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The use of errorless learning strategies for patients with

Alzheimers disease: a literature review
Ruijie Li
a
and Karen P.Y. Liu
b
The aim of this article was to review the evidence of
errorless learning on learning outcomes in patients with
early-stage Alzheimers disease. A computer-aided
literature search from 1999 to 2011 was carried out using
MEDLINE, Cumulative Index to Nursing and Allied Health
Literature (CINAHL), PsycINFO and PsycArticles. Keywords
included errorless learning or practice and Alzheimers
disease. Four studies that fulfilled the inclusion criteria
were selected and reviewed. Two of the studies were
clinical controlled trials: one was a single-group
pretestpost-test trial and the other was a multiple
single-participant study. Demographic variables, design,
treatment and outcome measures were summarized.
Recall trials were used as the primary outcome measure.
Results indicate that the use of errorless learning
promotes better retention of specific types of information.
Errorless learning is effective in memory rehabilitation of
older adults with Alzheimers disease. However, it would
require more studies with unified outcome measures to
allow for the formulation of standardized clinical protocol
and recommendations. International Journal of
Rehabilitation Research 00:000000 c 2012 Wolters
Kluwer Health | Lippincott Williams & Wilkins.
International Journal of Rehabilitation Research 2012, 35:292298
Keywords: Alzheimers disease, errorless learning, memory rehabilitation,
older adults
a
Health Services and Outcome Research, National Healthcare Group, Singapore,
Singapore and
b
School of Science and Health, University of Western Sydney,
Penrith, New South Wales, Australia
Correspondence to Karen P.Y. Liu, PhD, School of Science and Health, University
of Western Sydney, Locked Bag 1797, Penrith, NSW 2751, Australia
Tel: +61 2 4620 3432; fax: +61 2 4620 3792; e-mail: karen.liu@uws.edu.au
Received 8 August 2012 Accepted 4 September 2012
Introduction
Alzheimers disease (AD) is a disease that causes
significant functional impairments even in its early stage
(Henderson and Jorm, 2002). A hallmark of AD is the
degenerative changes in the hippocampus (Arnold et al.,
1991; Braak and Braak, 1995; Price and Morris, 1999),
resulting in the gradual loss of ability to form new
episodic memories (Tulving and Markowitsch, 1998).
This gradual loss limits the learning abilities of patients
with AD, causing them to have considerable difficulty in
activities of daily living (Nyga rd, 2004).
Errorless learning refers to a method of learning novel
things in an environment absent of errors (Clare and
Jones, 2008). This method of learning aims to prevent the
interference of the targeted stimulus to be learnt with
mistakes that would otherwise be made. The use of an
errorless environment in learning was first made on
pigeons (Terrace, 1963a, 1963b) and subsequently further
developed and studied for use in the rehabilitation of
individuals with memory impairments (Baddeley and
Wilson, 1994). It has since been studied extensively in its
use as a form of memory rehabilitation for patients with
brain injury (Wilson et al., 1994; Evans et al., 2000; Kalla
et al., 2001; Riley et al., 2004; Dou et al., 2006),
schizophrenia (Ocarroll et al., 1999; Kern et al., 2002,
2005) and other neurological conditions in which learning
is impaired.
It has been suggested that the advantage of errorless
learning lies in its use of the implicit memory (Wilson
et al., 1994), which has been found to be intact in patients
with AD (Golby et al., 2005). Using a classification of long-
term memory into explicit and implicit memory (Tulving
and Markowitsch, 1998; Markowitsch, 2000), it is indeed
plausible that the implicit memory offers an alternative
pathway for encoding information as it does not utilize
the episodic memory, one of the two forms of explicit
memory. The episodic memory has been found to
deteriorate with the degeneration of the hippocampus
in patients with AD (Arnold et al., 1991; Braak and Braak,
1995; Price and Morris, 1999).
