Improved Errorless Learning Strategies in Korsakoff patients A PILOT STUDY
Simone Swedo
MSc Thesis January 2009 Student : Simone Swedo (s0119008) Internal Supervisor : Dr. D.M.J. van den Heuvel External supervisors : Dr. A. Goossensen Miss. M. ten Wolde Second reader : Dr. E. Wekking Department of Clinical Neuropsychology- Leiden University
Abstract In the present study the effectiveness of two improved errorless learning strategies were examined within 18 Korsakoff patients. Errorless learning was improved by adding learning through observation and learning through visually presented external aids. Although no clear evidence was found, errorless learning through observation seemed to lead to better performance than errorless learning through visually presented external aids. Furthermore the learning capacity of patients who suffer from mild to moderate memory impairments was compared with the learning capacity of patients who suffer from severe memory impairments. Although no significant relationship was found, participants with severe memory impairment unexpectedly showed an advantage of successful learning compared to participants with better memory function.
Writters information: Simone Swedo Cornelis speelmanstraat 49 2595 XJ Den Haag +316-24 633 758 s.wedo@saffier-haaglanden.nl 2
Index Introduction
Page 4
Korsakoff syndrome
Page 4
Co morbidity
Page 5
Rehabilitation
Page 6
Improving the Errorless Learning technique
Page 7
Limitation of the Errorless Learning technique
Page 7
Additional addictive behavior in Korsakoff patients
Page 7
The Super Smoker
Page 8
The present study
Page 9
Method
Page 11 Design and participants
Page 11
Materials
Page 14
Procedure
Page 15
Statistical Analyses
Page 17
Results
Page 18
Discussion
Page 22
Conclusion
Page 24
References
Page 26
Appendix A
Page 29
Appendix B
Page 42
Appendix C
Page 50
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Introduction
Korsakoff syndrome The Korsakoff syndrome is characterized as a rest condition after cerebral damage (Arts, 2004), resulting from nutritional thiamine deficiency in association with alcoholism (Kopelman 1995), anorexia (Becker, Furman, Panisset, & Smith, 1990 as cited in Brand et al. 2003) or gastrectomy (Shimomura, Mori, Hirono, Imamura, & Yamashita, 1998 as cited in Brand et al. 2003). The majority of reported cases of the Korsakoff syndrome are associated with alcohol (Goossensen, Arts, & Beltman, 2007). Goossensen et al. (2007) estimated that among the chronic alcoholics of the Dutch population, 3% eventually develops the Korsakoff syndrome. Although there is no clear evidence, caretakers in psycho geriatric nursing homes have reported that the admittance of patients with this syndrome has increased. The pathological features of the Korsakoff syndrome include atrophy in the (pre) frontal lobes (Emsley et al., 1996; Moselhy, Georgiou, & Kahn, 2001; Reed et al., 2003) as well as lesions in the mammillary bodies, the dorsomedial thalamic nucleus (Kopelman, 1995), and the anterior thalamic nucleus ( e.g. Harding, Halliday, Caine, & Kril, 2000). d’Yewalle and Van Damme (2007) stated that the Korsakoff syndrome is characterized by severe retro- and anterograde amnesia in addition with impairment in the central executive functions. The impairments in central executive functioning shown by patients result from frontal lesions and are related to problems concerning attention span, problem solving, planning, lack of insight, inhibition and goal directed behaviour or organizing (Brand et al., 2003). The marked amnesia observed in Korsakoff patients has been associated with impairments in remote memory, a disability in recall of past public and autobiographical events (Kopelman, 1995). In addition to remote memory deficits, impairments in long term retention and
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conscious recollection occur in Korsakoff patients. According to McDowall (1981) and Carlesimo (1994) these impairments seem to result from a retrieval deficit, rather than from an encoding deficit. However, Berman and Pulaski (1997) have provided evidence suggesting that Korsakoff patients experience problems with associative learning. Conversely, it is still under discussion whether implicit learning or implicit memory are impaired within Korsakoff patients since the knowledge amassed from these processes (d’Yewalle & Van Damme, 2007) is difficult to express (Graf & Schacter, 1985).
Co- morbidity Apart from the aforementioned cognitive deficits in Korsakoff patients, Arts (2004) stated that there is a high incidence of Korsakoff syndrome in co- morbidity with severe psychological disorders. The psychological disorders serve as a cause as well as a consequence of alcohol related problems. Personality and mood disorders, such as depression and anxiety disorder commonly occur in Korsakoff patients. Additionally, Brand et al (2003) observed confabulations and affective disturbances. The affective disturbances are expressed by apathetic behaviour, dullness, detached behaviour (Labudda, Todorovski, Markowitsch, &Brand, 2008), emotional flatness or emotional hyperarousability, motivational deficits, and reduced spontaneously affective behaviour, (e.g. Rapaport, 1961, as cited in Brand et al, 2003). Behavioural disorders such as aggressiveness, paranoid, dependent, manipulative behaviour, rigid behaviour and resistance to change are also common in Korsakoff patients (Noppen van, Nieboer, Ficken, Weide van der, & Etten van, 2008). Furthermore, these patients show difficulties in expressing their needs. The above-mentioned behavioural problems cause difficulties in adapting to situational and structural changes.
