Learning, Memory, and Dementia

We often hear that those with dementia cannot learn new tasks. This is not true. Individuals with dementia can maintain skills and learn new patterns of responses (Johnson, 2017).

Most of this learning is done through repetition and what is called shaping, or successive approximations. Successive approximation requires breaking down a task into smaller, distinct steps. Each step is practiced repetitively before the patient is asked to perform the step in sequence. In backward chaining, the step learned first is the last step in a sequence. Think of learning to wash the dishes. The first step learned is putting the dishes in their correct place. The next step learned might be drying the dishes. The third would be rinsing them, etc. The steps are chained backward until all steps of the task are complete. Errors are corrected immediately, and guessing is avoided. Gradually, prompts are faded in either case.

There were times when dad would sit on the armchair of his recliner rather than in the seat of the chair because he did not move forward to the point where he could safely sit. This was getting downright dangerous as he would teeter on the edge, and we could not be sure we could catch him if he got off balance or fell to the outside of armrest. We needed dad to move closer to his chair before he sat down. We tried numerous strategies. We increased the amount of light. We tried prodding, prompting, encouraging, going past the seat, backing up till his legs touched the chair, turning to the left or right, etc. To make a long story short, our best efforts were not working.

It turns out that was the problem. We were trying too many different approaches and enabling dad to be repeatedly unsuccessful in his attempts to sit in the chair. We were talking and gesturing while he was trying to concentrate on moving closer. We were holding his arms on different sides to try to help. Each time, we were changing our technique and instructions. He was getting way too much input!!

To facilitate learning in dementia, we need to make the task as simple as possible. The task then needs to be broken down into smaller parts and sequenced into the entire motion we want performed. Dementia clients learn by practicing; they learn by doing. Tasks can become habitual if attempted in the same order each time, with the same cues as guidelines. It turns out we were also increasing the complexity of the task by telling him to “move up” or “turn around” when gestures would have been more effective. We needed to reduce the complexity of the stimuli around him—all our requests, and other noises and assorted sensory input made the task too complicated for him to respond to consistently. Multitasking does not work in dementia.

Dementia patients may not remember instructions to tasks. This can interfere with performance. If instructions are simple and direct “Step closer” rather than indirect “You need to get closer to your chair”, performance can be enhanced significantly. To facilitate understanding, we should also use a slower than normal speaking tone and a simplified vocabulary. Revise what is not understood.

Those with dementia do not self-correct, so a wrong response enhances the incorrect memory trace, or engram. Reduce the chances of giving a wrong response. In dad’s case, we visually marked the carpet with two adhesive felt footsteps in the place he needed to be prior to turning and sitting. We could also prompt this location by tapping our foot on it so he could attend to it. In addition, we must allow time—as much time as required—for a response.

When my mother-in -law was in a nursing home, there was a male patient across the hall that would call out loudly every 5 to 8 minutes, “What’d I do?”. The nursing staff had become oblivious to his repeated questioning. But to the other residents (and most visitors), this was disruptive. This man’s repetitive memory trace needed to be interrupted. After waiting 4 minutes prior to his question, he was told, “You ate breakfast” or “You had a shower”. This broke the repetitious nature of his question and reduced its frequency after consistent application. In fact, it even appeared to lessen his anxiety. We must remember that behavior has a purpose; in this case, it could have been a way to reduce confusion or anxiety, or even get attention.

Objects with emotional significance are more easily remembered, and symbols make better signs than words. An IWD will recognize a red stop sign more often than a sign declaring ‘Do not enter’.

Reduce the use of prepositions and pronouns. “He walked into the store with it” illustrates how ambiguous speech is confusing and too open-ended to make sense.

For nonsensical language, listen for embedded words or phrases that give a clue as to what is being said or referred to. Read the emotion underlying the words. Is it fear, anxiety, joy, etc.? This will give a clue to understanding what the person needs and is trying to convey.

Source:

Johnson PR (2017, March). Dementia: Cognitive Rehabilitation Strategies for Effective Evaluation & Treatment, PESI Seminar, Dallas, Texas.