1. Smith, Marianne MS, ARNP, CS
  2. Buckwalter, Kathleen PhD, RN, FAAN




Article Content

No!! No!! No!!" cries Esther Lattimore.


"But we need to get you washed up," the nursing assistant explains.


"No!! No!! Not that, no!! Stop. Stop!!" Ms. Lattimore cries, grabbing the aide's arm.


"That hurts!! You stop it!!" counters the aide, angry now as she tries to loosen the grip on her forearm. "Here I am, trying to help you, and you're just being mean!! Now, let go!!"





FIGURE. Messiah Vill... - Click to enlarge in new windowFIGURE. Messiah Village, a retirement community in Mechanicsburg, Pennsylvania, offers extended care for people with dementia and also features a day care center for children. One of the first "intergenerational" programs in the country, the center encourages interactions among its oldest and youngest clients. Photograph taken from

This article describes cognitive impairment; ways of assessing behavioral symptoms in a person with dementia; and nonpharmacologic interventions that take into consideration the person's environment, personality, and potential unmet needs.






















Creutzfeldt-Jakob disease is a rare, progressive neurologic disorder that occurs in people of all ages, but typically occurs between ages 40 and 60 years. A subacute spongiform encephalopathy caused by transmissible agents known as "slow viruses," or prions, it's believed by some to be linked to bovine spongiform encephalopathy (commonly known as "mad cow disease"). Clinical manifestations often occur in a triad that includes dementia plus involuntary movements (particularly myoclonus) and periodic activity seen on electroencephalography. Once symptoms appear, decline is rapid and death usually occurs within one year. Normal sterilization procedures do not kill the prions that cause this disease, requiring use of special procedures (developed in consultation with the infection control department of each facility) to protect health care workers and other patients alike.





A wide variety of symptoms throughout the course of dementia have been observed, including those that may be directly linked to cognitive deficits. For example, memory loss may result in losing or misplacing items and precipitate suspicions that someone is stealing things. Aphasia may cause a person to omit words ("Oh, it was so . . . you know, at the . . . with all the people . . . at the, you know"), and may result in neologisms (made-up words; "pintin" for peanut, for example), or substituting descriptions for names of things ("tick-tock" for clock). Agnosia may contribute to odd behavior, such as putting dentures in the refrigerator or attempting to brush hair with a toothbrush. Behavior may also be specific to the type of disease, such as the anger, apathy, disinhibition, poor hygiene, and poor judgment characteristic of frontotemporal dementia.


Because of perceptual, language, and memory deficits, people with dementia often have difficulty in understanding and talking about the sources of their discomfort. As a result, they often express themselves through actions. For example, Ms. Lattimore was not able to articulate why she did not want to bathe, but she was clearly telling the caregiver that that was the case, through speech ("No, no, no!!") and behavior (grabbing the care-giver by the arm).


Among the most common noncognitive behavioral symptoms are apathy and withdrawal; anxiety; irritability; dysphoria and depression; disinhibition; delusions, hallucinations and paranoia; agitation and aggression; activities such as wandering, purposeless behavior, or socially improper behaviors; disturbed diurnal or circadian rhythms that cause sleep changes; loss of the ability to feed oneself; and resistance to care. 9, 10 These symptoms aren't present in all people with dementia, they don't necessarily progress with the other aspects of the disease, and they are often considered "secondary symptoms" that respond to both drug therapy and supportive intervention. 9




The Language of Dementia Care

Changes in labeling are effecting changes in care.

The last two decades have seen a dramatic shift in the way people with dementia, and the behaviors they exhibit, are regarded, labeled, and "treated." Early dementia care emphasized loss and disability, labeled behaviors such as wandering or vocalizations with negative terms such as "disruptive" and "disturbing," medicalized people with dementia by calling them patients, and offered largely impersonal, custodial care for their "hopeless" and "inevitable" decline.


The importance of individualized approaches that emphasize the person, not the diagnosis, was underscored by Tom Kitwood in The New Culture of Dementia Care.1 In this 1995 text, Kitwood and the Bradford Dementia Group seriously challenged the "old culture" and advocated new language and practices that viewed the person with dementia as a person foremost-one whose "abilities, tastes, interests, values, and spirituality" were more important than the disabilities created by dementia. The movement toward more positive views of dementia care has been under way since the mid-1980s. The goal is care that emphasizes remaining abilities and strengths, promotes engagement in meaningful activities, and stresses capability.





