This spaced retrieval case study involves an elderly man who was quite forgetful due to Alzheimer’s disease. His physical therapist (PT) had gotten him off of a walker and using a cane, but he never remembered to use it unless reminded.
When I met my patient, PT had already discharged with the recommendation that he never be left alone during the day. This was a problem that I decided to tackle.
Here is an overview of this article:
- 24-hour supervision was a burden on the family.
- I learned spaced retrieval with errorless learning (SR with EL) in a matter of hours.
- How spaced retrieval with errorless learning works.
- My patient responded well to the new teaching method.
- He automatically used the cane within two sessions.
- My patient no longer required supervision on flat surfaces.
- You can use SR with EL with people who have many diagnoses.
- You can teach a wide variety of information and skills.
- SR with EL is not a magic bullet.
- My experience with SR with EL.
- Learn more + free downloads
- References
24-hour supervision was a burden on the family
My patient lived with his daughter’s family in a large house. It wasn’t reasonable for someone in the family to always be in the room with him. Everyone had their own preferred activities, and my patient was left alone in his TV room. Even though someone was always within earshot, my patient never asked for assistance before he got up.
My patient loved to watch old movies, and he often got up to get something to drink from a small fridge or use the bathroom. And when he got up, he forgot to use his cane which meant that he was at risk for falling.
I was called in to assess a long-standing swallowing problem, but it took several days to sort out the swallow history (it turned out to be esophageal). In the meantime, I decided to try to help the family out by teaching him to remember to use his cane.
I learned spaced retrieval with errorless learning in a matter of hours
Although I had previously read about spaced retrieval with errorless learning (SR with EL), I had never tried it. I found Spaced Retrieval Step by Step: An Evidence-Based Memory Intervention* on Amazon, ordered it, and read it over the weekend.
This book was very easy to read and understand, as it was written to be understood by family members who want to use the teaching method, as well as healthcare professionals.
The authors really did walk me step-by-step through how to use the teaching method and how to apply it with my patients. They provide a very quick screening task which helps me decide if my patient is likely to benefit from this method.
They also provide free downloadable resources, including:
- Spaced retrieval screening form
- Reading screening form
- Spaced retrieval data form
- Handout for families.
*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 spaced retrieval with errorless learning works
People who have a memory impairment often have trouble learning through the trial-and-error teaching method, which is our default teaching method. We teach some information or skill, then test our patient. If they make a mistake, we teach it again. While most people learn well with this teaching method, people who have a memory impairment often have trouble.
Spaced retrieval with errorless learning is quite different. With this teaching method, we don’t allow the person to make a mistake. As soon as it becomes apparent that they’re not going to get it right, we jump in with the correct response.
Once the person automatically produces the correct response, we slowly increase the time interval before we ask for the response again.
In this way, the person gradually moves the correct response into long-term procedural memory. We’ve conditioned them to respond to a stimulus (such as standing up) with a response (such as using the cane).
References are listed at the bottom of this article.
My patient responded well to the new teaching method
Using the SR with EL training method, I found that my patient could remember a new piece of information after a 30-second delay. This meant that he was a good candidate for the teaching method.
I then worked with him to develop a question and response that resulted in him using the cane when he stood up.
- My question: “What should you use when you stand up?”
- His response: “My cane” and then demonstrate walking around the room with the cane.
Using the SR with EL teaching method, we worked on this goal for the entire session.
He automatically used the cane within two sessions
When I came back for the next session, I assessed him prior to any instruction and he automatically reached for the cane when he stood up! We addressed the goal again to reinforce learning.
Since he was doing so well, the interval of time between us practicing the question and response was getting long. I introduced a new goal to remember the name of his grandson (he frequently called him by his son’s name).
My patient no longer required supervision on flat surfaces
When I returned for the second routine session the following week, he again used the cane automatically. His wife told me that he was using his cane all the time and no longer needed reminders. I was blown away!
Now my patient was at much lower risk for falling, and his family could pursue their own activities in the house guilt-free. Within the house, he only required supervision on the stairs and in the shower. And as an added bonus, he now correctly named his grandson when he saw his picture.
You can use SR with EL with people who have many diagnoses
Research supports using SR with EL with people who have impaired memory due to a variety of diagnoses:
- Alzheimer’s dementia
- Vascular dementia
- Mixed dementia
- Korsakoff syndrome
- Semantic dementia
- Mild cognitive impairment (MCI)
- CVA (stroke)
- Traumatic brain injury (TBI)
- Brain cancer
- HIV
- Schizophrenia
You can teach a wide variety of information and skills
Spaced retrieval with errorless learning is a teaching method that can be used by anyone. It can be used by family members, friends, or any healthcare professional.
Researchers have found that SR with RL can be used for learning or re-learning information or skills.
SR with RL for learning or re-learning information
- Face-name associations for family and staff
- Face-name and profession associations for family and staff
- Object naming
- Object-location associations
- Current events
- Reading name tags as a strategy
- Using memory book or wallet as a strategy
SR with EL for learning or re-learning skills
- Activities of daily living (ADLs)
- Setting the table
- Using a cane or walker
- Wayfinding
- Using swallowing strategies to avoid a modified diet.
- Prospective memory for intended actions.
- Using a clock or calendar.
- Making change and balancing a checkbook.
- Using and managing voice mail.
- Using mobile phones.
- Using the radio.
- Using the TV remote or VCR.
- Leisure Activities
- Reducing problem behaviors
- Repetitively asking the same questions.
- Urinating in inappropriate places.
Follow along in this tutorial as I use spaced retrieval with errorless learning to teach someone to use a chin tuck with thin liquids.
SR with EL is not a magic bullet
While I love SR with EL, I’ve had some failures. Some were due to my own learning curve, for instance:
- Allowing my patient to make a mistake before I interrupted, which reinforces confusion.
- Trying to accomplish too much in one goal.
- Trying to achieve a goal that was too advanced for the patient’s cognitive level.
Read about 7 tips to maximize errorless learning for moderate to severe memory loss.
Even the most experienced clinicians will not have success with every patient, because patient factors come into play as well. The person has to be able and willing to imitate you, and willing to repeat the action multiple times each session.
My experience with SR with EL
I’m a big supporter of this teaching method because I’ve seen first-hand how helpful and effective it can be. When I teach physical mobility skills, I follow the recommendations of the physical therapist (PT) or the occupational therapist (OT).
Some of the skills and information I’ve taught includes:
- Family, staff, and co-resident names.
- Personal information.
- Swallowing strategies to remain on thin liquids.
- To be oriented to time without using visual supports.
- To check the clock or calendar (rather than repeatedly asking the spouse).
- To use the TV remote (rather than frequently calling son on the telephone).
- To use a cane or walker safely per PT’s instructions.
- To get on and off toilet safely per OT’s instructions.
Co-treating with PT and OT
I address the use of assistive devices and transitions from supine to sit to stand from a cognitive standpoint: remembering to use the sequence of steps provided by the PT or OT.
On several occasions, I’ve co-treated with PT or OT. The other therapist focuses on how the patient should be moving and how the environment should be modified, while I focus on how to help the patient to understand and remember to use the instructions.
Learn more + free downloads
Learn 7 tips to maximize success by using EL with someone who has a moderate to severe memory impairment. The free download is a cheat sheet for how to use errorless learning.
Read this tutorial to see how I use SR with EL to teach someone to use a chin tuck with thin liquids. The free download is a blank data collection sheet, as well as a completed example.
What have you used spaced retrieval and/or errorless learning to teach? Please let me know in the comments below.
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.
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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