Patient Education and Counseling 73 (2008) 8–21

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Patient Education and Counseling

journal homepage: www.elsevier.com/locate/pateducou

Mini-review

Therapeutic communication training in long-term care institutions:

Recommendations for future research
Lené Levy-Storms a,b,*
a
University of California, Los Angeles, Schools of Public Affairs and Medicine, Departments of Social Welfare & Medicine/Geriatrics,
Borun Center for Gerontological Research, Los Angeles, CA, United States
b
Jewish Home for the Aging of Greater Los Angeles, Reseda, CA, United States

A R T I C L E I N F O A B S T R A C T

Article history: Objective: The purpose of this review is to critique contemporary experimental research and to
Received 22 September 2007 recommend future directions for research interventions on nursing aides’ therapeutic communication
Received in revised form 2 May 2008 with older adults who have cognitive impairment and/or dementia in institutional long-term care
Accepted 25 May 2008
settings.
Methods: This literature review covers 13 journal articles (1999–2006) and focuses on the strengths and
Keywords:
weaknesses of experimental research interventions to improve nursing aides’ therapeutic communica-
Communication
tion with older adults who have cognitive impairment and/or dementia in long-term care settings.
Long-term care
Nursing home Results: Based on this review, recommendations for improved experimental designs include a minimum
Nursing aides of two groups with one being a control and randomization of subjects at the care unit level, an average 3–
Dementia 5 h of total training, a minimum of a 6-month total evaluation period, and objective outcomes relevant to
Training both nursing aides and residents. Findings from studies in this review indicate that the following
therapeutic communication techniques can be taught and can benefit staffs and older adults’ quality of
life: verbal and non-verbal communication behaviors including open-ended questions, positive
statements, eye contact, affective touch, and smiling.
Conclusions: Some evidence exists to support that nursing aides can improve their therapeutic
communication during care.
Practice Implications: Nursing aides need not only more training in therapeutic communication but also
ongoing, dedicated supervision in psychosocial aspects of care.
ß 2008 Elsevier Ireland Ltd. All rights reserved.

1. Introduction
Licensed long-term care institutions face ongoing concerns
with labor costs and efforts to address extensive regulations. This is
especially true for the most regulated of all long-term care
institutions, nursing homes (NHs), where training frontline, direct-
care staffs rank relatively low in priority [1]. Despite the 1987
Federal Omnibus Budget Reconciliation Act’s (OBRA) precedent-
setting initiatives to train certified nursing aides (NAs) in
therapeutic care, continuing education in long-term care remains
problematic. According to a systematic review, these problems
include organizational and systemic barriers to implementing
educational programs and a lack of systematic standards for
* Correspondence at: UCLA School of Public Affairs-Soc Wel, BOX 951656, 5226
Pub Policy Bldg, Los Angeles, CA 90095-1656, United States. Tel.: +1 310 825 7388;
fax: +1 310 206 7564.
E-mail address: llstorms@ucla.edu.
evaluating efforts to address these initiatives [2]. For example, the
high turnover rates among NAs represent one systemic barrier [3],
but improving educational programs must continue because of
NAs’ vital role in the quality of care and the quality of life of older
adults.
Although NAs and other frontline staffs provide 90% of direct
care in NHs [4], they initiate little communication during
interaction with the older adult residents [5,6]. Their interaction
with residents who have dementia is less frequent and poorer in
quality compared with residents who do not have dementia [7].
About 50% of the older population with dementia live in NHs [8],
and 75% of residents in NHs have dementia [9]. Residents have
varying degrees of sensory and cognitive impairments, which not
only exacerbate the risk of poor communication but also require a
higher level of purposeful communication that is therapeutic [10].
However, therapeutic communication has not been consis-
tently defined [11]. van Servellen [23] defines therapeutic
communication as an: ‘‘. . .interpersonal exchange, using verbal
and non-verbal messages, that culminates in someone’s being