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Rehabilitation Since restoration of function cannot be achieved for most cognitive deficits (Wilson, 2000) and medication has not been proven to have a significant effect (Arts, 2004), treatment of the Korsakoff syndrome is focussed on rehabilitation. Cognitive rehabilitation programs usually focus on reinforcement of intact functions by training compensatory strategies. As mentioned above, Korsakoff patients show irreversible cognitive deficits as a result of cerebral damage. Therefore, within cognitive rehabilitation programmes for these patients, the focus is on compensating memory impairments by using a combination of different strategies (Arts, 2004). The combination usually involves environmental adjustments, learning to use external aids and/or optimizing preserved memory capacity. Furthermore, these cognitive rehabilitation programmes should be based on avoidance of errors during the learning phase, since the preserved implicit memory cannot discern correct from unintentionally wrong responses (Vreese de, Neri, Fioravanti, Belloi, & Zanetti, 2001). Errorless Learning (EL) is an empirically evaluated technique which has been used in cognitive rehabilitation in an effort to capitalize on preserved memory abilities. Several studies have shown that this technique is a successful method in rehabilitating people with explicit memory deficits, because it capitalizes on intact implicit skills. EL facilitates encoding new information under conditions in which errors are prevented to ensure the reinforcement of correct responses (Schmitter-Edgecombe, 2006). Learning is achieved through intensive repetitive training and structure. Several studies have found existing evidence to suggest that it is possible to improve this technique by adding other successful learning strategies (e. g. Evans et al., 2000 as cited in Tailby & Haslam, 2003). In the following section two improved EL strategies will be discussed.
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Improving the Errorless Learning technique EL might be facilitated by adding another successful strategy also known as observational learning. The observational learning strategy, whereby learning is achieved through imitation, has been proven to be a successful method when learning motor skills (Bandura, 1986 as cited in Badets & Blandin, 2004). In view of these conclusions, combining the learning strategies might lead to improvement of the learning ability of Korsakoff patients. Buddy (2006) reported on another successful strategy which can be added to improve EL. In his study it was concluded that patients with Korsakoff Syndrome are capable of learning visually presented information even though they can’t recall learning it. Considering these conclusions, Korsakoff patients might be able to compensate for learning and memory deficits by using EL in combination with visually presented information.
Limitation of the Errorless Learning technique Regardless of the reported successes, EL is not without limitations. Vreese de et al. (2001) reported on evidence suggesting that the severity of memory impairment interferes with the intensity of learning. There is consistent evidence suggesting that the outcome of successful learning is associated with the degree of memory impairment. Patients who suffer from mild to moderate explicit memory impairment might be able to acquire new skills through EL. However, severely memory impaired patients may face problems when learning skills involving multiple steps, even when learning through EL (Tailby & Haslam, 2003).
Additional addictive behavior in Korsakoff patients The co-occurrence of smoking and alcohol has been well-documented (e.g. Istvan & Matarazzo, 1984). Several studies concluded that many (former) alcohol consumers also smoke cigarettes. Cross-substance Cue Reactivity Theory proposes that alcohol and tobacco
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are often consumed together which create cues that result in a conditioned situation (Istvan & Matarazzo, 1984). The Cross-substance Coping Response Hypothesis described by Monti, Rohsenow, Colby, and Abrams (1995), also postulates that smoking may be used to cope with cravings for alcohol, or drinking may be used to cope with craving for cigarettes. According to these theories drinking may elicit urges to smoke and smoking may come to elicit urges to drink. Through informal research in nursing homes it has been revealed that this may have also been the case with Korsakoff patients. Since a vast majority of these patients are former alcohol consumers, the smoking behaviour of these patients is a frequently mentioned problem, which concerns matter of public health. Research has shown that smoking poses a health risks to the environment in addition to people who smoke themselves. Tobacco smoke and tar contain compounds which constitute the equivalent of a complete carcinogen. These substances contribute to smoking as a risk factor for several types of cancers and cancer mortality (Irigaray et al., 2007). Furthermore, longitudinal studies showed that the dead ratio among smokers is higher than among alcoholics (Litt et al., 2007). Aside from the health concerns of Korsakoff patients who smoke, there are smokingrelated matters that need to be considered. Namely, in the nursing homes where the majority of these patients reside, smoking occurs under close supervision of caretakers because of the high fire risk and inhibition problems caused by frontal lobes deficits. As a result of the inhibition problems, the majority of these patients are unable to stop smoking once initiated. With reference to the high amount of smokers, supervision is a time-consuming process which results in high costs for nursing homes.
The Super Smoker Many companies have produced several alternative products to discourage or reduce smoking. A new product which has been introduced to promote healthier smoking nowadays
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is the Super Smoker. This product is an alternative cigarette claimed to contain very low nicotine level and no harmful effects for the environment. The Super Smoker is an electronic cigarette which produces no tar, real smoke or carcinogenic substances. According to the producers of this cigarette, using it promotes healthier smoking which can result in a longer and healthier life for smokers as for the environment. It also reduces the fire risk and patients might even be able to smoke without supervision. The Super Smoker might be a cheaper alternative for the classical cigarette because long term usage can be financially beneficial for the patients.
The present study As mentioned above, informal research has revealed that smoking is a common occurring behaviour in Korsakoff patients. Besides the public health concerns of this addictive behaviour, there is also the matter of high fire risk. Replacing the classical cigarette with the Super Smoker might be a healthier, safer and more economic alternative to smoking. Therefore, implementation of this new product would be a significant benefit for the nursing homes. However, as stated earlier, Korsakoff patients face problems in learning new behaviour (such as using the Super Smoker). The present study investigates whether participants are capable of learning new information by using intact aspect of implicit memory, when replacing the classical cigarette with the Super Smoker. The purpose of this study is threefold: 1) We will examine if Korsakoff patients are able to compensate for learning and memory deficits by using the two improved EL strategies when learning new behaviour (e.g. using Super Smoker). 2) We will examine if there is a difference in effectivity between the two improved EL strategies in learning new behaviour (e.g. using Super Smoker) in Korsakoff patients.