A recent paper reviewed the efficacy of errorless learning
across a number of conditions including acquired and
traumatic brain injury, memory impairment, Korsakoff
syndrome, different stages of AD and vascular dementia
(Clare and Jones, 2008). Although the review is extensive
in terms of the scope and the number of papers reviewed,
it does not address specifically the benefit for AD and
related issues such as the proposed underlying mechan-
isms underpinning errorless learning. This paper hence
aims to focus on AD to gain a better understanding of the
efficacy and proposed mechanisms of errorless learning.
AD was chosen as the condition of focus as its aetiology
and course have been well studied and documented and
thus inferences to the proposed mechanisms can be
better grounded.
Materials and methods
A systematic review of the available literature from 1999
to 2011 was carried out. A systematic review is a literature
Review article 1
0342-5282 c 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins DOI: 10.1097/MRR.0b013e32835a2435
Copyright Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
review of available evidence with the aim of answering
the research question set. The main keywords used were
errorless learning or practice and Alzheimers disease.
The Medical Subject Headings (MeSH) term Alzheimer
Disease was also used in conjunction for the search.
The databases used included MEDLINE, Cumulative
Index to Nursing and Allied Health Literature,
PsycINFO and PsycArticles. The inclusion criteria were
as follows: human studies in the English language; studies
involving participants older than 60 years of age with a
diagnosis of probable AD according to the National
Institute of Neurological and Communicative Disorders
and Stroke and the Alzheimers Disease and Related
Disorders Association guidelines in the early stage
(McKhann et al., 1984); randomized-controlled trials
or quasi-experimental studies with a sample size of
more than five patients; use of errorless learning as a
strategy in memory rehabilitation; and use of recall trials
as a primary outcome. Figure 1 shows the process of the
review.
The purpose of including only patients 60 years of
age and older was to exclude patients with early-onset
dementia, which has a markedly different neuro-
psychological profile from the older patients (Henderson
and Jorm, 2002). Studies that included patients with
different forms or stages of dementia were excluded.
Retrieved articles that fulfilled the inclusion criteria were
selected. Out of 115 articles, only four fulfilled the
inclusion criteria. The four articles were rated according
to the Oxford Centre for Evidence Based Medicine levels
of evidence to assess the quality of the studies (Phillips
et al., 2009).
Fig. 1
Topic
Does the use of errorless learning streategies improve memory in patients with Alzheimers disease?
Study selection
Inclusion criteria
- Human studies
- English language
- Journals
- Age>60
- With a diagnosis of definite or probable Alzheimers
disease in the early stage
- Uses errorless learning as an intervention
- Randomized-controlled trials, quasi-experimental
studies
With sample size, n>5
- Primary outcome measure: recall trials
- Published between 11/1999 and 06/2010
Data sources
- MEDLINE (12)
- CINAHL (3)
- PsycINFO (102)
- PsycARTICLES (2)
Total: 115 articles after
eliminating duplicates
Keywords
- Errorless learning/practice
- Alzheimers disease
Excluded (111)
- 111 articles
91 articles not related to study objectives
9 case studies
5 review articles not specific to errorless training for
Alzheimer's disease
5 quasi-experimental studies with n<6
1 clinical controlled trial with mixed population
Included (4)
- 2 clinical controlled trials
- 1 single group pretestpost-test trial
- 1 multiple single-subject studies
Process of the review.
2 International Journal of Rehabilitation Research 2012, Vol 00 No 00
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Results
A summary of the characteristics of the studies is
presented in Table 1.
Population
A total of 59 patients were involved in the four studies, of
whom 23 were healthy controls. The mean age of the
patients ranged from 69.3 to 83.7 years. The mean Mini
Mental Status Examination (MMSE) score ranged from
22.9 to 24. One of the studies (Haslam et al., 2006) did
not report the MMSE profile of the patients.
Design
Out of the four studies, two were clinical controlled trials
(Haslam et al., 2006; Bier et al., 2008), one was a single-
group pretestpost-test trial (Clare et al., 2002) and one
was a multiple single-participant study (Clare et al.,
2000). The two clinical controlled trials were level 2b
evidence and the two remaining studies were level 4
evidence according to the Oxford Centre for Evidence
Based Medicine levels of evidence (Phillips et al., 2009).
No randomized-controlled trials were found from the
search that fulfilled the inclusion criteria.