0738-3991/$ – see front matter ß 2008 Elsevier Ireland Ltd. All rights reserved.
doi:10.1016/j.pec.2008.05.026
 L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21
helped to overcome stress, anxiety, fear, or other emotional
experiences that cause distress (p. 30).’’ Thus, for the purpose of
this review, the concept of therapeutic communication will be
operationalized as a variety of emotion-oriented approaches
including, person-centered care, cultural competence, dementia
skills, emotion-oriented care, and behavioral management skills
[12–15]. Such therapeutic notions of communication pale upon
considering how the institutional culture emphasizes technical or
custodial care. Such an emphasis may represent an organizational
barrier and only exacerbates the low frequency and poor quality of
staff communication with residents [2,16,17].
Residents value personal relationships and social interaction
[18,19], but few concrete strategies exist about how to facilitate
and optimize social interaction and interpersonal communication
between the diverse frontline long-term care staff and residents.
Still, federal guidelines recommend that frontline long-term care
staff take remedial action to engage in enhanced non-verbal
interactions with residents to compensate for residents’ commu-
nication deficits, regardless of whether they perceive that residents
will be responsive [20]. OBRA also requires that all NA certification
training programs have a minimum of 75 h of training [21,22], but
only a few hours address specifically on interpersonal skills. Yet,
communication is the hallmark to quality of care [23], and NAs
have rated communication skills as their number one learning
need in a survey on expected areas of work proficiency [24,25].
Therapeutic communication during care may affect both
quality of care and quality of life of older adults in institutional
long-term care settings. The purpose of this review is to critique
contemporary experimental research and to recommend future
directions for research interventions on NAs’ therapeutic com-
munication with older adults who have cognitive impairment and/
or dementia in institutional long-term care settings.
2. Methods
PubMed, CINAHL, Ageline, and PsychInfo academic databases
were searched for journal articles only (i.e., no books, book chapters,
dissertations, or reports) with the terms: nurse aide OR direct-care
worker OR nurse assistant OR healthcare assistant AND commu-
nication AND training. Because of a number of related literature
reviews [12,15,26–29], only empirical, peer-reviewed articles
published between the dates 1/1/99 and 12/31/06 were included.
Across these databases, a total of 190 articles were retrieved.
These 190 abstracts were reviewed for the following additional
criteria: (1) subjects included, but not exclusively, nursing assistants
in an institutional long-term care setting; (2) there was an
experimental intervention that addressed some aspect of ther-
apeutic communication directly or indirectly (see earlier definition
and operationalization of concept); and (3) the design included some
controls (e.g., a group or a pre-/post-design at a minimum). Because
of the noted tendency for poor grade, scientific evidence, no
observational studies (quantitative or qualitative) were reviewed
[2]. From the preliminarily retrieved 190 articles, 8 met these final
criteria for inclusion. In addition, five articles that met these criteria
for inclusion were identified through ‘‘related articles’’ links. These
articles were reviewed in detail for the following components:
(1) Sample and setting—sample sizes of individuals, wards/units,
and facilities; the consent, response, and/or attrition rates, if
reported.
(2) Design—whether the study had a randomized, delayed control
group or not and/or self-controls (i.e., pre-/post-tests) and
whether blinding occurred.
(3) Intervention—the structure of the training such as the length of
the sessions and how and what materials were presented (i.e.,
9
credentials of trainers, use of videotape, experiential, home-
work, etc.).
(4) Measurement—whether each variable was subjective (e.g.,
survey) or objective (e.g., based on direct observation),
duration of observational measures, follow-up period (if
any), affect and/or behavioral scales used, and covariates
measured.
(5) Analysis—core analysis strategy, scaling of variables (e.g., rates
or means), inter-rater reliability statistics, and controlling for
design effects or exploring them with multi-level analysis.
(6) Results—significant findings specific to nursing aides and/or
other paraprofessional/unlicensed institutional long-term care
staff.
Table 1 displays these key components of each study in this
review and pertains to Parts I and II of the results below. In Part II,
the articles were also reviewed for the content of the training
intervention.
3. Results
3.1. Overview
The paucity of experimental studies on training NAs to
communicate with institutional long-term care residents is a
finding. If confined to the U.S. only, 8 studies qualified according to
the criteria in the current study. Among these 13 controlled
studies, 8 randomized subjects or higher level units such as the
ward/unit or facility. Only one study reported actual consent rates
specifically for NAs, whereas the remaining studies either did not
report consent rates at all or did not distinguish among types of
nursing staff. Nine studies developed an intervention to explicitly
address communication, and, of these, three were from the same
set of authors and one major study. Two studies used objective
raters of NAs’ behaviors and reported inter-rater reliability
statistics, but only one of these reported using blinded raters.
One study asked residents about their perceptions of the NAs’ care
quality. Effect sizes for the 13 studies, although some were
statistically significant, were clinically small based on reported
unweighted differences (see Table 1: Results). The largest effect
size was a Cohen’s d of .5 but the measures from this study were all
self-report, survey-based.
With this overview presented, the first part of the results will
synthesize unique issues related to the results from evaluating
communication training programs in institutional long-term care
settings. These unique issues pertain to the systematic barriers to
randomized controlled group designs, whether to train only direct-
care or the entire staff, and nested data in institutional long-term
care research studies.
3.2. Part I
3.2.1. The systemic barriers to randomized, control group designs
3.2.1.1. Consent versus participation. Relatively little detail exists in
any of the studies reviewed about the unique issues related to
consenting human subjects in long-term care settings. The lack of
such detail leaves generalizability of the findings unclear. Human
subjects may include licensed and unlicensed staff as well as
residents and their families. Most studies either did not mention
how staff were recruited [13,30] or bypassed recruitment
altogether by having the organization mandate participation as
part of their regular job duties [31–33]. Pillemer et al. [38] noted
that a ‘‘facility liaison’’ (usually the social worker) recruited staff
and families, but they provided no details on exactly how this
 10
Table 1
Matrix of the reviewed studies with planning and evaluation components

Author Setting/sample Design Total time Intervention Measurement Analysis Results

frame of
intervention
and evaluation
a
Burgio Consent rates: Type of design: RCT 5 Months total Length: 3 h Type of measure: Focal analysis strategy: CNAs in Experimental group
et al. [13] residents = 42% Blinded: not reported Facilitator: Lic Clin Self-report survey; mixed factor ANOVA increased in their average
# Facilities: 5 Curricula/materials: Psychologist in-person observations 2 group by 3 time rate per hour use of
nursing homes memory books # Measurement with no adjustment positive statements
# Staff: CNAs = 64 periods: 3 with 2 times for multiple compared to CNAs in the
# Residents: 67 per period; minimum 5 comparisons control group with
Attrition rates: min period of interaction Scale of variables: differences being about
CNAs (35%); Scales: Residents- mean rate per hour 30 at post-test I, 40 at
residents (29%) MMSE, FIM Unit of analysis: post-test 2, and 60 at
nurses aides and post-test 3 (p < .05 all
residents separately three points).

L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21

a
Roth et al. [32] Consent rates: Type of design: 3 Months Length: 5 h in- Type of measure: in-person Focal analysis strategy: The median odds of CNAs’
not reported Pre/post only service and 3 observations Wilcoxon Signed Rank verbal prompts decreased
# Facilities: 2 Blinded: not weeks on the # Measurement periods: Test with Phi from 1.82 to 0.92 (p = .04),
nursing homes reported job training four interactions pre- Coefficient indicating that the odds
# Staff: CNAs = 87 Facilitator: not and post-training with Scale of variables: of resident agitation
# Residents: pre = reported average observation time Median rate per hour beginning during verbal
30; post = 20 Curricula/materials: of 10 min per session Unit of analysis: prompting or within 10 s
Attrition rates: – Behavior across several ADLs (e.g., Resident after a verbal prompt
management and dressing, grooming, Inter-rater were reduced by
communication transferring, and toileting) reliability: n/a approximately half
skills training Scales: not used Adjust S.E.: no after training
program

