The Castle of Remembrance" New Insights From A Cognitive Training Programme For Autobiographical Memory in Alzheimers Disease

Neuropsychological Rehabilitation, 2015
Vol. 25, No. 2, 254– 282, http://dx.doi.org/10.1080/09602011.2014.949276
“The Castle of Remembrance”: New insights from a

cognitive training programme for autobiographical
memory in Alzheimer’s disease
Jennifer Lalanne1,2, Thierry Gallarda2,3, and

Pascale Piolino1,2,4
1
Paris Descartes University, Sorbonne Paris Cité, Institute of Psychology,
Memory and Cognition Laboratory, Boulogne Billancourt, France
2
INSERM UMR S894, Centre for Psychiatry and Neurosciences, Paris,
France
3
Centre Hospitalier Sainte-Anne, Service Hospitalier Universitaire,
Université Paris Descartes, Paris, France
4
Institut Universitaire de France (IUF), Paris, France
(Received 16 October 2013; accepted 21 July 2014)
Autobiographical memory deficits are prominent from the early stages of Alz-
heimer’s disease (AD) and result in a loss of personal identity. Nevertheless,
standardised methods of autobiographical memory stimulation for the neurop-
sychological rehabilitation of patients with AD remain underdeveloped. Our
aim was to evaluate the impact of a new cognitive training programme for auto-
biographical memory (REMau) on both the episodic and semantic components
of autobiographical memory performance across lifetime periods, as well as on
mood. Pre/post evaluations were conducted on two groups of patients with
early to moderate AD, assigned to one of two different training activities:
either the REMau or a cognitive training programme focused on collective
semantic memory. Statistical comparisons showed significant improvement
of episodic and semantic autobiographical memory performance in the
REMau group, which was more pronounced for the semantic component, as
Correspondence should be addressed to Pascale Piolino, Laboratoire Mémoire et Cognition,

Université Paris Descartes, 71 avenue E. Vaillant, Boulogne Billancourt 92774 Cedex, France.
E-mail: pascale.piolino@parisdescartes.fr
This study was supported by the Association France Alzheimer through a grant to Pascale
Piolino (PhD funding for Jennifer Lalanne). The authors would like to offer sincere thanks to
all the patients and their families for their participation in this study. We also thank Maria
Abram and Paul Reeves for English corrections to the manuscript.
# 2014 Taylor & Francis

COGNITIVE TRAINING FOR AUTOBIOGRAPHICAL MEMORY IN AD 255
well as improved mood. By contrast, deleterious pre/post differences were

observed in the other group. Most interestingly, this study showed that the
REMau programme boosted autobiographical memory from the reminiscence
bump period, which is considered crucial for the construction and maintenance
of personal identity. We discuss the theoretical and practical implications of
these results for the reduction of autobiographical memory deficits in AD.
Keywords: Alzheimer’s disease; Cognitive training; Autobiographical

memory; Collective memory; Reminiscence bump; Identity.
INTRODUCTION
Memories of autobiographical experiences contribute to the construction,
maintenance, and updating of personal identity. Current cognitive models
of autobiographical memory distinguish a personal semantic component,
which stores general knowledge of our past, and an episodic component,
containing memories of specific personal events (Conway, 2005; Klein &
Gangi, 2010; Piolino, Desgranges, & Eustache, 2009; Tulving, Schacter,
McLachlan, & Moscovitch, 1988). The semantic component of autobiogra-
phical memory contains general knowledge about oneself (e.g., the names
of personal acquaintances and locations, personality traits) and memories
of general and repeated events (e.g., weekends at the sea, a trip to China),
without access to a particular encoding context. The episodic component
ensures the recollection of personally experienced events within a specific
spatio-temporal context (the day of a marriage) through mental time travel
and a sense of re-experiencing (Tulving, 2001). The two components are in
close interaction (Conway, 2005; Klein, 2010; Martinelli, Sperduti, &
Piolino, 2013), although they can be independently affected in different path-
ologies (Conway & Fthenaki, 2000; Duval et al., 2012; Klein & Gangi, 2010;
Picard et al., 2013). Indeed, most of the content of semantic autobiographical
memory is the result of a normal process of semantisation based on the
storage of common characteristics of similar events that are repeated in
time, at the expense of specific details (Cermak, 1984; Conway & Pleydell-
Pearce, 2000). Episodic autobiographical memories, in turn, depend on
retrieving personal general knowledge that provides clues that aid in the
recall of specific details. Thus, semantic and episodic aspects are inter-
related and form a “continuum”, such that the episodic-semantic ratio in auto-
biographical memory depends on the time interval: episodic memories tend to
be progressively replaced by general and semantic memories with remoteness
(Conway, 2009; Piolino et al., 2006). However, even in the very elderly, some
memories from remote life periods, especially those from adolescence and
young adulthood (i.e., the reminiscence bump), remain very specific and
256 LALANNE, GALLARDA, AND PIOLINO
vivid (Conway, 2005; Piolino, Desgranges, Benali, & Eustache, 2002; Rubin
& Schulkind, 1997).
Both components of autobiographical memory, either specific memories or
more abstracted knowledge, are known to ground our personal identity
(Klein, 2010; Conway, 2005; Prebble, Addis, & Tippet, 2013), and more
specifically memories from the reminiscence bump (Fitzgerald, 1986; 1996;
Rathbone, Moulin, & Conway, 2008). Thus, autobiographical memory has
important functions in everyday life: it provides a sense of continuity over
time and personal goals, it contributes to the establishment and maintenance
of familial and social interactions, it is involved in adaptive behaviour in the
present, and in the anticipation of future events (Bluck, 2003; Harris, Rasmus-
sen, & Berntsen, 2014).
Many neurological or psychiatric diseases impair autobiographical
memory, leaving patients, in extreme cases, like strangers to themselves.
Such impairments do in fact have a direct link with loss of identity, and
have been shown to have negative effects on well-being (Klein & Gangi,
2010; Jetten, Haslam, Pugliese, Tonks, & Haslam, 2010). For example, Alz-
heimer’s disease (AD) is characterised by many cognitive impairments,
including those of autobiographical memory which cause anterograde
(Lalanne, Rozenberg, Grolleau, & Piolino, 2013; Spaan, Raajimakers, &
Jonker, 2003) and retrograde memory disruptions (Donix et al., 2010;
Eustache et al., 2004; Irish, Hornberger, et al., 2011; Irish, Lawlor,
O’Mara & Coen, 2011; Kopelman, 1992; Martinelli, Anssens, Sperduti, &
Piolino, 2013; Meulenbroek, Rijpkema, Kessels, Olde Rikkert, & Fernandez,
2010; Piolino et al., 2003), but the consequences are often underestimated.
Anterograde aspects of autobiographical memory are severely affected
(Kopelman, 1992): AD patients experience difficulties in encoding new per-
sonal information and new life events (Morris & Mograbi, 2012). This results
in an inability to update autobiographical memory, with the consequence that
self-knowledge becomes obsolete (Morris & Mograbi, 2012; Klein & Gangi,
2010). Moreover, retrograde autobiographical amnesia leads to a progressive
loss of episodic memories and personal semantic knowledge that were
encoded and consolidated before the onset of the disease. The impairment
of episodic autobiographical memory (e.g., “The day I entered the military
academy at La Flèche in 1963...”) quickly becomes massive. Patients have
severe difficulties retrieving specific and detailed events from any period of
life, instead recalling vague and general information (e.g., “I was in a military
school when I was young”). Thus, self-awareness in subjective time and the
recollection of personal episodic events from the first-person perspective are
considerably altered (Piolino et al., 2003). AD patients cannot mentally relive
the sensory-perceptual and contextual details of their past, which induces a
disintegration of temporal continuity (Irish, Lawlor, et al., 2011). Semantic
autobiographical memory (e.g., self-knowledge, personal information and
generic memories) is usually better preserved in the early stages of AD

