Have you ever attempted to teach your loved one with dementia a new skill and became frustrated by lack of carry over?
Due to their memory impairments, people with dementia often experience challenges with learning new skills or relearning old tasks. Common examples of this I frequently see in my practice include learning how to follow movement precautions after surgery, locking the brakes before standing up from a wheelchair, and not pulling up from the walker when transitioning from sit to stand.
Although these skills may be more challenging for someone with dementia to learn, there are many approaches that can be implemented to improve retention. These approaches emphasize repetition and strategic cueing to elicit carry over and procedural memory formation.
What is Procedural Memory?
Procedural memory is the memory on how to sequence and complete routine activities. An example of procedural memory is riding a bike. Each time you ride a bike you are not constantly thinking about how to successfully coordinate your motor movements, it is automatic. In the progression of dementia, one’s episodic memory, or the memory of personal events and short-term recall, is often impacted. However, one’s procedural memory in dementia usually remains intact. In order to elicit learning and recall in dementia, we need to focus on facilitating their procedural memory.
The Difference Between Implicit and Explicit Processing
With this, there are two types of ways we encode and store memories, explicit and implicit processing. Explicit processing occurs on a conscious level, whereas implicit processing occurs on an unconscious level. Episodic memory formation occurs through explicit processing, whereas procedural memory occurs through implicit processing. It is important to distinguish these two types of processes because it dictates how we setup an activity for our individuals with dementia. Explicit learning strategies primarily use a trial and error approach for storing and encoding information. In comparison, implicit learning strategies do not require higher level cognitive processing for learning and has been found to be the more effective strategy for memory formation and recall in individuals with dementia (Crowe & Gabriel, 2013).
The following approaches are implicit learning strategies that emphasize using one’s procedural memory for improving carry over in everyday activities.
Errorless Learning
Errorless Learning (EL) is a technique that focuses on the elimination of errors during the learning process. This technique involves structuring an activity so the learner always completes it successfully. With this, the goal of EL is to decrease the amount of incorrect information the learner is processing. By eliminating conflicting information, the learner is then storing the correct sequence into his or her memory (Crowe & Gabriel, 2013)
Errorless Learning (EL) is a technique that focuses on the elimination of errors during the learning process. This technique involves structuring an activity so the learner always completes it successfully. With this, the goal of EL is to decrease the amount of incorrect information the learner is processing. By eliminating conflicting information, the learner is then storing the correct sequence into his or her memory (Crowe & Gabriel, 2013).
Important strategies with EL include: (Sohlberg et. al, 2005, as cited in Clare & Jones, 2008):
1. Break down the activity into steps
This is especially important when an activity is complex or has many steps. In order to not overwhelm the mind with processing a lengthy sequence, the teacher should break down the activity into steps. As the learner masters each step in the sequence, the teacher can incorporate additional steps.
For example, let’s imagine we are teaching an individual with dementia how to transfer onto the toilet from wheelchair level. Transferring onto the toilet requires many steps including locking the brakes, standing up, pivoting, managing one’s clothing, and sitting down. (In this example, we are assuming the wheelchair is already positioning the appropriate distance from the toilet for the transfer.) We would first have the individual with dementia practice the first step of the sequence repetitively. The first step is locking his or her wheelchair brakes. This would include prompting such as “you always lock your brakes first;” followed by strategic questioning such as, “what do you always do first?” After the individual is able to lock his or her brakes without consistent prompting, the learner can incorporate the next step in the sequence. This process continues until the individual is able to complete all the steps of the activity.
It is important to note that you do not necessarily need to start with the first step of the sequence for learning. There is an occupational therapy teaching technique called backwards chaining that has the teacher complete all the steps of the sequence for the individual except the last step. With this technique, you start teaching the last step of the sequence first, which empowers the learner feel successful. Then after the learner has mastered the last step, you begin teaching the next to last step until he or she can complete the whole sequence independently.
2. Demonstrate and Explain the activity to the learner prior to having him or her perform the activity
Providing a visual demonstration or verbal explanation of the sequence provides the learner a frame of reference for how to complete the activity. This is important because with this learning strategy we do not want the learner to be guessing or using trial and error problem solving. Providing visual or verbal prompting can reduce the amount of inaccurate information the learner is processing to promote procedural memory storage.
When using the example previously for toilet transfers, the teacher would demonstrate and verbally explain how to lock the brakes before requesting the learner to attempt to lock them.
3. Discourage guessing and trial and error problem solving
As explained previously, this technique is focusing on implicit processing in comparison to explicit processing. In order to prevent inaccurate information from becoming encoded in an individual’s memory we want to discourage guessing. That is why this technique has the teacher provide consistent prompting (at least in the beginning) in order to reduce the learner from trial and error problem solving.
The teacher would discourage guessing by telling the learner the correct answer if he or she appears hesitant. For example, if the teacher asked the learner after demonstration “how to do you lock your brakes?,” and the learner appeared confused, the teacher would immediately intervene by stating “you lock your brakes here” while simultaneously demonstrating locking the brakes.
