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Intervening with Everyday Memory Problems in

Dementia of Alzheimer Type: An Errorless Learning
Approach
Linda Clare , Barbara A. Wilson , Gina Carter , Kristin Breen , Antonie Gosses & John R.
Hodges
Published online: 09 Aug 2010.

To cite this article: Linda Clare , Barbara A. Wilson , Gina Carter , Kristin Breen , Antonie Gosses & John R. Hodges (2000)
Intervening with Everyday Memory Problems in Dementia of Alzheimer Type: An Errorless Learning Approach, Journal of
Clinical and Experimental Neuropsychology, 22:1, 132-146

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 Journal of Clinical and Experimental Neuropsychology 1380-3395/00/2201-132$15.00
2000, Vol. 22, No. 1, pp. 132-146 © Swets & Zeitlinger

Intervening with Everyday Memory Problems in Dementia of

Alzheimer Type: An Errorless Learning Approach*
Linda Clare1, Barbara A. Wilson2, Gina Carter2, Kristin Breen4, Antonie Gosses2,
and John R. Hodges2,3
1Sub-department of Clinical Health Psychology, University College London, UK, 2MRC Cognition &
Brain Sciences Unit, Addenbrooke’s Hospital, Cambridge, UK, 3University of Cambridge
Neurology Unit, Addenbrooke’s Hospital, Cambridge, UK, and 4Department of Clinical
Neuropsychology, Addenbrooke’s NHS Trust, Addenbrooke’s Hospital, Cambridge, UK
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ABSTRACT

Dementia of Alzheimer Type (DAT) is increasingly detected at an earlier stage of the disorder, when
interventions to assist with everyday memory difficulties might be most valuable. Some learning is possible
in DAT and a number of factors have been identified which may facilitate performance, although applica-
tions to everyday memory problems have been limited. The concept of errorless learning has not previously
been directly examined in relation to DAT, but might provide a useful additional strategy. In the present
study, 6 participants with early stage DAT (MMSE scores 21 – 26) received individually tailored interven-
tions, based on errorless learning principles and targeted at a specific everyday memory problem. Five of
the participants showed significant improvement on the target measures, and maintained this improvement
up to 6 months later. The results suggest that it is feasible to intervene with everyday memory problems in
the early stages of DAT and that errorless learning may be useful in addressing these problems.

The growing emphasis on early detection and in this group, yet there is a need for experimen-
diagnosis of dementia highlights the need for tal work which takes place in the real-life setting
effective psychological interventions for people and relates to the immediate situation of partici-
in the early stages of dementia of Alzheimer pants and their families. Although the degree of
type (DAT), who by definition will already have experimental control is likely to be more limited
significant memory impairments. One area in in the latter circumstances, this must be offset
which psychological interventions have the po- against the need for findings which have practi-
tential to help is that of maintaining cognitive cal and clinical relevance and which conse-
functioning and relearning important informa- quently offer direct benefits for participants.
tion which is already being lost. Such interven- The work reported here was designed to provide
tions need to be clinically effective and relevant clinically relevant information about ways of
to practical, day-to-day needs of participants. helping participants in the early stages of DAT,
Laboratory studies are important in helping to and their carers, to tackle everyday memory
clarify the factors which aid or hinder learning problems.

*
We are extremely grateful to the participants and carers who willingly gave their time to participate in the
research. We especially wish to acknowledge the contribution made to the work described here by the late Dr
Kristin Breen, who sadly died before the work could be submitted for publication. We thank Malcolm Adams and
Dr Peter Watson for statistical advice and Professor Gillian Cohen and Dr Martin Le Voi for helpful comments.
This work was partially funded by a R&D grant to B.A.Wilson, J.R.Hodges and K.Breen from the NHS Executive
Anglia and Oxford Region.
Address correspondence to: Linda Clare, Sub-department of Clinical Health Psychology, University College
London, Gower Street, London WC1E 6BT UK. E-mail: [email protected].
Accepted for publication: June 16, 1999.
 INTERVENING WITH EVERYDAY MEMORY PROBLEMS IN DAT 133