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3) We will compare the learning capacity of Korsakoff patients who suffer from mild to moderate memory impairments with the learning capacity of Korsakoff patients who suffer from severe memory impairments, by using the two improved EL strategies. For the purpose of this study the strategies are labelled as follow: A. The EL technique improved by adding observational learning (EL (o)). This strategy will be introduced by applying the EL technique by guidance of motoric actions. B. The EL technique improved by adding visually presented external aids (EL (v)). This strategy will be implemented by guidance of a visually presented external aid (such as an instruction booklet). Visually presented external aids as well observational learning techniques have been proven to be successful strategies in the process of learning new information. Hence, we state that patients will be able to successfully learn how to use the Super Smoker if it is implemented by both (EL (o)) and (EL (v)). However, there may be differences between the two strategies. Since they are both introduced in this study there is no clear evidence on which strategy might be more successful. Therefore, we hypothesize that there might be a difference between the two strategies.
Hypothesis1: There will be a difference in effectively learning new behaviour between participants in the (EL (o)) condition and participants in the (EL (v)) condition.
As mentioned above, another purpose of this study is to compare the outcome of both EL strategies (EL (o) and EL (v)) with the severity of memory impairment. Since all participants in this study are institutionalized and diagnosed as Korsakoff patients, they are less likely to suffer from mild memory impairments. Therefore, participants will be divided in two subgroups depending on the severity of memory impairment (mild to moderate and
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severe). Severity will be classified on the basis of performance on a standardised memory test. As previously mentioned, past research shows that severely memory impaired may benefit less from memory intervention strategies. Therefore, we hypothesize that there will be a difference in outcome between the two severity groups (mild to moderate, and severe) in both EL conditions (EL (o) and El (v)); the advantage of EL will decrease as the severity of impairment increases.
Hypothesis2: Participants who suffer from mild to moderate memory impairments will show more improvement than participants who suffer from sever memory impairments when learning to use the Super Smoker.
Method
Design and participants Initially a total of nineteen smoking patients with Korsakoff syndrome were recruited from two different nursing homes for the elderly to take part in this study. One patient was excluded because she did not met the inclusion criteria. In total eighteen patients took part in this pilot. Inclusion criteria were: (1) the participant is a permanent resident of the institutions; (2) the participant is screened by a neuropsychologist and a nursing home medical practitioner and diagnosed as a Korsakoff patient; (3) the participant is a regular smoker; (4) the participant is physically able to handle the Super Smoker. All participants had to give a written informed consent prior to the investigation which they had to fill out with help of caretakers. They did not receive financial allowance for participation but they were able to smoke at no cost during the course of the pilot. Since the aim of this study was to compare
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two variants of EL within a population of memory impaired people, no control subjects were used within this study.
The course of the pilot is being described in the following scheme: home
n
strategy
start date
duration
end date
observation week 1-5
Dijkhuis
9
EL(o)
27 May
6 weeks
7 July
4x a week
Lozerhof
9
EL(v)
18 June
6 weeks
31 July
4x a week
observation week 6 Every smoking break Every smoking break
Table 1: design pilot Super Smoker
The Dutch version of the National Adult Reading Task (Nederlandse Leestest voor Volwassenen (NLV)) was used to assess premorbid intelligence level. This task consists of 50 uncommon Dutch words which have to be pronounced aloud. Performance on this task estimates the participant’s vocabulary and premorbid verbal intellectual level. Unfortunately it was not possible to use the same neuropsychological tests to assess severity of memory impairment, because the nursing homes use different test to assess memory impairment. In the Dijkhuis the Woord Beeld Taak (WBT) on the Maastrichtse Neuropsychologische Sreeningset voor de Psychogeriatrie (MNSP) was chosen to classify participants into severity of memory impairment. In the Lozerhof the Visueel geheugen taak (VG) on the Amsterdamse Screeningstest voor Dementie (ADS-6) was chosen to classify participants into severity of memory impairment. •
The Woord Beeld Taak (WBT) on the Maastrichtse Neuropsychologische Sreeningset voor de Psychogeriatrie (MNSP) was selected as a relevant instrument for assigning participants to subgroups as the experimental tasks in this pilot were visual 12
and verbal in nature. Within this task a number of pictures are presented to the participant in three trials. After each trial participants have to recall as many pictures as possible. After 20 minutes a delayed free recall condition and a recognition condition follows. A total reproduction score falling between 0 and 17 was classified as severe (this score range is achieved by less than 5% of the general population). Mild to moderate impairment was defined as obtaining a score between 18 and 29 (indicative of performance between the fifth and hundredth percentiles). The nine participants in the EL (o) condition (three men and six women) were divided into two subgroups (mild to moderate memory impairment, and severe memory impairment), on the basis of their performance on the WBT. The summary of demographic information and screening statistics for participants in this condition appears in Table 2.