a
Burgio Consent rates: Type of design: 8 Months Length: 4 weeks of Type of measure: Self- Focal analysis strategy: Knowledge of basic management
et al. [31] Residents = 62% RCT in-service with 5 h report survey; in-person 2 by 2 ANOVA with skills increased from a mean of
# Facilities: 2 Blinded: – during week 1 and observations main effects of time 80.74–91.45 (p < .001) in FSM
nursing homes 13 LPNs were hands-on # Measurement then used ANCOVA group. Significant decreases in
# Staff: CNAs supervisors observation and periods: 4 to compare groups’ ineffective strategies occurred
= 106 implementing feedback for one Scales: Behavioral change scores with (mean of .20–.09; p < .05) in
# Residents: 88 management care episode per management skills baseline score as FSM but not increases in
Attrition rates: programs or nurse aide checklist (BMSC), covariate effective strategies. CNAs in
Residents = 10%; formal staff Facilitator: not computer-assisted behavior Scale of variables: both FSM and CSM groups
CNAs = 20% management reported observation system mean rate per hour increased in their use of positive
(FSM) versus Curricula/Materials: (CABOS), and Cohen- Unit of analysis: statements from pre- to
conventional staff Behavior management Mansfield Aggression nurses aides and post-tests (p < .001). At the
management (CSM) and communication Index (CMAI) residents separately 6-month follow-up, the FSM
skills training program Inter-rater reliability: group had higher change rates
with content including Kappa values ranged of positive statements maintained
videotaped depiction/ from 0.69 to 0.88 than the CSM group (+38 per
Discussion of written for care interaction hour versus +20 per hour,
vignettes/a workbook observations and respectively)
from 0.71 to 0.82
for time-sampling
Table 1 (Continued )
Author Setting/sample Design Total time Intervention Measurement Analysis Results
frame of
intervention
and evaluation
a
Caris-Verhallen Consent rates: Type of design: <1 Year Length: 2 day Type of measure: Focal analysis strategy: In the home for the elderly: nurses
et al. [30] # Facilities: Total Quasi-Exp introductory course; Self-report survey; Hierarchical Linear in the experimental group were
2: 1 home care Blinded: – six small group in-person observations; Modeling with MLn rated as more interested (+.48;
and 1 home for sessions with trainer video/audiotaping to compare within- p < .01); involved (+.29; p < .05);
the elderly in and peers present for # Measurement and between-groups’ and warm (+.51; p < .001) during
the Netherlands feedback; sessions periods: 2 pre- and post- the post-test. No other measured
# Staff: Nurses alternated at 6-week Scales: RIAS (proportion test changes changes in verbal or non-verbal
= 47 intervals with of total utterances); Scale of variables: communication were significant
# Residents: homework assignments micro-non-verbal mean duration, for the experimental group in
picked by Facilitator: yes behaviors (e.g., eyegaze, percent of the home for the elderly
nurses and Curricula/Materials: nodding, smiling, forward utterances, interval
variable general communication, leaning and touch) and affect ratings
Attrition rates: video interaction macro affect (e.g., warmth, Unit of analysis:

L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21

Nurses = 15% analysis and role playing interest, involvement, dyadic encounters
with simulated patients patronizing, irritability, of nurse aides and
residents holistic needs, nervousness, assertiveness)— older adults
verbal communication expressed as proportions of Inter-rater
techniques (e.g., observed time; patient reliability: .
paraphrasing, measures were comparable 70–.98 Pearson’s r
encouraging behaviors, Adjust S.E.: yes
open-ended questions)
and non-verbal behaviors
(e.g., eye contact, head
nodding, forward leaning)

a
Finnema Consent rates: – Type of design: About 2 years Length: 9 months Type of measure: Self- Focal analysis strategy: NAs in the experimental group
et al. [14] # Facilities: 14 RCT Facilitator: train the report survey ANCOVA with who reported to apply more
nursing homes Blinded: – trainer model # Measurement baseline measures emotion-oriented care skills at
in the Netherlands Curricula/Materials: periods: 2 as covariates Scale the time of the final measurement
# Staff: nurse emotion-oriented Scales: Residents: of variables: ordinal than during the baseline
assistants = 99 approaches as a behavioral and/or mood and interval scales measurement showed fewer
# Residents: 146 supplement to care based with BIP, Cornell Unit of analysis: stress reactions (GHQ-28) than
Attrition rates: on the medical model; Depression Scale in nurses aides and the nursing assistants in the
nursing assistants basic course for 2 days Dementia; CMAI, Geriatric residents separately control group, who felt they had
= 21%; residents (emphasized non-verbal Resident Goal Scale; and Inter-rater improved regarding these skills
= 25% empathic skills) with the Philadelphia Geriatric reliability: n/a (.37 less stress in experimental
additional advanced Center Morale Scale Adjust S.E.: n/a versus 2.33 more stress in
courses for fewer staff Assessment control; p = .003)
who would serve Scale for Elderly Patients,
as advisers ASEP); Nursing aides –
Jalowiec Coping Scale, The
Organization and Stress
Scale, The General Health
Questionnaire (GHQ-28),
Dutch Work Satisfaction
Scale

11
 12
Table 1 (Continued )
Author Setting/sample Design Total time Intervention Measurement Analysis Results
frame of
intervention
and evaluation
a
Pillemer Consent rates: – Type of design: 7 Months with Length: 7 h total with Type of measure: Self- Focal analysis Perceptions of staff empathy by
et al. [38] # Facilities: 20 RCT 1 day intervention approximately 1 day report survey strategy: 3  3 families increased from baseline
nursing homes Blinded: – for staff for staff and 2 half # Measurement repeated-measures to 2-month post-test (0.16 increase
# Staff: 655 days for family periods: 3 design (treatment versus 0.27 decrease in treatment
# Residents: n/a Facilitator: – Scales: Family-Interpersonal  time) used GLM and control groups, respectively;
# Family: 932 Curricula/Materials: Confict Scale; Staff with mixed model p = .04) and again to the 6-month
Attrition rates: Parallel training sessions Behaviors Scale, Staff methods to allow post-test for those in treatment
staff = 20%; on communication and Empathy Scale, Zarit Burden the use of data at group but not the controls (0.07

