Learn how to use spaced retrieval with errorless learning to improve memory as we work with an imaginary learner together. Spaced retrieval (SR) with errorless learning (EL) is a useful teaching method for people who have a mild to severe memory impairment due to many causes. SR with EL can help a person learn or relearn information or skills.
Free DIRECT download: Blank data sheets and completed example (cheat sheets). (Email subscribers get free access to all the resources in the Free Subscription Library.)
- What does our learner want or need?
- Let’s screen our learner.
- Establish the prompt question.
- Establish the expected response.
- Teach the prompt question and expected response.
- Start training.
- Follow-up sessions.
- 9 tips to maximize success.
- Learn more about how to use SR with EL.
- How are you using SR and/or EL?
- Related Eat, Speak, & Think posts.
- References.
What does our learner want or need?
Our first step is to identify what our potential learner wants or needs to achieve.
A want is something the person desires that isn’t necessary for safety or physical health, but will improve confidence, self-esteem, or enjoyment of life.
Some common wants include remembering:
- the names of family members or friends.
- the names of peer residents and facility staff members.
- the current year.
- their own age.
- the current president’s name.
- how to use a cell phone.
- how to change the channel using the TV remote.
On the other hand, needs are necessary to reduce frustration on the part of caregivers or to prevent possible injury or other bad outcome.
Some common needs include:
- looking at a clock or calendar to orient to time rather than repeatedly asking someone.
- operating a TV remote correctly rather than calling a family member multiple times per day.
- using a cane or walker correctly.
- standing up or sitting down safely.
- using a chin tuck with thin liquids to avoid nectar thick liquids.
For the sake of this tutorial, let’s say that our learner needs to use a chin tuck with thin liquids, as established by an instrumental swallow assessment. They don’t like nectar thick liquids, but they can’t remember to use the chin tuck consistently.
A word about motivation
By definition, the potential learner is motivated to learn or re-learn the “wants”. But the “needs” can be more challenging to get buy-in.
In my practice, I’ve found that people who have a moderate or severe memory impairment may not be willing to admit that they’re having trouble with their memory. In these cases, I’ve sometimes had success by asking open-ended questions that allows the person to talk about their concerns in a way that allows them to admit to an issue while saving face.
Others may not immediately understand why it’s necessary to learn or re-learn the information or skill. In these cases, once I’ve explained why we’re working on a particular goal, the person is often agreeable to participating. If they’re forgetful enough, I’ll start each training session by explaining the goal and how we’re practicing. As long as they participate, they can potentially achieve the goal.
If someone refuses to participate, then you’ll have to reduce the risk of a bad outcome some other way. For instance, by modifying the environment or relying on the caregiver for supervision.
The tricky situation is when someone agrees to work with you, perhaps to be polite, but they really don’t want to achieve the goal. I once had this come up with a lovely lady who knew she had to use the walker and did well during the sessions, but rarely used the walker when I wasn’t there. She finally told me that she wasn’t ready to accept that she needed it and deliberately chose NOT to use it.
What I learned from that situation was to explicitly tell the potential learner that they had the right to refuse to work on a particular goal with no judgment from me.
Let’s screen our learner
We quickly screen our potential learner by asking them to recall a new piece of information, such as a name or the current president’s name.
First, make sure the potential learner doesn’t already know the information you want to teach.
- Trainer: “Do you know my name?”
- Learner: “No”.
- Trainer: That’s perfect!”
Teach the prompt question and expected response
Then we tell our learner what we’re going to do.
- Trainer: “I’m going to try a memory training technique with you to see if it will help. I’m going to teach you my name. I’m going to ask, “What is my name?” and you’ll say “Lisa”. What is my name?”.
- Learner: “Lisa“.
If the person hesitates, says something different, or says “Lisa” but starts to add information, simply interrupt them and say “Lisa. What is my name?”.
If our learner answers correctly
Repeat this until the person answers correctly, without hesitation, and with no additional information. Then wait 5 seconds and ask the question again. Each time they’re correct, add time to the waiting period.
- 5 seconds, 10 seconds, 20 seconds, 30 seconds.
If our learner is wrong in any way
If at any point the person hesitates, self-corrects, gives a wrong response, or adds additional information, then simply interrupt by saying “Lisa. What is my name?”.