(Eustache et al., 2004; Klein, Cosmides, & Costabile, 2003; Martinelli,
Anssens, et al., 2013; Murphy, Troyer, Levine, & Moscovitch, 2008).
When it is altered, remote information is typically more spared compared
to recent information, in keeping with Ribot’s (1881) temporal gradient
(Addis & Tippet, 2004; Graham & Hodges, 1997; Ivanoiu, Cooper, Shanks,
& Venneri, 2004, 2006; Kopelman, Wilson, & Baddeley, 1989: Leyhe,
Muller, Milian, Eschweiler, & Saur, 2009). Declining autobiographical
memory in AD has a direct link with loss of identity (Massimi et al., 2008;
Fargeau et al., 2010; Jetten et al., 2010). For instance, in a study with AD
patients, Addis and Tippet (2004) reported a correlation between impairment
in the retrieval of episodic and semantic autobiographical memory from
childhood to early adulthood and change in the patients’ sense of identity.
Other AD studies have reported a loss of correlation between autobiographi-
cal memory and sense of identity, contrasting with the close correlations
observed in healthy elderly individuals (Martinelli, Anssens, et al., 2013;
Naylor & Clare, 2008). Overall, research suggests that the past of AD patients
is generally more abstract, disembodied, and based on disconnected remote
information, leading inevitably to a less stable and enduring personal identity.
For all these reasons, assessing and treating autobiographical memory is an
important issue for neuropsychology, especially in AD. It is important to use
valid and sensitive tools in clinical settings in order to detect problems as
early as possible and respond to them to improve patients’ quality of life.
In recent decades, new neuropsychological tools have been developed to
uncover and characterise autobiographical deficits. For example, some struc-
tured autobiographical questionnaires require the recall of semantic personal
information (e.g., personal address, names of relatives in the AMI: Kopelman
et al., 1989; Ivaniou et al., 2004) and/or autobiographical memories (AMI:
Kopelman et al., 1989; Test Episodique de Mémoire du Passé autobiographi-
que (TEMPau): Piolino et al., 2009; Levine, Svoboda, Hay, Winocur, &
Moscovitch, 2002). Beyond the neuropsychological assessment of disorders,
existing questionnaires could be adapted to provide standardised support for
the reconstruction of autobiographical memory, and contribute to strengthen-
ing the sense of identity.
Usually, at least two types of cognitive interventions are distinguished in
the literature: cognitive training and cognitive rehabilitation (for a recent
review, see Bahars-Fusch, Clare, & Woods, 2013). The aim of cognitive train-
ing, on the one hand, is to offer a structured intervention wherein specific
training exercises or tasks help to restore a particular impaired cognitive func-
tion (e.g., episodic memory). Cognitive rehabilitation, on the other hand, aims
to focus on improving the abilities involved in everyday tasks, with a more
ecological thrust. The latter aspires both to restore impaired cognitive pro-
cesses and to draw on preserved cognitive domains to enable patients to
exercise a set of skills that allows them to achieve ecological goals (e.g., a
recipe for baking a cake). Much research has highlighted the usefulness of
interventions focused on supporting autobiographical memory in AD: the
resulting findings are broad but unclear (for a recent review, see Cotelli,
Manenti, & Zanetti, 2012). Many authors have used reminiscence therapy,
focusing on mental processes that involve conscious recall of the past
through reliving personal experiences while referring to the current model
of identity and returning to unresolved conflicts (Butler, 1963). Reminiscence
therapy aims to reconcile patients with the negative aspects of life and facili-
tate their acceptance, but also to strengthen the sense of personal identity and
well-being, enhance autobiographical retrograde memory, and increase per-
sonal satisfaction (Bruce & Schweitzer, 2008; Butler, 1963).
Reminiscence therapies can be divided into those guided by patients’ free
recall, and those using the life-review, which aims to reconstruct the patient’s
life history in a structured way (Haber, 2006). The latter implies that patients
are active not only in the search for autobiographical memories, but also in
rebuilding their life story, culminating in the construction of a life book
based on the use of personal materials (photographs, music, etc.), which
can serve as a prosthetic memory aid. In patients with dementia, life
review-type reminiscence therapies could potentially function as a form of
cognitive rehabilitation, in their objective of supporting everyday autobiogra-
phical memory through the use of the life book. Some of these life-review
therapies are structured around different life periods (e.g., childhood, adoles-
cence), and themes (e.g., family life, professional life). However, in most
studies, life-review therapy has been practised without any real structured
methodology (for reviews: Cotelli et al., 2012; Dempsey et al., 2012;
Woods, Spector, Jones, Orrell, & Davies, 2005; Woods, Thorgrimsen,
Spector, Royan, & Orrell, 2006), and most often in a group therapy
context, although some have used individual life-review therapy (Haight
et al., 2003; Hirsch & Mouratoglou, 1999; Moos & Bjorn, 2006;
Romero & Wenz, 2001). Moreover, a few studies have used clinical and
neuropsychological pre/post evaluation, including assessment of autobiogra-
phical memory through standardised tests, to investigate the effect of life-
review therapy (Massimi et al., 2008; Morgan, 2000). Overall, undeniable
benefits have been observed, with decreases in depressive mood and
psycho-behavioural disorders (e.g., agitation, aggressiveness, anxiety),
enhanced sense of personal identity and self-esteem, and improved communi-
cation and sociability, but no benefit has been specifically demonstrated in
autobiographical memory.
Otherwise some authors have developed forms of cognitive training
designed to support retrograde autobiographical memory through methods
based on the repetition of semantic autobiographical information and episodic
memories (via a quiz), combined with errorless learning (i.e., prioritising the
avoidance of errors in responses during training) and/or spaced retrieval

