Errorless (re)learning of daily living routines by a woman with impaired memory and initiation: Transferrable to a new home?

Abstract

Primary objective: To use errorless learning to train a memory- and initiation-impaired woman on two activities of daily living routines and then to transfer these routines to a new home.

Research design: Single case quasi-experimental.

Methods and procedures: Over 9 months, a young woman with an anterior cerebral haemorrhagic stroke (secondary to a ruptured arteriovenous malformation) was trained on routines of morning self-care and diabetes management, involving extensive practice on a structured series of steps with intervention as needed to prevent errors. Once routines were established, family members were trained in the supervision and rating of the routines at home. Following discharge, caregivers continued to monitor the routines daily for 3 months.

Main outcomes: Errorless learning of self-care and diabetes routines was successful. The routines were transferred to a new home environment and maintained at a near perfect level over a 3-month follow-up period. The patient remained severely memory-impaired, indicating that her functional gains were not attributable to any recovery of her memory abilities over time.

Conclusions: This case offers evidence that even people with severe memory and initiation impairments can be trained on new routines using errorless learning and that, once learned, these routines can be carried out in novel contexts.

• Activities of daily living
• cognitive rehabilitation
• memory

Acknowledgements

The authors would like to thank Santanu Chakraborty MD for his helpful assistance selecting and describing the brain images.

Endnotes

Notes

1. During the pilot training period the major reason for data not being collected on any given day at the residential treatment centre was that the patient attended various morning medical appointments and may not have completed her morning and diabetes routines normally or independently. The modest differences in the percentage of days for which data were collected across the early to late training stages had mainly to do with variations in the frequency and duration of the patient’s leaves of absence with her family. Finally, during the follow-up period, the somewhat lower percentage of data collected is related to the fact the patient was moving into her new home during the first segment of the follow-up period, causing some disruption to the delivery of care by the home-based team. Care was also disrupted for a few days during the winter festive period.

2. Of course, questions arise about the typical period of training required to achieve consistent diabetes self-management in neurologically intact individuals. In this group, barriers to establishing routines are more commonly related to the processes of collaboration among the patient and significant others and with achieving compromise between self-care routine requirements and lifestyle preferences, rather than mainly from challenges learning the physical skills of diabetes management [32,33]. Regarding M.U., the authors are of the view that the extended period of training arose primarily from barriers learning the physical skills of her diabetes routine. Independent ratings by team members revealed only mild resistance to training by M.U. during the first week and none beyond this. In contrast, psychometric testing even post-training indicated continued marked memory impairment.