of AD.7 Table 3 summarizes the assessment tools that are widely
used to test face-name memory. Impairment in face name memory
Alzheimer’s Disease primarily affects the cortex of the brain. is a significant indicator of impairment in episodic memory and an
Magnetic resonance imaging scans and computed tomography early sign of dementia. Early detection of AD may help individuals
show brain lesions with neuritic plaques, neurofibrillary tangles, manage its symptoms and plan care decisions.
and degeneration at the ends of nerve cells.6 Face-name memory
demands a sophisticated cognitive process not only because of the
complexity and similarity among faces but also because of their Evidence-based techniques for improving face-name memory
arbitrary association with names. Neuroimaging studies have found
that face perception requires visuo-perceptual processes, which Two cognitive strategies, spaced retrieval and errorless learning
occur in the occipitotemporal cortex with interplay among a widely with vanishing cues techniques, are known to be useful to improve
distributed system of cortical areas.7 In general, AD causes neural face name memory in AD. Both techniques focus on repeated
degeneration in mediotemporal and temporocortical brain regions rehearsal of face name association over time and are considered to
that are associated with episodic and semantic memory functions. utilize intact procedural memory of persons with AD.28,29 By
Remembering faces and names are highly associated with episodic rehearsal or reinstatement, connections are established within the
and semantic memory performance. Table 2 presents major types cortex independent of the hippocampusdso called long-term
and definitions of memory. consolidation. Because normal hippocampal dependent learning
While there is limited evidence on which specific domain in the (or relearning) is essentially abolished in AD, rehabilitation stra-
brain involves face-name memory, testing memory for faces and tegies may operate by slowly reestablishing links between
names can be very useful in clinical settings. Assessments of face- phonological (name) and semantic (person-specific) representa-
name memory can reveal episodic and semantic memory perfor- tions in neocortical regions that are less damaged in early AD.30
mance of persons with AD.13 Remembering ‘newly-learned faces’ To date, memory training targeted to increase declarative
and names successfully is associated with episodic memory memory (episodic and lexical memory), which requires an elder to
capacity. Semantic memory can be measured by testing recogni- explicitly and actively remember words and facts, has shown
tion, identification, and naming of ‘familiar faces.’ minimal rehabilitative value for persons with dementia. Cognitive

Fig. 1. Conceptual model of face recognition and retrievals of name and person-related information. Adapted from Bruce & Yong3 and Burton, et al.4
292 S.H. Tak, S.H. Hong / Geriatric Nursing 35 (2014) 290e294

Table 2
Types and definitions of memory.

Term Definition8e12
Declarative memory (explicit memory) Memory for facts and events. Requires conscious recollection. Frequently is called explicit memory. Easy to form and be
easily forgotten.
Episodic memory Memory of autobiographical events (times, places, associated emotions and other contextual knowledge) that are
personally experienced and can be explicitly stated (e.g., memories of life events such as weddings).
Semantic memory Memory of factual information and general knowledge about the world, which is independent of context and personal
relevance (e.g., capital cities, math concepts).
Lexical memory Memory of a word (e.g., man) or a word element (e.g., -ed in walked) of a language.
Nondeclarative memory (Implicit memory) Memory for skills, skeletal muscular reflexes, and learned emotional responses. Does not require conscious recollection.
Procedural memory is one of major types of nondeclarative memory.
Procedural memory Memory for skills, habits, and behaviors (e.g., playing the piano, ride a bicycle) which operate smoothly or are often
automatic without conscious recollection. Frequently is called implicit memory because it results from direct
experience. Requires repetition and practice over a longer period to form but is less likely to be forgotten.