Treatment
Two of the studies compared the use of errorless learning
with other forms of memory rehabilitation (Haslam et al.,
2006; Bier et al., 2008), whereas the other two studies
focused on the treatment effects of the use of errorless
learning in memory rehabilitation (Clare et al., 2000,
2002).
Treatments that were being compared with errorless
learning included spaced retrieval, vanishing cues and
errorful learning (Haslam et al., 2006; Bier et al., 2008). In
the studies that focused on the treatment effects of
errorless learning (Clare et al., 2000, 2002), some
strategies were developed using the errorless learning
paradigm as background training. These strategies
include vanishing cues, spaced retrieval, forward cueing
and the use of mnemonics. It is noteworthy that
Table 1 Summary of the characteristics of the studies
Study and aims Population Design Treatment Outcome measures
Clare et al. (2000)
To determine treatment
effect of errorless learning
on memory recall and
memory aid training
n =6 (three women)
Mean age: 69.3 (3.9)
Probable AD
Early-stage AD
Mean MMSE: 24 (2.1)
MMSE range: 2126
Multiple single-case
experimental design
Multiple baseline across items
single-case designs
Variants of ABA single-
case designs
Controls: patient themselves
Level of evidence: 4
Errorless learning
Vanishing cues
Expanded rehearsal
Forward cuing
Mnemonic
Four patients underwent
memory recall interventions
(facename associations)
Two patients underwent
memory aid training
Steps taken to ensure
errorless learning taking
place
Recall trials for patients
receiving a memory recall
intervention (proportion of
faces correctly recalled)
Frequency of repetitive
questioning in daily tasks (as
recorded by the carer on a
diary sheet provided)
Clare et al. (2002)
To compare the treatment
effect of errorless learning
on free recall and cued
recall on facename
associations
n =12 (three women)
Mean age: 70.9 (8.3)
Probable AD
Early-stage AD
Mean MMSE: 22.9 (3.2)
MMSE range: 1929
Quasi-experimental pretest
post-test design/multiple
single-case experimental
designs
Controls: patient themselves
(using half of the test items as
controls, i.e. to test recall of
the items without training)
Level of evidence: 4
Errorless learning
Mnemonic
Vanishing cues
Spaced retrieval
(expanding rehearsal)
Facename associations
Steps taken to ensure
errorless learning taking
place
Free recall trials
Cued recall trials
Haslam et al. (2006)
To compare the treatment
effect between errorless
learning and errorful
learning on facename
associations
n =11
Three AD (three women)
Eight healthy (seven women)
Mean age AD: 83.7 (4.6)
Mean age healthy: 77.5 (8.3)
Probable AD
Early-stage AD
Quasi-experimental pretest
post-test
Controls: healthy individuals
Level of evidence: 2b
Errorless learning
Errorful learning
Facename associations
Immediate recall trials
Delayed recall trials
Bier et al. (2008)To
compare the treatment
effect between errorless
learning, spaced retrieval
and vanishing cues with
usual care (trial and error
learning) on immediate vs.
delayed recall
n =30
15 AD (nine women)
Fifteen healthy (nine women)
Mean age AD: 73.3 (7.9)
Mean age healthy: 72.5 (7.9)
Probable AD
Early-stage AD
Mean MMSE: 23.7 (3.2)
MMSE range: 1629
Quasi-experimental pretest
post-test/within-participant
design
Controls: healthy individuals
Level of evidence: 2b
Experimental interventions
Spaced retrieval
E rrorless learning
Vanishing cues
Usual care
Trial-and-error method with
explicit memory task
instructions
Trial-and-error method with
implicit memory task
instructions
Facename associations
Immediate recall trials
Delayed recall trials
Cued recall trials
Free recall trials
ABA, applied behaviour analysis; AD, Alzheimers disease; MMSE, Mini Mental Status Examination.
Errorless learning for Alzheimers disease Li and Liu 3
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vanishing cues and spaced retrieval were used as an
errorless learning technique (Clare et al., 2000) and as a
nonerrorless learning technique (Bier et al., 2008).
