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Dementia

“Dementia” is a syndrome of cognitive deficits caused by a variety of underlying neuropathologies.  The most common cause of dementia is Alzheimer’s disease, but other causes include Lewy body disease and vascular disease.  The prevalence of dementia in adults age 71 and older has been estimated to be 14%, with rates increasing to 24% for individuals age 80-89 and 37% for those individuals age 90 and older (Plassman et al., 2007).  The two most prominent diagnostic guidelines are those put forth by the National Institute on Aging / Alzheimer’s Association (McKhann et al., 2011) and the DSM-5 (American Psychiatric Association, 2013).  The DSM-5 had adopted the term “Neurocognitive Disorder” to replace “dementia,” although it is noted that the term can continue to be used.  One reason for this change is to reflect how this disorder can occur in adults of any age, whereas “dementia” is typically associated with older adults.  Traumatic brain injuries, for instance, are one of the causes of neurocognitive disorders and occur in adults of all ages.  The DSM-5 also designates neurocognitive disorders as mild or major, to incorporate the reality that this disorder occurs on a spectrum from mild deficits (also known as Mild Cognitive Impairment [MCI]) to major disorders at severe levels.

Both the McKhann et al. (2011) and DSM-5 criteria emphasize the important of neuropsychological assessment in the diagnosis of dementia.  Alzheimer’s disease (AD), the most common cause of dementia, most often causes deficits in memory, which manifests most clearly as impaired recall of information after a delay of 10-30 minutes on neuropsychological testing.  AD also leads to deficits in word-finding and other components of language, impaired executive functioning, and poor visuospatial skills, but the disease causes variable effects in every patient.  If neuropsychological assessment is not feasible, both sets of criteria offer less formal methods of assessing cognitive functioning.  Neuropsychological assessment has been found to be highly accurate in the detection of AD found on autopsy, as reviewed in Lezak and colleagues (2012), and Salmon and Bondi (2009).

Researchers are currently striving to find biomarkers of AD.  “Biomarkers” include genetic tests, neuroimaging findings, and cerebrospinal fluid measures.  Two key measurements under study include markers of brain amyloid-beta (Aβ) protein deposition and markers of downstream neuronal degeneration or injury such as measures of tau.  The use of biomarkers in diagnosis is currently limited by limited standardization of biomarkers across sites, a dearth of normative data, and lack of access for many patients (McKhann et al., 2011) and neither set of guidelines advocates for their use in routine clinical diagnosis as of 2013.  Eventually the use of these will enable more precise detection of disease processes and detection at earlier timepoints, when treatment may be more effective.  Biomarker diagnosis along with neuropsychological assessment will enable diagnostic clarity and also assessment of the cognitive functioning of each patient.  The disease has variable effects on each patient, and often patients require assessment of capacity or the ability to manage everyday activities of daily living such as financial management or the ability to make important medical or legal decisions.

Interventions

Neuropsychiatric symptoms (NPS), i.e., behavioral and psychological symptoms, are highly associated with dementia with approximately 80% of individuals with dementia exhibiting at least one neuropsychiatric symptom from the onset of their cognitive symptoms (Lyketsos et al., 2002). Neuropsychiatric symptoms associated with dementia cause a great deal of suffering for individuals with dementia and their family members, contribute to increased health care costs, increased likelihood for nursing home placement and caregiver burden (Beeri, Werner, Davidson, & Noy, 2002).  Neuropsychiatric symptoms can include agitation, apathy, depression, aggressiveness, and other challenging behaviors such as wandering, hoarding, and refusal of care.

