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Behavior Therapy 42 (2011) 9 – 21

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The Role of Behavior Analysis in the Rehabilitation of Persons

With Dementia
Jeffrey A. Buchanan
Angela Christenson
Daniel Houlihan
Minnesota State University, Mankato

Carly Ostrom
Gallaudet University

RECENTLY THERE HAS BEEN much written in the

With the rapidly aging population, it is expected that
increases in cases of dementia will double over the next 20
years. Currently, there is no cure for diseases such as
Alzheimer's disease or frontotemporal dementia (FTD) that
cause progressive dementia, and only a few pharmacological
interventions that slow the progression of the decline exist.
Given that there is no cure available, a rehabilitation
approach that emphasizes maintaining existing abilities and
removing excess disability (as opposed to emphasizing cure
or recovery) for as long as possible is warranted. The current
paper proposes that nonpharmacological rehabilitation
efforts need to target 5 broad areas/targets: memory
enhancement, altering social contingencies and communi-
cation styles, improving self-care skills, the arrangement of
physical environments to maintain and improve function-
ing, and increasing physical fitness/physical activity. The
purpose of this paper is to review specific behaviorally
oriented interventions that target these 5 areas and show
promise for inclusion in comprehensive rehabilitation
efforts for individuals with dementia.
Address correspondence to Jeffrey Buchanan, Ph.D., 23 Armstrong
Hall, Mankato, MN 56001; e-mail: Jeffrey.buchanan@mnsu.edu.
0005-7894/10/009–021/$1.00/0
© 2010 Association for Behavioral and Cognitive Therapies. Published by
Elsevier Ltd. All rights reserved.
scholarly literature (e.g., Fillit et al., 2002) and
popular press (e.g., Einstein & McDaniel, 2004;
Valliant, 2002; Wei & Levkoff, 2001) about how to
prevent age-related deterioration, and cognitive
decline in particular, in already healthy adults.
This literature can be generally summarized as
addressing the concept of “successful aging,” or
maximizing independent functioning while mini-
mizing disability/impairment. In fact, searches on
online bookstores using the terms “successful
aging” or “memory fitness” produce dozens of
hits for books, with many primarily targeting Baby
Boomers.
It is understandable that successful aging and
memory enhancement has become a popular topic.
Currently, 12.4% of the U.S. population (approxi-
mately 35 million people) is 65 or older and this is
expected to rise to 20% of the population (about 70
million people) by the year 2030 (United States
Census Bureau, 2000). Clearly, many more people
will be reaching older adulthood in the near future,
making effective ways to stay as healthy and
productive as possible into old age an important goal.
An area that appears to be less frequently
addressed in the popular and scholarly empirical
literature is how to maintain skills, maximize
functioning, and slow deterioration in persons
who already have been diagnosed with a condition
that causes progressive dementia (e.g., Alzheimer's
disease). Slowing decline and maintaining
10 buchanan et al.
independent functioning in persons with dementia
is becoming an increasingly important concern in
this country. For example, a recent report by
Alzheimer's Disease International (2009) projects
global doubling of cases of dementia every 20 years
and estimates that a total of 115 million people
worldwide will have dementia by 2050. In addition,
approximately 4.5 million individuals in the United
States suffer from Alzheimer's disease (AD) alone,
and projections are that approximately 13 million
will have the disease by the year 2050 (Hebert,
Scherr, Bienias, Bennett, & Evans, 2003).
Rehabilitation and Dementia
Conditions that cause progressive dementia inevi-
tably lead to the deterioration of a host of abilities
(e.g., short-term memory, language, reasoning,
computation, self-care). Professionals and family
members may feel hopeless in the face of such
inevitable decline. Many patients, as well as their
families who provide care, often ask a variation of
the following question: “Is there anything I can do
to stop or slow down the progression?” Patients,
especially families, often want to do everything
possible to fight the progression of the disease, even
if positive results are uncertain. It is the case that
patients are usually prescribed medications such as
cholinesterase inhibitors or glutamate inhibitors
that have been shown to slow cognitive and
functional decline (Geldmacher et al., 2006).
Caregivers, however, are often not provided
additional tools to manage the behavioral or
emotional aspects of the disease beyond recom-
mendations to attend support groups or are given
general advice such as “keep the patient active.”