1. Kitwood T, Benson S, editors. The New Culture of Dementia Care. London: Hawker Publications Ltd; 1995. [Context Link]



While broad terms like agitation are used to describe a wide range of behaviors-from irritability and restlessness to wandering and lashing out-the development of effective interventions relies on understanding the nature of the behavior and the message it expresses. It's important to know the person's traits and habits and to work with interdisciplinary teams on all shifts to identify and solve problems. In many situations, documentation of behaviors is needed to better understand what leads to them; it may help clinicians to understand whether the changes are related to a progressive loss of function or stress resulting from environmental triggers. Personalized "behavior logs" can ensure that behaviors are systematically recorded. Like standardized scales, these logs may be used to document increases or decreases in behavior.



Table 1 - Click to enlarge in new window




The Progressively Lowered Stress Threshold Model was developed in response to the observed behaviors of older adults with Alzheimer disease and related disorders. 14 According to this model, adults with dementia become less able to manage stress as the disease progresses. That is, their "stress threshold" is lower, resulting in anxiety and increasingly dysfunctional behaviors as stress builds. Stressors may include fatigue; changes in routine, caregiver, or environment; demands that exceed the person's ability to function; multiple and competing stimuli; perceptions of loss; and physiologic factors such as illness, pain, discomfort, and adverse effects of medications. 15


Six essential principles of care are proposed, including strategies to modify the environment to ensure safety; provide "unconditional positive regard"; use anxiety and avoidance as gauges of activity and stimulation levels; teach caregivers to "listen" to behaviors; modify environments to support losses and enhance safety; and provide ongoing education, support, care, and problem solving to caregivers. Promoting comfort and function, by understanding and managing personal, social, and physical factors that may trigger behaviors, is paramount.


The Need-Driven Dementia-Compromised Behavior Model, developed in 1993, "changes the prevalent view of dementia-related behaviors as 'disruptive' or 'disturbing' to a perspective that conceptualizes these behaviors as potentially understandable needs that, if responded to appropriately, enhance quality of life." 16


In this model, behavioral symptoms are considered to be the result of complex interactions between "background" and "proximal" factors. Background factors are relatively stable individual and disease-related characteristics that may predispose a person with dementia to behavioral symptoms. There are four groups of background factors: dementia-compromised functioning (such as language impairment), poor overall health status, demographic variables (such as marital status), and psychosocial variables (such as personality traits). Proximal factors are "those that induce a need state" that precipitates behavioral symptoms. The four groups of proximal factors are unmet physiologic need (such as hunger), unmet psychosocial need (such as contact with friends), disturbing environmental factors (such as a cold room), and uncomfortable social surroundings (such as too many people in a room). Proximal factors are used as a basis for developing nursing interventions.



A number of reasonably simple nursing interventions may reduce the risk of inadvertently precipitating behavioral symptoms. Many involve minor changes in the way care is provided. The overall goal of care-to enhance self-respect by promoting comfort and dignity-is often best achieved by focusing on the person's abilities and successes instead of disabilities and failures. Caregivers can ensure that the person is able to use his remaining abilities by minimizing the adverse effects of other health conditions, sensory impairment, and cognitive deficits while optimizing social and environmental factors that support functional capacity.




Adjust interaction and communication strategies.

Three steps toward communication are getting the person's attention, making eye contact, and speaking directly to the person (unless this is culturally inappropriate) to ensure he perceives the message. 17 Nonverbal communication is of equal importance, including tone of voice, facial expressions, and use of nonverbal gestures (for example, showing the person how to brush her teeth while saying "brush your teeth"). 18 Slowing down the pace of speech, using short sentences, and using nouns (chair, bathroom) instead of pronouns (it, there) will help. Avoiding commands that include the word "don't" and questions that begin with "why" may prevent a feeling of being reprimanded or tested.


Respect is conveyed by not reminding the person of his disabilities. Well-meaning but misguided care-givers can worsen anxiety and frustration by asking the person to "try harder." (For example, "You did it yesterday; what's the problem today?" Or "If you wanted to, you could do it.") Breaking down tasks into steps, while providing encouragement and reassurance, helps the person to act as independently as possible. Likewise, confronting delusions with facts is rarely reassuring. For example, instead of responding to someone who says she is going to see her father with "Your father is dead," it's better to distract her by reminiscing with her about her childhood.