Pharmacological interventions, typical and atypical antipsychotic medications, are commonly used to treat NPS, but they are not FDA approved for managing challenging behaviors due to dementia (Maher & Theodore, 2012). Studies also suggest they are only modestly effective while having serious adverse effects such as mortality, and effects that may significantly increase risk of injury due to falls, such as sedation, Parkinsonism, and orthostatic hypotension (Maher & Theodore, 2012).  Nonpharmacological interventions, including behavior and environment modification, are suggested first line approaches (Turnham, Esq., OBRA 1987 summary) due to these numerous serious adverse risks  and emerging research support for their effectiveness in reducing challenging behaviors (Ayalon, Gum, Feliciano, & Arean, 2006).  Ayalon et al. (2006), in their review, found that the majority of nonpharmacological interventions were possibly efficacious pending further replication. Interventions in their review included the unmet needs interventions, which requires careful assessment of underlying motivations behind the NPS and designing an intervention that helps meet the need; behavioral interventions address NPS by contingency management such as removing reinforcements of behaviors or reinforcing positive behaviors or behavioral redirection (Heard & Watson, 1999); caregiving interventions include approaches that use education or support for the caregiver, which can include educating caregivers on unmet needs or behavioral approaches (Teri, McCurry, Logsdon, & Gibbons, 2005); and environmental  and reduced stress-threshold models, which modifies environmental triggers or factors such as light therapy (Lovell, Ancoli-Israel, & Gevirtz, 1995). There is need for further research that use more rigorous methodology such as randomized controlled trials or more large-scale single case designs. However, the literature, to date, suggests that non-pharmacological interventions, particularly those that are individually-tailored, hold a great deal of promise.

Written by Brian Yochim, PhD and J.W. Terri Huh, PhD, from the VA Palo Alto Health Care System and  Stanford University

GENERAL

Cipher, D. J., Clifford, P. A., & Roper, K. D. (2006). Behavioral manifestations of pain in the demented elderly. Journal of the American Medical Directors Association, 7(6), 355-365. doi: 10.1016/j.jamda.2005.11.012

Cipher, D. J., Clifford, P. A., & Roper, K. D. (2006). Behavioral manifestations of pain in the demented elderly. Journal of the American Medical Directors Association, 7(6), 355-365. doi: 10.1016/j.jamda.2005.11.012

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Alzheimer’s Association. (2012) 2012 Alzheimer’s Disease Facts and Figures. Chicago, IL: Alzheimer’s Association. See more at: http://www.usagainstalzheimers.org/activists-learn-more#_ftn4

Alzheimer’s Association. (2012) 2012 Alzheimer’s Disease Facts and Figures. Chicago, IL: Alzheimer’s Association.  See more at: http://www.usagainstalzheimers.org/activists-learn-more#_ftn4

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Plassman, B. L., Langa, K. M., Fisher, G. G., Heeringa, S. G., Weir, D. R., Ofstedal, M. B., … Wallace, R. B. (2007). Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology, 29, 125-132. doi: 10.1159/000109998

Plassman, B. L., Langa, K. M., Fisher, G. G., Heeringa, S. G., Weir, D. R., Ofstedal, M. B., … Wallace, R. B. (2007). Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology, 29, 125-132. doi: 10.1159/000109998

Posted in reference | Tagged , | Comments Off on Plassman, B. L., Langa, K. M., Fisher, G. G., Heeringa, S. G., Weir, D. R., Ofstedal, M. B., … Wallace, R. B. (2007). Prevalence of dementia in the United States: The aging, demographics, and memory study. Neuroepidemiology, 29, 125-132. doi: 10.1159/000109998

Lyketsos, C. G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J., & DeKosky, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. Journal of the American Medical Association, 288(12), 1475-1483.

Lyketsos, C. G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J., & DeKosky, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. Journal of the American Medical Association, 288(12), 1475-1483.

Posted in reference | Tagged , | Comments Off on Lyketsos, C. G., Lopez, O., Jones, B., Fitzpatrick, A. L., Breitner, J., & DeKosky, S. (2002). Prevalence of neuropsychiatric symptoms in dementia and mild cognitive impairment: results from the cardiovascular health study. Journal of the American Medical Association, 288(12), 1475-1483.

