Errorless learning of prospective memory tasks: An experimental investigation in people with memory disorders

The Development of a Pilot App Targeting Short-Term and Prospective Memory in People Diagnosed with Dementia

BACKGROUND

According to the World Health Organization, people suffering from dementia exhibit a serious decline in various cognitive domains and especially in memory.

AIMS

This study aims to create a pilot computer app to enhance short-term memory and prospective memory in individuals with dementia using errorless learning based on their individualized needs.

METHODS

Fifteen dementia patients and matched controls, matched for age, sex, and education, were selected. Their daily routines were analyzed, and cognitive abilities were assessed using the MoCA test. Considering the participants' illness severity and daily needs, the pilot app was designed to aid in remembering daily tasks (taking medication and meals), object locations, and familiar faces and names.

RESULTS

An improvement in patients' short-term and prospective memory throughout the training sessions, but not in overall cognitive functioning was observed. A statistically significant difference between patients and healthy controls was indicated in their ability to retain information relevant to them in their short-term memory, or to remember to act in the future following schedules organized at present (p < 0.001).

CONCLUSION

This app appears beneficial for training dementia patients and healthy individuals in addressing memory challenges.

RECOMMENDATION

While the pilot app showed promise, further research with larger samples is recommended.

Age-related learning difficulty through trial-and-error method associated with decreased default mode network integration in healthy middle-aged adults

INTRODUCTION

Efficient learning is critical to adapting to different environments. There are well-known learning principles in cognitive rehabilitation, including errorless (EL) and trial-and-error (T&E) learning; however, little is known about their underlying neural mechanisms. In the current study, to understand the age-related changes in learning benefits and neural mechanisms applying EL and T&E learning methods in healthy middle-aged adults, we conducted a graph theoretical analysis using functional magnetic resonance imaging data and analyzed the relationship between learning benefits and age, as well as functional network connectivity and age, with both learning principles.

METHOD

A total of 43 participants performed a color-name association task through EL and T&E learning methods. We focused on the functional connectivity patterns of the default mode network (DMN) since previous studies demonstrated this network to be more distinctive and important for the T&E learning method than EL. Within-network functional connectivity was used as the graph metric.

RESULTS

Age showed significant moderate negative correlations with T&E scores and within-DMN functional connectivity in the test state following T&E learning. Conversely, age was not significantly correlated with EL scores or within-DMN functional connectivity in either the EL learning or test states.

CONCLUSIONS

Our findings demonstrate the age-related learning decline associated with decreased DMN integration with aging, when applying the T&E method but not the EL method, even in healthy middle-aged adults. Relationships between the underlying neural network and age are different depending on the learning method. This suggests the need to take into consideration the remaining learning ability through the T&E learning method compared to normal aging and to utilize residual DMN functioning, in addition to the comparison between score differences between EL and T&E methods, when tailoring an individual learning approach.

INCOG 2.0 Guidelines for Cognitive Rehabilitation Following Traumatic Brain Injury, Part V: Memory

INTRODUCTION

Memory impairments affecting encoding, acquisition, and retrieval of information after moderate-to-severe traumatic brain injury (TBI) have debilitating and enduring functional consequences. The interventional research reviewed primarily focused on mild to severe memory impairments in episodic and prospective memory. As memory is a common focus of cognitive rehabilitation, clinicians should understand and use the latest evidence. Therefore, the INCOG ("International Cognitive") 2014 clinical practice guidelines were updated.

METHODS

An expert panel of clinicians/researchers reviewed evidence published since 2014 and developed updated recommendations for intervention for memory impairments post-TBI, a decision-making algorithm, and an audit tool for review of clinical practice.

RESULTS

The interventional research approaches for episodic and prospective memory from 2014 are synthesized into 8 recommendations (6 updated and 2 new). Six recommendations are based on level A evidence and 2 on level B. In summary, they include the efficacy of choosing individual or multiple internal compensatory strategies, which can be delivered in a structured or individualized program. Of the external compensatory strategies, which should be the primary strategy for severe memory impairment, electronic reminder systems such as smartphone technology are preferred, with technological advances increasing their viability over traditional systems. Furthermore, microprompting personal digital assistant technology is recommended to cue completion of complex tasks. Memory strategies should be taught using instruction that considers the individual's functional and contextual needs while constraining errors. Memory rehabilitation programs can be delivered in an individualized or mixed format using group instruction. Computer cognitive training should be conducted with therapist guidance. Limited evidence exists to suggest that acetylcholinesterase inhibitors improve memory, so trials should include measures to assess impact. The use of transcranial direct current stimulation (tDCS) is not recommended for memory rehabilitation.