strategies that employ automatic and procedural memory pro- techniques were successfully used to teach AD patients face and
cesses have shown more promise.30e32 Self-generation of cues and name associations.13,28e30
various forms of cueing are emphasized for persons with AD.18,33 A
recent review of memory stimulation programs in AD concludes
Caregiving strategies for improving face-name memory
that errorless learning, and spaced retrieval and vanishing cues
techniques, are most efficacious in stimulating face-name memory
Improving face-name memory is possible, particularly in early
in persons with AD.13,28,29,31,32,34,35
AD, if the rehabilitation effort is focused on optimizing procedural
memory processes that are preserved even until the late stage of
Spaced retrieval techniques AD.5,13,18,28,29,31e35 Caregivers can use strategies that enhance pro-
cedural memory processes such as rehearsal, association, imagery
The spaced retrieval technique was first introduced by Landauer and concentration in order to help persons with AD improve their
and Bjork36 and used to teach the name of a person in a photograph face-name memory.34,36,41 Combinations of rehearsal, association,
to persons with AD. Successful applications of the technique have and imagery and concentration are frequently used instead of a
been demonstrated for numerous tasks such as naming, face-name stand-alone strategy.
associations, phone numbers, etc. Camp and his associates also Rehearsal is one of most effective strategies in remembering
demonstrated that spaced retrieval is an effective memory training faces and names. Repeated presentation of a face greatly increase
technique for persons with AD.28,29,34,35,37 In this technique, per- familiarity and activates simultaneous cognitive processes for the
sons with AD are given a specific information to remember. Im- relevant face encoding and the recognition of the face. The next
mediate recall is solicited. If the recall attempt is successful, the time the same face is presented, the activation of face recognition
next inter-trial interval is expanded systematically (e.g., 5, 10, 20, occurs more quickly. Further repetitions can lead to automaticity,
40, and 60 s, increasing in 30 s intervals thereafter). Following a which refers to a phenomenon of making the retrieval process
recall failure, the inter-trial interval is reduced to that of the pre- automatic.4,38e40
vious trial. In previous studies, persons with AD generally became Associations are used to link a person’s name with his or her
more proficient and made fewer failures on the spaced-retrieval facial characteristics (e.g., hair, eyes, or nose), unique personal
task over extended training. They were able to perform face- features (e.g., a distinctive voice or gait), and jobs or interesting
name associations for weeks after initial acquisitions. The efficacy facts.34,41 Using senses, words, and sentences, caregivers can assist
of spaced retrieval for persons with AD has been attributed to persons with AD to come up with a verbal game that connects a
implicit memory processes that are thought to be spared until face with his or her name in a memorable way (e.g., Tina Tea or Joel
the later stages of AD.28,29,38 The repetition priming of the tech- from Jersey). Use of multiple sensory modalities or preserved
niques is found to be effective across settings, materials, and semantic knowledge are effective strategies for persons with AD to
procedures.13,18,32,39,40 enhance the ability of remembering faces and recalling names.
Imagery entails a visual representation of associations.41 Care-
Errorless learning with vanishing cues givers can help persons with AD picture images that sound like a
person’s name in a funny or memorable way. For example, a person
Another technique successfully used in AD patients for whose name is Penny Keane can be visualized in an image like
learning face-name association is errorless learning with vanishing “She’s a penny-pincher and keen at a bargain.”
cues, which taps into patients’ preserved implicit memory Finally, concentration involves paying attention and focusing on
abilities.28e31,38e40 This technique consists of providing the patient physical appearance and features that may help the person with AD
with progressively fading cues. The patient is first given full cues on remember a name.41 Similarity in hair, eyes or mouth can help
a name. If the patient successfully recalls the correct name, the cues associate names with famous people or close family and friends
are progressively withdrawn. Previous studies28e30,33 found that (e.g., Shirley with curly hair like actress Shirley Temple, or Anna like
the vanishing cue method combined with the spaced retrieval my sister). Caregivers can encourage persons with AD to use a
techniques was beneficial for people with early AD in relearning combination of the effective strategies to improve their face-name
names of famous persons. In Clare et al’s studies,30,33 fourteen memory.
names were learned over 20 sessions (twice weekly; one session Recently, computer-based face name training programs (e.g.,
per week was used for practice). Only 20% of the names were Remembering Faces (RF) by Parrot Software, Recognition by Posit
recalled at baseline, 100% by the end of training, and 98% over the Science, Associating Names with Faces by Lumosity) are in
posttests 1, 3, 6, and 9 months later. A follow-up study found that demands in face-name memory trainings because of their easy and
70% of the names were retained over a 2-year period. The combined convenient access for daily use.42e45 The computer-based training
Table 3
Assessment tools of face-name memory.

