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
early symptom of Alzheimer’s Disease (AD). Forgetfulness in AD is
different from ordinary forgetfulness that a normal person may
experience. For example, people with ordinary forgetfulness can
still remember other facts associated with the thing they have
forgotten. They may briefly forget their next-door neighbor’s name
but they still know the person they are talking to is their next-door
neighbor. A person with AD not only forgets her or his neighbor’s
name but also does not know whom she or he is talking to. This
results in embarrassment, loss of self-confidence, and social with-
drawal among persons with AD. Ability to remember names and
faces decreases as the disease progresses (see Table 1). Human faces
are critical socio-emotional signals in everyday life. Family care-
givers experience loss and grief as their loved ones increasingly
have difficulties in remembering and recognizing them as daugh-
ters or a spouse. They face challenges in interacting with their loved
ones in a meaningful way and in helping engage in everyday
activities. Caregiver’s stress is one of the most important factors
leading to institutionalization of persons with AD.2 The purpose of
this article is to describe a conceptual model, to review assessment
tools, and to explore cognitive strategies for improving face-name
memory in persons with AD.
* Corresponding author. Tel.: þ1 901 678 3092; fax: þ1 901 678 3439.
E-mail address: shtak@memphis.edu (S.H. Tak).
The models of face recognition and name recall were developed
initially by Bruce and Yong3 and modified by Burton, Bruce, and
Johnston.4 Face-name memory involves the following areas: (a) face
recognition; (b) name recall; and (c) retrieval of person-related
information (see Fig. 1). First, the cognitive process of face recog-
nition involves structural encoding of the face. A face is a complex
and configural representation that requires a perceptual process for
face analysis where individual features (nose, eyes, etc.) are exam-
ined in order to discriminate between different faces.5 The analysis
of the structural information of a face takes place initially. Rarely,
visuo-perceptual deficits due to cortical degeneration may interfere
with the analysis process and lead to failure of an integration of
facial features. The face analysis includes comparison with previ-
ously stored structural representations in order to make a familiarity
judgment. If the face is a representation of a familiar person, first a
specific area of the brain will be activated so that recognition of face
may take place. Second, name recall will occur, which involves
“name access and generation.” Finally, the retrieval of person-
related information occurs, which is generated from cognitive pro-
cesses of retrieving the particular knowledge that one has about an
individual. The knowledge may include semantic information such
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
retrieval of both name and relevant semantic information associated
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.,
J.F. Kennedy) represented by a photograph would involve the
following cognitive processes: the encoding of structural informa-
tion of the face, the activation of the J.F. Kennedy face recognition,
the recall of the name of “J.F. Kennedy,” and the retrieval of semantic
information “President.”
Assessment tools for face-name memory
Alzheimer’s Disease primarily affects the cortex of the brain.
Magnetic resonance imaging scans and computed tomography
show brain lesions with neuritic plaques, neurofibrillary tangles,
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
arbitrary association with names. Neuroimaging studies have found
that face perception requires visuo-perceptual processes, which
occur in the occipitotemporal cortex with interplay among a widely
distributed system of cortical areas.7 In general, AD causes neural
degeneration in mediotemporal and temporocortical brain regions
that are associated with episodic and semantic memory functions.
Remembering faces and names are highly associated with episodic
and semantic memory performance. Table 2 presents major types
and definitions of memory.
While there is limited evidence on which specific domain in the
brain involves face-name memory, testing memory for faces and
names can be very useful in clinical settings. Assessments of face-
name memory can reveal episodic and semantic memory perfor-
mance of persons with AD.13 Remembering ‘newly-learned faces’
and names successfully is associated with episodic memory
capacity. Semantic memory can be measured by testing recogni-
tion, identification, and naming of ‘familiar faces.’
Alzheimer’s disease affects an estimated 5.4 million Americans.
This number has doubled since 1980, and will continue to grow to
an estimated 16 million by 2050.13 Alzheimer’s Disease usually
begins after age 60 and risk increases with age. Approximately 3
percent of Americans between the ages of 54e74, and almost half of
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
of AD.7 Table 3 summarizes the assessment tools that are widely
used to test face-name memory. Impairment in face name memory
is a significant indicator of impairment in episodic memory and an
early sign of dementia. Early detection of AD may help individuals
manage its symptoms and plan care decisions.