Marked impairment of anterograde episodic has been adapted for use in DAT by Camp
memory is the earliest and most pervasive defi- (1989) and has been shown to facilitate new
cit in DAT (Welsh, Butters, Hughes, & Mohs, learning for several kinds of information (Camp,
1992; Welsh, Butters, Hughes, Mohs, & Hey- 1989; Abrahams & Camp, 1993; McKitrick &
man, 1991) and has been attributed to a deficit Camp, 1993; Moffat, 1989). Studies using this
in encoding without increased forgetting of approach have reported maintenance of the ef-
learned information (Kopelman, 1985). Never- fects of training over several weeks, despite
theless, some new learning is possible for people concurrent decline in cognitive functioning and
with DAT (Burgess, Wearden, Cox, & Rae, evidence of generalisation (Abrahams & Camp,
1992; Camp et al., 1993; Little, Volans, Hems- 1993; Camp, 1989; Moffat, 1989). The interven-
ley, & Levy, 1986). Furthermore, working mem- tions reported appear relevant to everyday life,
ory, procedural memory and some components can be delivered in the home setting (Moffat,
of implicit memory are relatively spared in the 1989), and can be carried out by caregivers with
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early stages (Greene, Baddeley, & Hodges, professional support (McKitrick & Camp,
1996). This suggests that it should be possible to 1993).
design interventions to help with some of the Use of external memory aids such as note-
everyday memory problems experienced by peo- books, diaries, and alarms is well established in
ple with DAT. neurorehabilitation (see, for example, Kime,
Recent work has demonstrated that when ap- Lamb, & Wilson, 1996; Sohlberg & Mateer,
propriate cognitive support for remembering is 1989). The possibility of training people with
provided both at encoding and at retrieval peo- DAT in the use of external memory aids or other
ple with DAT can show facilitation of episodic forms of environmental support has been inves-
memory performance (Bäckman, 1992; Bird & tigated in a small number of studies (Bourgeois,
Luszcz, 1991, 1993; Herlitz & Viitanen, 1991; 1992; Hanley, 1986; Kurlychek, 1983). In some
Karlsson et al., 1989; Lipinska & Bäckman, cases, use of the aids was maintained once train-
1997; Lipinska, Bäckman, Mantyla, & Viitanen, ing stopped (Bourgeois, 1992), whereas other
1994 ). The clinical significance of these experi- studies report that improvements were not main-
mental studies is not yet established; neverthe- tained or fail to discuss the issue of maintenance
less, the findings offer some guidance regarding (Hanley, 1986). In general, with studies involv-
the factors which need to be considered in de- ing introduction of external aids, training usu-
signing clinical interventions. ally consists of prompting by relatives or carers,
Another approach to tackling everyday mem- but the selection and application of the method
ory problems in DAT has involved adapting of training itself tends to receive relatively little
methods used for people with acquired brain attention, with few links being made to the evi-
injury (see, for example, Wesolowski & Zen- dence on methods of facilitating learning.
cius, 1994; Wilson, 1995). These include inter- The evidence reviewed above indicates that a
nal mnemonic strategies, expanding rehearsal number of principles regarding facilitation of
techniques, and external memory aids. learning can be derived for application to clini-
Mnemonic strategies are likely to prove too cally relevant interventions, although some
difficult for many people with DAT. However, promising practical interventions have paid little
experimental investigations suggest they may attention to parameters of the learning process.
assist a small number of individuals with learn- It remains to be established whether there are
ing specific information such as face-name asso- additional methods which offer the potential for
ciations (Bäckman, Josephsson, Herlitz, Stigs- facilitating learning in this group and which may
dotter, & Viitanen, 1991; Hill, Evankovich, enhance the effectiveness of those currently
Sheikh, & Yesavage, 1987; Thoene & Glisky, available.
1995). One area currently receiving attention in the
The expanding rehearsal method (Landauer & field of brain-injury rehabilitation is the extent
Bjork, 1978; Schacter, Rich, & Stampp, 1985) to which errorless learning – the elimination or
 134 LINDA CLARE ET AL.

reduction of incorrect or inappropriate responses The present study set out to investigate
during training – facilitates memory perfor- whether errorless learning principles could be
mance. Errorless learning of discriminations used effectively to design practical interventions
was first described in the animal literature by for everyday memory problems which would
Terrace (1963), and the concept was adapted to produce facilitation of memory performance in
aid learning in people with learning disabilities early stage DAT. A multiple single case experi-
(Jones & Eayrs, 1992; Llorente & Gaffan, mental design was adopted.
1989). In studies of people with acquired brain
injury, advantages have been demonstrated both
on experimental tasks and in clinical settings METHOD
(Baddeley & Wilson, 1994; Squires, Hunkin, &
Parkin, 1996, 1997; Wilson, Baddeley, Evans & Participants
Shiel, 1994). Wilson and colleagues (Wilson & Memory Clinic records for the previous 2 years
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Evans, 1996) have speculated that some of the were examined to identify potential participants,
who were then approached by letter and offered the
successful interventions described in the litera-
opportunity to discuss the project with the re-
ture on cognitive rehabilitation may have suc- searcher either at their home or at the hospital. Ini-
ceeded because an indirect result of the methods tial meetings were arranged with those who indi-
used was keeping errors to a minimum. Jones cated they were willing. People newly referred to
and Eayrs (1992) note, however, that errorless the clinic and diagnosed with DAT during the re-
methods may be more suitable for relatively cruitment period who met the criteria were ap-
straightforward discrimination tasks such as proached in the same way.
Participants were selected according to the fol-
name learning than for more complex skills of lowing criteria: medical diagnosis of probable
daily living, and may also not be optimal for DAT according to NINCDS-ADRDA criteria
ensuring generalisation and maintenance. (McKhann et al., 1984); minimal or mild DAT
This suggests that in using an errorless learn- (minimal = MMSE > 23; mild = MMSE 18 – 23) in
ing paradigm it will be essential to select tasks keeping with previous studies based on the
which are amenable to being taught in this way, Addenbrooke’s Memory Clinic cohort (Hodges &
and to pay special attention to designing inter- Patterson, 1995); impairments predominantly in
memory, without widespread general intellectual
ventions so as to give the maximum possible impairment; absence of major psychiatric disorder;
opportunity to encourage generalisation and age range 60 – 75; living with a spouse or other
maintenance. Errorless learning does, however, relative who was willing to participate; English
offer one important parameter which may be spoken as first language; able to give informed
very beneficial for people with DAT; as errors consent.
are avoided or minimised, participants have the A total of 16 potential participants was identi-
fied, of whom 13 agreed to an initial visit. One was
opportunity to experience success at every stage
subsequently admitted to hospital, so 12 initial vis-
of the learning process. Furthermore, application its were carried out. Seven people were recruited
to relatively straightforward discrimination tasks to the present study. Six of these are reported here;
may be precisely what is required. In view of the the remaining man developed a medical illness
potential strengths of the principle, it would which delayed the progress of his intervention. Of
seem worthwhile to consider whether it might the 5 people who were visited but not recruited to
constitute a useful addition to the range of possi- the study, 4 were found not to meet the criteria and
in one case the carer felt that participation would
ble methods of facilitating memory performance
be too stressful. Two of those not meeting the cri-
in DAT. As yet there do not appear to have been teria were offered, and accepted, different forms of
any attempts to investigate whether the applica- intervention.
tion of errorless learning principles may be of The 6 study participants included 3 men and 3
benefit for people with DAT, and if so, under women. Their ages ranged from 65 to 75, with a
what circumstances. mean of 69.33 years (SD = 3.93). One of the men
lived with his sister; each of the other participants
lived with a spouse. Prior to retirement, 2 of the
 INTERVENING WITH EVERYDAY MEMORY PROBLEMS IN DAT 135