One of the reasons for this is that providers may be
unaware that there is a growing body of empirical
work supporting the effectiveness of nonpharma-
cological interventions for improving or maintain-
ing important skills such as short-term memory,
verbal communication, or self-care.
Although diseases that cause dementia cannot
currently be cured, rehabilitation is still a worth-
while goal that is increasingly being recommended
(Arkin, 2001; Bird, 2000). With other conditions,
rehabilitation efforts typically focus on cure or
recovery, but with dementias a worthy goal is
stabilization. As will be discussed in the sections
below, improving or strengthening specific skills
may be possible to a certain extent with some
dementia patients. Ultimately, however, rehabilita-
tion with the goal of cure or recovery is clearly not
warranted in the case of dementia. Consequently,
rehabilitation efforts with those with dementia have
a different set of goals, namely preserving existing
skills and compensating for existing cognitive
deficits. Similarly, Bird states the goal of rehabili-
tation in the case of dementia as “. . . minimizing the
emotional and behavioral sequelae of cognitive loss
and maximizing the potential of the social, physical,
and sensory world to make it less confusing and
confronting. . . .”
These goals of rehabilitation with regard to
dementia can be conceptualized quite well within
the framework of the selective optimization with
compensation model (Baltes & Baltes, 1990). This
model proposes that older people best adapt to age-
related declines through a process of: selection,
which involves restricting life work to fewer
domains or activities that are of highest importance
to the person; optimization, which involves efforts
to maximize successful execution and satisfaction
with chosen life domains; and compensation, which
involves implementing new adaptive strategies
when existing abilities are lost or are insufficient
for adequate functioning. The application of the
selective optimization with compensation model to
persons with dementia is slightly different than
originally proposed by Baltes and Baltes in that
caregivers (not just the patient) are very involved in
the process of selection of relevant repertoires,
efforts to optimize these repertoires, and imple-
menting strategies to help patients compensate for
lost abilities.
Some brief examples may clarify the relevance of
this model to the rehabilitation of persons with
dementia and the role caregivers can play in
carrying out these processes. First, consider the
process of selection. Selection is related to the
rehabilitation goal of preserving existing repertoires
in that the first step in a rehabilitation program is
choosing specific behaviors to be preserved (e.g.,
self-care, independent ambulation, or recalling the
name of a caregiver). Although patients may be
directly involved in selecting relevant behaviors to
target during rehabilitation, in cases where patients
are more severely cognitively impaired, selection
will likely involve input from caregivers such as
family members, nurses, or occupational therapists.
The process of optimization is also related to the
rehabilitation goal of preserving existing repertoires
in that efforts can be made to help individuals
maximize and maintain selected repertoires. For
example, teaching caregivers strategies such as
prompting, reinforcing, and assisting with the
repeated practice of behaviors such as ambulating
independently or recalling specific pieces of infor-
mation can help patients optimize these remaining
skills. The process of compensation is clearly
related to the rehabilitation goal of compensating
for cognitive losses. For example, introducing
 rehabilitation in dementia
external memory aids such as lists or calendars can
help compensate for deficiencies in short-term
memory. Compensating for cognitive decline may
also involve changing the social environment. For
example, social environments that provide too
much and/or too little support may serve as a
source of excess disability that causes impairment in
functioning disproportionate to that directly attrib-
utable to the disease (Dawson, Wells, & Kline,
1993). Interventions designed to teach staff more
effective ways to assist patients during personal
cares may remove this source of excess disability by
helping patients compensate for cognitive and
physical impairments while also maintaining exist-
ing repertoires.
Rehabilitation efforts with this set of goals in
mind may produce a number of important out-
comes. For example, slowing deterioration and
preserving existing skills may result in patients
living at home longer, an outcome that is often
desirable because home care is usually less expen-
sive than care provided in a facility and patients
typically are much happier living at home. Further-
more, when patients live at home longer, govern-
ment insurance programs such as Medicaid also
save money. Patients may also experience improved
psychological and physical well-being as a result of
participating in comprehensive rehabilitation pro-
grams. Finally, rehabilitation efforts may also
reduce the burden and stress experienced by
caregivers (family or professional) because patients
function more independently.