Beeri, M. S., Werner, P., Davidson, M., & Noy, S. (2002). The cost of behavioral and psychological symptoms of dementia (BPSD) in community dwelling Alzheimer’s disease patients. International Journal of Geriatric Psychiatry, 17(5), 403-408. doi: 10.1002/gps.490

Beeri, M. S., Werner, P., Davidson, M., & Noy, S. (2002). The cost of behavioral and psychological symptoms of dementia (BPSD) in community dwelling Alzheimer’s disease patients. International Journal of Geriatric Psychiatry, 17(5), 403-408. doi: 10.1002/gps.490

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American Psychiatric Association. (2013). DSM 5. American Psychiatric Association.

American Psychiatric Association. (2013). DSM 5. American Psychiatric Association.

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Alzheimer’s Prevention Registry recruiting 250,000 volunteers: The Alzheimer’s Prevention Registry (www.endalznow.org), launched in October, 2012 by the Banner Alzheimer’s Institute, is a new online community of people who want to help scientists find treatments to slow, halt, or prevent the memory-robbing disorder.

Alzheimer’s Prevention Registry recruiting 250,000 volunteers: The Alzheimer’s Prevention Registry (www.endalznow.org), launched in October, 2012 by the Banner Alzheimer’s Institute, is a new online community of people who want to help scientists find treatments to slow, halt, or prevent the memory-robbing disorder.

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Seignourel, P.J., Kunik, M.E., Snow, L., Wilson, N., & Stanley, M.A. (2008). Anxiety in dementia: A critical review. Clinical Psychology Review , 28(7):1071-1082. PMCID: PMC2575801

Seignourel, P.J., Kunik, M.E., Snow, L., Wilson, N., & Stanley, M.A. (2008). Anxiety in dementia: A critical review. Clinical Psychology Review , 28(7):1071-1082. PMCID: PMC2575801

Posted in reference | Tagged , , , | Comments Off on Seignourel, P.J., Kunik, M.E., Snow, L., Wilson, N., & Stanley, M.A. (2008). Anxiety in dementia: A critical review. Clinical Psychology Review , 28(7):1071-1082. PMCID: PMC2575801

Allery, A. J., Aranda, M. P, Dilworth-Anderson, P., Guerrero, M., Haan, M. N., Hendrie, H., Hinton, L., Iris, M. A., Jackson, J. S., Jervis, L. L., Lampley-Dallas, V., Manly, J. J., Radebauth, T. S., Robinson, J. W., Tang, P., Valle, R., & White, L. (2004). Alzheimer’s disease and communities of color. In K. E. Whitfield (Ed), Closing the gap: Improving the health of minority elders in the new millennium (pp. 81-86).

Allery, A. J., Aranda, M. P, Dilworth-Anderson, P., Guerrero, M., Haan, M. N., Hendrie, H., Hinton, L., Iris, M. A., Jackson, J. S., Jervis, L. L., Lampley-Dallas, V., Manly, J. J., Radebauth, T. S., Robinson, J. W., Tang, P., Valle, R., & White, L. (2004). Alzheimer’s disease and communities of color. In K. E. Whitfield […]

Posted in reference | Tagged , , , , | Comments Off on Allery, A. J., Aranda, M. P, Dilworth-Anderson, P., Guerrero, M., Haan, M. N., Hendrie, H., Hinton, L., Iris, M. A., Jackson, J. S., Jervis, L. L., Lampley-Dallas, V., Manly, J. J., Radebauth, T. S., Robinson, J. W., Tang, P., Valle, R., & White, L. (2004). Alzheimer’s disease and communities of color. In K. E. Whitfield (Ed), Closing the gap: Improving the health of minority elders in the new millennium (pp. 81-86).

ASSESSMENT OF DEMENTIA

Salmon, D. P., & Bondi, M. W. (2009). Neuropsychological assessment of dementia. Annual Review of Psychology, 60, 257-282.

Salmon, D. P., & Bondi, M. W. (2009). Neuropsychological assessment of dementia. Annual Review of Psychology, 60, 257-282.