Memory impairment
Age
Male/Female
M (SD)
WBT M (SD)
Estimate Premorbid IQ 1 M (SD)
Mild to moderate (N=3)
52.33 (15.28) (range 39-69)
1/2
20 ( 3 ) (range 18-24)
79.67 (7.64) (range 73-88)
Severe (N=6)
55.00 (10.02) (range 40-68)
2/4
11.50 (1.64) (range 10-14)
88.33(6.47) (range 80-96)
Table 2: Demographic information and results of screening tests as a function of severity of memory impairment for participants in the EL (o) condition
•
The Visueel geheugen taak (VG) on the Amsterdamse Screeningstest voor Dementie (ADS-6) was selected as a relevant instrument for assigning participants to subgroups as the experimental tasks in this pilot were visual in nature. Within this task a number
1
Premorbid IQ estimated using the Nederlandse Leestest voor Volwassenen (NLV)
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of pictures are presented to the participant. Immediately after having presented the picture, the participant is asked to the point out the picture between other irrelevant pictures. In the second trial the participant is asked to point out the picture between other irrelevant pictures. After 20 minutes a delayed recognition condition follows. A weighted score lower than 0 (≼ 2 error responses) was classified as severe. Mild to moderate impairment was defined as obtaining a weighted score 1 or 0 (≤ 1 error responses) The nine participants in the EL (v) condition (two men and seven women) were also divided into two subgroups (mild to moderate memory impairment, and severe memory impairment), on the basis of their performance on the VG. A summary of demographic information and screening statistics for participants in this condition appears in Table 3
Memory impairment
Age
Male/Female
M (SD)
VG M (SD)
Estimate Premorbid IQ M (SD)
Mild to moderate (N=6)
60.83(8.80) (range 54-77)
1/5
1 (0)
93.67 (13.95) (range 74-111)
Severe (N=3)
57.33 (9.45) (range 50-68)
1/2
-2 (0)
94.67 (20.84) (range 72-113)
Table 3: Demographic information and results of screening tests as a function of severity of memory impairment for participants in the EL (v) condition
Materials The materials comprised twenty sets of Super Smokers, ten instruction booklets for the participants, four instruction booklets for the caretakers, observation lists, and twenty questionnaires.
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One set Super Smoker consists of additional components needed for durable use of the product. The set contains: an atomizer, a lithium battery, a storage dummy tip, an adapter, a cable, and a manual. The manual, which contains stepwise information to employ the Super Smoker, was converted into synoptic booklets in order to elucidate the instructions for the participants. Since there were two different implementation strategies, the booklet in the EL (o) condition was intended for the caretakers and the booklet in the EL (v) condition was intended for the participant. (See Appendix A and Appendix B for the instruction booklets). A self composed observation list was used to determine to what extent participants were able to use the Super Smoker during the experiment. (See Appendix C for the observation list).
Procedure Before the pilot started the caretakers who guided the experiment were professionally instructed by a Super Smoker sales representative about the utilization of this product. Caretakers played an important role in this experiment since they had to instruct and guide participants about the utilization of this product. As previously mentioned the pilot consisted of two learning conditions (i.e. EL (o) and EL (v). Both conditions consisted of four learning phases and one test phase. Since, Korsakoff patients are not capable of self corrective behaviour and inhibiting incorrect responses due to explicit memory deficit, guessing was discouraged during the learning phases in both conditions. In order to diminish incorrect responses and prevent incorrect learning, participants were given the correct information the instant errors or uncertainties were observed.
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The course of the phases is being described in the following table: Phase 1
Phase 2
Phase 3
Phase 4
Test Phase
Week 1
Week 2
Week 3
Week 4+5
Week 6
become accustomed the taste
change the filter
change the filter change the filter change the battery change the battery change the cartridge
observation during every smoking break
Table 4: course of the learning phases in the two learning conditions (i.e. EL (o) and EL (v)).
In the (EL (o)) condition (Dijkhuis), nine participants were placed isolated from classical smokers, in a room where the classical cigarette is usually being smoked. Because the residents of the Dijkhuis smoke collectively in large groups, the size of the group might appear as a distraction for both the Super Smokers as for the classical smokers. Therefore, the participants were placed separately from the classical cigarette smokers before regular smoking breaks. In this condition, the caretakers asked the participants to imitate their actions while demonstrating the tasks set for that learning phases. In the (EL (v)) condition (Lozerhof), nine participants were placed in the common smoking area amongst classical cigarette smokers. The participants in this learning condition (EL (v)) were placed amongst the classical cigarette smokers because the residents of the Lozerhof smoke in small divided groups. In this condition, the participants were handed a booklet of instructions together with the Super Smoker. The booklet contained a written instruction program guided by photographs of the implementation. Caretakers asked the participants to read and carry out the instructions set for that learning phase. The intention of the first learning phase was to let participants smoke the electronic cigarette instead of their regular cigarette in order to get used to the taste. However, during the first day of the experiment all participants refused to continue with the experiment because
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they did not want to replace their regular cigarette. In order to prevent endangerment of the experiment, all participants received their regular cigarette after the Super Smoker. During phase two to four tasks were added. In phase two participants learned to change the filter. In phase three participants learned to change the battery. In phase four participants learned to change the cartridge (see table 4). Following completion of the four learning phases in both conditions, “Use of the Super Smoker” (dependent measure) was assessed through observation during every smoking break in the test phase. Use of the Super Smoker was rated by using three categories. Participants were assigned to a category depending on the smoking behaviour they display. The participants who were incapable of using the new product or quitted before the end of the test phase were assigned to the “red” category. The participants who were able to use the product with minimal assistance from caretakers were assigned to the “orange” category. In this study minimal assistance is phrased as reminding participants once to read instruction or assisting once in changing parts of the product. The participants who were able to use the products without assistance of caretakers were assigned to the “green” category (dependent variable).