Evidence-based techniques for improving face-name memory
Two cognitive strategies, spaced retrieval and errorless learning
with vanishing cues techniques, are known to be useful to improve
face name memory in AD. Both techniques focus on repeated
rehearsal of face name association over time and are considered to
utilize intact procedural memory of persons with AD.28,29 By
rehearsal or reinstatement, connections are established within the
cortex independent of the hippocampusdso called long-term
consolidation. Because normal hippocampal dependent learning
(or relearning) is essentially abolished in AD, rehabilitation stra-
tegies may operate by slowly reestablishing links between
phonological (name) and semantic (person-specific) representa-
tions in neocortical regions that are less damaged in early AD.30
To date, memory training targeted to increase declarative
memory (episodic and lexical memory), which requires an elder to
explicitly and actively remember words and facts, has shown
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-
cesses have shown more promise.30e32 Self-generation of cues and
various forms of cueing are emphasized for persons with AD.18,33 A
recent review of memory stimulation programs in AD concludes
that errorless learning, and spaced retrieval and vanishing cues
techniques, are most efficacious in stimulating face-name memory
in persons with AD.13,28,29,31,32,34,35
Spaced retrieval techniques
The spaced retrieval technique was first introduced by Landauer
and Bjork36 and used to teach the name of a person in a photograph
to persons with AD. Successful applications of the technique have
been demonstrated for numerous tasks such as naming, face-name
associations, phone numbers, etc. Camp and his associates also
demonstrated that spaced retrieval is an effective memory training
technique for persons with AD.28,29,34,35,37 In this technique, per-
sons with AD are given a specific information to remember. Im-
mediate recall is solicited. If the recall attempt is successful, the
next inter-trial interval is expanded systematically (e.g., 5, 10, 20,
40, and 60 s, increasing in 30 s intervals thereafter). Following a
recall failure, the inter-trial interval is reduced to that of the pre-
vious trial. In previous studies, persons with AD generally became
more proficient and made fewer failures on the spaced-retrieval
task over extended training. They were able to perform face-
name associations for weeks after initial acquisitions. The efficacy
of spaced retrieval for persons with AD has been attributed to
implicit memory processes that are thought to be spared until
the later stages of AD.28,29,38 The repetition priming of the tech-
niques is found to be effective across settings, materials, and
procedures.13,18,32,39,40
Errorless learning with vanishing cues
Another technique successfully used in AD patients for
learning face-name association is errorless learning with vanishing
cues, which taps into patients’ preserved implicit memory
abilities.28e31,38e40 This technique consists of providing the patient
with progressively fading cues. The patient is first given full cues on
a name. If the patient successfully recalls the correct name, the cues
are progressively withdrawn. Previous studies28e30,33 found that
the vanishing cue method combined with the spaced retrieval
techniques was beneficial for people with early AD in relearning
names of famous persons. In Clare et al’s studies,30,33 fourteen
names were learned over 20 sessions (twice weekly; one session
per week was used for practice). Only 20% of the names were
recalled at baseline, 100% by the end of training, and 98% over the
posttests 1, 3, 6, and 9 months later. A follow-up study found that
70% of the names were retained over a 2-year period. The combined
techniques were successfully used to teach AD patients face and
name associations.13,28e30
Caregiving strategies for improving face-name memory
Improving face-name memory is possible, particularly in early
AD, if the rehabilitation effort is focused on optimizing procedural
memory processes that are preserved even until the late stage of
AD.5,13,18,28,29,31e35 Caregivers can use strategies that enhance pro-
cedural memory processes such as rehearsal, association, imagery
and concentration in order to help persons with AD improve their
face-name memory.34,36,41 Combinations of rehearsal, association,
and imagery and concentration are frequently used instead of a
stand-alone strategy.
Rehearsal is one of most effective strategies in remembering
faces and names. Repeated presentation of a face greatly increase
familiarity and activates simultaneous cognitive processes for the
relevant face encoding and the recognition of the face. The next
time the same face is presented, the activation of face recognition
occurs more quickly. Further repetitions can lead to automaticity,
which refers to a phenomenon of making the retrieval process
automatic.4,38e40
Associations are used to link a person’s name with his or her
facial characteristics (e.g., hair, eyes, or nose), unique personal
features (e.g., a distinctive voice or gait), and jobs or interesting
facts.34,41 Using senses, words, and sentences, caregivers can assist
persons with AD to come up with a verbal game that connects a
face with his or her name in a memorable way (e.g., Tina Tea or Joel
from Jersey). Use of multiple sensory modalities or preserved
semantic knowledge are effective strategies for persons with AD to
enhance the ability of remembering faces and recalling names.
Imagery entails a visual representation of associations.41 Care-
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
whose name is Penny Keane can be visualized in an image like
“She’s a penny-pincher and keen at a bargain.”
Finally, concentration involves paying attention and focusing on
physical appearance and features that may help the person with AD
remember a name.41 Similarity in hair, eyes or mouth can help
associate names with famous people or close family and friends
(e.g., Shirley with curly hair like actress Shirley Temple, or Anna like
my sister). Caregivers can encourage persons with AD to use a
combination of the effective strategies to improve their face-name
memory.
Recently, computer-based face name training programs (e.g.,
Remembering Faces (RF) by Parrot Software, Recognition by Posit
Science, Associating Names with Faces by Lumosity) are in
demands in face-name memory trainings because of their easy and
convenient access for daily use.42e45 The computer-based training
Table 3
Assessment tools of face-name memory.
Instrument
Benton Facial Recognition
Test (BFRT)14
Warrington Recognition
Memory Test (RMT)16
Cambridge Face Memory
Test (CFMT)19
Rivermead Behavioral
Memory Test (RBMT)21,22
Doors and People
Test (DPT)23,24
Hodges and Wald Famous
Faces and Names25e27
Description
Commercially available and used by clinicians and
neuropsychologists. Because the test is easy to
administer and has extensive normative data, it is
commonly used for clinical and research purposes.