methods to bring about the reactivation and relearning of forgotten infor-
mation in AD patients (Arkin, 1998; Clare et al., 2000; Davis, Massman, &
Doody, 2001). The objective of these particular types of cognitive training
is to allow patients to relearn particular autobiographical information: the
results showed that this information was better recalled and richer after the
training, and was maintained durably. Nevertheless, most studies in these
two groups (using life-review type reminiscence therapy or specific cognitive
training of autobiographical memory) lacked a clear framework based in
recent theoretical concepts on the episodic and semantic aspects of autobio-
graphical memory, and did not work with various life periods covering the
entire lifespan.
To overcome these limitations, we have developed a standardised and
structured programme of autobiographical training (the REMau programme,
for réminiscence autobiographique, or “autobiographical reminiscence”)
which aims to improve both the episodic and semantic aspects of autobiogra-
phical memory across all life periods. The goal of the REMau programme is
thus to gradually reintroduce an orientation in time, a chronology of personal
events, and information and strategies for accessing specific event memories.
In theoretical terms, this programme is based on Conway’s model (Conway,
Singer, & Tagini, 2004; Conway, 2005), which postulates a hierarchical
organisation of autobiographical memory retrieval, from the most abstract
levels of information to the most specific memories. The idea is that
priming effects due to the repeated use of cueing and retrieval strategies
(facilitating method) can enhance access to autobiographical memory
(Tulving et al., 1988). Thus, this programme aims to help patients rebuild a
sense of personal identity and continuity by strengthening their personal
semantic knowledge across life periods and stimulating the recollection of
episodic memories. The REMau programme adheres to the cognitive training
objectives recently defined by Bahar-Fuchs et al. (2013): it tries to improve,
or at least maintain, autobiographical memory retrieval ability using specific
learning and strategy training (cognitive training), in the long term it provides
patients with external assistance (a personal life timeline).
The main objective of the present study was to test the possibility, in patients
with early and moderate AD, of enhancing the retrieval of personal semantic
knowledge and specific memories of five periods of life covering the entire
lifespan (i.e., childhood, young adulthood, beyond age 30, the last 5 years,
the last 12 months) through a specific and standardised cognitive training pro-
gramme. In order to evaluate the effect of this intervention on autobiographical
memory performance, we compared two groups of AD patients, one that
followed the REMau programme, and one that followed another cognitive
training programme (control group), with the target being general collective
semantic memory across a similar set of time periods (from 1930 to 2000).
We thought that this programme could work well as a control in assessing the
specific impact of the REMau programme on autobiographical memory
retrieval for several reasons. First, in contrast to autobiographical memory,
collective memory refers to the shared pool of information held by a social
and cultural group (here, that of France). It encompasses factual semantic
information pertaining to the world in general, and is frequently used in infor-
mal cognitive stimulation groups. Second, like autobiographical memory,
collective memory is a type of remote memory associated with generational
effects across the lifespan (Schuman & Rieger, 1992; Piolino, Lamidey,
Desgranges, & Eustache, 2007), and it can sometimes be related to the
memory of the personal source of acquisition of a given piece of information,
or be otherwise connected to personal history (Brown, 1990; Brown & Kulik,
1977; Conway, 1995; Larsen, 1992; Piolino et al., 2007; Westmacott &
Moscovitch, 2003). The control cognitive training programme thus aimed to
train non-autobiographical memory, but could also be helpful in indirectly
reactivating both general and specific personal memories.
The experimental design was to compare autobiographical memory per-
formance pre- and post-training with a follow-up after two weeks. Our first
hypothesis was that the performance of both episodic and semantic autobio-
graphical memory would improve after the REMau programme but not after
the control cognitive training programme – benefits that we expected to be
maintained after two weeks. In addition, we expected the massive impairment
of episodic features and the phenomenon of generalisation observed in recall
to lead to a lesser benefit for episodic memories than for personal semantic
knowledge. Moreover, since autobiographical impairment varies according
to life period, we also expected that the life periods associated with specific
memories that are particularly important for defining the self (, 30 years)
to be more improved by the REMau training. Finally, because life-review
therapy is supposed to strengthen personal identity and self-esteem, we also
expected the REMau programme to have a positive impact on patients’ mood.
METHOD
Participants
A sample of 33 patients (aged 58–89 years) with AD in mild to moderate
stages (MMSE . 18) freely consented to participate in the study, which
was conducted in line with the Declaration of Helsinki and approved by the
local ethical committee. The participants were recruited through several
health institutions in Paris, France, according to the criteria of McKhann
et al. (1984). They were at 2 or 3 years since diagnosis, and did not present
any neurological or psychiatric diseases other than AD.
Table 1
Descriptive characteristics of AD patients
REMau Group Control Group
Mean and Mean and

standard standard
deviation deviation Comparison REMau/Control groups
Age 71.44 8.81 73.06 6.90 p . .10

Years of study 9.75 2.72 10.47 3.74 p . .10
MMSE 24.87 2.73 25.00 3.54 p . .10
Mill Hill 30.10 3.34 30.00 2.24 p . .10
Mood 3.46 3.41 3.86 3.22 p . .10
Subjects were randomly assigned either to the REMau programme (n ¼

16) or to the control cognitive training programme (n ¼ 17). Descriptive
information on each group is given in Table 1. The two groups were
matched on: overall cognitive efficiency (t ¼ –0.11, df ¼ 31, p . .10), eval-
uated with the MMSE (Mini-Mental State Examination: Folstein, Folstein, &
McHugh, 1975), level of education (t ¼ –0.63, df ¼ 31, p . .10), age (t ¼
–0.59, df ¼ 31, p . .10), mood (t ¼ –0.33, df ¼ 31, p . .10) estimated by
the MADRS (Montgomery-Asberg Depression Rating Scale: Montgomery &
Asberg, 1979), and crystallised intelligence and semantic knowledge (t ¼
0.23, df ¼ 31, p . .10), assessed by the Mill Hill Vocabulary Test
(Deltour, 1993).
Autobiographical and mood assessments