Outcome measures
All the studies used recall trials as their primary outcome
measure. The method of recording recall trials varies
across studies and is mainly tailored to suit the needs of
the study. Recall trials were divided into free and cued
recall trials by two studies (Clare et al., 2002; Bier et al.,
2008) and immediate and delayed recall trials by two
studies (Haslam et al., 2006; Bier et al., 2008). One study
did not classify the type of recall trial used (Clare et al.,
2000).
Results of studies
A summary of the results is presented in Table 2. In the
two studies that compared the effects of errorless
learning with other memory rehabilitation interventions
(Haslam et al., 2006; Bier et al., 2008), one found an
advantage of errorless learning over errorful learning only
when the patient was required to recall specific details of
the stimulus presented (Haslam et al., 2006). It suggested
that the efficacy of errorless learning might be sensitive
to the type of data. The other study that found an
advantage in errorless learning compared five different
memory strategies including errorless learning (Bier et al.,
2008). It did not find any significant advantage among
them for immediate recall. This study also found that for
delayed recall, vanishing cues had a significant advantage
in free recall and none of the interventions had any
advantage in cued recall. On examining subgroups within
the study, it was found that the best-performing patients
did not produce fewer mistakes than the rest of the
group, indicating that error production may not have an
effect on learning.
In the two studies that focused on the effects of errorless
learning (Clare et al., 2000, 2002), significant improve-
ments were found in the recall trials hit rate from the
baseline to after the intervention when errorless learning
strategies were used and these improvements were
maintained for at least 6 months.
Clare et al. (2000), also found that although depression
ratings increased after the errorless learning programme,
the improvements in recall trials were maintained. The
study also found that carers reported a lower rating of
memory problems of the patients. In the other study
carried out by Clare et al. (2002), it was found that the
learning outcome was correlated with the MMSE score
(r =0.639, P<0.05) and the Clifton Assessment Proce-
dures for the Elderly (CAPE) behaviour score (r =0.668,
P<0.05). There was also an inverse correlation between
Table 2 Summary of the results of the studies
Study Results Other findings
Clare et al.
(2000)
Improvements from the baseline to after the intervention
Memory recall group improvement in recall between 32.3% (33.4) and
81.0% (29.8) and significant at P<0.05. Improvements were sustained at
the 6-month follow-up.
Memory aid training group decrease in the frequency of repetitive
questioning of 1.31.45 and significant at P<0.05. Improvements were
sustained only for one patient.
Neuropsychological profile change in patients ratings
of depression (z =2.0226, P=0.043, two tailed)
Five out of the six carers assigned a lower rating of
memory problems (of patients) than they had done
previously
Clare et al.
(2002)
Free recall
Trained items significant improvement P<0.05
Seven patients showed sustained improvements 12 months after the
intervention
Two patients required follow-up sessions to maintain improvements
One patient showed a slight improvement after the intervention but was
not maintained at the 1-month follow-up
Control items no significant improvement
Cued recall
Trained items significant improvement, t(10) = 4.665, P<0.001, two
tailed
Control items no significant improvement, t(10) =1.701, P>0.05 two
tailed
Learning outcome correlated with
The MMSE score (r =0.639, P<0.05)
CAPE behaviour score (r = 0.668, P<0.05)
MARS after controlling for MMSE and CAPE
scores (r = 0.764, P<0.01)
MARS after further controlling for MMSE, CAPE
and RBMT profile scores (r = 0.75, P<0.05)
Haslam et al.
(2006)
Errorless learning had an increasing advantage over errorful learning as the recall
task moved from general knowledge towards specific knowledge of the
stimulus presented
Bier et al.
(2008)
Immediate recall
No significant difference between all five methods on free and cued recall
(Friedmans w
2
=5.3; P=0.25).
Delayed recall
Free recall trend towards a significant advantage for vanishing cues
(Friedmans w
2
=9.7, P=0.046) over the other methods.
Cued recall no significant advantage for any of the methods.
Best-performing AD patients did not produce fewer
mistakes than the rest of the group.
AD, Alzheimers disease; CAPE, Clifton Assessment Procedures for the Elderly; MARS, Memory Awareness Rating Scales; MMSE, Mini Mental Status Examination;
RBMT, Rivermead Behavioural Memory Test.