4. Correct errors immediately when they occur
This strategy is very similar to the last point about limiting trial and error problem solving. In EL, errors are ignored while the teacher reinforces the correct answer/sequence.
For instance, if the teacher asked “what do you do first to transfer onto the toilet?,” and the learner responded “stand up,” the teacher would intervene without acknowledging the error, “you lock your brakes first” while simultaneously demonstrating locking the brakes.”
5. Decrease the amount of prompting and cues provided over time
In order to promote autonomy and new learning, the teacher must gradually decrease the amount of support he or she is providing the learner over time. As the individual becomes more successful at certain steps of the sequence, the teacher should decrease the amount of cues being provided to the learner, until he or she can complete the activity independently.
For our toilet transfer example, the teacher would begin with providing maximum cueing as the sequence is being learned, then over time gradually decrease the amount of cues.
It is important to acknowledge that the goal for your loved one may not be to complete the activity independently. Depending upon’s your loved one’s stage, the goal may be to complete the task with less support from the caregiver.
The following is a video example of the errorless learning strategy.
Spaced Retrieval Training
The next technique to help your loved one with dementia to learn new skills is spaced retrieval training (SR). This strategy challenges the learner to recall information over progressively longer intervals.
Similarly to EL, SR incorporates an individual’s implicit processing, requiring minimal conscious effort to learn new material. In general, the amount of time is doubled between intervals when the learner responds successfully. For instance, the teacher would start the learner with recalling the information immediately, then after 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, and 16 minutes.
Research shows that information is usually encoded into one’s long term memory after approximately 16 minutes. At that point, the information is considered “learned” (Vance, Struzick & Farr, 2010 as cited in Crowe & Gabriel, 2013). If the learner is unable to recall the information correctly at a specific interval, the teacher would revert the length of time back to the previous successful interval. In this strategy, guessing is also discouraged. When the learner is unable to recall the correct information, the teacher immediately provides the correct answer (Crowe & Gabriel, 2013).
Example of Spaced Retrieval Training
Let us use our toilet transfer example from above to outline how to implement spaced retrieval training with your loved one. The first step is to determine a verbal cue to consistently use throughout the learning session. For our example, the cue will be “what is the first step to get onto the toilet?” The following is a simulated exchange to demonstrate this strategy.
1st Interval (Immediately)
The teacher sets up the activity by positioning the learner the appropriate distance from the toilet in his or her wheelchair.
Teacher: “The first step to get onto the toilet is to lock your brakes.” Demonstrates how to lock the brakes. Unlocks the brakes to reset. “What is the first step to get onto the toilet?”
Learner: “Lock my brakes” while simultaneously locking the brakes.
2nd Interval (30 seconds)
The teacher resets the brakes by unlocking them. Then waits 30 seconds before having the learner recall the information.
Teacher: “What is the first step to get onto the toilet?”
Learner: “Lock my brakes” while simultaneously locking the brakes.
3rd Interval (1 minute)
The teacher resets the brakes by unlocking them. Then waits 1 minute before having the learner recall the information. For this interval, we are going to pretend the learner was unable to recall the information correctly.
Teacher: “What is the first step to get onto the toilet?”
Learner: “Stand up.”
Teacher: “Lock your brakes” while demonstrating locking the brakes.
Note: The teacher would then revert back to the last successful interval, 30 seconds, before reattempting recall at 1 minute.
This process would continue until the learner is able to recall the information after approximately 16 minutes, in which the skill is considered encoded into long-term memory.
The following is a video example of the spaced retrieval training strategy.
Important Considerations
When teaching an individual with dementia a new skill, it is important to be aware of the environment. You want to implement these learning strategies in the environment in which he or she will perform the skill. Transferability, or the ability to implement a learned skill in a different, but similar context, can be challenging for individuals with dementia. For example, an individual with dementia may demonstrate challenges with recalling to lock the wheelchair brakes when transferring into bed, even though he or she can recall locking them in the bathroom. For this reason, if you need your loved one to perform a skill in multiple situations, such as locking the wheelchair brakes, you need to have him or her practice that skill in a variety of settings/contexts.
Lastly, it is important to acknowledge that new learning takes time, especially for individuals with dementia. Depending upon the severity of the dementia, the above strategies may need to be modified to address the specific needs of your loved one. There are also additional strategies not listed above that may be more applicable to your situation. From this, I encourage you to seek out a licensed occupational or physical therapist in your area if you are looking for additional support for you and your loved one.
Please be sure to check out the full video on these strategies on our Youtube channel: https://youtu.be/iJYSrZaCs_4
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References:
Crowe, J., & Gabriel, L. (2013) Errorless learning and spaced retrieval training for clients with alzheimer’s dementia. Physical & Occupational Therapy In Geriatrics, 31(3), 254-267, DOI: 10.3109/02703181.2013.796037
Clare, L. & Jones, R. S. P. (2008). Errorless learning in the rehabilitation of memory impairment: A critical review. Neuropsychology Review, 18, 1-23. DOI 10.1007/s11065-008-9051-4