participants had run family businesses, 2 had been and People (Baddeley, Emslie, & Nimmo-Smith,
counsellors, 1 had been a carpenter and one had 1994); Rivermead Behavioural Memory Test
worked as a school crossing attendant. The mean (RBMT) (Wilson, Cockburn, & Baddeley, 1985);
MMSE score was 24 (SD = 2.1). Participants had Visuospatial perception: Visual Object and Space
been experiencing memory problems for between Perception Battery (VOSP) (Warrington & James,
18 months and 5 years when first seen for the 1991).
study. All were administered at initial assessment and
repeated wherever possible at the end of the inter-
Design vention. At 6-month follow-up, the SCOLP and the
The study was conceptualised as a multiple single- Story Recall subtest of the RBMT were repeated
case experimental design. Standardised neuropsy- wherever possible.
chological and self-report measures were com- The 3 participants for whom the intervention
pleted by all participants at the outset of the study, involved learning face-name associations were
and repeated following the intervention, with a also assessed on memory for famous faces as part
small subset of neuropsychological tests repeated of the initial assessment, and 2 were assessed on
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again at follow up 6 months later. Nonparametric facial recognition. The measures used were: Facial
statistical tests were used to assess the significance Recognition Test (Benton, Hamsher, Varney, &
of changes in the scores on the self-report mea- Spreen, 1983); and Famous Faces Test (described
sures. by Greene & Hodges, 1996).
Each participant received an individually tai- Self-report questionnaires were administered to
lored intervention, which was evaluated using provide an indication of the participants’ mood,
individualised measures, allowing a comparison of behaviour and memory functioning, and the rela-
performance at baseline with performance during tives’ mood and subjective experience of caregiver
and after intervention. The individual interventions strain. All the measures were completed at initial
were designed either as multiple baseline across assessment and repeated following the interven-
items single-case designs or as variants of ABA tion. It was of interest to establish whether changes
single-case designs. In order to facilitate compari- in performance on target tasks were accompanied
son between interventions, scores within each by changes in the perceptions of either carer or
phase were calculated in one of two formats, either participant. The instruments used were as follows:
mean proportion (%) of responses correct, or mean Behaviour rating scale from the Clifton Assess-
daily frequency of target behaviour. Nonpara- ment Procedures for the Elderly (CAPE) (Pattie &
metric statistical tests, ANOVA, Pearson’s pro- Gilleard, 1979) – completed by the relative with
duct-moment correlation coefficient, and time se- regard to the participant; Dysexecutive question-
ries analyses (ITSACORR, Crosbie 1993; series of naire (DEX) from the Behavioural Assessment of
events analysis, Cox & Lewis, 1966) were used for the Dysexecutive Syndrome (BADS) (Wilson, Al-
statistical examination of the data, as appropriate. derman, Burgess, Emslie, & Evans, 1996) – com-
pleted by the relative with regard to the partici-
Procedures pant; Memory problems questionnaire (Kapur &
Pearson, 1983; Wilson & Moffat, 1992) – used by
Assessment both participant and relative to rate the partici-
The neuropsychological measures were selected to pant’s memory functioning; Hospital Anxiety and
provide a short battery of tests that would provide Depression Scale (Snaith & Zigmond, 1994) –
an indication of premorbid and current intellectual used by both participant and relative to report their
ability, episodic memory, and visuospatial percep- own current mood; Caregiver Strain Index (CSI)
tion, without being too onerous for the partici- (Robinson, 1983) – completed by the relative to
pants. These measures were included both to give indicate current level of strain.
an indication of the initial level of functioning and
to establish whether any change in functioning oc- Intervention
curred over the period of the intervention, which All the interventions were designed to meet the
would have implications for the interpretation of necessary conditions for errorless learning and to
results. The tests used were as follows: General minimise the possibility of errors occurring during
intellectual functioning: National Adult Reading learning. The errorless learning principle was ap-
Test (NART) (Nelson, 1982); Speed and Capacity plied to a number of methods with the aim of en-
of Language Processing (SCOLP) (Baddeley, suring that the occurrence of errors was minimal.
Emslie, & Nimmo-Smith, 1992); Standard Pro- Four of the interventions involved learning or
gressive Matrices (Raven, 1976); Memory: Doors relearning specific information, using a multiple
 136 LINDA CLARE ET AL.