Purpose of the Paper
The purpose of this paper is to describe interven-
tions based on behavioral principles that may be
included as part of rehabilitation efforts designed to
minimize deterioration and improve functioning of
persons with conditions that cause irreversible,
progressive dementia such as AD, vascular demen-
tia, or frontotemporal dementia. By “minimizing
deterioration and improving functioning,” we
mean achieving outcomes such as maintaining or
slowing the progression of cognitive symptoms of
dementia, improving self-care skills, improving
ambulation, and/or maintaining independence. It
should be emphasized that rehabilitation efforts are
conceptualized as supplements to empirically sup-
ported medical interventions, not substitutes. Of
final note is that this paper will not review
interventions for reducing challenging behaviors
that frequently emerge as dementia progresses.
Although managing challenging behaviors is often
part of a larger care program, this paper will focus
on interventions designed to maintain or improve a
11
patient's functioning as opposed to reducing
challenging behaviors (see Buchanan, 2006, or
Spira & Edelstein, 2006).
We will discuss five domains that are critical to
address as part of a comprehensive rehabilitation
effort. These domains include: (a) cognitive reha-
bilitation and memory enhancement, (b) altering
social contingencies and communication styles, (c)
improving self-care skills, (d) the arrangement of
physical environments, and (e) increasing physical
fitness/physical activity.
Cognitive Rehabilitation and Memory
Enhancement
Deterioration in short-term memory and the ability
to learn new information is a hallmark symptom of
dementia, most notably AD. The individual may
have difficulties remembering names, dates, faces,
verbal instructions, steps in a multistep task,
appointments, and other important information
that can make everyday life challenging and
potentially dangerous (e.g., forgetting one's place
of residence and getting lost; failing to take
medications; leaving an oven turned on). Memory
impairment can also be stressful for caregivers, such
as when objects are misplaced, questions are
continually repeated, and requests do not result in
compliance.
Clearly, there are currently no interventions
(pharmacological or otherwise) that can reverse
the cognitive decline associated with diseases that
cause dementia, but there are behaviorally oriented
interventions that have been shown to at least
temporarily improve the ability to remember. These
interventions can be part of cognitive rehabilitation
programs with dementia patients. Cognitive reha-
bilitation (CR) for persons with dementia focuses
on remediating cognitive deficits with the goal of
improving or maintaining cognitive skills so as to
maximize and optimize the patient's daily function-
ing. These interventions involve: (a) providing
environmental cues to enhance recall, and/or (b)
intervening directly with the individual to enhance
the ability to recall information independently or
with minimal prompting.
external memory aids
External memory aids (sometimes called cognitive
prosthetics) are items that are used to supplement
memory or “remember” information that an
individual may tend to forget. Although they can
take many forms, these external aids share a
common characteristic: They all provide sensory
cues in an individual's surroundings to help
compensate for difficulties with memory. Common
12 buchanan et al.
external memory aids include lists (e.g., shopping
lists), appointment calendars, contact information
(e.g., important phone numbers), labels (e.g.,
identifying what is inside a drawer or cupboard),
signs, and photo albums.
Applications are numerous and variable, and
therefore highly practical. For external memory
aids to be effective, however, additional training
may be required. For example, a person with
dementia may need to be taught and reminded to
look at labels before searching through drawers or
to write down grocery items in a special notebook.
Family members or care providers can assist with
the process by choosing the cue location (e.g.,
placing contact information on or near the tele-
phone), reminding the individual to use the cues,
and encouraging consistency. Studies have demon-
strated that the use of external memory aids or
cognitive prosthetics can successfully improve
functioning if combined with adequate training
(Bourgeois et al., 2003).
Another approach for improving both retrieval
of information as well as communication involves
utilizing personalized memory books (also called
memory wallets) consisting of a series of bound
pages that portray a picture and sometimes a
description of a person, place, or symbol that is
meaningful to the individual. For example, a war
veteran's memory book may contain pictures of his
wife, himself, and his dog on a hunting trip, and a
fighter jet similar to one he flew in the Air Force.