Statistical analysis Statistical analysis was done using SPSS 16.0 for Windows package for computerized statistical analysis. Because the data were not normally distributed nonparametric methods were used for analyses. The significance level was set at p<0.05 (two tailed, when applicable). To determine whether there are differences in outcome between participants in the EL (o) learning condition and participants in the EL (v) learning condition, the final test phase observations between both conditions were compared.
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To determine whether there are differences in outcome between the two severity subgroups (i.e. mild to moderate and severe) in both EL conditions (EL (o) and El (v)), the outcome between the groups were compared. The initial intention was to conduct several Pearson’s chi-square Tests to compare the performance under both conditions (i.e. EL (o) and EL (v)), and the outcome between both severity subgroups (i.e. mild to moderate and severe). All analyses showed that more than 2 cells had expected count less than 5, so an exact significance test was selected for Pearson’s chi-square. The Fisher’s exact test was used to overcome the problem due to small cell frequencies because it requires a non-zero frequency in each cell. Hence, the category “orange” and “red” were combined as one variable because both indicated an unsuccessful outcome.
Results Due to the small group size and due to the fact that participants reside in different nursing homes, it was not possible to match them in terms of age, gender, and premorbid intellectual functioning. Differences in outcome between participants in the two conditions (EL (o) and EL (v)) were determined by conducting a Fischer exact test. Since no predictions have been made on which strategy might be more successful, the two tailed p value was used to determine the significance level. The two tailed p value generated by Fisher’s exact test for the above contingency variable was 0.131. As the p value is greater than 0.05, the null hypothesis was accepted, which means that the fisher’s exact test did not reveal a significant difference in outcome between the two conditions (EL (o) an (EL (v)).
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Although statistically no significant effect was found, 56 per cent of the participants in the EL (o) condition were able to successfully learn to use to Super Smoker (category green) in contrast to the 11 per cent in the EL (v) condition. In other words, the percentage (89) of participants who were not able to successfully learn was higher in the EL (v) condition (see table 5).
outcome
Green Red&Orange
Visual errorless learning N % 1 11
Observational errorless learning N % 5 56
8
89
4
44
9
100
9
100
Table 5: overview of the differences in outcome between EL (o) and EL (v), P=0.131 (Fisher’s Exact test, two tailed)
Differences in outcome between the two severity subgroups (i.e. mild to moderate and severe) in both EL conditions (EL (o) and El (v)) were determined by conducting a Fischer exact test. Since we predicted a difference in outcome between the two severity groups (mild to moderate, and severe) in both EL conditions (EL (o) and El (v)), the one tailed p value was used to determine the significance level. The one tailed p value generated by Fisher’s exact test for the contingency variable (orange&red) was 0.31. As the p value is greater than 0.05, the null hypothesis was accepted, which means that the fisher’s exact test did not reveal a significant difference in outcome between the two severity groups (mild/moderate, and severe). Although statistically no significant effect was found, the participants with mild to moderate impairment (22%) were less successful in learning to use the Super Smoker than participants with severe impairment (44%) (See table 6).
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outcome Green Red&Orange Total
Mild/moderate N % 2 22
Severe N % 4 44
7
78
5
56
9
100
9
100
Table 6: overview of the differences in outcome between the two severity groups, P=0.31 (Fisher’s Exact test)
Particular mention should be made of the overall performance over the two conditions. The number of times caretakers had to intervene at the end of learning phases two, three and four were used as an informal evaluation to monitor the stage of improvement. The evaluation showed that most interference was made during phase two and three of the experiment. During phase four of the experiment, the participants who were able to successfully learn how to use the Super Smoker, needed less interference than the participants who failed to use the product (see table 7 and 8). Additionally, all participants who were able to successfully learn to use the Super Smoker (green category) started the experiment in the “orange” category. Most participants who started in the “red” category either relinquished before end or were not able to successfully learn to use the Super Smoker within six weeks (see table 7 and 8).
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EL (o)
P1 P2 P3 P4 P5 P6 P7 P8 P9
Phase 2 Interfer. (category) 1 1 1 1 1 2 2 2 2
(Orange) (Orange) (Orange) (Orange) (Orange) (Red) (Red) (Red) (Red)
Phase 3 Interfer. (category) 1 1 1 1 2 2 2 2 3
(Orange) (Orange) (Orange) (Orange) (Red) (Red) (Red) (Red) (Red)
Phase 4 Interfer. (category) 0 0 0 0 1 1 2 2 3
Test phase Outcome
(Orange) (Green) (Green) (Green) (Orange) (Orange) (Red) (Red) (Red)
Green Green Green Green Green Orange Red Red Red
Table 8: overview of numbers of interventions and the outcome in the EL (o) condition.
EL (v)
P1 P2 P3 P4 P5 P6 P7 P8 P9
Phase 2 Interfer. (category) 1 1 1 1 3 1 1 3 2
(Orange) (Orange) (Orange) (Orange) (Red) (Orange) (Orange) (Red) (Red)
Phase 3 Interfer. (category) 1 1 1 1 2 3 3 1 3
(Orange) (Orange) (Orange) (Orange) (Red) (Red) (Red) (Orange) (Red)
Phase 4 Interfer. (category) 0 1 1 1 1 3 2 1 2
Test phase Outcome
(Green) (Orange) (Orange) (Orange) (Orange) (Red) (Red) (Orange) (Red)
Green Orange Orange Orange Orange Red Red Red Red
Table 7: overview of numbers of interventions and the outcome in the EL (v) condition.