baseline across items design, and these were as- before beginning the vanishing cues process from
sessed in terms of proportion of items correctly this starting point. Participant C practised the task
recalled and the pattern of change across items. only during sessions with the researcher.
Follow-up assessments were scheduled 1, 3 and 6
months after completion of the intervention. Mean Participant D This participant worked on improv-
scores (averaged across items) in each phase of the ing recall of personal information. A ‘personal
study – baseline, intervention, post-intervention, quiz’ was devised and items were trained using
and follow up – were compared to assess the level expanding rehearsal, supplemented by structured
of change in performance. During the intervention practice using an instructional audiotape similar to
phase of the study, one training session was given that described by Arkin (1992). Participant D’s
for each item, and a test trial consisting of all items husband assisted with between-session practice.
was administered at the end of each training ses-
sion. Details of the four interventions in this cate- In these interventions the errorless learning princi-
gory were as follows: ple was incorporated in two ways. First, some of
the strategies selected, such as vanishing cues and
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Participant A The intervention target was to learn expanding rehearsal, limited the likelihood of mak-
the names of 11 members of participant A’s social ing errors, and all the selected training methods
club. The learning method involved a combination were implemented in such a way that the possibil-
of several strategies. First, the participant was ity of errors would be minimised. Second, during
helped to identify a verbal elaboration of the name the training sessions, participants were requested
based on a prominent facial feature, then the name not to guess, and only to give answers if they were
was trained using vanishing cues (Glisky, certain these were correct; if they were not sure,
Schacter, & Tulving, 1986) and practised by ex- they were to say ‘don’t know’. A ‘don’t know’ re-
panding rehearsal. Photographs were used in train- sponse was not considered to represent an error;
ing but supervised practice was also given in the only active production of an incorrect answer was
real-life setting by the researcher. Participant A classified as an error. Thus, responses could fall
practised with the photographs between sessions into one of three categories: correct, error or ‘don’t
and continued to practise after completion of the know’.
intervention. Participant A’s intervention is de- The intervention sessions for each item to be
scribed in more detail in Clare, Wilson, Breen, and trained provided virtually error-free learning con-
Hodges (1999). ditions. This must be distinguished from the situa-
tion during test trials, whether in the baseline or
Participant B The intervention target was to learn subsequent phases. Here participants were also
the names of 13 members of the support group he requested not to guess, and to say ‘don’t know’ if
attended with his wife. The strategy used was ver- unsure, but errors were occasionally made. This
bal elaboration based on prominent facial features. does not imply a failure to make the learning itself
This was supported by either repeated presenta- error free. Errors in baseline responding are equiv-
tion, or expanding rehearsal, or both. Photographs alent to having a prior history of errors on a given
were used in training and supervised practice was item or task, while errors made following interven-
given in the club setting by Participant B’s wife. tion can be viewed as an approximation to the way
Participant B continued to practise with the photo- in which new learning is tested out in the real-life
graphs at home. Results for all 13 names were situation.
analysed together since results were similar across The remaining two interventions involved train-
all three methods used to support the elaborative ing in the use of a memory aid with the aim of pro-
strategy. viding an alternative to repetitive questioning of
the carer, using an ABA design. These were as-
Participant C Four errorless learning methods for sessed in terms of daily frequency of repetitive
learning the names of famous people were com- questioning, recorded by the carer on a diary sheet
pared. These were a memonic strategy involving provided for this purpose. The errorless learning
verbal elaboration based on a prominent facial fea- methods involved regular practice in the form of
ture, vanishing cues, and expanding rehearsal (as prompting by the carer, carried out according to a
described in Clare et al., 1999) and forward predetermined schedule, and supplemented by a
cueing, a more effortful variant of the cueing pro- standard prompt given in response to spontaneous
cedure, in which the minimum number of cues re- questions, to ensure consistency. Follow-up as-
quired to elicit the correct answer is first assessed sessments were scheduled 3 and 6 months after
 INTERVENING WITH EVERYDAY MEMORY PROBLEMS IN DAT 137