L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21

family = 16% conflict resolution Scale; Nursing aides-CES-D,
Family Behaviors Scale,
Family Empathy Scale
one time point increase versus 0.20
even when other decrease; p = .03)
time points are
missing
Scale of variables:
ordinal scales
Unit of analysis:
nurses aides and
family separately
Inter-rater
reliability: n/a
Adjust S.E.: n/a

a
Irvine Consent rates: – Type of design: Self-paced but Length: 1 h per video Type of measure: Self- Focal analysis Knowledge levels increased
et al. [39] # Facilities: Total RCT doable in a day but one was interactive report survey strategy: repeated significantly (p < .001): IMM
2: 1 nursing Blinded: – and thus varied in # Measurement measures ANOVA group scored a mean of 3.41
home and 1 time to completion periods: 2 on the total number (S.D. = 1.35) on correct responses
senior center Facilitator: – Scales: satisfaction of correct versus videotape lecture group
# Geographical Curricula/Materials: and self-efficacy responses to video scored 2.25 (S.D. = 1.18) at
sites: 2 4 modules of an vignettes post-test. Cohen’s f = .51
# Staff: 88 (mix interactive multimedia Scale of variables:
of professional (IMM) compared to a ordinal and interval
caregivers and standard VHS recorded Unit of analysis:
paraprofessional in-service on the same caregivers
caregivers) content (i.e., speaking Inter-rater
# Residents: n/a skills; reacting skills; reliability: n/a
Attrition rates: – redirection; Adjust S.E.: n/a
communication cards)
with pre- and post-test
quizzes
Table 1 (Continued )
Author Setting/sample Design Total time Intervention Measurement Analysis Results
frame of
intervention
and evaluation
a
McCallion Consent rates: Type of design: 6 Months with Length: five 45-min Type of measure: Focal analysis No change in nurse aides’
et al. [3] nursing RCT crossover group sessions and Self-report survey strategy: Student’s knowledge of Alzheimer’s.
assistants = 98% Blinded: – four 30 min individual # Measurement t-test for baseline Ability to manage behavior
# Facilities: 2 sessions with make periods: 4 and Chi-squared. problems in general and
nursing homes up sessions possible Scales RERMS or random specifically agitation improved
# Staff: nursing Facilitator: – Residents – MMSE; GDS; effects regression from baseline to 3 (+.19) and
assistants = 88 Curricula/Materials: CMAI, Cornell Depression models for the 6 (+.38) months (p < .01)
# Residents: 115 Nursing Assistant Scale in Dementia; effects of
Attrition rates: – Communication Skills MOSES; nurse aides:, condition and

L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21

Program (NACSP); topics
included: (1) stages of
dementia; (2) review of
verbal and non-verbal
communication strategies,
(3) memory aids, (4)
problem behaviors. A
MSW was trained and
delivered the intervention.
Individual sessions
alternated with the group
sessions and were on
the floor in real situations
Knowledge of time
Alzheimer’s Test Scale of variables:
(KAT), Penn State Mental nurses aides and
Health Questionnaire residents separately
(MHQ) Interval/# correct;
ordinal
Unit of analysis
Inter-rater
reliability: n/a
Adjust S.E.: n/a

a
van Weert Consent rates: Type of design: 19 Months Length: four, weekly, Type of measure: Self- Focal analysis strategy: CNAs improved more in the
et al. [33] Residents = 84% Quasi-Exp 4 h in-service sessions report survey; in-person Differences between experimental than in the
# Facilities: 6 Blinded: yes and homework + two observations; video/ pre and post and exp control group in eye-contact
nursing homes general meetings with audiotaping; chart review groups was done (121.96 s difference between
# Staff: CNAs = 117 supervisory staff (e.g., # Measurement with chi-square or pre-/post-tests; p < .001),
# Residents: 129 head nurses) and 3 in- periods: 2 t-tests; used MLwiN affective touch (44.16 s
Attrition rates: house supervision Scales: RIAS (Roter Scale of variables: difference; p < .001), smiling
CNAs = 30%; meetings with the Interaction Analysis interval and 2.87 times difference; p < .05),
Residents = 40% trainer System) percent utterances and number of affective
Facilitator: yes Unit of analysis: dyad utterances (19.15; p < .001)
Curricula/Materials: Inter-rater reliability:
Trained in snoezelen or mean Pearson’s r:
emotion-oriented care .93 for non-verbal
and .84 for verbal
Adjust S.E.: yes

13
 14
Table 1 (Continued )
Author Setting/sample Design Total time Intervention Measurement Analysis Results
frame of
intervention
and evaluation
a
McGilton Consent rates: Type of design: About 1 year Length: Sessions were Type of measure: Focal analysis Residents’ perceptions of staff:
et al. [36] Residents = 92%; Quasi-Exp 15–20 min and took Self-report survey strategy: Independent Relational Care scale improved
Nurses = 93% Blinded: no place over 7 months. # Measurement t-tests for baseline 3.8 units in Intervention versus
# Facilities: 1 3 sessions were for periods: 2 data; and repeated decreased .9 in Control
nursing home licensed staff and 5 Scales: Residents- measures ANOVA Group (p = .014)
# Staff: 32 (mix were for unlicensed Relational Care Scale for changes in each aCare providers: Relational
of licensed and staff Relationship visual analog group’s outcomes Behavior Scale increased .3
unlicensed) Facilitator: n/a scale; Care providers- over time in Intervention versus
# Residents: 90 Curricula/Materials Relational Behavior Scale; Scale of variables: decreased .2 in Control Group
(40 observed Theoretical foundation Continuity Index = # of interval scales
only and 50 for intervention was times a care provider Unit of analysis:
interviewed only) Winnicott’s theory of provided direct-care for nurses aides and

L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21

Attrition rates: relationships (e.g., a resident on a day or residents separately
Residents = 10%; continuity, interactional evening shift relative t Inter-rater
Nurses = 8% skills, and support for the total shifts worked reliability: n/a
care provider). The in a 2-week period Adjust S.E.: n/a
content included: (1)
empathy; (2) putting
oneself in an old
person’s position; (3)
continuity in
assignments; (4)
resident profiles; (5)
sharing resident profiles

a
Stevens-Roseman Consent rates: – Type of design: >1 Year total Length: 7 modules Type of measure: Focal analysis strategy: Findings were inconsistent
and Leung [34] # Facilities: 4 Pre/post only Facilitator: Geriatric Self-report survey ANOVA was used but with some items decreasing
# Staff: 74 Blinded: no Social Worker # Measurement only pre- and from pre- to post-test one
# Residents: n/a Curricula/Materials: periods: 2 post-test groups
Attrition rates: n/a Topics included: Scales: Attitude toward were compared
relationship building; Elderly People Scale of variables:
communication with Questionnaire, Knowledge interval scales
elders with memory and Skills, Client Unit of analysis:
loss; chronic pain satisfaction instrument nurse aides
effects on attitude; Inter-rater
depression in the elderly; reliability: n/a
working with older Adjust S.E.: yes, for
clients and their multiple testing
families; self-care of
the paraprofessional
care provider; community
resources for elders
living alone; Structure
of Intervention included
case studies and
role playing
Table 1 (Continued )
Author Setting/sample Design Total time Intervention Measurement Analysis Results
frame of
intervention
and evaluation
a
Schrijnemaekers Consent rates: – Type of design: Approximately Length: 6 days with 2–4 Type of measure: Focal analysis strategy: Linear trend analyses were
et al. [35] # Facilities: 16 RCT 2 years week with breaks in Self-report survey Hierarchical Linear in favor of the intervention
nursing homes Blinded: – between and 4 months of # Measurement periods: 4 Modeling group. Of these, four were
# Staff: 300 supervision meetings Scales: Maastricht Work Unit of Analysis: nurses statistically significant