In order to analyze the possible specific contribution of age, est. premorbid IQ, and gender on outcome in the test phase, several Fischer exact tests were conducted. In advance to conducting the Fischer test, both continues variables age and est. premorbid IQ were classified. The participants were classified into two age groups (<55 and â&#x2030;Ľ55) and two IQ level groups (low IQ: <90; average IQ: â&#x2030;Ľ90).
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The analysis showed no significant relationship between outcome and these variables (significance level, pâ&#x2030;¤ .05). estimated permorbid IQ level, age and gender seem to have no influence on the learning ability of the participants.
Discussion In the present paper we studied whether Korsakoff patients were capable of learning new information by using intact aspects of implicit memory with use of the Errorless Learning technique. The technique was improved by adding two other successful learning techniques. The improved techniques were introduced as Errorless learning through observation and Errorless learning through visually presented external aids. The present results do not show clear evidence for beneficial effects for either errorless learning through observation or through visually presented information. Although we cannot draw firm conclusions on the effect of errorless learning and the manner in which the to be learned information is presented, we found a trend towards a benefit for learning through observation. Observation during the learning phases pointed out that the interactive manner in which the instructions were given and imitation of actions may lead to more successful learning. For that reason we do expect that a larger sample and extended period of time might favor the observational learning method. The second matter involved using the two improved EL techniques to determine whether the severity of memory impairment influences the learning outcome. Previous studies have proven that people who suffer from mild to moderate memory impairment may be able to benefit with more success from errorless learning than people with severe memory impairment. The present study unexpectedly failed to find a significant relationship between learning outcome and severity of memory impairment, we found large individual differences.
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Participants with severe memory impairment on the two memory tasks (VG and WBT) showed an advantage of successful learning compared with participants with better memory function. A possible explanation for this finding could be that participants were classified using different scales. Another explanation could be that, aside from the memory impairments, Korsakoff patients also suffer from affective disturbances such as motivational deficits. Observation during the course of the experiment and the overall irregular learning pattern revealed that most participants were not always equally motivated to learn to use the Super Smoker. In view of the fact that successful EL learning is not only influenced by severity of impairment but also relies on fundamental individual aspects such as motivation. The motivational deficits may have contributed to the unexpected outcome in successful learning. Aside from evidence of no particular benefits of the two conditions, there were several additional effects that emerged in the course of conducting this experiment. It should be noted that the nature of the information to be learned plays an important role in successful learning. The examination of the participants revealed that they did not seem to be motivated to learn to use the Super Smoker; they did not experience the information as directly relevant. Most of the participants complained about the taste of the Super Smoker. They did not experience the satisfaction of smoking when using the Super Smoker. In addition, the experimenter noted that the motivation of the caretakers who guide the process is related to the motivation of the participant. In other words, if a caretaker is motivated to guide the learning process, in most cases this leads to a more successful outcome of the participants. Despite the fact that these factors were not the primary focus of this study, they provide additional support for the unexpected findings in this experiment.
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There are also some methodological considerations that have to be taken into account in the interpretation of the present findings. It should be noted that the sample size used in his experiment is small, our results require replication in larger samples and more extend period of application. Additionally different neuropsychological tests were used to assess severity of memory impairment. Furthermore, most studies on the effects of errorless learning were conducted with participants who suffer from dementia. The neuropsychological profile of those participants differs from the profile of our participants who are diagnosed with the Korsakoff syndrome, which might lead to different findings. Furthermore, this research has only explored one aspect of behavior while successful learning is influenced by a combination of underlying fundamental aspects. It is possible that the effectiveness of the errorless learning technique relies on other variables such as effort and relevance of the information.
Conclusion The abovementioned considerations notwithstanding, the present study has shown a tendency that an already beneficial memory rehabilitation technique might be improved by adding the observational learning technique. Although the data of the present findings was unclear, it is possible that the neuropsychological profile of Korsakoff patients have a contributed effect on the observed outcome. The findings indicate that the EL technique alone is not sufficient to guarantee successful learning. Additionally the severity of impairment alone is not sufficient to explain performance. Another suggestion is that the effectiveness the errorless learning technique may be determined by a subject variable that is as yet unknown. While the concept itself is common in most psycho geriatric nursing homes, the results of this study might be of use with respect to the clinical applicability of the errorless learning
24
approach. The present findings indicate that the clinical applicability of the errorless learning approach within patients with the Korsakoff syndrome may be limited. The correlation between performance and memory impairment as well as learning through EL remains complex issues in Korsakoff patients. Further research is required to clarify the influence of other variables on EL learning in Korsakoff patients who suffer from motivational problems.