CONCLUSION

These recommendations for memory rehabilitation post-TBI reflect the current evidence and highlight the limitations of group instruction with heterogeneous populations of TBI. Further research is needed on the role of medications and tDCS to enhance memory.

Memory rehabilitation: restorative, specific knowledge acquisition, compensatory, and holistic approaches

Memory impairment following an acquired brain injury can negatively impact daily living and quality of life—but can be reduced by memory rehabilitation. Here, we review the literature on four approaches for memory rehabilitation and their associated strategies: (1) the restorative approach, aimed at a return to pre-morbid functioning, (2) the knowledge acquisition approach, involving training on specific information relevant to daily life, (3) the compensatory approach, targeted at improving daily functioning, and (4) the holistic approach, in which social, emotional, and behavioral deficits are addressed alongside cognitive consequences of acquired brain injury. Each memory rehabilitation approach includes specific strategies such as drill and practice (restorative), spaced retrieval (knowledge acquisition), memory aids (compensatory), or a combination of psychotherapy and cognitive strategies (holistic). Past research has demonstrated mixed support for the use of restorative strategies to improve memory function, whereas knowledge acquisition strategies show promising results on trained tasks but little generalization to untrained tasks and activities of daily living. Compensatory strategies remain widely used but require intensive training to be effectively employed. Finally, the holistic approach is becoming more widespread due to improvements in psychosocial wellbeing, yet there are considerable resource and cost requirements. Several factors can influence rehabilitation outcomes including metacognition and emotional disturbances. Considerations for future research to improve the applicability of strategies for memory rehabilitation include assessing memory impairment severity, examining memory needs in daily life, and exploring the long-term effects of memory rehabilitation.

The effects of implementation intentions on prospective memory in young and older adults

Prospective memory (PM) is the ability to perform a planned action at a future time, while carrying on with other unrelated tasks. Implementation Intentions (II) is a promising metacognitive strategy for improving PM in older adults, though its generalization and longer-term effects are not well-understood. We examined the effects of II on PM in 48 community-dwelling older adults (77% female, M_age = 71.52) and 59 young adults (75% female, M_age = 19.86). Participants were randomly allocated to a conventional instruction or II group and administered a laboratory-based PM task in the first session. In the second session, participants returned to complete a similar but new laboratory-based PM task and an ecological PM task without prompts to use a strategy. We found strong age effects on PM performance whereby older adults performed worse than young adults across all PM tasks. While the overall facilitation effect of II was not statistically significant, there was a trend that this strategy facilitated PM performance on the laboratory-based PM task in the first session for older adults with a medium sized effect (d = 0.37). The generalization and longer-term effect of II were not significant for either the similar laboratory-based or the ecological PM task. These results suggest that a single-session II intervention may not be sufficient to elicit transfer to other similar new PM tasks in healthy populations.

Do Errorless Methods Improve Discharge Medication Instruction and Adherence?

PURPOSE AND DESIGN

Postdischarge adverse drug events are a national issue, and effective inpatient instruction may help. Therefore, this intervention study examined whether using errorless teaching/learning methods including pictorial medication cards (ETL + card) improved RN teaching and patient medication adherence among persons with cognitive challenges (PWCCs).

METHODS

Convenience samples of RNs and PWCCs from a 24-bed rehabilitation unit provided baseline data. RNs implemented ETL + card, and postintervention data were collected. Adapted and investigator-designed instruments had preliminary reliability/validity.

FINDINGS

Postintervention RNs demonstrated more teaching strategies (p = .003), and teaching satisfaction rose from 0% to 50%. Minutes per teaching interaction were unchanged (p > .05). Baseline patients filled a higher number (p = .02) but a lower percentage (67%) of their prescriptions than did postintervention patients (85%). Medication dose adherence scores were unchanged (p > .05).