The objective of the pre/post assessments was to investigate the impact of the
two cognitive training programmes on patients’ autobiographical memory
and mood. Three similar assessments were conducted: a first assessment a
few days before the programme (T1), a second one a few days after the pro-
gramme (T2), and a third two weeks after the second (T3).
Two previous validated assessments of semantic and episodic autobiogra-
phical memory were used to assess these two components across the five life-
time periods: childhood and adolescence (ages 0–17), young adulthood (ages
18 –30), adulthood (age . 30), the last 5 years, and the last 12 months. These
periods were investigated in a fixed sequence. For each period, a personal
information recall task was administered first to assess semantic autobiogra-
phical memory (SAM), followed by a personal events recall task to assess epi-
sodic autobiographical memory (EAM).
SAM recall was explored using four topics (see Piolino et al., 2002): the
names of three acquaintances along with their status (e.g., friend, neighbour),
three pieces of information about the date of personally relevant events (e.g.,
birth, marriage), three pieces of information about school life, working life, or
life in retirement (e.g., the name of a teacher or a superior, the location of the
person’s desk in the classroom or office, etc.) and three pieces of information
about the patient’s address and leisure activities (e.g., name and address of a
new leisure activity). One point was given for each correct response (checked
with the patient’s family), and half a point was given if the information was
incomplete (e.g., a person’s name without his or her status). For each period,
the maximum SAM score was 12.
After SAM retrieval, patients had to recall, for each lifetime period (except
the most recent one), one specific and personally experienced event for each
of four topics (EAM: see the TEMPau task, Piolino et al., 2003, 2006): (1) a
meeting or event linked to a person, (2) an event that occurred during the par-
ticipant’s schooling, working life, or retirement, (3) a trip, and (4) a family
event. For the very recent past (the last 12 months), eight memories were
required (about last summer, Christmas, New Year’s Day, last week, last
weekend, 2 days ago, yesterday, and today). When possible, the memories
had to concern unique brief personal events (shorter than one day), be situated
in time and space, and be mentally relived with phenomenological details.
The patients were always asked to give as many details as possible and to
be as specific as possible. If they could not spontaneously recollect an
event, cues and/or encouragements were provided (e.g., “A striking day
with a teacher or a school friend at primary or secondary school; when
taking a written or oral exam such as school leaving certificate”). These
sentence-cues were selected from previous experimental AM studies on
healthy elderly and AD participants (Piolino et al., 2002, 2003, 2006, 2008;
Eustache et al., 2004). After recall, either spontaneous or not, we encouraged
patients three times to give more details if necessary and/or to be more
specific if they recalled a generic event (e.g., “Do you remember a particular
day?” “Did this take place only once?”) with no time constraint. Thereafter,
the test switched to another theme or question, regardless of the nature of the
recall.
Each event recall was scored according to the information retrieved in the
test and checked with the patient’s family on a 5-point episodic scale (see
Baddeley & Wilson, 1986; Kopelman et al., 1989; Piolino et al., 2002,
2003). This scale took into account the specificity of the content (i.e.,
single or repeated event), the spatiotemporal situation, and the presence of
internal details (i.e., perceptions, thoughts, and feelings). A specific event
with sensory details situated in time and space was given a score of 4. A
specific event with no details but situated in time and space was scored
3. A generic (repeated or extended) event was scored 2 if it was situated in
time and space, or 1 if it was not. An absence of memory, or only general
information about a theme, was scored 0. A total EAM score per life
period was recorded (maximum score 16; for the most recent period the score
was 32 divided by 2). This score took into account all specific and generic
memories, and corresponds to the classic autobiographical memory score
used in the well-known Autobiographical Memory Interview (AMI; Kopel-
man et al., 1989). The higher the score, the more specific and detailed the
memories. Each memory was rated by two independent experts, including
one who was blind to the group, and scoring was discussed in case of discre-
pancy. The patients were encouraged to provide different memories at T1, T2
and T3. Moreover, those in the REMau group could not provide the same
specific memories at T2 and T3 as those trained in the cognitive training
programme.
Finally, the patients completed a second scale assessing their mood, the 30-
item Geriatric Depression Scale (GDS; Mitchell, Bird, Rizzo & Meader,
2010).
Cognitive training programmes

Two programmes, administered individually, were performed during a
weekly one-hour session over six weeks. We chose individual programmes
in light of neuropsychological evidence that individual training is more effec-
tive than group training, both in cognitive and in mood terms (for recent
reviews, see Bahar-Fuchs et al., 2013; Clare & Woods, 2004).
REMau: Autobiographical cognitive training programme. The aim of the

REMau (“Réminiscence Autobiographique” – “Autobiographical reminis-
cence”) programme is to stimulate access to episodic and semantic autobio-
graphical memory. REMau is based primarily on a method of facilitating
access to the autobiographical information across different lifetime periods
through priming effects induced by repeated questioning (Tulving et al.,
1988) and through retrieval strategies based on the model of Conway
(Conway, 2005; Conway & Pleydell-Pearce, 2000). More specifically, the
programme seeks to improve recollection by stimulating the sense of remem-
bering rather than just knowing or guessing. Finally, it ultimately provides an
external aid, an autobiographical timeline that is gradually filled in over the
course of the different sessions with the patient. The verbal cues used in
the programme come from information obtained in the autobiographical com-
ponent of the first baseline assessment (the personal information recall task
and the personal events recall, or TEMPau, task) and from a questionnaire
completed by the patients’ family members. In this questionnaire, the
family had to report, for each life period, general information about the
patient (names of family members and acquaintances, addresses, school or
work information, important dates, habits and routines, heroes and tastes,
etc.), and a personally important event (avoiding very negative ones)
experienced by the patient with as many details as possible (what, who, how,
where, when, and emotion from the patient’s perspective). The timeline
included five A4 sheets, each one for a studied life period, (1) 0–17 years,
(2) 18 –30 years, (3) . 30 years (4) the last 5 years, and (5) the last
12 months. Some visual cues (i.e., photos of significant public events, presi-
dents and celebrities) and some music cues (i.e., famous popular music) were
supplied to facilitate the temporal contextualisation of each period of life. As
in the control cognitive training programme (see below), patients were
informed that they must not rework the elements outside the sessions, and
for this reason the experimenter kept the timeline during the programme.
However, patients recovered their timeline at the end of the programme (T3).
The first two sessions were entirely devoted to recovering personal seman-
tic knowledge of the five life periods on the timeline: session 1 for the first two
periods (0–17 and 18–30 years), session 2 for the latter three periods (. age
30, the last 5 years, and the last 12 months). We first asked the patients
to identify their family members and close or important people (friends,
teachers, co-workers, etc.). Next, the patients had to identify their main
residences and recall the school or work information associated with places
and dates. The patients had also to remember their habitual leisure activities,
their holidays, and their idols. Finally, they had to retrieve important generic
memories (e.g., chess club) without going into detail. In case of difficulty, we
provided other personal cues obtained at T1 using an errorless learning
method that consists of giving the correct response before the production of
an error (Clare et al., 2000).
The last four sessions of the programme were devoted to the retrieval of
specific autobiographical events from each life period: session 3 focused on
ages 0–17, session 4 on ages 18–30, session 5 on the period above age 30,
and session 6 on the last 5 years and the last 12 months. After the expectations
for this part of the REMau programme were explained to the patients, they
had to learn the characteristics of episodic memories (i.e., short duration of
a few minutes to a few hours, uniqueness, location in time and space, and
links to emotions, perception and thoughts). Then, for each life period, they
had to evoke detailed episodic memories associated with semantic infor-
mation mentioned in previous sessions (name, place, date, habit, etc.). The
patients’ task was to try and systematically provide responses to questions
on the different characteristics of episodic events. Feedback was given to
patients on the level of specificity that they had been able to reach. Only
the main elements were then reported in detail on the timeline (“My marriage
in the chapel of San Domenico, a Sunday, in July, I remember I stumbled...”).
If patients were unable to provide detailed episodic memories, they were first
encouraged to enhance the factual content of memories (people, activities),
their spatial content (location and description, position within a place),
their temporal content (age, year, time of year, day, hour, temporal sequence),
and the related emotions, perceptions and thoughts. In the absence of answers,
cues were provided. Wherever possible, we provided the unrecalled details at
the end of the session.
Control cognitive training programme. The aim of the control pro-