Although it's common to rephrase a question a person doesn't understand, this could actually increase confusion. Instead, ask only one question at a time, allow time for a response, and repeat the question if needed. Another common error is to assume that there's no point in explaining procedures or care because the person won't understand. On the contrary, providing guidance will minimize surprises. For example, when approaching a person with dementia, a nurse should first identify herself and address him by name, then explain in simple terms what she will do. A silent approach from behind may be unnecessarily frightening. And people with sensory impairments must have eyeglasses, hearing aids, and adequate lighting; without them, misinterpretations of stimuli can lead to behavioral or psychological symptoms. 19


Change reactions and responses to behavior.

A tendency to repeat questions is common in people with dementia. The untrained caregiver may find this repetition monotonous and annoying, think that the behavior is purposeful, and become angry or withdraw in response. Instead, when a person repeats a question, the educated caregiver will listen carefully to detect the real message. For example, someone repeatedly asking "When is lunch?" may be hungry or thirsty and should be offered food or drink.


In a similar vein, people with dementia may say or do things that caregivers don't understand or that they find silly. For example, a woman may try to "go to work" after 20 years of retirement or ask to see parents who have been dead for decades. It's easy to view these as meaningless delusions, yet they may be better understood as attempts to remain engaged in life. Having a "workplace," or engaging in an activity such as gardening, food preparation, or reminiscence, may provide a therapeutic distraction. By providing assistance early, rather than ignoring behaviors or hoping they will stop on their own, nurses may avoid more intense and discomforting behaviors.


Monitor and adjust the environment.




Successful nonpharmacologic interventions are individually tailored and take into consideration a person's needs, abilities, customs, preferences, and favorite activities. 20, 21 Various interventions have been tried, with mixed results, in an effort to reduce behavioral symptoms. Disparate outcomes of studies are often related to the diverse symptoms seen in people with dementia, as well as study limitations. Many interventions are very effective for a subset of persons with dementia and are worthy approaches in clinical practice while additional research is being conducted. Selected interventions within three broad domains-sensory enhancement, socialization, and structured activities-are highlighted.


Sensory enhancement.
















In studies the presence of a pet has been shown to reduce agitated and aggressive behaviors in people with Alzheimer disease, and a "therapy dog" on a special care unit resulted in increased socialization (such as verbalization, smiles, looks, and touch) among residents with dementia. 28, 29 Positive effects on caregivers have also been suggested. 30



Nurses and family members can use sensory cues, such as a photo album, to stimulate comforting, positive, long-term memories (which are better preserved than short-term ones). Reminiscence is often used as a distraction-for example, showing someone pictures of cats that look like ones she had as a younger person as a way to calm agitation.






Structured activities, which alleviate boredom and agitation in people with dementia, may be recreational (sewing, sorting) or physical (walking, movement, and exercise programs). For people with late-stage dementia and severe cognitive impairment, it can be particularly difficult to develop therapeutic activities. Buettner developed "Simple Pleasures" as an intervention for this population. 36 This intervention involves handmade items such as tether balls and fleece-covered hot water bottles made by families and volunteers and given to people with dementia; the goal is to improve interactions between visitors and people with dementia by giving the visitors the ability to provide something tangible that can decrease boredom and agitation. Buettner found that "the families viewed their visits much more positively during the intervention," and that "agitation levels significantly and dramatically declined." A 2002 study had similar results. 37 (See "Simple Pleasures," page 54.)


The family involvement in care intervention.

Most family caregivers possess much information about the person's history, routines, and preferences. But when the person with dementia is relocated to a long-term care facility, family members often need help in developing a new caregiving role, one that emphasizes more indirect, supportive, and interpersonal care. The "family involvement in care intervention" was developed by Maas and colleagues to help nursing home staff and family members negotiate a partnership, in which the particular expertise of each is used to best advantage. 38 The intervention involves orienting the family to the facility and partnership role, negotiating a partnership contract, educating family members on involvement in care, and evaluating and renegotiating the partnership contract as needed. The intervention is associated with positive outcomes for both sets of caregivers. 39 Families report reduced emotional burden, while staff report reduced stress from the care recipient's behavior, and both family and staff caregivers report improved perceptions of their relationships with one another, the care provided, and facility management.


Promotion of continuity between levels of care.

Over the long and unpredictable course of most dementias, care is often provided in a variety of settings, from home to hospice. A particular challenge for nurses is continuity between levels of care. Because much relies on knowing the person's history, nurse-to-nurse exchange of information is often critical when the person is discharged or transferred from one level of care to another. For example, appropriate care plans are facilitated by-in addition to the usual medical and surgical histories-the prompt provision of consent forms signed by legal representatives, mental status assessments, personal care preferences, psychosocial and behavioral histories, and information about the person's premorbid personality characteristics.