The benefits of memory books have been demon-
strated in empirical studies. Positive outcomes
include more novel, detailed, and factual statements
during conversations; less ambiguity when speak-
ing; reductions in negative caregiver interactions;
better turn-taking during conversations; and fewer
problem behaviors (Bourgeois, 1991, 1992, 1993;
Hoerster, Hickey, & Bourgeois, 2001).
spaced retrieval
Over the past 20 years, Cameron Camp and his
colleagues have described and empirically investi-
gated a procedure called spaced retrieval (SR). SR is
basically a shaping paradigm that targets a
cognitive skill such as remembering. SR involves
giving a person practice at successfully recalling
information over successively longer time periods
(Camp, 1998). For example, an individual may be
shown a picture of a face along with a name. The
individual is then shown the picture and is asked to
recall the name after an interval of 5 s. If the
individual responds correctly, this interval is
expanded (perhaps to 10 s) and recall is assessed
again; if the individual responds incorrectly, the
correct answer is given, the client is asked to repeat
the correct answer, and the interval is shortened to
the previous interval in which successful recall
occurred. As long as correct responding continues,
the interval length is expanded. This procedure
provides a great deal of feedback and reinforcement
in the form of correct responding and perhaps
praise/encouragement from the trainer.
One interesting aspect of the SR procedure is that
testing sessions occur within the context of a social
visit, such as a game of checkers or a casual
conversation (Camp & Stevens, 1990). This form of
testing provides a great deal of social interaction
and reduces demands placed on clients who may
otherwise feel threatened or anxious in more
traditional testing situations (Camp & Stevens).
The social nature of the intervention may also
reduce the amount of cognitive effort required of
clients, which may partially account for the success
of SR (Camp, Bird, & Cherry, 2000; Camp &
Stevens). Furthermore, anecdotal reports (Camp &
Stevens; Stevens, O'Hanlon, & Camp, 1993)
suggest that clients seem to enjoy sessions.
SR has been successfully used to improve recall of
a number of different specific types of information.
For example, Camp and Schaller (1989) reported
the use of SR to teach a memory-impaired man the
name of a nurse at his assisted living facility after
three weekly training sessions and this information
was retained at a 6-month follow-up. Abrahams
and Camp (1993) reported successfully teaching
object-name associations in two individuals with
dementia. SR has been used to help individuals
remember to use an external memory aid (e.g., a
calendar) and complete tasks written on the
calendar (Stevens, O'Hanlon, & Camp, 1993). SR
procedures have also been successfully implemen-
ted by family caregivers, which would presumably
increase the likelihood that treatment gains would
be maintained (McKitrick & Camp, 1993). It
should be noted that in many of these studies,
information can eventually be retained across
training sessions that may be a week or more
apart, thus demonstrating that learning occurs not
only for a few minutes, but can occur over clinically
meaningful periods of time (Camp et al., 2000).
errorless learning approaches
It has been proposed that SR is effective because
errors are minimized (Camp et al., 2000). Techni-
ques such as SR that minimize or eliminate the
possibility of making errors during the learning
process are collectively referred to as errorless
learning approaches, and they are based on basic
behavioral research with pigeons (originally con-
ducted by Terrace, 1963). In essence, errorless
learning approaches maximize contact with
 rehabilitation in dementia
reinforcers (e.g., correct answers, praise) and
minimize aversive consequences (e.g., feedback
that answers are incorrect). Errorless learning
procedures may be particularly useful for indivi-
duals with dementia because once errors are
produced during the learning process, persons
with memory impairments have difficulties elimi-
nating those errors (Wilson, Baddeley, Evans, &
Shiel, 1994).
Clare and colleagues (Clare, Wilson, Breen, &
Hodges, 1999; Clare et al., 2000) examined the use
of errorless learning techniques for teaching face-
name associations in patients with early stage AD.
One technique they implemented, called vanishing
cues, has been conceptualized as a form of
behavioral chaining (Wilson et al., 1994). Vanish-
ing cues involved the following steps: (a) providing
a target person's picture and his/her written name
with the last letter removed, (b) asking the
individual to “fill in the name,” and (c) removing
letters one-by-one following correct answers.
Through this process, few errors are made and
participants are eventually able to recall names only
upon presentation of the picture. To enhance
retention of this information, SR procedures were
implemented. The number of faces correctly named
increased for most participants and improvements
were maintained for 6 months.