Instrument Description Administration Interpretation


Benton Facial Recognition Commercially available and used by clinicians and Participants are presented with a target face and six test faces The BFRT has a short form (13 items) with 27
Test (BFRT)14 neuropsychologists. Because the test is easy to and are asked to choose the test faces that match the target face. possible points and a long form (22 items) with
administer and has extensive normative data, it is No time limits are placed on individual items or the test as a whole. 54 possible points. Short form scores can be
commonly used for clinical and research purposes. converted to long form scores, and scores of 41 or
Reliability and validity of BFRT has been established.15 above are classified as normal.
It is useful to establish whether visuoperceptual
discrimination ability of unfamiliar faces is in
the normal range.
A low score is strongly associated with impairment
in lesions in the right posterior structures.
Because the target face and the test faces are
presented simultaneously, a low sensitivity for
discriminability has been reported. Scores in the
normal range of FRT should be interpreted
cautiously, and testing needs to be supplemented
by other face tests.
Warrington Recognition Commercially available and commonly used by both Participants are presented with 50 target photos of unfamiliar The maximum score is 50. Means range between

S.H. Tak, S.H. Hong / Geriatric Nursing 35 (2014) 290e294


Memory Test (RMT)16 clinicians and cognitive neuropsychologists. faces at the same rate. Then, they are presented with a series 42.4 and 44.3 (S.D., 3.5) depending on the age group.
Test-retest reliability coefficient of 0.81 along with of 50 faces, and are asked to identify the same faces that were Because of the photos in the RMF include many
convergent and divergent validity was reported.17 presented earlier. non-facial features (e.g., clothing and hair) which
can be used to discriminate between target and
distracter images, clinicians need to be cautious
in interpreting scores in the normal range.
Yet, evidence has shown that RMT has a high
sensitivity for the discriminability of patients
with mild cognitive impairment from healthy
elderly.18
Cambridge Face Memory Available free of charge when used for research Participants view six target faces in a random order, and then A total of 72 items are tested, it is reported that
Test (CFMT)19 purposes. An online version of CFMT is available must choose a target face among three faces. During the healthy elders averaged 58 out of 72.20 CFMT is
for self-administration (http://www.icn.ucl.ac.uk/ forced-choice tasks per target face, target faces are presented in used as a diagnostic tool of prosopagnosia and
facetests/fgcfmt/fgCFMT.php). three different views: (a) identical view (those studied in the considered to be useful to identify early signs of
Reliability and validity of CFMT has been reported.19,20 introduction), (b) novel views (e.g., different lighting, new facial dementia and impairment of episodic memory
expression, etc.), and (c) novel views with Gaussian noise. to recognize newly-learned faces.
Rivermead Behavioral Commercially available and commonly used by clinical In Face Recognition subtest, participants are shown 5 facial Raw score of each subtest is converted subtest
Memory Test (RBMT)21,22 psychologists, occupational therapists, and speech and portraits (15 faces in RBMT-Extended version22) one at a time scaled score with a mean of 10 and a standard
language therapists. The inter-scorer reliability of 0.9 or for 3 s each. Later they are asked to select the original 15 from a deviation of 3. Percentile ranks for scaled scores
higher along with construct and ecological validity was set of 30. During the First and Second Names subtest, they are are also available. The Face Recognition subtest
reported. shown two photographic portraits along with their names and includes pictures of ethnically diverse populations.
later asked to recall them. RBMT is considered as cross modal associate
learning-sensitive in the earliest stages of dementia.
Doors and People Commercially available and widely used both as a During the People subtest of DPT, a set of four facial portraits are A raw score of DPT can be converted into a scaled
Test (DPT)23,24 clinical tool and a research instrument. Reliability showndfor each of which participants are told an occupation, score. Using the test manual, a scaled index of
and validity of DPT has been reported.23,24 first name and family name. In the test phase, they are asked for People subtest can be derived from the overall
the name in each case at the presentation with the person’s DPT score. The People subtest is useful to test
occupation. Unless recall is perfect on the first trial, they are given episodic memory for newly learned faces and
up to 2 more learning and test trials. name in association with semantic memory
and identify early signs of dementia.
Hodges and Wald Famous A full list of the famous persons used in the test is A set of 50 target photographs of prominent public figures (10 Scores are obtained for the overall total correct
Faces and Names25e27 provided in published research articles for use. from each of 5 decades) are used for the test. Each target and for the items for each decade in each of the
Reliability and validity has been reported.25e27 photograph is presented to participants in a 2  2 array with its three test conditions (recognition, naming, and
three matched non-famous people’s photographs. For each target identification). The test is used to determine the
photograph, they are tested for the ability in recognition, naming, temporal gradient of retrograde memory and is
and identification. culture-specific with national variants. It is useful
to test semantic memory and useful for preclinical
stages of AD or early AD.