Complete the CE test for this article by using the mail-in form available in this issue, or visit's "CE Connection" to take the test and find other CE activities and "My CE Planner."



Behavior: Roslyn Jensen sits in her room, staring out the window. Her nurse says, "It's a beautiful day out there, isn't it? Aren't the flowers pretty?" Ms. Jensen looks blankly at her and doesn't reply. Touching Ms. Jensen's arm, the nurse tries again. "You used to have a big flower garden, right?" Quietly, she replies, "Yes, I did."


Intervention: Although flowers were once a focus of Ms. Jensen's life, she now seems indifferent to them. The nurse persists, "Come with me to the activity group. You can help us name all those flowers in the courtyard." She takes Ms. Jensen's hand and gently tugs to get her to stand up. "We really need your help," she says. "We'll have fun, I promise!!" Shaking her head, Ms. Jensen gets up from her chair, follows the nurse, and once there, participates.


Sudden Withdrawal

Behavior: Edward Bateman pushes his chair away from the dinner table and rises to leave after taking only a few bites of food. "Aren't you hungry today, Mr. Bateman?" asks the nurse as she walks toward him. He puts his hand up as if to keep her away, frowns, glances around, and promptly walks out of the room. This is not the first time Mr. Bateman has withdrawn from the active and sometimes noisy dining area. Staff accept that Mr. Bateman "knows" when the stimulation is too much and accommodate his wish to leave.


Intervention: A simple plate of food and a glass of milk are delivered to Mr. Bateman's room. The nurse coaxes him, "Try this nice sandwich. It's grilled cheese, your favorite." When he takes a bite, she continues to cue him: "Now how about a drink of cold milk?" In the quiet of his room, Mr. Bateman eats most of his lunch.


'A New Look at the Old' Online

A series of Webcasts designed to improve multidisciplinary care.

Further explore the topics presented in the series "A New Look at the Old" by going online; over the course of the series 15 free Webcasts will run, created through a collaboration of AJN, the Gerontological Society of America, and PRIMEDIA Healthcare and sponsored in part through a grant from Atlantic Philanthropies. The most recent Webcast was "Acute Illness: Unmet Needs of the Cognitively Impaired," and "Nutrition in Older Adults" will premiere on July 19. For information on the schedule or to view an archive of previous Webcasts, go to AJNolderadults. This Web site includes a forum for comments and questions about the Webcasts or articles in this series.



Behavior: "No, no, no!! Get away from me. I'm not like that. Leave me alone!!" screams Joseph Greenberg as the nurse's aide tries to remove his pajama top. "But you can't run around in PJs all day, Mr. Greenberg. Let's get you dressed," the aide replies. "Don't you touch me, you slut!!" he yells, pushing her hand away.


Intervention: His reference to "not being like that" and name-calling suggest that the caregiver's sex might play a role. A male nurse is sought and he is able to help Mr. Greenberg remain calm while he is dressed and groomed.


My Stepfather in the Nursing Home

For lunch he wears a clean white shirt, strapped into his wheelchair with his hair smoothed back, the shoulders of his good Brooks Brothers jacket straight. He takes a tiny sip of water, puts down his glass, forgets and picks it up, twelve times. Strangers he once knew pass through the lobby of his mind, ask him questions he can't answer, change his sheets and towels. He throws his tray across the room and howls the hotel's lost his luggage just when he's close to a big deal. He can't find a pencil, does the math in his head, and everyone's stealing his money. He tries to tell the nurse he'll get her a job in sporting goods (the company he built from scratch, nights, weekends), but the sentences slur like acrobats who've lost their timing. I remember he'd choke up reading every heartbreak story in the Denver Post. Afterwards he'd send a check.


-Wendy Drexler, senior editor at Educators Publishing Service, Cambridge, MA


Tips for Nurses By Health Care Setting




Nursing home



Ambulatory care



Home care




Behavior: Agatha Rittmeister walks down the hall, calling out "Where am I? Where am I? Is it all right?" As her cries become louder, her frightened facial expression signals that she is becoming more agitated.


Intervention: Establishing eye contact, the nurse says in a soothing voice, "Ms. Rittmeister, I'm so glad to see you. I need your help. Can you come with me, please?" She extends her hand and smiles. Ms. Rittmeister continues to look confused, but pauses. The nurse continues, "Come to the kitchen. I have some cookies for you to taste." Still looking a bit puzzled, Ms. Rittmeister replies, "Well, all right. I suppose," and begins to walk toward the kitchen with the nurse.