gramme is to enhance general semantic memory of collective information
through a specific training method. The main interest here was to use a
non-autobiographical memory training programme that nonetheless shares
some characteristics with the REMau programme (see introduction). More-
over, like autobiographical memory, collective memory of famous persons
or events is disrupted in AD (Thomas-Antérion, Borg, Vioux, & Laurent,
2010). Therefore, the objective in the control group was to train and
improve capacities that are known to be deficient. This programme was stan-
dardised derived from Piolino et al.’s (2007) test of famous persons. This test
consists of the recognition of celebrities from the 1930s to the 2000s and the
assessment of semantic knowledge related to them. Each training session
included a series of photographs followed by a series of questions. The first
four were multiple-choice questions about the person: (1) name (e.g., “Is
this Tino Rossi, Charles Trenet, or Georges Guétary?”), (2) job (e.g., “Is he
a singer, a journalist, or an actor?”), (3) professional specialty (e.g., “Is he
a children’s singer, a love film actor, or a cabaret artist?”), (4) personal life
or other detail (e.g., “What song did he sing? Marinella, Boléro, or Tchi-
tchi?”). The other questions concerned, (5) the time period during which
the person was the most famous among six possible decades, and if the
person was still alive, or if not, when did he/she die?, and (6) a personal
assessment of the character (whether the patient likes/liked the celebrity).
The patient was also encouraged to provide as much information as possible
about the famous person. Moreover, some naming or dating was conducted
using photos of old objects (cars, money, film posters, etc.) and recordings
of popular music. In case of failure, we provided the correct answer.
Statistical analysis
In order to evaluate the benefits of the REMau programme, we conducted
several statistical analyses on the autobiographical performances obtained
at the three evaluations (sessions T1, T2, T3). We performed a 2 (Group:
REMau, control cognitive training) × 5 (Time Period: 0–17 years, 18–
30 years, . 30 years, last 5 years, last 12 months) × 3 (Session: T1, T2,
T3) analysis of variance (ANOVA) on (1) total semantic autobiographical
memory (SAM) score and (2) total episodic autobiographical memory
(EAM) score. We also compared the two scores by performing a 2
(Content: semantic and episodic) × 2 (Groups) × 5 (Time Periods) × 3 (Ses-
sions) ANOVA on performance scores. Finally, we carried out a 2 (Groups)
× 3 (Sessions) ANOVA on the total GDS score. To assess the effect sizes on
ANOVA, partial Eta-squared values were used with h2 . .01 interpreted as a
small effect, h2 . .06 as a medium effect, and h2 . .14 as a large effect
(Guéguen, 2009). Post hoc Fisher’s LSD tests were used for within- and
between-group comparisons, with an alpha level of p , .05, and Cohen’s d
was used to assess effect sizes on post hoc tests (Cohen, 1988), with d .
0.20 considered a small effect, d . 0.50 a medium effect, and d . 0.80 a
large effect. The comparison between T2 and T1 evaluated the immediate
benefits of the training programmes, and the comparison between T3 and
T1 evaluated the prolongation of the benefits over a longer time period.
RESULTS
Personal semantic knowledge (SAM)

The ANOVA conducted on total semantic knowledge scores showed signifi-
cant main effects of group, F(1, 31) ¼ 6.30, p ¼ .01, h2 ¼ .17, and time
period, F(4, 124) ¼ 95.85, p , .001, h2 ¼ .75, and a trend toward a signifi-
cant effect of session, F(2, 62) ¼ 2.63, p ¼ .08, h2 ¼ .08. We also found sig-
nificant Group × Session, F(2, 62) ¼ 5.89, p ¼ .004, h2 ¼ .16, and Group ×
Time Period, F(4, 124) ¼ 7.70, p , .001, h2 ¼ .20, interactions. The Time
Period × Session interaction was not significant, F(8, 248) , 1, p . .10, h2
¼ .02. Finally, the three-way Group × Time Period × Session interaction
was significant, F(8, 248) ¼ 2.80, p ¼ .005, h2 ¼ .08. Thus, the effects of
training on personal semantic performance varied according to the type of
programme, the life period recalled, and the evaluation session (see Figure 1).
Figure 1. Total mean performance and standard error in personal semantic recall (SAM) by life
period, type of programme, and evaluation session. Fisher’s LSD test comparisons between T2 and
T1 and between T3 and T1 are reported: ∗ p , .05, ∗∗ p , .005, ∗∗∗ p , .001.
Post hoc t-tests indicated that the overall performance of the group that
received the REMau programme was greater after the treatment (T2 vs. T1:
p , .001, d ¼ 0.52) for four of the five periods, 0–17 years (p , .001, d
¼ 0.77), 18 –30 years (p , .001, d ¼ 1.06), . 30 years (p , .001, d ¼
0.58), and the last 12 months (p ¼ .05, d ¼ 0.39), but not for the last
5 years (p . .10, d ¼ 0.22). The overall benefits were still present two
weeks post-treatment (T3 vs. T1: p ¼ .02, d ¼ 0.35). The benefit for child-
hood (0 –17 years) became marginal (p ¼ .07, d ¼ 0.26), but remained
highly significant for the periods of 18–30 years (p , .001, d ¼ 0.84), .
30 years (p ¼ .04, d ¼ 0.35), and the last 12 months (p ¼ .02, d ¼ 0.41).
The score for the last 5 years (p . .10, d ¼ 0.08) did not differ between
the two assessments.
By contrast, the control group’s performance did not improve after the
treatment (T2 vs. T1: p . .10, d ¼ – 0.12), regardless of life period: 0–
17 years (p . .10, d ¼ –0.20), 18 –30 years (p . .10, d ¼ –0.29), .
30 years (p . .10, d ¼ –0.07), the last 5 years (p . .10, d ¼ –0.04), or
the last 12 months (p . .10, d ¼ 0.20). At 2 weeks post-treatment, the
control group’s total performance tended to decrease (T3 vs. T1: p ¼ .07,
d ¼ –0.36). This trend was significant for the periods 18 –30 years (p ,
.001, d ¼ –0.81) and the last 5 years (p ¼ .05, d ¼ –0.28), but not for the
periods 0–17 years (p . .10, d ¼ –0.13), . 30 years (p . .10, d ¼
–0.22) or the 12 last months (p . .10, d ¼ 0.05).
Between-group comparisons indicated no difference in performance in
session T1, regardless of time period (all ps . .10). In session T2, the per-
formance of the REMau group was significantly better than that of the
control group for the periods 0–17 years (p , .01, d ¼ 1.13), 18–30 years
(p , .001, d ¼ 1.80), and . 30 years (p , .001, d ¼ 1.16), but not for
the last 5 years or the last 12 months (p . .10, d ¼ 0.24 and d ¼ 0.10). In
session T3, the REMau group performed significantly better than the
control group for the periods 18–30 years (p , .001, d ¼ 2.22) and .
30 years (p , .001, d ¼ 1.14), but not for the other periods (p . .10).
Autobiographical memories (EAM)