completion of the intervention. The two interven- When retested at the end of the intervention
tions in this category can be described as follows: and at 6-month follow up, there were no signifi-
cant changes in the neuropsychological profile,
Participant E This participant’s first target in-
except in the case of Participant D whose condi-
volved learning to use a calendar to find out what
day it was, instead of asking her husband. Subse- tion had declined to the extent that she was un-
quently, she also learned to use a memory board to able to complete most of the tests.
find out what was planned for the day. Between
sessions, participant E’s husband provided the Ratings of mood and behaviour
agreed prompts and responses. Ratings of the participants’ mood and behaviour
made by the participant and the carer at initial
Participant F This participant’s target was to use a
memory strategy to find out what day it was in-
assessment and following intervention are
stead of asking his wife. Several strategies were summarised in Table 1. CAPE scores showed
tried during the intervention phase. These were: a that all participants were regarded by their rela-
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diary with prompts provided by a NeuroPage® tives as functioning in the independent or low
electronic pager; a diary with prompts provided by dependency categories. Rating scores for dys-
the participant’s wife; a page-a-day calendar and executive behaviour suggested that this was not
diary; a calendar and wipe-clean memory board. a major component. Parallel ratings of memory
In these interventions the errorless component was problems made by participant and carer showed
provided by the repeated prompting given to par- few discrepancies. Only one of the participants
ticipants, coupled with a consistent response to reported significant anxiety and none reported
occurrences of the target behaviour by the carer. In significant levels of depression. Following inter-
effect, a deviation from the intervention plan such vention, there were no significant changes in
that a question was responded to inappropriately carers’ ratings of behaviour or in either partici-
would have represented an ‘error’.
pants’ or carers’ ratings of memory problems.
There was, however, a tendency for carers to
report fewer memory problems than at initial
RESULTS
assessment; 5 of the relatives gave a lower rat-
ing than they had done previously. Participants’
Neuropsychological assessment
self-reported levels of anxiety were also not sig-
The initial neuropsychological profiles showed
nificantly different. The only statistically signif-
that the participants all had estimated optimal
icant change was in participants’ ratings of de-
levels of functioning in the average to high aver-
pression (z = –2.0226, p = .043, two-tailed).
age range. Current functioning in terms of
Five of the 6 participants recorded slightly
abstract reasoning was well-preserved in most
higher scores, with one score staying the same;
cases, although Participant D could not complete
in two cases the increase shifted the partici-
this test. Speed of information processing
pant’s score into the ‘mild depression’ range.
ranged from average to impaired, with the ma-
Carers’ self-ratings of mood and strain at ini-
jority performing in the low average range. All
tial assessment and following intervention are
the participants showed severe impairments of
also summarised in Table 4. Initially, none re-
memory. All but one performed in the normal
ported significant levels of strain, and only one
range on tests of visual object and space percep-
reported mild anxiety and depression. There
tion; Participant D’s difficulty in this area was
were no significant changes in ratings following
taken into account when planning her interven-
intervention. At this stage a second carer, who
tion. Participants A and B achieved scores in the
had experienced periodic depression and anxiety
normal range for face recognition but were se-
for many years, also reported mild anxiety and
verely impaired on naming famous faces. Partic-
depression.
ipant C also showed some impairment in naming
famous faces, although this was less marked.
 138 LINDA CLARE ET AL.

Table 1. Subjective Ratings by Participants and Carers.

Measure Rated by Pre/Post A B C D E F

(a) Ratings of participants’ mood and behaviour

CAPE Carer Pre 3 7 2 7 2 0

(max 36) Post 1 7 2 10 1 2
DEX Carer Pre 14 24 6 16 4 3
(max 80) Post 12 26 16 24 1 10
Memory Carer Pre 7 13 8 15 12 12
problems Post 5 19 4 13 0 6
(max 22) Participant Pre 13 13 8 11 12 5
Post 11 17 7 13 12 4
HADS Participant
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Anxiety Pre 1 6 3 4 12 4
(max 21) Post 4 6 5 3 11 2
Depression Pre 0 1 5 5 4 0
(max 21) Post 3 2 5 10 8 1

(b) Carers’ self-ratings of mood and strain

HADS
Anxiety (max 21) Pre 1 7 2 9 1 2
Post 3 6 9 9 1 3
Depression (max 21) Pre 3 7 1 8 0 0
Post 1 4 8 8 1 0
CSI (max 13) Pre 0 3 1 5 2 0
Post 0 3 1 10 1 3

Note. CAPE = Clifton Assessment Procedures for the Elderly; DEX = Dysexecutive questionnaire; CSI =
Caregiver Strain Index

100
% correct

Individual interventions
The results of the interventions are summarised
in Figures 1, 2, and 3; Table 2 gives a summary
75
of the data. The first group of interventions,
shown in Figure 1, involved learning face-name
associations or improving recall of personal in-
formation. All 4 participants showed marked 50
improvement in scores following intervention,
which was wholly or largely maintained at fol-
low up. 25
A detailed breakdown of the overall score for
Participant C into scores achieved within each of
the four training conditions is displayed in Fig-
ure 2; this shows that although there was im- 0
1

provement in all conditions following interven- BL INT POST FU

tion, the change was most marked for the mne- Phase
monic and expanding rehearsal conditions,
while the vanishing cues condition produced Fig. 1. Improvements in naming and accessing per-
sonal information . (Square = Patient A; dia-
least change. Improvements were maintained at
mond = Patient B; circle = Patient C; trian-
follow up in all except the vanishing cues condi- gle = Patient D.)
 INTERVENING WITH EVERYDAY MEMORY PROBLEMS IN DAT 139