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294 S.H. Tak, S.H. Hong / Geriatric Nursing 35 (2014) 290e294

programs may automate evidence-based strategies and offer standard errorless learning of face-name associations in people with Alz-
heimer’s disease. Neuropsychol Rehabil. 2010;20:197e211.
application versatility for AD patients, families, and health care
19. Duchaine BC, Nakayama K. Developmental prosopagnosia: a window to
providers in a variety of care settings.42 However, further research content-specific face processing. Curr Opin Neurobiol. 2006;16:166e173.
is needed on their effectiveness on improving face-name memory 20. Bowles DC, McKone E, Dawel A, et al. Diagnosing prosopagnosia: effects of
in persons with AD. ageing, sex, and participantestimulus ethnic match on the Cambridge Face
Memory Test and Cambridge Face Perception Test. Cogn Neuropsychol.
2009;26:423e455.
Conclusion 21. Wilson BA, Clare L, Baddeley AD, Cockburn J, Watson P, Tate R. The Riv-
ermead Behavioural Memory Test e Extended Version. London: Pearson
Assessment; 1999.
In summary, face recognition and name recall involves compli- 22. Yassuda MS, Cid CG, Flaks MK, et al. P3-050: preliminary analyses of the
cated cognitive processes. Assessments of face-name memory can psychometric characteristics of the Rivermead Behavioural Memory Test
(RBMT) as an early detection instrument for AD in Brazil. Alzheimer’s Dementia.
contribute to early detection of memory deficits in persons with 2006;2:S387.
initial stages of AD. Further, it is possible to improve face-name 23. Greene JD, Baddeley AD, Hodges JR. Analysis of the episodic memory deficit in
memory by implementing cognitive rehabilitation strategies that early Alzhiemer’s disease: evidence from the doors and people test. Neuro-
psychologia. 1996;34:537e551.
utilize preserved procedural memory systems. As a result, persons
24. Baddeley AD, Emslie H, Nimmo-Smith I. Doors and People: A Test of Visual and
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25. Hodges JR, Salmon DP, Butters N. Recognition of famous faces in Alzheimer’s
longer period of time.
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27. Snowden JS, Thompson JC, Neary D. Knowledge of famous faces and names in
This manuscript was supported by the Beverly Healthcare, Inc. semantic dementia. Brain. 2004;127:860e872.
Dr. Tak was a Claire M. Fagin Post-doctoral fellow of John A. Hart- 28. Haslam C, Hodder K, Yates P. Errorless learning and spaced retrieval: how do
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ford Building Academic Geriatric Nursing Capacity program. We 2011;33:432e447.
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