The analyses focused on the total episodic autobiographical recall score: the
higher the score, the more specific and detailed the memories. The ANOVA
conducted on total EAM scores highlighted significant main effects of time
period, F(4, 124) ¼ 32.09, p ¼ .001, h2 ¼ .51; session, F(2, 62) ¼ 7.00, p
¼ .002, h2 ¼ .18; and a slight tendency toward a group effect, F(1, 31) ¼
3.07, p ¼ .09, h2 ¼ .09. All three two-way interactions were significant:
Group × Session, F(2, 62) ¼ 15.67, p , .001, h2 ¼ .33; Group × Time
Period, F(4, 124) ¼ 4.89, p ¼ .001, h2 ¼ .14; and Session × Time
Period, F(8, 248) ¼ 2.89, p ¼ .004, h2 ¼ .09. Finally, the three-way
Group × Time Period × Session interaction was also significant, F(8, 248) ¼
2.47, p ¼ .01, h2 ¼ .08. The effects of the training programme on autobio-
graphical memory performance again varied depending on the type of pro-
gramme, the life period explored, and the evaluation session (see Figure 2).
Post hoc tests indicated that the performance of the REMau group
improved immediately after the programme (T2 vs. T1, p , .001, d ¼
0.66) for the same four out of the five periods, 0–17 years (p , .001, d ¼
1.25), 18–30 years (p , .001, d ¼ 0.76), . 30 years (p ¼ .02, d ¼ 0.48)
and the last 12 months (p , .001, d ¼ 0.66), but not for the last 5 years (p
. .10, d ¼ 0.05). The overall benefits were still highly significant at
2 weeks post-treatment (T3 vs. T1: p ¼ .003, d ¼ 0.35). However, only
the benefits for the period 0–17 years were consistent (p ¼ .01, d ¼ 0.66).
The benefit observed for the period . 30 years became marginal (p ¼ .07,
d ¼ 0.38), while the benefits observed in session T2 for the periods 18–
30 years (p . .10, d ¼ 0.16) and the last 12 months (p . .10, d ¼ 0.26)
were not maintained at T3. Performance for the last 5 years (p . .10, d ¼
0.08) was again unchanged (p . .10, d ¼ 0).
In contrast, the overall performance of the control group was not affected
by the programme (T2 vs. T1: p . .10, d ¼ 20.21). The effect of the pro-
gramme varied according to the life period explored, however, although no
difference was found for the periods 0–17 years (p . .10, d ¼ –0.16), the
last 12 months (p . .10, d ¼ –0.47), and the last 5 years (p . .10, d ¼
–0.17), there was a significant performance decrease for the periods 18 –
30 years (p ¼ .003, d ¼ –0.46), and . 30 years (p ¼ .03, d ¼ –0.37).
The same pattern was observed at 2 weeks post-treatment (T3 vs. T1: p .
.10, d ¼ 20.27). Performance for the time periods 0–17 years (p . .10, d
Figure 2. Total mean performance and standard error in episodic autobiographical memory (EAM),
by life period, type of programme, and evaluation session. Fisher’s LSD test comparisons between T2
and T1, and between T3 and T1 are reported: ∗ p , .05, ∗∗ p , .005, ∗∗∗ p , .001.
¼ –0.09), the last 12 months (p . .10, d ¼ –0.42), and the last 5 years (p .
.10, d ¼ 0.04) did not change, while the decreased performance for the time
periods 18–30 years (p ¼ .003, d ¼ –0.42) and . 30 years (p ¼ .03, d ¼
–0.30) persisted.
Between-group comparisons indicated no performance difference in
session T1, regardless of time period (all ps . .10). In sessions T2 and T3,
the REMau group performed significantly better than the control group for
the 18 –30 years period (p , .001; d ¼ 1.93 for T2, and d ¼ 1.15 for T3),
but not for the other periods (p . .10), although there was a trend toward sig-
nificance for the period 0–17 years (p ¼ .07, d ¼ 0.50) in session T2.
Semantic versus episodic autobiographical comparison (SAM

vs. EAM)
Finally, we carried out an ANOVA comparing performance scores on the
semantic and episodic components of autobiographical memory. The
results highlighted a main effect of component, F(1, 31) ¼ 150.59, p ,
.001, h2 ¼ .83, with significantly superior performance on the semantic com-
ponent than on the episodic component. The results also indicated a trend
toward a significant Group × Component interaction, F(1, 31) ¼ 3.46, p
¼ .07, h2 ¼ .10, with the REMau group performing better than the control
group on the semantic component (p ¼ .004, d ¼ 0.90) but not the episodic
component (p ..10, d ¼ 0.66). Moreover, the Component × Group × Time
Period interaction, F(4, 124) ¼ 3.96, p ¼ .004, h2 ¼ .11, and the Component
× Group × Time Period × Session interactions, F(8, 248) ¼ 1.98, p ¼ .04,
h2 ¼ .06, were also significant. Post hoc analyses indicated that the REMau
group, for episodic memory, performed better than the control group only in
sessions 2 and 3 and for the 18–30 years period (T2: p ¼ .001, d ¼ 2.04; T3:
p ¼ .02, d ¼ 1.21), and, for semantic memory, for the periods 0–17 years
(T2: p ¼ .004, d ¼ 1.17), 18–30 years (T2: p , .001, d ¼ 1.85; T3: p ,
.001, d ¼ 2.28), and . 30 years (T2: p , .001, d ¼ 1.20; T3: p , .01, d
¼ 1.18). Moreover, for both groups, performance on the semantic component
was superior to performance on the episodic component for the two earliest
time periods (0 –17 and 18 –30 years, all ps , .001, d . 0.80), regardless
of session. In addition, for the REMau group the same profile (SAM .
EAM) was observed for the periods . 30 years (T2 and T3: p , .001,
d ¼ 1.97 and d ¼ 1.13) and the last 5 years (T2: p , .05, d ¼ 0.98).
Mood
The ANOVA on the participants’ GDS score showed a non-significant main
effect of group, F(1, 31) ¼ 2.24, p . .10, h2 ¼ .07, but a significant main
effect of session, F(2, 62) ¼ 11.69, p , .001, h2 ¼ .27, as well as a significant
Group × Session interaction, F(2, 62) ¼ 6.78, p ¼ .002, h2 ¼ .18. The mood
Figure 3. Mean score and standard error on the GDS (depressed mood) by programme type and
evaluation session. Fisher’s LSD test comparisons between T2 and T1, and between T3 and T1 are
reported: ∗ p , .05, ∗∗ p , .005, ∗∗∗ p , .001.
of patients who completed the REMau programme was significantly

improved immediately after the end of the programme (p , .001, d ¼
0.75), a result that was maintained at 2 weeks post-treatment (p , .001,
d ¼ 0.60). The mood of the patients who received the control cognitive train-
ing programme was not improved immediately post-treatment (p . .10, d ¼
0.02), but it was improved at 2 weeks post-treatment (p ¼ .003, d ¼ 0.44).
Figure 3 gives the values for each group.
Between-group comparisons indicated no difference in mood in sessions
T1 and T3 (p . .10, d ¼ 0.25 and d ¼ 0.39, respectively), but the mood
of the REMau group in session T2 was significantly better than that of the
control group (p , .01, d ¼ 0.91).
DISCUSSION
This study aimed to investigate the impact of a cognitive training programme
(REMau) developed specifically for the rehabilitation of impaired autobiogra-
phical memory. We compared this programme to an alternative cognitive
training programme focused on collective semantic memory in order to deter-
mine whether any benefits observed with the REMau programme were
specific to its support and not due to the social interaction between therapist
and patient, the novelty of a stimulating activity, or the act of stimulating old
information acquired across the lifespan independently of its nature. The
results indicated that only the REMau programme improved autobiographical
memory performance; improvement that was maintained 2 weeks after the
post-treatment evaluation. In contrast, the patients in the control cognitive
training programme tended to show a decrease in autobiographical memory