Table 2. Summary of Intervention Results

Participant Baseline Intervention Post-intervention Follow up

M SD M SD M SD M SD

(a) Recall Interventions

A 21. 6 (26.0) 93.4 (6.0) 98.0 (4.5) 100 (0.0)

B 2.3 (8.3) 75.2 (26.0) 91.5 (12.8) 83.3 (28.6)

C 10.6 (12.1) 53.8 (34.6) 58.4 (40.5) 52.1 (43.3)

D 51.0 (17.3) 77.3 (17.5) 88.3 (13.9) 83.3 (28.6)

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(b) Memory Aid Training

E Target 1 2.6 0.7 0.3 0.4

Target 2 0.7 0.2 0.1 0.1

F 1.7 0.7 0.4 2.0

(a) Interventions involving recall of face-name associations and personal information – proportion (%) of correct
responses in each phase (and SD), averaged across items and trials
(b) Interventions involving training in use of a memory aid – mean daily frequency of repetitive questioning
during each phase of the study

tion, where performance declined almost to

baseline levels. 100
The statistical analyses of the individual mea-
responses
% correct

90
sures for each participant are summarised in Ta-
ble 3. The changes following intervention were 80
significant for all 4 participants. 70
The three cases where aggregated data were 60
analysed using nonparametric tests all showed a
50
significant trend in the expected direction. In the
case of Participant C, analysis of variance was 40
used to explore the aggregated data, employing 30
a model consisting of the individual name face-
20
associations as items, phase of study as a within-
items factor, and type of training as a between- 10

items factor. As the scores were expressed in 0

INT
BL

POST

FU

terms of proportion of faces named correctly,

the analysis was carried out on an arcsin trans- Phase
formation of the data. The results, also sum-
marised in Table 3, showed significant main Fig. 2. Results achieved by Participant C with each
effects of both phase and type of training, and of four learning methods – proportion of cor-
no significant interaction between phase and rect responses averaged across items within
each condition for each phase of the study.
training type. Investigation of contrasts showed (Square = Vanishing cues; diamond = Ex-
that for the training phase the significant differ- panding rehearsal; circle = Forward cuing;
ence lay in the comparison of results for initial triangle = Mnemonic.)
 140 LINDA CLARE ET AL.

Table 3. Statistical Analyses for Individual Interventions

Pt Comparison Analysis Result p

A Mean proportion of faces correctly Friedman c2(4,11) = 30.0 < .0005

named in each phase Page’s L L (5,11) = 580 < .001

B Mean proportion of faces correctly Friedman c2 (5,13) = 32.3 < .0001

named in each phase Page’s L L(4,13) = 376 < .001

C Mean proportion of faces correctly ANOVA*

named during each phase in each study phase F(3,24) = 5.9 = .003
condition: (VC – vanishing cues; FC training type F(3,24) = 4.7 = .04
– forward cueing; MN – mnemonic; Contrasts:
ER – expanding rehearsal) Phase –
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init bline vs others F(1,24) = 17.6 = .003

Type –
VC vs. others F(1,24) = 12.1 = .008
VC vs. FC F(1,24) = 9.0 = .02
VC vs. MN F(1,24) = 10.3 = .01

D Mean proportion of items correctly Friedman c2 (3,4) = 10.1 = .01

recalled in each phase Page’s L L (3,4) = 56 = .001

E Mean daily frequency of repetitive

questioning in initial and post-inter-
vention baseline
Target 1 – calendar ITSACORR
Overall change F(2,93) = 3.11 < .05
Intercept t (93) = –4.78 < .001
Slope t (93) = 0.85 NS
Target 2 – memory board Series of events analysis z = 2.88 < .005

F Daily frequency of repetitive ques- ITSACORR

tioning in initial and post-interven- Overall change F 2,32 = 0.28 NS
tion baselines

* Only significant results reported

baseline with those for subsequent phases, indi- tirely error free. Errors were made on some test
cating a significant improvement with interven- trials, however. Although it would be of interest
tion. For type of training, the significant differ- to assess the extent to which making errors dur-
ence lay in the comparison of scores for the van- ing baseline trials had an impact on subsequent
ishing cues condition with scores in the other learning, the proportion of items for which re-
three conditions. Looking at the conditions indi- sponses classed as active errors were made was
vidually, scores for vanishing cues were signifi- generally too low to allow for a sufficiently
cantly lower than those for forward cueing and powerful statistical analysis. Additionally, in the
for mnemonic, but not those for expanding re- post-intervention and follow-up phases ceiling
hearsal. There were no significant differences effects for some participants precluded corre-
between the scores achieved in the four condi- lational analysis. In the case of Participant A,
tions at baseline. there was a nonsignificant trend towards an as-
As noted previously, learning sessions for all sociation between errors during baseline and
4 participants in this category were almost en- less efficient learning during the intervention
 INTERVENING WITH EVERYDAY MEMORY PROBLEMS IN DAT 141