Pain Management And Alzheimer Disease

It can be challenging.

Many people with Alzheimer disease are unable to report their pain. In such cases, clinicians must rely on behavioral cues. Also, each person might have a "pain signature"; if so, it can alert the clinician that there is a problem. 1, 2 For example, one person's pain may cause him to become agitated and combative, while another may withdraw. Failure to recognize and treat pain adequately can lead to sleep disturbances, malnutrition, depression, decreased mobility, nursing home placement, and needless suffering. 1




Because self-report is the single most reliable indicator of pain, those who are able to communicate verbally should be asked directly about the presence of pain. 1, 3, 4 (It's recommended that a variety of simple words, such as "ache" or "sore," be used to discuss the concept of pain and that adequate time be given for responses. 2) A self-reporting tool, such as a 0-to-10 or a faces pain-rating scale, should be used to determine pain intensity.






The principles of good pain management in adults without Alzheimer disease apply universally to those with the disease. Nonopioid analgesics (acetaminophen and nonsteroidal antiinflammatory drugs) should be considered for mild-to-moderate pain. Opioid analgesics are added to the treatment plan for more severe pain. If neuropathic pain is suspected, adjuvant analgesics, such as local anesthetics, anticonvulsants, and antidepressants, are indicated. 1 As with all older adults receiving analgesia, the adage "start low, go slow" applies. Finally, systematic reassessment of pain will help ensure continuity and the timely recognition of the need for adjustments in the treatment plan. -Amanda Simmons, MSN, RN, nursing instructor for the Technical College of the Lowcountry, Beaufort, SC, and Chris Pasero, MS, RN, FAAN, pain management educator and consultant in El Dorado Hills, CA



1. The management of persistent pain in older persons. J Am Geriatr Soc 2002;50(6 Suppl):S205-24. [Context Link]2. Herr K. Pain assessment in cognitively impaired older adults. Am J Nurs 2002;102(12):65-8. [Context Link]3. Acello B. Pain assessment in patients with dementia and how to use pain scales. Home Healthc Nurse 2001;19(8):473-6. [Context Link]4. Lane P, et al. A pain assessment tool for people with advanced Alzheimer's and other progressive dementias. Home Healthc Nurse 2003;21(1):32-7. [Context Link]



Behavior: With lots of cues and encouragement, Sarah Cohen is helped to the bathroom, where her shower begins. Working as a team, the nurse and nurse's aide try to make "quick work" of an often-difficult task. Instead, they trigger an intense reaction, as water is accidentally sprayed on Ms. Cohen's face. Ms. Cohen grabs and pinches the closest caregiver as she screams in distress, then clenches her fists and begins striking out, hitting both providers.


Intervention: The nurse quickly apologizes, saying, "I'm sorry. You're safe with us. Here, hold this over your eyes," and she hands Ms. Cohen a washcloth to cover her face.




1. Evans DA, et al. Prevalence of Alzheimer's disease in a community population of older persons: higher than previously reported. JAMA 1989;262(18):2551-6. [Context Link]






4. Hebert LE, et al. Alzheimer disease in the US population: prevalence estimates using the 2000 census. Arch Neurol 2003;60(8):1119-22. [Context Link]


5. International Psychogeriatric Association. BPSD online educational pack: introduction to behavioral and psychological symptoms of dementia. 2005. [Context Link]


6. Madhusoodanan S. Introduction: antipsychotic treatment of behavioral and psychological symptoms of dementia in geropsychiatric patients. Am J Geriatr Psychiatry 2001; 9(3):283-8. [Context Link]


7. Alzheimer's Disease Education and Referral Center, National Institute on Aging. Connections 1999;8(2):1-12. [Context Link]




9. Cummings JL. The Neuropsychiatric Inventory: assessing psychopathology in dementia patients. Neurology 1997;48(5 Suppl 6):S10-6. [Context Link]


10. Mahoney E, et al. Management of challenging behaviors in dementia. Baltimore, MD: Health Professions Press; 2000. [Context Link]


11. Rasin J, Barrick AL. Bathing patients with dementia. Am J Nurs 2004;104(3):30-4. [Context Link]


12. Beck C, et al. Correlates of disruptive behavior in severely cognitively impaired nursing home residents. Gerontologist 1998;38(2):189-98. [Context Link]


13. Burgio LD, et al. Agitation in nursing home residents: the role of gender and social context. Int Psychogeriatr 2000;12(4):495-511. [Context Link]