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McKhann, G. M., Knopman, D. S., Chertkow, H., Hyman, B. T., Jack, C. R., Kawas, C. H., . . . Phelps, C. H. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging – Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 263-269. doi: 10.1016/j.jalz.2011.03.005

McKhann, G. M., Knopman, D. S., Chertkow, H., Hyman, B. T., Jack, C. R., Kawas, C. H., . . . Phelps, C. H. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging – Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 263-269. doi: […]

Posted in reference | Tagged , | Comments Off on McKhann, G. M., Knopman, D. S., Chertkow, H., Hyman, B. T., Jack, C. R., Kawas, C. H., . . . Phelps, C. H. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging – Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7, 263-269. doi: 10.1016/j.jalz.2011.03.005

Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological assessment (5th ed.). New York: Oxford University Press.

Lezak, M. D., Howieson, D. B., Bigler, E. D., & Tranel, D. (2012). Neuropsychological assessment (5th ed.). New York: Oxford University Press.

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Chodosh, J., Edelen, M. O., Buchanan, J. L., Yosef, J. A., Ouslander, J. G., Berlowitz, D. R. et al. (2008). Nursing Home Assessment of Cognitive Impairment: Development and Testing of a Brief Instrument of Mental Status. Journal of the American Geriatrics Society, 56, 2069-2075.

Chodosh, J., Edelen, M. O., Buchanan, J. L., Yosef, J. A., Ouslander, J. G., Berlowitz, D. R. et al. (2008). Nursing Home Assessment of Cognitive Impairment: Development and Testing of a Brief Instrument of Mental Status. Journal of the American Geriatrics Society, 56, 2069-2075.  *Note:  the BIMS is a required part of the MDS-3.0 completed […]

Posted in reference | Tagged , , | Comments Off on Chodosh, J., Edelen, M. O., Buchanan, J. L., Yosef, J. A., Ouslander, J. G., Berlowitz, D. R. et al. (2008). Nursing Home Assessment of Cognitive Impairment: Development and Testing of a Brief Instrument of Mental Status. Journal of the American Geriatrics Society, 56, 2069-2075.

Ravdin, L.D. & Katzen, H. L. (Eds.). (2013). Handbook on the neuropsychology of aging and dementia. New York, NY: Springer.

Ravdin, L.D. & Katzen, H. L. (Eds.). (2013). Handbook on the neuropsychology of aging and dementia. New York, NY: Springer.

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Storandt, M. & Vendenbos, G. R. (Eds). (1999). Neuropsychological Assessment of Dementia and Depression in Older Adults: A Clinician’s Guide . Washington, DC: American Psychological Association.

Storandt, M. & Vendenbos, G. R. (Eds). (1999). Neuropsychological Assessment of Dementia and Depression in Older Adults: A Clinician’s Guide . Washington, DC: American Psychological Association.

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Moye, J., Butz, S. W., Marson, D. C., & Wood, E. (2007). A conceptual model and assessment template for capacity evaluation in adult guardianship. The Gerontologist, 47, 591- 603.

Moye, J., Butz, S. W., Marson, D. C., & Wood, E. (2007). A conceptual model and assessment template for capacity evaluation in adult guardianship. The Gerontologist, 47, 591- 603.

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Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.

Lichtenberg, P.A. (Ed.) (2010). Handbook of assessment in clinical gerontology (2nd edition). Burlington, MA: Academic Press.

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Kempler, D. (2005). Neurocognitive disorders in aging . Thousand Oaks, CA: Sage Publications.

Kempler, D. (2005). Neurocognitive disorders in aging . Thousand Oaks, CA: Sage Publications.

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American Psychological Association Task Force to Update the Guidelines for the Evaluation of Dementia and Age-Related Cognitive Decline. (2010). Guidelines for the evaluation of dementia and age-related cognitive change. Washington, DC: American Psychological Association. http://www.apa.org/pi/aging/resources/dementia-guidelines.pdf

American Psychological Association Task Force to Update the Guidelines for the Evaluation of Dementia and Age-Related Cognitive Decline. (2010). Guidelines for the evaluation of dementia and age-related cognitive change. Washington, DC: American Psychological Association.    http://www.apa.org/pi/aging/resources/dementia-guidelines.pdf