4 International Journal of Rehabilitation Research 2012, Vol 00 No 00
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the learning outcome with the Memory Awareness Rating
Scales score (lower score implies higher awareness) after
controlling for MMSE and CAPE scores (r = 0.764,
P<0.01). The correlation was maintained even after
controlling for MMSE, CAPE and the Rivermead
Behavioural Memory Test scores (r = 0.75, P<0.05).
This indicates that errorless learning is most beneficial
for individuals who have the most awareness of their own
memory deficits irrespective of the severity of their
memory impairments.
Discussion
Except for Bier et al. (2008), the findings of other studies
generally support the use of errorless learning in memory
rehabilitation for patients with early-stage AD.
Errorless learning as an effective strategy
In the three studies that supported the use of errorless
learning (Clare et al., 2000, 2002; Haslam et al., 2006), it
was used in the context of learning facename associa-
tions. The studies supported previous findings in
individuals with other clinical conditions that errorless
learning could improve learning in an experimental
condition (Wilson et al., 1994; Evans et al., 2000) and in
functional activities (Wilson et al., 1994; Hunkin et al.,
1998a) in patients with memory impairments.
It is also noteworthy that in Clare et al.s (2002) study,
a strong correlation was found between recall trials
and Memory Awareness Rating Scales, indicating that
patients with awareness of their own memory deficits
have a better outcome with the use of errorless learning
strategies. This might also imply that improving aware-
ness of memory deficits can potentially improve memory
performance when using the errorless learning strategy. It
occurs with other studies that improving awareness of
ones own problems could enhance the outcome of
rehabilitation (Liu et al., 2002).
Errorless learning as an ineffective strategy
In the study that found no significant advantage between
errorless learning and four other strategies (Bier et al.,
2008), a different method of errorless learning was used.
Patients were shown a picture and told the name of the
individual in the picture and the picture was then
removed from sight. The patient was given 5 s to rehearse
the name of the individual and at the end of the 5 s, the
picture was presented again. This was in contrast with
the method used by Clare et al. (2000, 2002) and Haslam
et al. (2006) in which the errorless procedure used
involved presenting the picture (in the case of facename
association) and allowing the patient to rehearse the
facename association in the presence of the picture.
Therefore, rehearsal of things learnt seems to be required
to enhance performance when using errorless learning.
Without rehearsal, patients with AD might not be able to
benefit from the errorless learning.
Factors contributing towards effective errorless
learning
To further understand the difference between the
strategies used in these two groups of studies, the
information processing model was adopted. The advan-
tage of errorless learning is that it taps on the intact
implicit memory to allow learning of novel tasks. On
examining the application of errorless learning in the
study by Bier et al. (2008), it appears that it taps more
heavily on the explicit memory by emphasizing less on
the amount of repetitions than the studies carried out
by Clare et al. (2000, 2002) and Haslam et al. (2006). The
intervention by Bier et al. (2008) focused more on
effortful recall in the absence of the picture in the case
of the facename association task. This is in contrast to
the higher amounts of repetitions by the three studies
that found an advantage in errorless learning. The higher
amounts of repetitions would utilize the implicit memory
more extensively through repetitive priming, which has
been shown to rely heavily on implicit memory (Rugg
et al., 1998; Golby et al., 2005). The differing loads on the
explicit and implicit memory in the two different ways in
which errorless learning was carried out could be a
plausible explanation for the difference in the results
obtained in the studies.
Role of implicit memory in errorless learning
Although the role of implicit memory has been high-
lighted in errorless learning (Wilson et al., 1994), two
studies not included in the current review refute this
claim (Hunkin et al., 1998b; Kessels et al., 2005). The
studies were not included as they did not study patients
with AD and therefore did not fulfil the inclusion criteria
for the review. The two papers suggest that residual
explicit memory function is what is responsible for
learning that takes place in an errorless environment
(Hunkin et al., 1998b; Kessels et al., 2005). In Hunkin
et al.s (1998b) study, the attribution of the advantage to
errorless learning was based on the lack of a positive
correlation between recall and priming. The authors
suggested that as priming is an indicator of the use of
implicit memory, with the lack of a positive correlation
between the prime and the recall objects, the residual
explicit memory system is the most likely contributor
towards the effects of errorless learning. In Kessels et al.s
(2005) study, the differential effects between the
performance of young and old adults on errorless learning
implied that the advantage of errorless learning lies with
the explicit system as the implicit memory system would
be similar between the young and the old adults.