3 agreed protocol, occurred in these interventions.

of repetitive questioning
Mean daily frequency Discussion with the carers suggested that this
2.5
situation arose very infrequently for Participant
E, but quite often for Participant F.
All participants and carers were asked about
2 their views of the intervention. Some were en-
thusiastic and felt that they had been helped con-
1.5
siderably. Others were very aware of the pro-
gression of the disorder and in this context the
positive effects of the intervention seemed of
1 more limited significance. Two of the partici-
pants, although seeming very pleased to receive
visits, either rememberred little about the inter-
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0.5
vention or felt they did not really need it. One
carer felt uncomfortable about giving her hus-
0 band prompts and encouraging him to use mem-
1

4
BL INT POST FU ory aids, as she believed it was part of her role
Phase as a wife to keep track of activities and appoint-
ments for him.
Fig. 3. Reductions in repetitive questioning. (Square
= Patient E(1); diamond = Patient E(2); cir-
cle = Patient F.)
DISCUSSION

phase (r = 0.416, NS). There was no indication The results show that participants with early
from the individual results that a greater degree stage DAT can demonstrate significant improve-
of impairment resulted in production of a greater ments on specific everyday memory tasks fol-
number of errors. lowing training based on errorless learning prin-
The second group of interventions, for which ciples. These improvements are not attributable
the results are summarised in Figure 3 and Table to changes in cognitive functioning or beha-
2, involved learning to use a memory aid to find viour, and indeed may be observed in the con-
out basic information with the aim of reducing text of overall deterioration.
the frequency of repetitive questioning. Statisti- The successful results shown by participants
cal analyses are summarised in Table 3. Both who learned face-name associations were
participants showed a reduction in the frequency achieved despite severe impairments on formal
of repetitive questioning following intervention; tests of naming famous people. For two of these
this was significant in the case of Participant E, participants, gains were generalised from the
but not Participant F. At follow up, Participant E training sessions in which photographs were
maintained the improvements she had made and used to the real-life setting. Participant A bene-
continued to use her memory aids, but Partici- fited from a combined teaching method and it
pant F’s repetitive questioning increased again was of interest to consider which aspects of the
and rose above baseline levels. In Participant F’s method were critical to his success. The mne-
case, although there was a reduction in recorded monic strategy was successful for Participant B,
frequency of repetitive questioning during inter- whether it was coupled with either expanding
vention, use of a memory aid never became rehearsal, or repeated presentation of the stimu-
firmly established and he chose to discontinue lus at regular intervals, or both. For Participant
using the aids at the end of the intervention. C, the mnemonic strategy used in isolation again
Because of the necessity of relying on reports proved beneficial. All 3 participants who learnt
by carers, it was difficult to assess the frequency face-name associations therefore benefited from
with which ‘errors’, or deviations from the a mnemonic strategy involving using a key fea-
 142 LINDA CLARE ET AL.

ture of the face to make a verbal elaboration would not necessarily be very practicable in
about the name. Furthermore, the associations daily life.
were retained over intervals of a week or more Training in the use of memory aids produced
during training, names were recalled without changes in behaviour during intervention for
first-letter cues or other specific verbal prompts, both participants, although this was statistically
and the gains were largely maintained at follow significant for only one of the participants. In
up 3, or in some cases 6 months later. It may be this case, not only were gains maintained 6
that the use of a mnemonic method holds prom- months after the end of the intervention, but in
ise for a larger subgroup of people in the milder addition there was evidence of generalisation to
stages of DAT than Bäckman et al. (1991) sug- other areas, in the sense that this couple began to
gest, provided the strategy is applied in a way discuss, devise, and apply memory strategies
which enables the participants with DAT to when new situations or difficulties arose.
make effective use of it. The only significant change revealed by the
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Expanding rehearsal was a component of the repeated cognitive and behavioural measures
intervention for all 3 participants. In the case of was an increase in the participants’ self-reported
Participant C, expanding rehearsal proved suc- scores on the self-report depression subscale of
cessful when used in isolation. This is consistent the HADS. This was statistically significant, but
with the previous work on expanding rehearsal represents fairly small differences in scores,
as a method of teaching face-name associations with only 2 participants shifting into the clinical
(Camp, 1989). Again, recall was demonstrated range. Further research would be needed to es-
after relatively long intervals and knowledge of tablish the extent to which these changes were
the associations was maintained at follow up, related to the intervention. It is possible that in-
suggesting that this method does have strong tervention led to increased awareness of mem-
potential for clinical application. Recall of per- ory difficulties, resulting in lower mood. This is
sonal information (Participant D) was another not, however, supported by the results from the
area where expanding rehearsal proved accept- memory problems self-rating questionnaire, be-
able and useful. cause there was no significant increase in partic-
Cueing methods were also used with Partici- ipants’ ratings of their memory problems.
pants A and C. Vanishing cues were a compo- There was a trend for carers to report lower
nent of Participant A’s intervention, and the memory problem ratings following intervention,
vanishing cues method formed one training con- and although this was not statistically significant
dition for Participant C. The results for Partici- it does suggest that carers’ perceptions of the
pant C indicated that this method used in isola- memory problems may have been influenced by
tion was not beneficial, whereas the more the intervention. This aspect deserves closer in-
effortful forward cueing variant was effective. vestigation in future studies.
This supports the view that effortful processing The key principle underlying the design of all
is helpful for people with DAT. Thoene and the interventions reported here is that of error-
Glisky (1995) found a mnemonic strategy more less learning. The distinctive and unifying fea-
effective than a cueing strategy (which they ture of the interventions is that errors were elim-
termed vanishing cues but which combined fea- inated or kept to a minimum during learning.
tures of the two procedures we have termed for- Attempting to apply errorless learning principles
ward cueing and vanishing cues) for their partic- in clinical settings necessarily entailed having
ipants with memory impairments. The vanishing less control over participants’ learning experi-
cues method has been shown to facilitate cued ences than would be possible in a purely experi-
recall (e.g. Glisky et al, 1986), but the goal in mental situation, and the interventions described
the present study was free recall and the vanish- here should therefore be viewed as approxima-
ing cues method did not facilitate this. Clearly, tions of an errorless paradigm. One difficulty
dependence on external cues such as the provi- was that errors sometimes occurred during base-
sion of a first-letter prompt by another person line testing; this was conceptualised as equiva-
 INTERVENING WITH EVERYDAY MEMORY PROBLEMS IN DAT 143