L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21

nurse aides Facilitator: Yes, but
# Residents: n/a credentials not presented
Attrition rates: 20% Curricula/Materials: Topics
included: dementia
syndromes, care models,
caregiver-resident
relations, attitude and
non-verbal communication;
structure included
lecturing, homework,
exercises, video
presentations, and role playing
Satisfaction Scale for
Healthcare (MAS-GZ)
aides nested within wards
within homes
Inter-rater reliability: n/a
Adjust S.E.: Yes
(p < .05): the job satisfaction
subscale ‘‘opportunities for
self-actualization,’’ the short
version of the job satisfaction
scale, the study-specific
satisfaction item ‘‘contact
with residents,’’ and the
subscale ‘‘personal
accomplishment’’ of the
burnout questionnaire
Change analyses over time period
had modest effects but mostly
after 12 months (p < 05)

a
Peterson Consent rates: – Type of design: Approximately Length: One 6-h class; Type of measure: Focal analysis strategy: CNAs’ knowledge about dementia
et al. [37] # Facilities: 750 Pre/post only 8 months offered a total of 10 over Self-report survey Changes in pre- and improved by 10% from pre-test to
long-term care Blinded: – 6 months # Measurement post-tests controlling post-tests (p = .000); CNAs’ pass
facilities Facilitator: Yes, but may periods: 3 for education, prior rates increased by 42% at post-test
# Staff: 51 nurse be CNA or RN credentialed Scales: Dementia Quiz; training, and experience 1 (p = .009) and 52% at post-test 2
aides; 21 licensed Curricula/Materials: Topics Formal Caregiver Stress Unit of Analysis: CNAs (p = .041). These improvements
staff included: physiology of Index; Reciprocal and RNs were even better among CNAs
# Residents: n/a dementia; coping with Empowerment Scale Inter-rater reliability: n/a with less education and less
Attrition rates: 14% challenging behaviors Adjust S.E.: No experience compared to those
(sensitization and with more education and more
communication exercises); experience
and performing ADLs
(brainstorming and role
playing)

Note: ‘‘-’’ means the item was not reported; S.E.: standard error; n/a means the item was not applicable to the study design; RCT: randomized controlled trial.
a
Results focus on only the non-licensed, institutional long-term care staff given the purpose of this study.