performance. These results support the idea that a standardised, structured
training activity targeting autobiographical memory is an effective way to
improve autobiographical memory in AD patients. They also extend previous
findings by revealing the differential impact of such a programme on the com-
ponents of autobiographical memory (episodic/semantic) and across lifetime
periods.
Two cognitive training programmes were used with AD patients who pre-
sented a classic dissociation between episodic and semantic autobiographical
memory performance (see assessment session T1), with the latter better pre-
served than the former (Irish, Lawlor, et al., 2011; Ivanoiu et al., 2004, 2006;
Martinelli, Anssens, et al., 2013). Episodic memory was massively impaired
and replaced by more generic memories, with a Ribot’s temporal gradient in
favour of remote periods (Eustache et al., 2004; Irish, Lawlor, et al., 2011;
Leyhe et al., 2009; Piolino et al., 2003). This deficit is generally linked to
the disruption of neuroanatomical structures, including the hippocampal for-
mation, which are involved in the recollection of episodic autobiographical
memories (for reviews, Cabeza & St Jacques, 2007; Martinelli, Sperduti, &
Piolino, 2013; Viard, Desgranges, Eustache, & Piolino, 2012). More pre-
cisely, neuroimaging studies have reported that EAM recruits medial tem-
poral lobe structures, along with different prefrontal regions, including
lateral and medial prefrontal cortex, anterior cingulate cortex, and posterior
cortical structures, to a greater extent than SAM (Ford, Addis, & Giovanello,
2011; Holland, Addis, & Kensinger, 2011; Levine et al., 2004; Martinelli,
Sperduti, & Piolino, 2013). Interestingly, several studies have reported that,
in AD, the recall of remote autobiographical (semanticised) memories is
related to metabolism in extrahippocampal regions (Donix et al., 2010;
Eustache et al., 2004). These results suggest that AD patients could benefit
from autobiographical memory training thanks to the resulting activation of
a compensatory network underpinned by extrahippocampal regions.
Our study showed that a cognitive training programme based on a hierarch-
ical model of autobiographical memory (Conway, 2005) enhances retrieval
processes and the relearning of personal information (Morgan, 2000). The
REMau programme improved the recall of autobiographical memories and
semantic personal knowledge, while no benefit was observed after a cognitive
training programme focused on collective semantic memory. The benefit was
maintained up to two weeks after the post-treatment evaluation. This finding
confirms that even after an interval of two weeks, the REMau group benefited
from the relearning and recovery of old personal information, albeit to a lesser
extent for the recovery of episodic autobiographical memories than for per-
sonal semantic knowledge. In contrast, the control group’s autobiographical
performance continued to decrease from T1 to T3, suggesting the importance
of providing AD patients with highly targeted training in order to compensate
for their autobiographical information and memory deficits. The stimulation

of collective semantic memory acquired during the lifespan could have been
thought to have indirect positive effects on autobiographical memory (see
introduction), but in fact this intervention seems to have been ineffective in
reactivating autobiographical memory in AD.
The REMau programme brought memory benefits in relation to all life
periods in terms of both autobiographical memories and personal semantic
knowledge, with the exception of the last five years, for which no improve-
ment was seen (see discussion below). As we had predicted, the REMau pro-
gramme particularly improved the earliest personal memories and knowledge
(those from childhood, adolescence and young adulthood: 0–17 and 18–
30 years), which are best consolidated in AD (Eustache et al., 2004; Irish,
Lawlor, et al., 2011; Leyhe et al., 2009; Piolino et al., 2003). In fact, the
period for which the response of episodic and semantic autobiographical
memory to cognitive training peaked was between adolescence and early
adulthood, a period known as the reminiscence bump (Conway & Pleydell-
Pearce, 2000; Rubin & Schulkind, 1997), which is maintained in ageing
(Piolino et al., 2002; 2006). Autobiographical memories are not distributed
equally across the lifespan: instead, they are more concentrated between
the ages of 10 and 30. It has been suggested that this reminiscence bump rep-
resents a major landmark for the current self (Conway & Pleydell-Pearce,
2000; Fitzgerald, 1996) and that it supports the emergence of a stable and
enduring self (Rathbone et al., 2008), especially for older adults (Haight &
Webster, 1995). The reminiscence bump typically concerns self-defining
memories, which are memories highly related to the self, characterised by
emotional intensity, vividness, a high level of repetition, and strong connec-
tions to other similar memories and personal goals (Conway, 2005; Conway
et al., 2004; Singer, Rexhaj, & Baddeley, 2007). Importantly, self-defining
memories are more resistant than other autobiographical memories in
ageing, but deficient in AD (Martinelli, Anssens, et al., 2013). Improvement
in AD patients’ retrieval of episodic and semantic autobiographical memory
from childhood to early adulthood could thus be directly linked with positive
changes in their sense of identity (e.g., consistence and valence of self, see
Addis & Tippet, 2004).
Interestingly, the REMau programme was also found to improve recall of
the last 12 months, covering the period of anterograde amnesia. In fact, AD
patients were better able to recall some details of the very recent past (e.g.,
last week, 2 days ago, yesterday, or today) after the programme (T2 and
T3). This finding may be related to the fact that in some cases patients recalled
specific elements from their participation in the REMau programme (e.g.,
recall of the last session with the neuropsychologist; situations where they
discussed REMau with other people). We surmise that participating in the
REMau programme offered patients a set of unusual and emotionally
stimulating new experiences, which may have favoured their encoding and
consolidation (see Rauchs et al., 2013). Moreover, these new experiences
were related to the reactivation of older self-relevant information, which
may have led to a positive self-reference effect on new encoding (Klein,
2012). The self-reference effect (i.e., the positive effect of the self on sub-
sequent memory performance) is still relatively preserved in the early to mod-
erate stages of AD (Lalanne et al., 2013). In contrast, no improvement was
found in memory for the last five years, even though this period also included
the period of anterograde memory deficits, like the last 12 months, in addition
to retrograde memory deficits. This period of life included AD diagnosis (2 or
3 years since diagnosis) and thus consisted of memories and knowledge that
were poorly consolidated compared to other remote periods. Moreover, it may
have involved negative situations related to the beginning of the impact of the
disease on everyday life, loss of autonomy, etc. This life period could poten-
tially therefore be more resistant to the REMau programme because of both
the weakness of memory and its incongruence with the maintenance of a
positive self-image and a positive self-concept (Brandstädter & Greve,
1994; Carstensen, Fung, & Charles, 2003; Clare, 2003; Kensinger & Schacter,
2008; Macquarrie, 2005).
It is important to note that the REMau programme increased the recall of
personal semantic knowledge more than the recall of autobiographical mem-
ories, and induced more frequent access to generic rather than very specific
and detailed memories of the periods covering childhood, adolescence and
adulthood (i.e., few memories received a score of 4). Nevertheless, the retrie-
val of generic memories was enriched by mental images, subjective feelings
and thoughts, and some idiosyncratic details. All these findings lead us to
question the nature of the REMau programme’s impact on the sense of iden-
tity of AD patients (Caddell & Clare, 2010). Although the link between auto-
biographical memory and the self seems evident, because of its multifaceted
nature it is nevertheless very complex. Based on current conceptions, it was
expected that cognitive training of autobiographical memory such as REMau
could enhance both the subjective (“I”) and objective (“Me”) aspects of self
(James, 1890; see also Duval et al., 2012; Klein, 2010; Prebble et al., 2013),
respectively, by improving the episodic and semantic components of autobio-
graphical memory across the lifespan. Episodic memories are needed to
provide a subjective sense of self, a temporally extended self, and to update
personal semantics (Klein, 2012; Picard et al., 2013; Prebble et al., 2013).
Personal semantic knowledge and generic memories consist of conceptual
self-knowledge that stores summaries of information such as schemes, proto-
types, rules, beliefs, values, attitudes, opinions, tastes and goals about oneself
(Conway, 2005) and personality traits (Klein, 2010). Although the present
findings show that episodic autobiographical memory was less improved by
the REMau programme, its positive and lasting impact on personal semantic
and generic memories could help AD patients to construct a better