lent to having a prior history of errors on the A, B, and C, it was assumed there was prior
item in question. Although the prior history of knowledge of some, but perhaps not all, items
errors may have influenced the efficiency of used in training, so it is unclear how much of
learning during the intervention phase, there was their learning was new learning and how much
no clear indication regarding an effect on even- was relearning. It is also unclear to what extent
tual outcome; again, further work would be re- they may have had implicit knowledge of the
quired to explore this issue. associations at the outset of training. This could
Despite these limitations, the results demon- be clarified in future studies by testing implicit
strate for the first time that errorless methods as well as explicit knowledge during the initial
can be adapted for use in clinical settings in at- baseline phase.
tempting to intervene with everyday memory Most of the participants were involved in
problems in early stage DAT. The mechanisms daily practice, and this may be an important key
by which errorless learning exerts its effects, to the degree of success experienced. Practice
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however, remain unclear. It has been suggested during follow up appears, at least for some of
that errorless learning facilitates implicit mem- the participants, to have had an impact on the
ory, which is relatively preserved in people with level of maintenance observed. The clinical im-
DAT (Baddeley & Wilson,1994; Wilson et al., plication is that continued input following inter-
1994). The results of the present study cannot, vention is likely to be necessary in many cases
however, be taken to support the view that the to ensure that gains are maintained for signifi-
beneficial effects are based on implicit memory. cant periods (Bäckman, 1992; Woods, 1996).
The 5 participants who showed statistically sig- For the participants whose intervention in-
nificant improvements also demonstrated ex- volved the use of memory aids, continued use of
plicit knowledge of the targets they were work- the given aid may represent the equivalent of
ing on or the strategies employed. The remain- practice. Participant F stopped using any of the
ing participant showed no explicit learning of memory strategies at the end of the intervention
his strategy and failed to maintain any changes period, and at follow up the frequency of his
in behaviour. repetitive questioning had increased above base-
Recent results from studies with participants line levels. His response is particularly interest-
with brain injuries have also suggested that er- ing because, despite his expressed enthusiasm,
rorless learning may operate by strengthening none of the strategies tried proved acceptable to
residual explicit memory, or may facilitate both him in practice; although he did show changes in
implicit and explicit memory (Squires et al., behaviour, these were not statistically signi-
1997). This is further supported by the findings ficant, and there was no lasting behavioural
of Thoene and Glisky (1995). change. This indicates the importance of taking
The present study serves as a reminder that into account individual factors such as aware-
errorless learning is a guiding principle and not ness of memory difficulties, motivation, beliefs,
a specific technique; as shown in the case of and values, and psychosocial factors such as the
Participant C, different errorless techniques can quality of the marital relationship (Quayhagen &
be applied to equivalent learning tasks with Quayhagen, 1989).
varying degrees of success. In this case it is evi- There are a number of constraints which
dent that factors other than the absence of errors place limitations on the extent to which general
must also have been operating to influence conclusions can be drawn from the results of the
learning. It seems, therefore, that the errorless present study. It is not possible to draw conclu-
learning principle may be applied in different sions about the relative efficacy of errorless
ways to facilitate learning, and that the extent to learning compared to trial-and-error methods,
which the techniques facilitate implicit or ex- because no such comparison was made. This
plicit learning would depend on the way in was, however, not the intention. The aim was to
which the task is constructed. Prior learning may explore the applicability of errorless learning
also be relevant here. In the case of Participants methods to everyday memory problems, and to
 144 LINDA CLARE ET AL.

see if this principle might provide a useful addi- Baddeley, A. D., & Wilson, B. A. (1994). When im-
tion to the range of methods already known to be plicit learning fails: Amnesia and the problem of
error elimination. Neuropsychologia, 32, 53-68.
facilitative with this group. The use of a multi-
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