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References Arts, K. (2004). Het syndroom van Korsakov (II): Centraal executieve stoornissen en behandeling. Patient care neuropsychiatrie & gedragsneurologie/overdruk, 10-16. Badets, A., and Blandin, Y. (2003). The role of knowledge of results frequency in learning through observation. Journal of motor behavior, 36, 62-70. Brand, M., Fujiwara, E., Kalbe, E., Steingass H., Kessler J., and Markowitsch, H. (2003) Cognitive estimation and affective judgments in alcoholic Korsakoff patients. Journal of Clinical and Experimental Neuropsychology, 25, 324-334. Buddy, T. (2006). New hope for alcoholics with Korsakoff syndrome. Affected alcoholics can learn to perform new tasks. Retrieved March, 2008, from http://alcoholism.about.com/od/dementia/a/blacer060422.htm Carlesimo, G. (1994). Perceptual and conceptual priming in amnesic and alcoholic patients. Neuropsychologia, 32, 903-921. Cooney, N. L., Cooney, J. L., Litt, M. D., Pilkey, D. T., Steinberg, H. R., & Oncken C. A. (2007). Alcohol and tobacco cessation in alcohol-dependent smokers: Analysis of realtime reports. Psychology of Addictive Behaviours, 21, 277-286. Emsley, R., Smith, R., Roberts, M., Kapnias, S., Pieters, H., & Maritz, S. (1996). Magnetic resonance imaging in alcoholic Korsakoffâ&#x20AC;&#x2122;s syndrome: Evidence for an association with alcoholic dementia. Alcohol and Alcoholism, 31, 479-486. Goossensen, A., Arts, K., & Beltman, M. (2000) Zorgprogramma Korsakoff in het verpleeghuis. Rotterdam: Korsakoff Kenniscentrum. Graf, P., & Schacter, D.L. (1985). Implicit and explicit memory for new associations in normal and amnesic subjects. Journal of Experimental Psychology: Learning, Memory, and Cognition, 11, 501-518.
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Harding, A., Halliday, G., Caine, D., & Kril, J. (2000). Degeneration of anterior thalamic nuclei differentiates alcoholics with amnesia. Brain, 123, 141-154. Irigaray, P., Newby, J. A., Clapp, R., Hardell, L., Howard, V., Montagnier, L., Epstein, S., & Belpomme, D. (2007). Lifestyle-related factors and environmental agents causing cancer: An overview. Biomedicine & pharmacotherapy, 61, 640-658. Istvan, J., & Matarazzo, J. D. (1984). Tobacco, alcohol and caffeine use: A review of their interrelationships. Psychological Bulletin, 95, 301-326. Kopelman, M. (1995). The Korsakoff syndrome. British Journal of Psychiatry, 166, 154-173 Labudda, K., Todorovski, S., Markowitsch H., & Brand, M. (2008). Judgment and memory performance for emotional stimuli in patients with alcoholic Korsakoff syndrome. Journal of clinical and experimental neuropsychology, 30, 224-235. McDowall, J. (1981). Effects of encoding instructions on recall and recognition in Korsakoff patients. Neuropsychologia, 19, 43-48. Monti, P. M., Rohsenow, D. J., Colby, S. M., & Abrams, D. B. (1995). Smoking among alcoholics during and after treatment: Implications for models, treatment strategies, and policy. In J. B. Fertig & J. P. Allen (Eds.), Alcohol and tobacco: From basic science to clinical practice ALCOHOL AND TOBACCO CESSATION 285 (NIAAA Research Monograph 30, pp. 187-206). Washington, DC: U.S. Government Printing Office. Moselhy, H., Georgiou, G., & Kahn, A. (2001). Frontal lobe changes in alcoholism: A review of the literature. Alcohol and Alcoholism, 36, 357-368. Noppen van, M., Nieboer, J., Ficken, M., Weide van der, W. & Etten van, N. (2007). De empathische-directieve benadering: zorg voor cliĂŤnten met het syndroom van Korsakoff. Den Haag: Pasmans Drukkerij bv. Oscar-Berman, M., & Pulaski, J. (1997). Association learning and recognition memory in
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alcoholic Korsakoff patients. Neuropsychology, 11, 282-289. Schmitter-Edgecombe, M. (2006). Implications of basic science research for brain injury rehabilitation a focus on intact learning mechanisms. Journal of head trauma rehabilitation, 21, 131-141. Tailby, R., & Haslam, C. (2003). An investigation of EL in memory-impaired patients: improving the technique and clarifying theory. Neuropsychologia, 41, 12301240. Vreese de, L. P., Neri, M., Fioravanti, M., Belloi, L., & Zanetti, O. (2001). Memory rehabilitation in Alzheimerâ&#x20AC;&#x2122;s disease: a review of progress. International journal of geriatric psychiatry, 16, 794-809. Wilson, B. (2000). Compensating for cognitive deficits following brain injury. Neuropsychology Review, 10, 233-243. dâ&#x20AC;&#x2122;Ydewalle, G., & Van Damme, I. (2007). Memory and the Korsakoff syndrome: Not remembering what is remembered. Neuropsychologia, 45, 905-920.
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Appendix A
Instruction booklet for caretakers in the EL (o) condition
29
Geachte Zorgmedewerkers, Zoals u weet is er gedurende de komende 6 weken een onderzoek gaande over het aanleren van de Super Smoker bij een aantal Korsakoff patiënten. Wij vragen uw medewerking in het uitvoeren en begeleiden van dit experiment. Doel van het experiment: Het zelfstandig leren gebruiken van de Super Smoker is het hoofddoel van dit experiment. Leermethode: Het aanleren van de Super Smoker zal geschieden door gebruik te maken van de principes van “foutloos leren”. Alvast bedankt voor uw medewerking
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Inhoudsopgave Procedure van het experiment
Pagina 4
Algemene informatie en voorzorgsmaatregelen
Pagina 5
Onderdelen van de SuperSmoker
Pagina 6
Instructies voor het in gebruik nemen van het product.