self-concept in the present and a better sense of self in time (i.e., temporally
extended narrative: see Prebble et al., 2013). Future studies in AD patients
should investigate this hypothesis by assessing the effects of autobiographical
memory training on different dimensions of the self (e.g., “I” and “Me”).
The last, but not the least interesting result concerns the positive impact of
the REMau programme on patients’ mood. This positive effect on mood was
maintained two weeks post-programme. Negative mood decrease is probably
one of the most common advantages observed after interventions focused on
supporting autobiographical memory, and our data confirm this idea (Chao
et al., 2006; Goldwasser, Auerbach, & Harkins, 1987; Hsieh et al., 2010;
Lai, Chi, & Kayser-Jones, 2004; Scogin & McElreath, 1994; Thorgrimsen,
Schweitzer, & Orrell, 2002; Woods et al., 2005). This benefit could also be
linked with the objectives of the REMau programme, which aims to trigger
mainly positive memories, and their re-experiencing from a subjective per-
spective. Several studies have shown that the evocation of positive memories,
even generic ones, allows older adults to re-appropriate their past and increase
their personal satisfaction or self-esteem (Bruce & Schweitzer, 2008; Marti-
nelli, Anssens, et al., 2013). Moreover, as mentioned above, the REMau pro-
gramme may have improved the patients’ capacity to build a more coherent
temporally extended narrative, which in turn may increase positive thoughts
and self-esteem (Prebble et al., 2013). Finally, the social function of autobio-
graphical memory may also have contributed to the improved mood in
patients (Bluck, 2003; Bruce & Schweitzer 2008). Future studies are
needed to substantiate these hypotheses. The fact that there was no improve-
ment in the mood of the patients in the control group after the cognitive train-
ing argues in favour of a direct relationship between autobiographical
memory enhancement and mood. However, this group did show a significant
mood improvement two weeks after the end of the programme. It may be that
collective semantic memory training improves social relationships and self-
esteem (Woods et al., 2012), which in turn could improve patients’ mood
two weeks after treatment. However, some unknown elements in the patients’
personal lives might also lie behind this enhancement.
Despite its hopeful results, the present study has a few limitations that only
further research will be able to overcome. First, the measures used in the pre/
post evaluations and the REMau programme itself shared similar methods
(e.g., same time periods explored, similar general cues), which could have
led to an overestimation of the positive effect of REMau on autobiographical
memory retrieval. In order to somewhat limit this issue, we asked patients to
provide different memories between intervention and outcome measure-
ments. Nevertheless, in further research, other standard autobiographical
memory pre/post assessments (e.g., Kopelman et al., 1989; Levine et al.,
2002; Piolino, Coste, Martinelli, Mace, & Quinette, 2010) should be used
in addition to the TEMPau procedure (Piolino et al., 2009). Second, future

research should also include more extensive pre/post cognitive and clinical
evaluations (e.g., basic cognitive assessment, self-esteem, subjective well-
being, staff rating of communication and behaviour), including multidimen-
sional self-assessments (e.g., Addis & Tippet, 2004; Duval et al., 2012;
Lalanne et al., 2013; Martinelli, Anssens, et al., 2013; Naylor & Clare,
2008), in order to investigate the REMau programme’s specific impact on
patients’ personal identity. Finally, comparisons with other types of pro-
grammes (e.g., basic cognitive stimulation programmes) will be required to
draw definitive conclusions about the impact of REMau in AD patients (for
recent reviews, see Bahar-Fuchs et al., 2013; Cotteli et al., 2012; Woods,
Aguirre, Spector, & Orell, 2012), as we have done recently in the domain
of schizophrenia (Lalova et al., 2013). Finally, further studies are needed to
investigate whether more frequent REMau sessions could produce a further
improvement of autobiographical memory, and especially of episodic recol-
lection (here we used a weekly session over six weeks, whereas most reminis-
cence therapy programmes use at least two weekly sessions over a longer
period; Baecker et al., 2006; Crete-Nishihata et al., 2012; Damianakis,
Crete-Nishihata, Smith, Baecker, & Marziali, 2010; Morgan, 2000).
In conclusion, we have developed a standardised and personalised cogni-
tive training programme for autobiographical memory that encompasses both
episodic and semantic components and that covers the entire lifespan. This
new programme appeared to strengthen both components of autobiographical
memory in AD patients, and more specifically memories belonging to the
reminiscence bump period, which is especially important in maintaining
the sense of self. Because personal identity is grounded in the past, but is
also updated by new experiences, an interesting challenge will be to
combine cognitive training targeting both the anterograde and retrograde
aspects of autobiographical memory in a single programme, and to investigate
the effects of training on different dimensions of the self (e.g., “I” and “Me”).
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The Castle of Remembrance" New Insights From A Cognitive Training Programme For Autobiographical Memory in Alzheimers Disease

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Neuropsychological Rehabilitation, 2015

Vol. 25, No. 2, 254– 282, http://dx.doi.org/10.1080/09602011.2014.949276

“The Castle of Remembrance”: New insights from a

Jennifer Lalanne1,2, Thierry Gallarda2,3, and

(Received 16 October 2013; accepted 21 July 2014)

Correspondence should be addressed to Pascale Piolino, Laboratoire Mémoire et Cognition,

# 2014 Taylor & Francis

well as improved mood. By contrast, deleterious pre/post differences were

Keywords: Alzheimer’s disease; Cognitive training; Autobiographical

generic memories) is usually better preserved in the early stages of AD

avoidance of errors in responses during training) and/or spaced retrieval

REMau Group Control Group

Mean and Mean and

Age 71.44 8.81 73.06 6.90 p . .10

Subjects were randomly assigned either to the REMau programme (n ¼

Autobiographical and mood assessments

Cognitive training programmes

REMau: Autobiographical cognitive training programme. The aim of the

Control cognitive training programme. The aim of the control pro-

Personal semantic knowledge (SAM)

Autobiographical memories (EAM)

Semantic versus episodic autobiographical comparison (SAM

of patients who completed the REMau programme was significantly

training programme tended to show a decrease in autobiographical memory

for their autobiographical information and memory deficits. The stimulation

and generic memories could help AD patients to construct a better

in addition to the TEMPau procedure (Piolino et al., 2009). Second, future

Proceedings of the World Congress on Internet in Medicine (MEDNET). Retrieved from

Westmacott, R., & Moscovitch, M. (2003). The contribution of autobiographical significance to

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