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American Bar Association Commission on Law and Aging & American Psychological Association. (2008). Assessment of older adults with diminished capacity: A handbook for psychologists. Washington, DC: American Bar Association and APA. http://www.apa.org/pi/aging/programs/assessment/capacity-psychologist-handbook.pdf

American Bar Association Commission on Law and Aging & American Psychological Association. (2008). Assessment of older adults with diminished capacity: A handbook for psychologists. Washington, DC: American Bar Association and APA.   http://www.apa.org/pi/aging/programs/assessment/capacity-psychologist-handbook.pdf

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MEASURES OF DEMENTIA

Look at the extensive assessment database of geriatric measures from the University of Alabama’s Alabama Research Institute on Aging! Register for access to the database HERE.

TREATMENT OF DEMENTIA

McCurry, S.M. & Drossel, C. (2011). Treating dementia in context: A step by step guide to working with individuals and families. Washington DC: American Psychological Association Press.

McCurry, S.M. & Drossel, C. (2011). Treating dementia in context: A step by step guide to working with individuals and families. Washington DC: American Psychological Association Press.

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de Souto Barreto, P., Lapeyre-Mestre, M., Vellas, B., & Rolland, Y. (2013). Potential underuse of analgesics for recognized pain in nursing home residents with dementia: A cross-sectional study. PAIN, 154(11), 2427-2431.

de Souto Barreto, P., Lapeyre-Mestre, M., Vellas, B., & Rolland, Y. (2013). Potential underuse of analgesics for recognized pain in nursing home residents with dementia: A cross-sectional study. PAIN, 154(11), 2427-2431.

Posted in reference | Tagged , , | Comments Off on de Souto Barreto, P., Lapeyre-Mestre, M., Vellas, B., & Rolland, Y. (2013). Potential underuse of analgesics for recognized pain in nursing home residents with dementia: A cross-sectional study. PAIN, 154(11), 2427-2431.

Ballard, C., Hanney, M. L., Theodoulou, M., Douglas, S., McShane, R., Kossakowski, K . . . Yu, L. (2009). The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial. The Lancet Neurology, 8(2), 151-157. doi: 0.1016/S1474-4422(08)70295-3

Ballard, C., Hanney, M. L., Theodoulou, M., Douglas, S., McShane, R., Kossakowski, K . . . Yu, L. (2009). The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial. The Lancet Neurology, 8(2), 151-157. doi: 0.1016/S1474-4422(08)70295-3

Posted in reference | Tagged , , | Comments Off on Ballard, C., Hanney, M. L., Theodoulou, M., Douglas, S., McShane, R., Kossakowski, K . . . Yu, L. (2009). The dementia antipsychotic withdrawal trial (DART-AD): Long-term follow-up of a randomised placebo-controlled trial. The Lancet Neurology, 8(2), 151-157. doi: 0.1016/S1474-4422(08)70295-3

Teri, L., McCurry, S. M., Logsdon, R., & Gibbons, L. E. (2005). Training community consultants to help family members improve dementia care: a randomized controlled trial. Gerontologist, 45(6), 802-811.

Teri, L., McCurry, S. M., Logsdon, R., & Gibbons, L. E. (2005). Training community consultants to help family members improve dementia care: a randomized controlled trial. Gerontologist, 45(6), 802-811.

Posted in reference | Tagged , | Comments Off on Teri, L., McCurry, S. M., Logsdon, R., & Gibbons, L. E. (2005). Training community consultants to help family members improve dementia care: a randomized controlled trial. Gerontologist, 45(6), 802-811.

Maher, A. R., & Theodore, G. (2012). Summary of the comparative effectiveness review on off-label use of atypical antipsychotics. Journal of Managed Care in Pharmacy, 18(5 Suppl B), S1-20.

Maher, A. R., & Theodore, G. (2012). Summary of the comparative effectiveness review on off-label use of atypical antipsychotics. Journal of Managed Care in Pharmacy, 18(5 Suppl B), S1-20.

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Lovell, B. B., Ancoli-Israel, S., & Gevirtz, R. (1995). Effect of bright light treatment on agitated behavior in institutionalized elderly subjects. Psychiatry Research, 57(1), 7-12.