CONCLUSIONS

ETL + card improved RN teaching and possibly patient adherence. Further study is warranted.

CLINICAL RELEVANCE

ETL + card may help PWCCs achieve safe medication self-management.

Prospective memory impairment in neurological disorders: implications and management

Prospective memory is a core neurocognitive ability that refers to memory for future intentions, such as remembering to take medications and to switch off appliances. Any breakdown in prospective memory, therefore, has serious implications for the ability to function independently in everyday life. In many neurological disorders, including Parkinson disease and dementia, prospective memory deficits are common even in the earliest stages and typically become more severe with disease progression. Consequently, clinical assessment of prospective memory is of critical importance. This article provides an overview of the various manifestations and neural bases of prospective memory deficits. To facilitate clinical decision-making, validated measures of this construct are identified and their suitability for clinical practice is discussed, focusing in particular on clinical sensitivity and psychometric properties. The article concludes by reviewing the approaches that can be used to rehabilitate different types of prospective memory impairment, and algorithms to guide the evaluation and treatment of these impairments are provided.

A review of prospective memory in individuals with acquired brain injury

OBJECTIVE

Prospective memory (PM) deficits have emerged as an important predictor of difficulty in daily life for individuals with acquired brain injury (BI). This review examines the variables that have been found to influence PM performance in this population. In addition, current methods of assessment are reviewed with a focus on clinical measures. Finally, cognitive rehabilitation therapies are reviewed, including compensatory, restorative and metacognitive approaches.

METHOD

Preferred reporting items for systematic reviews and meta-analyses guidelines were used to identify studies. Studies were added that were identified from the reference lists of these.

RESULTS

Research has begun to elucidate the contributing variables to PM deficits after BI, such as attention, executive function and retrospective memory components. Imaging studies have identified prefrontal deficits, especially in the region of BA10 as contributing to these deficits. There are now several clinical measures available with good psychometric properties. Rehabilitation techniques have mostly focused on compensatory strategies, but, in addition, some restorative and metacognitive approaches have shown preliminary promise.

CONCLUSIONS

PM deficits are a common and important deficit after BI. Clinical evaluation is recommended and further understanding of rehabilitation techniques is needed.

Google Calendar Enhances Prospective Memory in Alzheimer's Disease: A Case Report

We investigated whether an external memory aid (i.e., Google Calendar) would alleviate prospective memory compromise in a patient with mild Alzheimer's disease. The patient was asked in the baseline phase to perform three prospective targeted events (e.g., attending her weekly bridge game at the community club) and three prospective control events (e.g., buying her weekly magazine). The same six prospective events were assessed in the intervention phase but the targeted-events were cued by Google Calendar while the control-events were not. Results showed less omission of the targeted events in the training phase than in the baseline phase, suggesting a positive effect of Google Calendar. This case report offers a unique view into how smartphone calendars may alleviate prospective memory compromise in patients with mild Alzheimer's disease.

Improving Work Outcome in Supported Employment for Serious Mental Illness: Results From 2 Independent Studies of Errorless Learning

BACKGROUND

Heterogeneity in work outcomes is common among individuals with serious mental illness (SMI).

OBJECTIVE

In 2 studies, we sought to examine the efficacy of adding errorless learning, a behavioral training intervention, to evidence-based supported employment to improve SMI work outcomes. Work behavior problems were targeted for intervention. We also explored associations between early work behavior and job tenure.

METHODS

For both studies (VA: n = 71; community mental health center: n = 91), randomization occurred at the time of job obtainment with participants randomized (1:1) to either errorless learning plus ongoing supported employment or ongoing supported employment alone and then followed for 12 months. Dependent variables included job tenure, work behavior, and hours worked and wages earned per week. For the primary intent-to-treat analyses, data were combined across studies.