14. Hall GR, Buckwalter KC. Progressively lowered stress threshold: a conceptual model for care of adults with Alzheimer's disease. Arch Psychiatr Nurs 1987;1(6):399-406. [Context Link]


15. Gerdner LA, et al. Caregiver training for people with Alzheimer's based on a stress threshold model. Image J Nurs Sch 1996;28(3):241-6. [Context Link]


16. Kolanowski AM. An overview of the need-driven dementia-compromised behavior model. J Gerontol Nurs 1999; 25(9):7-9. [Context Link]


17. Bartol MA. Dialogue with dementia: nonverbal communication in patients with Alzheimer's disease. J Gerontol Nurs 1979;5(4):21-31. [Context Link]


18. Teri L, Logsdon RG. Assessment and management of behavioral disturbances in Alzheimer disease. Compr Ther 2000; 26(3):169-75. [Context Link]


19. Palmer CV, et al. Reduction in caregiver-identified problem behaviors in patients with Alzheimer disease post-hearing-aid fitting. J Speech Lang Hear Res 1999;42(2):312-28. [Context Link]


20. Hall GR, Buckwalter KC. Whole disease care planning: fitting the program to the client with Alzheimer's disease. J Gerontol Nurs 1991;17(3):38-41. [Context Link]


21. Wells DL, et al. Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers. J Am Geriatr Soc 2000;48(4):442-9. [Context Link]


22. Goddaer J, Abraham IL. Effects of relaxing music on agitation during meals among nursing home residents with severe cognitive impairment. Arch Psychiatr Nurs 1994;8(3):150-8. [Context Link]


23. Ragneskog H, et al. Individualized music played for agitated patients with dementia: analysis of video-recorded sessions. Int J Nurs Pract 2001;7(3):146-55. [Context Link]


24. Gerdner LA. Effects of individualized versus classical "relaxation" music on the frequency of agitation in elderly persons with Alzheimer's disease and related disorders. Int Psychogeriatr 2000;12(1):49-65. [Context Link]




26. Brooker DJ, et al. Single case evaluation of the effects of aromatherapy and massage on disturbed behaviour in severe dementia. Br J Clin Psychol 1997;36(Pt 2):287-96. [Context Link]


27. Burns I, et al. Leisure or therapeutics? Snoezelen and the care of older persons with dementia. Int J Nurs Pract 2000;6(3):118-26. [Context Link]


28. Fritz CL, et al. Association with companion animals and the expression of noncognitive symptoms in Alzheimer's patients. J Nerv Ment Dis 1995;183(7):459-63. [Context Link]


29. Churchill M, et al. Using a therapy dog to alleviate the agitation and desocialization of people with Alzheimer's disease. J Psychosoc Nurs Ment Health Serv 1999;37(4):16-22. [Context Link]


30. Fritz CL, et al. Companion animals and the psychological health of Alzheimer patients' caregivers. Psychol Rep 1996;78(2):467OE81. [Context Link]


31. Lund DA, et al. Video Respite: an innovative resource for family, professional caregivers, and persons with dementia. Gerontologist 1995;35(5):683-7. [Context Link]


32. Malonebeach EE, et al. Is cognitive impairment a guide to use of Video Respite? Lessons from a special care unit. J Gerontol Nurs. 1999;25(5):17-21. [Context Link]


33. Woods P, Ashley J. Simulated presence therapy: using selected memories to manage problem behaviors in Alzheimer's disease patients. Geriatr Nurs 1995;16(1):9-14. [Context Link]


34. Peak JS, Cheston RI. Using simulated presence therapy with people with dementia. Aging Ment Health. 2002;6(1):77-81. [Context Link]


35. Miller S, et al. Audio presence intervention for decreasing agitation in people with dementia. Geriatr Nurs 2001; 22(2):66-70. [Context Link]


36. Buettner L. Simple Pleasures: a multilevel sensorimotor intervention for nursing home residents with dementia. Am J Alzheimers Dis Other Demen 1999;14(1):41-52. [Context Link]


37. Colling KB, Buettner LL. Simple pleasures: interventions from the need-driven dementia compromised behavior model. J Gerontol Nurs 2002;28(10):16-20. [Context Link]


38. Maas ML, et al. The caring partnership: staff and families of persons institutionalized with Alzheimer's disease. Am J Alzheimers Dis Other Demen 1994;9(6):21-30. [Context Link]


39. Maas ML, et al. Outcomes of family involvement in care intervention for caregivers of individuals with dementia. Nurs Res 2004;53(2):76-86. [Context Link]