Pagina 7
Instructies voor het opladen van de batterij
Pagina 10
Instructies voor het verwisselen van het mondstukje
Pagina 11
Instructies voor het verwisselen van de cartridge
Pagina 12
(Verwisselen en/of opladen van onderdelen alleen toepassen indien nodig)
Voor vragen kunt u terecht bij â&#x20AC;Śâ&#x20AC;Ś
31
Procedure: ( belangrijk voor begeleiders van het experiment) Dit geschiedt tijdens elke rookmoment gedurende de periode 27mei t/m 1 juli • 10 participanten worden tijdens rookmomenten in een aparte rookruimte geplaatst (belangrijk dat participanten niet afgeleid worden). • Deze rookmomenten worden begeleidt door 3 zorgmedewerkers. • De SuperSmoker wordt overhandigd aan de participanten • Het mapje met instructies voor gebruik wordt eveneens overhandigd (instructies voor begeleiders zie volgende pagina) • De begeleiders nemen de instructies stapsgewijs door met de participanten. • De begeleiders doen de handelingen stapsgewijs voor. • De begeleiders helpen bij het uitvoeren van de instructies • De begeleiders waken voor fouten (belangrijk)
32
Algemene informatie en voorzorgsmaatregelen •
Voorkom verkeerd gebruik en volg de gebruiksaanwijzingen strikt op.
•
Als de led aan de voorzijde knippert, wacht dan 15 seconden met het gebruiken van de “SuperSmoker
•
Elke 8 inhaleringen is gelijk aan 1 sigaret
•
Elke cartridge gaat ongeveer 80 tot 100 inhaleringen mee.
•
Als de rookproductie minder wordt moet u de cartridge vervangen voor een nieuwe.
•
Stop geen losse cartridges in de mond.
•
De oplader is voorzien van een led welke rood zal branden als de batterij geladen wordt en zal groen kleuren indien de batterij vol is.
•
U dient altijd te wachten tot de led groen wordt en niet tijdens het laden de batterij uit de oplader nemen.
•
Wees voorzichtig met het dragen van de SuperSmoker in uw zak.
•
Houd de SuperSmoker gescheiden van andere voorwerpen en voorkom stoten.
•
SuperSmoker bevat onderdelen welke een magnetische lading hebben en houd deze weg bij alle elektronische apparatuur en/of magneten of creditkaarten.
•
Stel de SuperSmoker niet bloot aan hoge temperaturen.
33
De SuperSmoker bestaat uit de volgende onderdelen:
34
Instructies voor gebruik SS
Verwijder de gele plakkertjes
Verwijder dummie om nieuwe cartridge te kunnen plaatsen.
Verwijder het dopje en het rubberen hoesje van cartridge 35
Het rubberen hoesje is verwijderd van de cartridge
Plaats de cartridge strak tot tegen de rand van de verdampingskamer aan
Let op: cartridge strak tegen de rand aandraaien
36
Het luchtgaatje vrij houden tijdens gebruik Filter goed aandrukken op de cartridge
Filter goed tegen cartridge aandrukken
U kunt beginnen met roken!
37
Opladen van de batterij:
Schroef de batterij los van door naar links te draaien
Schroef de batterij in de oplader en laad deze 3-4 uur op
38
Verwisselen van het mondstukje:
Schroef het mondstukje los van de verdampingskamer door naar links te draaien Plaats een nieuw mondstukje op de verdampingskamer door naar rechts te draaien
39
Verwisselen van de cartridge:
Verwijder het dopje en het rubberen hoesje van cartridge
Het rubberen hoesje is verwijderd van de cartridge
Plaats de cartridge strak tot tegen de rand van de verdampingskamer aan
40
Let op: cartridge strak tegen de rand aandraaien
41
Appendix B
The instruction booklet for Participants in the EL(v) condition
De SuperSmoker bestaat uit de volgende onderdelen:
42
Verwijder de gele plakkertjes
Verwijder dummie om nieuwe cartridge te kunnen plaatsen.
Verwijder het dopje en het rubberen hoesje van cartridge
43
Het rubberen hoesje is verwijderd van de cartridge
Plaats de cartridge strak tot tegen de rand van de verdampingskamer aan
Let op: cartridge strak tegen de rand aandraaien
44
Het luchtgaatje vrij houden tijdens gebruik Filter goed aandrukken op de cartridge
Filter goed tegen cartridge aangedrukken
U kunt beginnen met roken!
45
Opladen van de batterij:
Schroef de batterij los van door naar links te draaien
Schroef de batterij in de oplader en laad deze 3-4 uur op
46
Verwisselen van het mondstukje:
Schroef het mondstukje los van de verdampingskamer door naar links te draaien Plaats een nieuw mondstukje op de verdampingskamer door naar rechts te draaien
47
Verwisselen van de cartridge:
Verwijder het dopje en het rubberen hoesje van cartridge
Het rubberen hoesje is verwijderd van de cartridge
Plaats de cartridge strak tot tegen de rand van de verdampingskamer aan
48
Let op: cartridge strak tegen de rand aandraaien
49
Appendix C Observation list
50
Week: Datum:
Tijd:
Zelfstandig Gebruik met gebruik van het minimale hulp product van begeleider (vb.herinneren a.d.h.v. instructies)
Niet in staat product zelf te gebruiken, voortijdig stoppen met het experiment
Opmerkingen
Naam:
Naam:
Naam:
Naam:
Naam:
Naam:
Naam:
Naam:
Naam:
Naam:
Algemene opmerking:
51