15
16 L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21
occurred. Irvine et al. [39] noted the use of posted notices and
‘‘word-of-mouth’’ in addition to in-service announcements plus a
$20 incentive, but, again, without details. One study reported only
that a wide range of paraprofessionals ‘‘signed up’’ [34], and two
other studies reported using selection criteria for staff including
age, education, and number of years working with residents with
dementia [14,35].
Of two studies that actually reported staff consent or
participation rates, neither presented both or differentiated by
licensure and/or shift. The highest consent rate among NAs was
98% with similar rates across two ‘‘volunteer’’ and ‘‘public’’ homes
[3]. In a Canadian study, among eligible staffs, 34 (93%) consented.
Although no detail exists on how consents were obtained, some
details on non-consenters included mistrust of research, potential
breach of confidentiality, and maternity leave [36].
Among studies reporting resident consent rates, these included
92% for Canadian residents [36], and about 84% for Dutch residents
[33]. One Dutch study selected 50% of 387 residents from
participating wards based on eligibility criteria, but it is not clear
whether these were the only selection criteria and/or whether
residents were consented [14]. Among studies reporting only
participation rates, certified NAs’ participation rate was 80%
[31,35,37] and the families’ participation rate was 41% [38]. One
study had the staff invite the residents (excluded very sick,
terminally ill, and those with dementia) and reported a resident
participation rate of 50% at pre-test and 75% at post-test [30]. The
few details and statistics on the NAs’ consent rates suggest that the
generalizability of most of these studies to all NAs is questionable.
3.2.1.2. Unit of observation: individual versus group. Most of the
reviewed studies randomized or matched units/wards and not
individuals. Only one study had the unit of observation at the level
of individual NAs and/or other staff [37]. Three studies had
relatively unique evaluation designs and merit elaboration. The
first of those studies used different long-term care sites but still
randomized at the level of the individual [39]. The second study
used a within-group pre- and post-test design for select NAs and
residents in two nursing homes that were from a larger study
sample [32]. Like this second study, the third study did not have a
separate control group but the unit of analysis was the group.
Participants answered surveys anonymously in both pre- and two
post-tests [34]. The lack of observation at the individual level may
be one reason for the subsequent inconclusive results since within-
group comparisons were not possible. For example, the Peterson
et al. [37] study’s pre-/post-test results for knowledge changes
were significant for measures at the individual level.
3.2.2. Train one for all and all for one
3.2.2.1. Unit of treatment versus observation. In long-term care
settings, only staff and/or families’ communication behaviors can
potentially be changed, since most residents have communication
difficulties. When evaluating communication interventions aimed
at improving relationships, though, outcomes include staff, family,
and residents. So, the units of treatment (i.e., staff and families)
may not be exactly the same as the units of observation (i.e., staff,
families and residents).
Staff and/or family outcomes included their communication
behaviors [13,30–33], turnover rates [3], stress [14,37], knowl-
edge/attitudes [3,34,37,39], and relationships with residents [36],
family [38], or other staff [38]. The most commonly measured
resident outcomes included those related to agitation/behavioral
problems [3,13,31,32], and mental well-being or mood [3,14], but
some studies measured changes in residents’ communication
[30,33], perceived relationships with staff [36], and satisfaction
[34]. All but one study measured both types of resident, staff, and/
or family outcomes [39]. Most studies measured ‘‘primary’’
outcomes that were directly addressed by the intervention, but
some studies had ‘‘secondary’’ outcomes including staff turnover
rates [3], staff job satisfaction and burnout [35], and residents’
communication behaviors [30,33].
Several shortcomings of these studies’ outcomes merit men-
tioning. Despite these studies’ rigorous research designs, more
relied on self-report than on directly observable staff and family
outcomes. Because of the strong possibility of self-report bias,
independently observed behaviors represent a higher standard for
outcomes. While some studies relied solely on directly observable
behaviors [30,33], others measured both self-report and obser-
vable behaviors [13,31,32,36]. Further, some studies measured
only self-reported knowledge and attitudes without any beha-
vioral outcomes [3,14,34,35,37–39]. Because knowledge and
attitudes do not necessarily lead to behavior changes, these were
shortcomings.
3.2.3. Multi-level measures over time, multiple comparisons, and
clinical significance
3.2.3.1. Attrition and missing data. Subjects in institutional long-
term care settings are at high risk of attrition and/or missing data
for several reasons. First, residents tend to be frail and old, which
increases their risk of hospitalization or mortality. NAs have high
turnover rates and often call in sick [13]. Licensed staff and family
members either do not share these issues to the same extent or
have different issues. For example, family members may have work
commitments that could affect their participation in the study. The
studies reviewed varied in their staff and resident attrition rates
because of these and other reasons including eligibility criteria, the
time period of the intervention and evaluations, and use of
methods for ‘‘replenishing’’ those lost to follow-up.
All of the studies reviewed had an intervention and an
accompanying evaluation period that occurred over a period of
time (range: 1 day to about 2 years; Bimodal: about 6 months and a
year or longer). Five studies addressed the attrition and missing
data issues related to NAs and/or residents. The NA attrition rates
for four of these studies were similar and ranged from 14% to 21%
[14,30,35,37]. The fifth study’s attrition was not entirely clear
because the researchers replenished NAs lost to follow-up with
new NAs who met the study criteria, and noted that the new NAs
were similar between intervention and control groups [33]. In the
absence of valid consent rates, these attrition rates for NAs must be
viewed with caution. Finally, some reported that there were no
differences in NAs’ attrition between the experimental and control
groups [14,31,33,36].
The resident attrition rates were more varied than those for
NAs. They ranged from a low of 10% [31,36] over 20 months to a
high of 40% over a 19-month intervention and evaluation period
[33].
3.2.3.2. Nested data between- and within-groups. Classic research
designs with one (pre and post) or two (treatment and control)
comparison groups that ultimately lead to or allow multiple
comparisons need to be adjusted for multiple testing using
Bonferroni, Tukey, etc. Another possible layer of complexity exists
in analyzing data from long-term care settings, because data may
be nested.
Although several studies used various ANOVA techniques, only
one mentioned the use of multiple comparison tests [35]. With
regard to nested data, after determining that enough variation was
due to nesting within NAs using intra-class correlation coefficients,
three studies used hierarchical linear modeling to account for this
 L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21
variation in explaining the changes observed at the level of the
encounter or both the NAs and residents’ communication
behaviors [30,33,35]. Another form of nesting might occur when
data are collected on the same subjects over time. One study used a
random effects regression model (RERM) to account for when data
collected earlier may associate with data collected later [3], but
hierarchical linear modeling (HLM) may also be used. Since the
studies that used HLM did not mention nesting by time, it is not
clear whether HLM was used to adjust for nesting both within
facilities and within time simultaneously.
3.2.3.3. Clinical versus statistical significance of the magnitude of
improvement. Assessing the clinical importance of any statistically
significant findings may be done in two ways. First, one can
calculate the sample size needed for a clinically, meaningful effect
size. Two studies calculated either the effect size of their findings
or the sample size needed to achieve a large effect size of .5 using
Cohen’s d [39], but none of the reviewed studies’ final results
reported standardized effect sizes [33]. Another study reported a
sample size calculation for an effect size of 1.5, but the final results
were not statistically significant [35].
Among those studies reporting results on staffs’ observable
behavioral changes some of the largest changes from before to
after the intervention included: verbal communication—a differ-
ence between the experimental and control groups in the mean
rates per hour of simple one-step statements of 30, positive
statements of 57 [13] and social conversation (9 utterances) and
information (23 utterances) [33]; non-verbal communication—a
difference between the experimental and control groups in the
duration (in seconds) of eye contact (122) and affective touch (44)
and the frequency of smiling (5) [33]. Even though some of these
differences reported may appear to be large, it is not clear whether
the differences are clinically observable and meaningful to
consumers. That is, would consumers watching these improved
interactions notice a difference in their quality? None of the studies
reviewed here addressed this issue, so the clinical significance of
their findings is questionable.
3.3. Part II
The remaining results will synthesize the best evidence-to-date
for improving NAs’ therapeutic communication skills.
3.3.1. Evidence-to-date for therapeutic communication skills
All of the studies reviewed conducted some variation of a
therapeutic communication intervention. van Servellen [23]
defines therapeutic communication as an: ‘‘. . .interpersonal
exchange, using verbal and non-verbal messages, that culminates
in someone’s being helped to overcome stress, anxiety, fear, or
other emotional experiences that cause distress (p. 30).’’ Thus, for
the purpose of this review, the concept of therapeutic commu-
nication will be operationalized as a variety of emotion-oriented
approaches including, person-centered care, cultural competence,
dementia skills, emotion-oriented care, and behavioral manage-
ment skills [12–15]. This variety of references reflects the lack of a
universal term to address interpersonal communication skills in
long-term care settings [11]. The skills taught in the intervention
ranged from simple ‘‘tips’’ to relatively more abstract principles of
therapeutic communication.
While verbal and non-verbal communication skills may have
been taught in any of these interventions, both were not
necessarily evaluated and, therefore, not necessarily clearly
described in the intervention’s description or the measures. For
example, among the simplest skills were several types of verbal
statements including positive and negative, specific instructions,
17
one-step instructions, bibliographic statements, and verbal and
non-verbal distraction techniques [13,31,32]. However, the