RESULTS

Findings revealed that participants in the errorless learning plus supported employment group stayed on their jobs significantly longer than those in the supported employment alone group (32.8 vs 25.6 wk). In addition, differential treatment effects favoring errorless learning were found on targeted work behavior problems (50.5% vs 27.4% improvement from baseline to follow-up assessment). There were no other differential treatment effects. For the prediction analyses involving work behavior, social skills explained an additional 18.3% of the variance in job tenure beyond levels of cognition, symptom severity, and past work history.

CONCLUSIONS

These data support errorless learning as an adjunctive intervention to enhance supported employment outcomes and implicate the relevance of workplace social difficulties as a key impediment to prolonged job tenure.

A systematic review of prospective memory in HIV disease: from the laboratory to daily life

OBJECTIVE

Prospective memory (PM) is described as the capacity to form and maintain an intention that is executed in response to a specific cue. Neural injury and associated neurocognitive disorders are common among persons living with HIV disease, who might therefore be susceptible to impairment in PM.

METHOD

This literature review utilized a structured qualitative approach to summarize and evaluate our current understanding of PM functioning in people living with HIV disease. 33 studies of PM in HIV+ persons met criteria for inclusion.

RESULTS

Findings showed that HIV is associated with moderate deficits in PM, which appear to be largely independent of commonly observed comorbid factors. The pattern of PM deficits reveals dysregulation of strategic processes that is consistent with the frontal systems pathology and associated executive dysfunction that characterizes HIV-associated neural injury. The literature also suggests that HIV-associated PM deficits present a strong risk of concurrent problems in a wide range of health behaviors (e.g. medication non-adherence) and activities of daily living (e.g. employment). Early attempts to improve PM in HIV disease have revealed that supporting strategic processes might be effective for some individuals.

CONCLUSIONS

HIV-associated PM deficits are common and exert a significant adverse effect on the daily lives and health of infected persons. Much work remains to be done to understand the cognitive architecture of HIV-associated PM deficits and the most efficient means to enhance PM functioning and improve health outcomes in persons living with HIV.

Designing Serious Computer Games for People With Moderate and Advanced Dementia: Interdisciplinary Theory-Driven Pilot Study

Background

The field of serious games for people with dementia (PwD) is mostly driven by game-design principals typically applied to games created by and for younger individuals. Little has been done developing serious games to help PwD maintain cognition and to support functionality.

Objectives

We aimed to create a theory-based serious game for PwD, with input from a multi-disciplinary team familiar with aging, dementia, and gaming theory, as well as direct input from end users (the iterative process). Targeting enhanced self-efficacy in daily activities, the goal was to generate a game that is acceptable, accessible and engaging for PwD.

Methods

The theory-driven game development was based on the following learning theories: learning in context, errorless learning, building on capacities, and acknowledging biological changes—all with the aim to boost self-efficacy. The iterative participatory process was used for game screen development with input of 34 PwD and 14 healthy community dwelling older adults, aged over 65 years. Development of game screens was informed by the bio-psychological aging related disabilities (ie, motor, visual, and perception) as well as remaining neuropsychological capacities (ie, implicit memory) of PwD. At the conclusion of the iterative development process, a prototype game with 39 screens was used for a pilot study with 24 PwD and 14 healthy community dwelling older adults. The game was played twice weekly for 10 weeks.

Results

Quantitative analysis showed that the average speed of successful screen completion was significantly longer for PwD compared with healthy older adults. Both PwD and controls showed an equivalent linear increase in the speed for task completion with practice by the third session (P<.02). Most important, the rate of improved processing speed with practice was not statistically different between PwD and controls. This may imply that some form of learning occurred for PwD at a nonsignificantly different rate than for controls. Qualitative results indicate that PwD found the game engaging and fun. Healthy older adults found the game too easy. Increase in self-reported self-efficacy was documented with PwD only.

Conclusions

Our study demonstrated that PwD’s speed improved with practice at the same rate as healthy older adults. This implies that when tasks are designed to match PwD’s abilities, learning ensues. In addition, this pilot study of a serious game, designed for PwD, was accessible, acceptable, and enjoyable for end users. Games designed based on learning theories and input of end users and a multi-disciplinary team familiar with dementia and aging may have the potential of maintaining capacity and improving functionality of PwD. A larger longer study is needed to confirm our findings and evaluate the use of these games in assessing cognitive status and functionality.