It’s important that we don’t say “No”, “That’s wrong”, or add any information at all. Simply interrupt with the expected response and ask the prompt question again.
If they answer correctly this time, drop down to the last waiting time interval they were successful at and continue. If they answer incorrectly three times in a row, stop and try at another time.
It’s important to give the person more than one chance to succeed. They may be nervous, tired, hungry, or distracted by some worry or concern. So if our learner failed to recall my name after three attempts once we started using the timer, then we’d try again on another day.
Our learner is able to remember my name after a 30-second delay, so they’re a good candidate for the training method.
Our written goal
We’re assuming that our learner’s overall status plus the results of the instrumental swallow study support using the chin tuck with thin liquids. We don’t see a high risk for aspiration pneumonia even if they don’t use the chin tuck 100% of the time.
Our goal might be:
- Patient will swallow thin liquids via cup using a chin tuck swallow maneuver with 90 percent accuracy independently to reduce risk of aspiration and improve comfort with swallowing by 11.23.18.
This goal is quite possible for someone with a memory impairment when SR is paired with EL.
Establish the prompt question
Now that we’ve identified a need for our learner and they’ve passed the screening, it’s time to establish the prompt question to achieve our learner’s need.
The key is to ask a question that will prompt the anticipated response in a way that makes sense to our learner. Some possibilities:
- What should you do when you drink?
- What should you do when you swallow liquids?
- How should you swallow liquids?
- What should you do when you use a cup?
The planned outcome of the training is for the learner to automatically perform a chin tuck whenever they swallow thin liquids.
Let’s start off with “How should you swallow liquids?” as this would include soup and cold cereal from a spoon.
Since our learner has a moderate to severe memory impairment, I would train only with a cup until the habit is established, and then train with the spoon if necessary.
Establish the expected response
Now it’s time to carefully establish the expected response. I say “carefully” because it’s important that the response be performed the same way every time during practice. Making changes during the course of therapy can lead to sub-optimal outcomes.
The expected response should always include a verbal response and may include a physical action. The verbal response should make sense to the learner.
Use our learner’s vocabulary
We’ll spend a little time to figure out what the verbal response should be. We’ll demonstrate what we want our learner to do and ask them to describe the action in their own words.
- Trainer: “I’m going to show you a way of drinking that protects your lungs. I’ll take a small mouthful of liquid and hold it in my mouth. Then I’ll look all the way down. When I’m ready, I’ll swallow fast and hard. Now watch me”.
- Trainer demonstrates the chin tuck.
- Trainer: “Now how would you describe that?”
- Learner: “You took a drink, looked down, and swallowed”.
The key part of our learner’s response was “look down.” We wouldn’t want to use their entire answer, as it’s probably too long for them to remember. It doesn’t matter how accurate or complete the verbal response is, as long as it makes sense to them.
In this case, our verbal response will be “look down.”
Teach the prompt question and expect response
Now that we’ve established the question and response, it’s time to teach it.
- Trainer: I’m going to ask you, “How should you swallow liquids?” and you’re going to say, “Look down” and then take a drink like this.” [model taking a drink with a chin tuck] “How should you swallow liquids?”
- Learner: “Look down” and demonstrates correct procedure.
If our learner responds correctly
If our learner answers immediately, with no hesitation, no error, no additional information, and demonstrates correctly, then we wait quietly for 5 seconds and then ask the question again.
Each time the learner provides the correct response, we increase the waiting period.
- 5 seconds, 10 seconds, 20 seconds, 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, 16 minutes (continue, doubling each time)
If our learner makes any mistake at all
If our learner makes any type of error, we don’t shake our head “no” or provide any sort of feedback.
Instead, we immediately interrupt with the correct verbal response and perform the action.
- Trainer: “Look down” [and models drinking with chin tuck] “How should you swallow liquids?”
If our learner responds correctly, then we drop down to the last waiting period. For instance, if they hesitated when we presented the prompt question after a four-minute delay, then we would drop down to a two-minute delay for the next waiting period.
If our learner makes a mistake, interrupt again with the expected response. If our learner makes three mistakes in a row, take a break.