published observational measures tested only for improvements
in verbal communication, so what composed distraction techni-
ques remains unclear. Noted improvements in verbal commu-
nication included an increase among NAs in the mean rate per hour
of positive statements (pre-/post-intervention difference = 30 and
18, respectively), in two separate studies [13,31]. Whether the
vocal non-verbal intonations, speech rate, etc., were embedded in
the evaluation of the verbal statements was not clear, since no
definition of positive and negative statements was presented. At
the other extreme were two studies that focused on ‘‘high level’’
communication for relationships between residents and their
caregivers, but neither specified the actual communication skills
used in their relationships including ‘‘empathy’’ [36] and ‘‘relation-
ship building’’ [34].
The bulk of the studies offered therapeutic interventions with a
moderate amount of detail on the actual communication skills
(e.g., [37]). One part of a larger intervention had a MSW-led
component on fostering supportive interactions with persons with
dementia via verbal and non-verbal communication strategies, but
did not specify these strategies [3]. Another study included four
interactive media modules on (1) speaking skills, (2) reacting skills,
(3) redirecting, and (4) communication cards. Speaking skills
focused on proper greetings that used the resident’s name and
introducing oneself, but the other three modules were not
described at all [39]. The last two studies focused on ‘‘emotion-
oriented care’’ which entailed instruction on the ego-experience of
the person with dementia and emphasized non-verbal empathetic
skills [14,35]. No details were provided on what specific behavioral
skills were involved except for a reference in Dutch [14]. Despite
the elaborate nature of these four studies’ interventions, none
measured communication directly in the outcomes of residents or
NAs; thus, no evidence exists for improvements in NAs’ actual
communication skills [37].
Two Dutch studies explicitly included verbal and non-verbal
communication skills in the training and evaluation. Thus, it was
clearer what communication skills the NAs were supposed to learn,
and whether or not they learned them. One study trained NAs in
verbal communication skills such as paraphrasing, open-ended
questions, and encouraging behaviors, and in non-verbal skills
including eye contact, head nodding, and forward leaning. Videos
of the participants were taken prior and used during the
intervention in which they met with a facilitator to review their
tapes. This training technique is called ‘‘video interaction analysis’’
[30]. Participants also engaged in role playing and peer feedback.
Although the authors measured a wide range of communication
behaviors, the results indicated that only two behaviors showed
improvement: nurses in the institutional setting provided patients
with more information about nursing and health topics, and they
used more open-ended questions. Consequently, they were also
rated as more involved, warmer, and less patronizing.
The second study focused on snoezelen (English transla-
tion = ‘‘sniffing and dozing’’) or multi-sensory stimulation care.
This care avoids intellectual stimuli, and, instead, is resident-
oriented and appeals to their senses (e.g., sight, hearing, smell,
etc.) [33]. According to the hypotheses, implementation of
snoezelen would result in an increase in rapport-building non-
verbal communication (e.g., eye gaze, affective touch, smiling)
and positive affective verbal communication (e.g., empathy, social
talk, validation or recognizing and accepting any emotion
displayed by residents). The results from this study included
both increases in desirable communication and decreases in
undesirable communication behaviors. Several improvements
occurred in non-verbal eye contact, affective touch, and smiling.
18 L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21
Increases in verbal positive affective (e.g., social, understanding,
agreement, and sensory topics) and positive instrumental
communication (e.g., information) occurred with negative com-
munication (e.g., knowledge topics) decreasing significantly in
the experimental groups.
In summary (see Table 1), evidence exists for NAs’ ability to
improve in the following specific verbal and non-verbal ther-
apeutic communication behaviors: (1) Verbal—positive statements
and one-step instructions [13,31]; open-ended questions and
information topics [30,33]; and social, validation, agreement, and
sensory topics [33] and; (2) Non-verbal—eye contact, affective
touch, and smiling [33].
4. Discussion and conclusion
4.1. Discussion
4.1.1. Recommended evaluation standards
Relevant reviews on therapeutic communication interventions
prior to 1999 consistently reported weak research designs with
limited evidence for changing behaviors [15]. However, Kruijver
and colleagues’ review was on licensed nurses and other
professionals in primarily acute-care settings and not unlicensed
NAs and other paraprofessionals in institutional long-term care
settings. Thus, intervention research in institutional long-term
care settings needs rigorous standards for designing and evaluat-
ing continuing education programs on therapeutic communication
[1,2,24,40].
The findings from this review on primarily unlicensed NAs and
other paraprofessionals suggest the following for the design and
evaluation of therapeutic communication training programs for
institutional long-term care staff: (1) determine consent and
participation rates of residents and of licensed and unlicensed
staffs separately; (2) randomize at the level of the group; (3)
measure changes in different types of behavior for staff and
residents over a minimum of 6 months with blinded raters for
observational data; (4) design sampling target with anticipation of
different attrition rates for staff and residents; and (5) adjust for
nested data. Incorporating these standards will improve both the
internal and external validity of educational programs as well as
future efforts to translate findings into high grade ‘‘evidence-
based’’ practices [2].
Ideally, an intervention incorporating all of the recommenda-
tions above would address both the efficacy (short-term behavior
change) and to a more limited extent the effectiveness (long-term
sustainability) of therapeutic communication training programs.
This review focused on only experimental studies, and the findings
provide the strongest support for the ability to improve the short-
term communication behaviors of NAs (i.e., efficacy).
The ability to translate these programs into practice or policy
requires them to be feasible [40]. Feasibility is what long-term care
organizations value as well as what their staff value. Although one
study mentioned that their program was low cost, it provided no
evidence as to what specifically this meant [3]. Only one of the
studies reviewed documented that the therapeutic communica-
tion programs were acceptable to or actually received by the target
staff [36]. Such efforts would suggest the need for formative and
process evaluations [41].
The sheer length of follow-up in most studies and the built-in
feedback mechanism suggest some effort towards effectiveness,
but these are not sufficient. In institutional long-term care settings,
quality and cost of care can be competing issues, so any effective
program must be feasible in practice and cost to be sustained. In
such environments where resources are notoriously strained, some
studies brought in an external, professional change agent to train
licensed, long-term care staff in providing feedback and super-
vision so vital to sustain behavior changes over time among non-
licensed staff [24,31,33]. The idea for doing so is good, but in reality
any indigenous, licensed staffs already have their work roles
defined and adding to them risks not sustaining the program.
Based on the psychosocial nature of therapeutic communication
programs critically reviewed in the current study, the key
recommendation would be to have dedicated psychosocial care
supervisors.
4.1.2. Best evidence for therapeutic communication behaviors
Verbal communication such as positive statements and one-
step instructions [13,31], open-ended questions and information
topics [30,33], social, validation, agreement, and sensory topics
[33] and non-verbal, non-vocal communication such as eye
contact, affective touch, and smiling [33] have the best empirical
evidence for potential improvement to date. These recommended
verbal and non-verbal communication behaviors overall lack a
larger conceptual framework. Such a framework would explain
how each should be employed on an as-needed basis, not as a
universal standard of constant behavior [11]. Further, this frame-
work would have a clear goal, so as to give the caregiver a focus for
using these behaviors. A possible framework with a clear goal
appears in Fig. 1.
Fig. 1 displays a summary of three independent sets of expert/
clinically-recommended interpersonal skills for anyone (e.g.,
nurses, nurse aides, and/or family caregivers) who cares for
persons with dementia. The therapeutic communication skills
supported by the current review all fall within these recommended
interpersonal skills. While all three sources [42–44] (see columns
1–3, respectively) present a long list of mostly concrete and
specific behavioral skills, only one does so within higher level
strategies that all aim to reach a goal (see column 1).
In column 1, Kohler [43] presents recommended behavioral
skills within nine behavioral strategies. These behaviors compose a
comprehensive set of strategies to attain an ‘‘emotional connec-
tion’’ with persons who have dementia. In column 2, Williams’
et al. [44] behavioral skills list composes a core competency that
being able to ‘‘adapt communication to cognitive/emotional needs
of the person with dementia.’’ In column 3 [42], the study offers no
specific higher level strategy or competency other than the chapter
heading of ‘‘interpersonal skills.’’ Gillogly and Williams’ skills are
organized hierarchically within Kohler’s nine strategies to
illustrate that they can be organized at higher levels. Further
research needs to be done to see if this higher level of organization
aids in teaching caregivers how to use them. Moreover, presenting
these strategies with real-life examples of interpersonal commu-
nication of NAs and residents during long-term care should also be
used in designing future training programs to aid in retention and
understanding [45].
Therapeutic communication behaviors should include both
verbal and non-verbal types, because the latter is especially
important for conveying warmth, caring, and respect [11,28]. Most
of the studies reviewed emphasized verbal communication
behaviors with one exception [35]. Further, while self-report data
may be necessary to capture the scope of changes in communica-
tion behaviors (i.e., knowledge through concrete behaviors), they
are not sufficient alone. Blinded, independent observers must
reliably document improvements in actual behaviors [46].
Moreover, statistically significant improvements in staffs’
behaviors are also necessary but not sufficient. Many studies
included outcomes related to both staff and residents with the
rationale being that any improvement in residents would suggest
clinical significance. Another perspective on the clinical signifi-
cance could be from ‘‘stakeholders’’ or those with a vested interest
L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21 19