Lovell, B. B., Ancoli-Israel, S., & Gevirtz, R. (1995). Effect of bright light treatment on agitated behavior in institutionalized elderly subjects. Psychiatry Research, 57(1), 7-12.

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Heard, K., & Watson, T. S. (1999). Reducing wandering by persons with dementia using differential reinforcement. Journal of Applied Behavioral Analysis, 32(3), 381-384. doi: 10.1901/jaba.1999.32-381

Heard, K., & Watson, T. S. (1999). Reducing wandering by persons with dementia using differential reinforcement. Journal of Applied Behavioral Analysis, 32(3), 381-384. doi: 10.1901/jaba.1999.32-381

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Ayalon, L., Gum, A. M., Feliciano, L., & Arean, P. A. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188. doi: 10.1001/archinte.166.20.2182

Ayalon, L., Gum, A. M., Feliciano, L., & Arean, P. A. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188. doi: 10.1001/archinte.166.20.2182

Posted in reference | Tagged , | Comments Off on Ayalon, L., Gum, A. M., Feliciano, L., & Arean, P. A. (2006). Effectiveness of nonpharmacological interventions for the management of neuropsychiatric symptoms in patients with dementia: a systematic review. Archives of Internal Medicine, 166(20), 2182-2188. doi: 10.1001/archinte.166.20.2182

Ravdin, L.D. & Katzen, H. L. (Eds.). (2013). Handbook on the neuropsychology of aging and dementia. New York, NY: Springer.

Ravdin, L.D. & Katzen, H. L. (Eds.). (2013). Handbook on the neuropsychology of aging and dementia. New York, NY: Springer.

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Terri, L., Logsdon, R. C., Uomoto, J. & McCurry, S. M. (1997). Behavioral Treatment of Depression in Dementia Patients: A Controlled Clinical Trial. Journals of Gerontology: Series B, 52B (4), 159-166.

Terri, L., Logsdon, R. C., Uomoto, J. & McCurry, S. M. (1997). Behavioral Treatment of Depression in Dementia Patients: A Controlled Clinical Trial. Journals of Gerontology: Series B, 52B (4), 159-166.

Posted in reference | Tagged , , , , | Comments Off on Terri, L., Logsdon, R. C., Uomoto, J. & McCurry, S. M. (1997). Behavioral Treatment of Depression in Dementia Patients: A Controlled Clinical Trial. Journals of Gerontology: Series B, 52B (4), 159-166.

Rabinowitz, Y. G., Mausbach, B. T., Thompson, L. W., & Gallagher-Thompson, D. (2007). The relationship between self-efficacy and cumulative health risk associated with health behavior patterns in female caregivers of elderly relatives with Alzheimer’s dementia. Journal of Aging and Health, 19, 946-964. doi: 10.1177/0898264307308559.

Rabinowitz, Y. G., Mausbach, B. T., Thompson, L. W., & Gallagher-Thompson, D. (2007). The relationship between self-efficacy and cumulative health risk associated with health behavior patterns in female caregivers of elderly relatives with Alzheimer’s dementia. Journal of Aging and Health, 19, 946-964. doi: 10.1177/0898264307308559.

Posted in reference | Tagged , , | Comments Off on Rabinowitz, Y. G., Mausbach, B. T., Thompson, L. W., & Gallagher-Thompson, D. (2007). The relationship between self-efficacy and cumulative health risk associated with health behavior patterns in female caregivers of elderly relatives with Alzheimer’s dementia. Journal of Aging and Health, 19, 946-964. doi: 10.1177/0898264307308559.

Mace, N. & Rabins, P. V. (2001). The 36-Hour Day: A Family Guide to Caring for Persons With Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life . New York: Warner Books.

Mace, N. & Rabins, P. V. (2001). The 36-Hour Day: A Family Guide to Caring for Persons With Alzheimer Disease, Related Dementing Illnesses, and Memory Loss in Later Life . New York: Warner Books.

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