Be patient
With a moderate or severe memory impairment, we may have to practice the question and response multiple times in a row. As long as the person isn’t showing frustration, we can continue teaching and asking for an immediate response for several minutes.
Sometimes, they just need several repetitions to be able to answer correctly immediately following the training.
What if our learner is struggling?
If our learner is struggling, we should try to figure out why.
- Does the prompt question or verbal response use unfamiliar language?
- Is the expected physical response too complicated?
- Is it too much to remember the words and the actions together?
Does the prompt question or verbal response use unfamiliar language?
If our learner were struggling with the verbal response, we would stop training and talk about the goal. We’d see if the wording we selected for the prompt question and verbal response makes sense to our learner. We could ask our learner how they would explain it to someone else. Then we could use their wording.
Now is the best time to try out different wording, although it’s still better to keep changes to a minimum. The more variability there is in training, the more confusion and errors we may see during the entire process.
Is the physical response too complicated?
If our learner struggles to imitate the task, consider breaking the expected response down into more manageable chunks.
For instance, the goal may be to have our learner correctly stand up, release the brakes on a walker, walk, return to the correct position in front of the chair, lock the brakes, and sit down.
If this is too much all at once, our initial target for training may be locking the brakes before sitting down. Once our learner has mastered that, add in the rest of the sequence (or another part of the sequence).
Is it too much to remember the words and the actions together?
- Use a visual aid.
- Train the verbal response first.
- Eliminate the verbal response (in extreme cases).
1. Use a visual aid
We can write down the verbal response, and let the learner know they can refer to it. In this case, whenever they don’t respond correctly, we’d point to the printed message as we said the verbal response.
2. Train the verbal response first
I’ve had some success spending a few minutes to train the verbal response first. Once the learner is easily able to say the verbal response, I add in the physical response before extending the waiting periods.
3. Eliminate the verbal response (in extreme cases)
The final option is to eliminate the verbal response altogether and simply have the person perform the physical task. The research I’m familiar with pairs the verbal response with the physical response, so I definitely recommend doing that.
I had one patient who couldn’t say even a simple verbal response with a visual aid and still remember to do the action. He could say the response or perform the response, but not both together. I eliminated the verbal response and simply had him perform the action, and he was successful in learning how to change the volume and channel on his TV remote.
In hindsight, I could have written (DO IT) on his visual aid. That may have worked for him. But at least he met his goal.
Start training
If our learner can provide the verbal response and perform the expected action immediately following our instruction, then we move right into training by waiting 5 seconds and asking the question again.
Each time our learner provides the expected response with no hesitation and no mistakes, we increase the waiting period. The basic schedule is:
- 5 seconds, 10 seconds, 20 seconds, 30 seconds, 1 minute, 2 minutes, 4 minutes, 8 minutes, 16 minutes (continue, doubling each time)
Each time our learner hesitates, makes the slightest mistake, or adds information, immediately interrupt by saying the expected verbal response and performing the physical task (if any). Then immediately ask the question again. If our learner is correct, we’d shorten the waiting period by dropping down one level. We don’t want to let any error slide.
The waiting period schedule is flexible. We can shorten the waiting periods to ensure our learner is answering correctly. I often find I have to do this at the start of training a new goal with someone who has a moderate or severe memory impairment. It’s still important that the waiting periods get longer between each correct response.
For someone with a mild impairment, they may find it annoying to be asked the same question over and over within a short time period. In that case, I jump up the schedule, perhaps skipping up to a two or four minute delay. However, if they aren’t correct, I take the time to explain why I’m going to shorten the time period again.
Follow-up sessions
The next time we work with our learner, we’ll assess how well they’ve remembered the expected response. Before any instruction (and after removing any visual aid), we’d ask the prompt question.
If our learner responds correctly, we can skip the tiny waiting periods and perhaps start at a one-minute delay. Once we pass the two-minute delay, we can start talking during the wait periods. We’ll likely find better outcomes if we avoid working on closely-related goals during the longer waiting periods.
(Working on documentation is a great use of the waiting periods.)
I’d also suggest sticking to easy topics and tasks until the learner is more secure in knowing the expected response. You’ll have to judge this for each learner you work with.