Fig. 1. Theoretical therapeutic communication skills.

20 L. Levy-Storms / Patient Education and Counseling 73 (2008) 8–21
in the well-being of older adults in long-term care settings. Such
stakeholders include cognitively intact residents and families who
may notice improvements in staffs’ communication behaviors.
Such data, if possible to collect from video and audio clips, could
suggest the clinical significance of any improvements in staffs’
behaviors [38].
4.2. Conclusion
This review summarizes and critiques research related to the
design and evaluation of therapeutic communication programs for
NAs and other direct-care staff who work with older adults in long-
term care settings. This review examined only experimental
studies with a minimum of a pre-/post-design. Improving the
design and evaluation of therapeutic communication training
would address an important gap in certified NAs’ training and
certification [24] and could help reduce turnover among long-term
care staff by increasing their perceived competency [3].
4.3. Practice implications
The findings from this review should be considered in the
contexts of the type of long-term care settings, the diversity among
the staff and residents, and the feasibility of sustaining them.
While three studies worked in two or more long-term care settings,
only one actually compared the results and found differences
between two of the settings: a home care organization and a home
for the elderly [30]. The authors attributed the findings to the
different time constraints within each setting. Routines in the
home for the elderly were more rigid and busier than the home
care environment. A major flaw in this and other studies with more
than one type of setting is that the researchers do not mention the
unique challenges of comparing different settings.
In training staff to communicate with other staff, residents, and/
or family, a major risk factor for poor communication is the diversity
among these groups. Whereas the studies reviewed here reported
demographics of their study samples, only two mentioned the
cultural diversity issue directly or explained how it was addressed in
the training [34,38]. One explanation may be that cultural diversity
in these studies did not include language differences.
Staffs were also diverse in their educational training in that they
included licensed and unlicensed staffs, but studies did not provide
enough detail on the staffs’ differences in their backgrounds or
performance after training. Residents may not be diverse in their
ethnicity, but they are so in their cognitive functioning levels. With
regard to data collection, the reviewed studies handled this issue in
a variety of ways with end results being that the source of
inclusion/exclusion for residents based on their cognitive func-
tioning varied and specific criteria were absent or vague.
In the studies reviewed here, incorporation of a component to
sustain their behavioral intervention varied from directly testing a
program with and without a formal sustainability component to
merely including licensed staff in the training. For example, one
study had one ‘‘conventional supervisory model’’ (CSM) and a
second ‘‘formal staff management’’ (FSM) model [31]. Another
study used a more specific supervisory model, a MSW, to reinforce
and sustain changes in NAs’ behaviors [3].
In summary, therapeutic communication training programs for
NAs in institutional long-term care settings should: (1) emphasize
simple, concrete, verbal and non-verbal communication beha-
viors; (2) have an external, professional trainer lead the interven-
tion; (3) focus the training program on psychosocial aspects of
long-term care for any staff with direct-care responsibilities; (4)
design the evaluation and intervention as a quality improvement
effort with both in-class and on-the-floor training and feedback
with indigenous licensed staff supervision; and (5) work in more
than one long-term care setting, preferably of the same type (e.g.,
nursing homes). Finally, regarding the range of long-term care
facilities, more research is needed to compare the short- and long-
term effects of therapeutic communication interventions across
facility types and to determine the impact of cultural and/or
structural differences in these organizations. Of these differences,
cultural issues could be best addressed in therapeutic commu-
nication training programs.
Acknowledgements
The author would like to thank Nancy Hooyman, Gwen van
Servellen, John Schnelle, Maria Carpiac, Fernando Torres-Gil, and
Ruth Matthias for their feedback and acknowledge the UCLA
Pepper Center, National Institute on Aging (1 K01 AG020561-
01A1), John A. Hartford Foundation, and the National Alzheimer’s
Association for their support.
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