Prospective memory intervention using visual imagery in individuals with brain injury

Prospective memory deficits are common after brain injury and can create impediments to independent living. Most approaches to management of such deficits are compensatory, such as the use of notebooks or electronic devices. While these can be effective, a restorative approach, in theory, could lead to greater generalisation of treatment. In the current study a metacognitive technique, using visual imagery, was employed under conditions of rote repetition and spaced retrieval. Treatment was provided in an AB-BA crossover design with A as the active treatment and B as a no-treatment attention control to 20 individuals with brain injury. A group of 20 healthy participants served to control for effects of re-testing. Individuals with brain injury demonstrated improvement on the main outcome measure of prospective memory, the Memory for Intentions Screening Test, only after the active treatment condition. In addition, some generalisation of treatment was measured in daily life. Moreover, treatment gains were maintained for one year after treatment was completed.

Retrieval cue and delay interval influence the relationship between prospective memory and activities of daily living in older adults

OBJECTIVE

Older adults commonly experience mild declines in everyday functioning and the strategic aspects of prospective memory (PM). This study used multiprocess theory to examine whether the strategic demands of retrieval cue type (event vs. time based) and delay interval length (2 vs. 15 min) influence the relationship between PM and activities of daily living (ADLs) in older adults.

METHOD

Participants included 97 community-dwelling older adults recruited from the Western Australia Participant Pool. Participants were administered the Memory for Intentions Screening Test (MIST) and Prospective and Retrospective Memory Questionnaire (PRMQ) as part of a larger neurocognitive assessment. A knowledgeable informant completed the Activities of Daily Living Questionnaire (ADLQ), from which a cutpoint of ≥ 1 was used to classify participants into "ADL normal" (n = 37) or "mild ADL problems" (n = 60) groups. Repeated measures multivariate analysis of variance (MANOVA) controlling for age was conducted with ADL group as the between-subjects factor and either MIST or PRMQ cue and delay scores as the within-subjects factors.

RESULTS

We observed a significant ADL group by PM interaction on the MIST, with pair-wise analyses showing that the mild ADL problems group performed worse than ADL normal participants on the 15-min time-based scale (p < .001, Cohen's d = 0.71). No other MIST or PRMQ cue-delay variable differed between the two ADL groups (ps > .10).

CONCLUSION

Findings indicate that decrements in strategically demanding cue monitoring and detection over longer PM delays may partly explain older adults' mild problems in everyday functioning. Findings may inform neuropsychological interventions aimed at maintaining ADL independence and enhancing quality of life in older adults.

Do Old Errors Always Lead to New Truths? A Randomized Controlled Trial of Errorless Goal Management Training in Brain-Injured Patients

Both errorless learning (EL) and Goal Management Training (GMT) have been shown effective cognitive rehabilitation methods aimed at optimizing the performance on everyday skills after brain injury. We examine whether a combination of EL and GMT is superior to traditional GMT for training complex daily tasks in brain-injured patients with executive dysfunction. This was an assessor-blinded randomized controlled trial conducted in 67 patients with executive impairments due to brain injury of non-progressive nature (minimal post-onset time: 3 months), referred for outpatient rehabilitation. Individually selected everyday tasks were trained using 8 sessions of an experimental combination of EL and GMT or via conventional GMT, which follows a trial-and-error approach. Primary outcome measure was everyday task performance assessed after treatment compared to baseline. Goal attainment scaling, rated by both trainers and patients, was used as secondary outcome measure. EL-GMT improved everyday task performance significantly more than conventional GMT (adjusted difference 15.43, 95% confidence interval [CI] [4.52, 26.35]; Cohen's d=0.74). Goal attainment, as scored by the trainers, was significantly higher after EL-GMT compared to conventional GMT (mean difference 7.34, 95% CI [2.99, 11.68]; Cohen's d=0.87). The patients' goal attainment scores did not differ between the two treatment arms (mean difference 3.51, 95% CI [-1.41, 8.44]). Our study is the first to show that preventing the occurrence of errors during executive strategy training enhances the acquisition of everyday activities. A combined EL-GMT intervention is a valuable contribution to cognitive rehabilitation in clinical practice.