The study carried out by Hunkin et al. (1998b) has since
been pointed out to be methodologically flawed in that
the use of the word fragment completion as an indicator
of implicit learning was inappropriate. Therefore, the
results implying limited involvement of implicit memory
in errorless learning are likely to be compromised. The
Errorless learning for Alzheimers disease Li and Liu 5
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study carried out by Kessels et al. (2005) found that
errorless learning did not have any advantage over errorful
learning in older adults in a task that required spatial
recall of the location in which an item was kept. Such use
of visual contextual learning, which can be considered
implicit in nature, has been shown to be dependent on
the hippocampus function (Chun and Phelps, 1999).
This dependence on the hippocampus, which undergoes
degeneration in patients with AD, may be a possible
reason for the ineffectiveness of the strategy (Arnold
et al., 1991; Braak and Braak, 1995; Price and Morris,
1999).
Furthermore, one of the studies in the review (Haslam
et al., 2006) suggests that the involvement of implicit
memory in errorless learning may be sensitive to the type
of information registered in the recall task. Errorless
learning appears to have an advantage in specific features
(e.g. occupation of the patient) over general features (e.g.
familiarity of the patient) in a facename association task.
Relating the studies on implicit memory in errorless
learning to the review, we can surmise that the
differences in the results between the studies on the
effectiveness of errorless learning may be because of the
type of recall task and the way in which the intervention
using errorless learning was carried out. From the studies
included in the review, it would seem that recall tasks
that focus on high frequencies of repetitions of a face
name association task would have the best effects.
Limitations
A limitation of this study is that the populations in the
four selected articles are very small (n =59) and must be
interpreted with caution. Moreover, two of the studies
used controls that may not assist well in eliminating some
of the threats to internal validity (Clare et al., 2000, 2002),
thus conferring less credibility to the studies as evident
by the level of evidence. Only two of the studies took
steps to ensure as much as possible that true errorless
learning was taking place (Clare et al., 2000, 2002). This is
necessary to truly distinguish errorless from trial and error
learning and to isolate the effects of each method.
However, it has been suggested that true errorless
learning may not be possible even with the total omission
of observable errors as the patients may commit internal
errors and self-correct before presenting the answer
(Clare and Jones, 2008). Nevertheless, proper controls
to ensure that error committed during errorless learning
remains low is important to improve the internal validity
of the study.
Implications and future directions
Despite the small number of studies included, this
review provides preliminary information on the efficacy of
errorless learning and suggests that the efficacy may be
dependent on the type of information registered and the
manner in which the errorless learning intervention was
carried out. This may prompt further studies to identify
which information types would show a longer retention
period with the use of errorless learning. A study on the
way to carry out the errorless learning approach is also
required to explore how different ways of recall (effortful
vs. effortless) can have an impact on learning.
Conclusion
The efficacy of errorless learning may be influenced by
the type of information that is registered. From the
review, information that is more specific in nature would
show greater retention with the use of errorless learning.
Visual contextual learning, being considered as tapping on
the implicit memory system, however, does not enhance
efficacy in errorless learning because such information
would depend on hippocampal activations, with which
patients with AD have problems. Moreover, the manner
in which errorless learning is carried out will have an
effect on its efficacy. Utilizing it in a way that capitalizes
on implicit memory rather than on explicit memory would
result in greater learning effects. Finally, more work needs
to be carried out to explore the cognitive processes that
underlie the use of errorless learning processes to allow
better delineation of the limitations of the strategy. This
would enable the use of errorless learning more precisely
in patients who may benefit from it.
Acknowledgements
Conflicts of interest
There are no conflicts of interest.
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