If our learner isn’t correct, we’d immediately interrupt with the expected response. Then we have a choice. We can either jump right into the training as above, or we can take a moment to explain what we’re working on and why. Some of my learners forget why they’re working on something, so I’ll take the time to remind them so that they’re fully motivated to participate.
The goal is considered met when our learner can answer the prompt question correctly at the start of three consecutive sessions prior to any instruction.
9 tips to maximize success
- Work in a quiet, well-lit room.
- Use familiar vocabulary.
- Make sure the learner can easily imitate you.
- Do not talk during the waiting periods until you’ve passed the two-minute mark.
- Ask the prompt question as soon as the waiting period is up, even if you interrupt.
- Make sure you have the learner’s attention before you ask the prompt question.
- Do not allow the slightest hesitation or variation in the response.
- Be patient. It can take a few sessions to get past the two-minute mark.
- Modify the waiting period schedule as needed to ensure success without annoying your learner.
You can read more in last week’s post about 7 tips to maximize errorless learning for moderate to severe memory impairment.
Learn more about how to use SR with EL
Spaced Retrieval Step by Step: An Evidence-Based Memory Intervention* is the book I read over the course of a few hours to learn SR with EL. I’ve been recommending this book to other clinicians ever since I read it almost three years ago.
The book includes several case studies and additional information about how to use visual cues and memory aids.
Researchers have many different protocols for studying the effects of SR with EL, and there isn’t a gold standard. If you’re having good success with a different method than the one I’ve described above, please let me know! I’m always interested in learning new ways of doing things.
*This is an Amazon affiliate link. As an Amazon associate, I may earn a small commission on qualifying purchases. There is no extra charge to you, and it will help keep Eat, Speak, & Think sustainable.
How are you using SR and/or EL?
I’d love to hear how you’re using SR and/or EL. While I think my skills improve every time I use SR with EL, I’m not successful with every patient. I’m always open to improving my own skills, and I think it’s helpful to hear how other people are using it!
Download data sheets (a blank copy and a completed example).
Related Eat, Speak, & Think posts
- Spaced retrieval case study: Using a cane.
- 7 tips to maximize errorless learning for moderate to severe memory loss.
- Writing SMART memory goals for a reluctant patient.
- Treating cognition in the real world.
References
- Benigas, J. E., Brush, J. A, Elliot, G. M. (2016). Spaced Retrieval Step by Step: An Evidence-Based Memory Intervention*. Baltimore: Health Professions Press, Inc.
- De Werd, M. ME., Boelen, D., Olde Rikkert, M. GM., Kessels, R. PC. (2013). Errorless learning of everyday tasks in people with dementia. Clinical Interventions in Aging, 8, 1177-1190.
- Hopper, T., Bourgeois, M., Pimentel, J., Qualls, C. D., Hickey, E., Frymark, T., & Schooling, T. (2013). An evidence-based systematic review on cognitive interventions for individuals with dementia. American Journal of Speech-Language Pathology, 22, 126-145. (Summary)
- Voigt Radloff, S., de Werd, M. ME., Leonhart, R., Boelen, D. HE., Olde Rikkert, M, GM., Fliessbach, K., … Hull, M. (2017). Structured relearning of activities of daily living in dementia: the randomized controlled REDALI-DEM trial on errorless learning. Alzheimer’s Research & Therapy, 9(1):22.
*This is an Amazon affiliate link. As an Amazon associate, I may earn a small commission on qualifying purchases. There is no extra charge to you, and it will help keep Eat, Speak, & Think sustainable.
Lisa earned her M.A. in Speech-Language Pathology from the University of Maryland, College Park and her M.A. in Linguistics from the University of California, San Diego.
She participated in research studies with the National Institute on Deafness and other Communication Disorders (NIDCD) and the University of Maryland in the areas of aphasia, Parkinson’s Disease, epilepsy, and fluency disorders.
Lisa has been working as a medical speech-language pathologist since 2008. She has a strong passion for evidence-based assessment and therapy, having earned five ASHA Awards for Professional Participation in Continuing Education.
She launched EatSpeakThink.com in June 2018 to help other clinicians be more successful working in home health, as well as to provide strategies and resources to people living with problems eating, speaking, or thinking.
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