Reliability and validity of BFRT has been established.15
Commercially available and commonly used by both
clinicians and cognitive neuropsychologists.
Test-retest reliability coefficient of 0.81 along with
convergent and divergent validity was reported.17
Available free of charge when used for research
purposes. An online version of CFMT is available
for self-administration (http://www.icn.ucl.ac.uk/
facetests/fgcfmt/fgCFMT.php).
Reliability and validity of CFMT has been reported.19,20
Commercially available and commonly used by clinical
psychologists, occupational therapists, and speech and
language therapists. The inter-scorer reliability of 0.9 or
higher along with construct and ecological validity was
reported.
Commercially available and widely used both as a
clinical tool and a research instrument. Reliability
and validity of DPT has been reported.23,24
A full list of the famous persons used in the test is
provided in published research articles for use.
Reliability and validity has been reported.25e27
Administration
Participants are presented with a target face and six test faces
and are asked to choose the test faces that match the target face.
No time limits are placed on individual items or the test as a whole.
Participants are presented with 50 target photos of unfamiliar
faces at the same rate. Then, they are presented with a series
of 50 faces, and are asked to identify the same faces that were
presented earlier.
Participants view six target faces in a random order, and then
must choose a target face among three faces. During the
forced-choice tasks per target face, target faces are presented in
three different views: (a) identical view (those studied in the
introduction), (b) novel views (e.g., different lighting, new facial
expression, etc.), and (c) novel views with Gaussian noise.
In Face Recognition subtest, participants are shown 5 facial
portraits (15 faces in RBMT-Extended version22) one at a time
for 3 s each. Later they are asked to select the original 15 from a
set of 30. During the First and Second Names subtest, they are
shown two photographic portraits along with their names and
later asked to recall them.
During the People subtest of DPT, a set of four facial portraits are
showndfor each of which participants are told an occupation,
first name and family name. In the test phase, they are asked for
the name in each case at the presentation with the person’s
occupation. Unless recall is perfect on the first trial, they are given
up to 2 more learning and test trials.
A set of 50 target photographs of prominent public figures (10
from each of 5 decades) are used for the test. Each target
photograph is presented to participants in a 2  2 array with its
three matched non-famous people’s photographs. For each target
photograph, they are tested for the ability in recognition, naming,
and identification.
Interpretation
The BFRT has a short form (13 items) with 27
possible points and a long form (22 items) with
54 possible points. Short form scores can be
converted to long form scores, and scores of 41 or
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.
The maximum score is 50. Means range between
S.H. Tak, S.H. Hong / Geriatric Nursing 35 (2014) 290e294
42.4 and 44.3 (S.D., 3.5) depending on the age group.
Because of the photos in the RMF include many
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
A total of 72 items are tested, it is reported that
healthy elders averaged 58 out of 72.20 CFMT is
used as a diagnostic tool of prosopagnosia and
considered to be useful to identify early signs of
dementia and impairment of episodic memory
to recognize newly-learned faces.
Raw score of each subtest is converted subtest
scaled score with a mean of 10 and a standard
deviation of 3. Percentile ranks for scaled scores
are also available. The Face Recognition subtest
includes pictures of ethnically diverse populations.
RBMT is considered as cross modal associate
learning-sensitive in the earliest stages of dementia.
A raw score of DPT can be converted into a scaled
score. Using the test manual, a scaled index of
People subtest can be derived from the overall
DPT score. The People subtest is useful to test
episodic memory for newly learned faces and
name in association with semantic memory
and identify early signs of dementia.
Scores are obtained for the overall total correct
and for the items for each decade in each of the
three test conditions (recognition, naming, and
identification). The test is used to determine the
temporal gradient of retrograde memory and is
culture-specific with national variants. It is useful
to test semantic memory and useful for preclinical
stages of AD or early AD.
293
294 S.H. Tak, S.H. Hong / Geriatric Nursing 35 (2014) 290e294
programs may automate evidence-based strategies and offer
application versatility for AD patients, families, and health care
providers in a variety of care settings.42 However, further research
is needed on their effectiveness on improving face-name memory
in persons with AD.
Conclusion
In summary, face recognition and name recall involves compli-
cated cognitive processes. Assessments of face-name memory can
contribute to early detection of memory deficits in persons with
initial stages of AD. Further, it is possible to improve face-name
memory by implementing cognitive rehabilitation strategies that
utilize preserved procedural memory systems. As a result, persons
with AD may remain engaged in daily activities and retain con-
nections to their families and friends and the world as a whole for a
longer period of time.
Acknowledgment
This manuscript was supported by the Beverly Healthcare, Inc.
Dr. Tak was a Claire M. Fagin Post-doctoral fellow of John A. Hart-
ford Building Academic Geriatric Nursing Capacity program. We
thank Ms. Gail Spake for editorial assistance.
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