Other skills can also be taught using errorless
learning principles. For example, Clare et al. (2000)
reported using errorless learning procedures to
teach two individuals with mild AD to use memory
strategies such as referring to a calendar instead of
repeatedly asking a spouse. This intervention was
successful with both individuals at posttreatment.
Only one participant showed lasting improvement
at the 6-month follow-up; however, this is most
likely because the second participant stopped using
the memory strategies after treatment ended. As
noted in other studies in this literature, individual
difference variables, such as degree of family
involvement, motivation, and awareness of memo-
ry difficulties, may help predict who will or will not
respond to rehabilitation efforts (Clare et al.;
Stevens et al., 1993).
The work of Arkin (1991, 2001) represents
another application of errorless learning procedures
to help persons with dementia improve memory for
personal information. In these studies, participants
listen to an audiotape of someone describing
important events from their life. Following the
presentation of a piece of information (e.g., his/her
date of birth), the participant is immediately asked a
question about that material (e.g., “What was the
date and year of your birth?”) and then is provided
the answer after a brief pause (Arkin, 1992). This
13
procedure dramatically increases the likelihood that
correct responses will be given during learning trials
and provides correct answers when errors occur.
Arkin (2001) also found that this memory enhance-
ment procedure could successfully be implemented
by college students as part of a larger rehabilitation
program that included language therapy, physical
fitness training, and volunteer work sessions.
It seems clear that the application of CR
procedures with persons with dementia is an
encouraging line of research. There is still much to
be learned about these procedures, however. For
example, the relationship between SR success and
degree of cognitive impairment (as measured by
standard neuropsychological screening instru-
ments) has not been established. Therefore, it is
unclear how to determine a priori who will or will
not benefit from the procedure (Camp et al., 2000).
It is also unclear how much information can be
taught to individuals, how to optimally individual-
ize SR programs, and how to best maintain gains
once they are made (Camp et al.). Another
important limitation of much of the CR literature
is the relatively small number of empirical studies
supporting these interventions and the small sample
sizes utilized. Eventually, larger randomized control
trials with longer follow-up periods will need to be
conducted in order for these interventions to be
elevated to the status of “empirically supported” so
that they may be more widely recommended and
disseminated. Future research may also benefit
from incorporating aspects of errorless learning
procedures into more comprehensive cognitive
stimulation/rehabilitation programs, as was done in
two recent randomized controlled trials (Lowenstein,
Acevedo, Czaja, & Duara, 2004; Moore, Sandman,
McGrady, & Kesslak, 2001). Finally, it will be
important to determine how the effects of CR
programs compare to the effects of standard medical
interventions alone or in combination with CR, not
only in terms of slowing cognitive decline, but also
in delaying institutionalization and maintaining
independent daily functioning.
Altering Social Contingencies and
Communication Styles
Aphasia, defined as a reduction in the ability to
express or comprehend language, is a common
symptom of dementia and can greatly vary in terms
of severity, specificity, and type across individuals.
These language deficits have important everyday
implications for patients and caregivers. For exam-
ple, patients may misinterpret caregivers or struggle
to clearly express needs, which can result in out-
comes such as aggression, noncompliance, social
14 buchanan et al.
isolation, overdependency, or idleness. While the
patient's language deficits clearly contribute to
communication difficulties between caregivers and
patients, dementia inevitably results in declines in
verbal abilities. Therefore, it is perhaps even more
important to understand the contribution of the
social environment in either maintaining the
patient's verbal abilities or exacerbating the deteri-
oration of existing skills.
Several lines of empirical and theoretical work
have investigated what changes in communication
are made by those in the patient's social environ-
ment and how these changes affect patients. For
example, Baltes and Wahl (1996) investigated a
conceptual model of learned dependency that
occurs in the elderly when they are moved from
their homes to long-term care facilities such as
assisted living facilities or nursing homes (see
Baltes, 1995). Within these facilities, the healthy
and independent are often left to fend for
themselves, whereas the frail gain access to
important social reinforcers through their worsen-
ing conditions (Baltes & Wahl). This cycle of
coercion and dependency is maintained and
exacerbated by a blending of negative reinforce-
ment (e.g., things that are tedious or painful for
the elderly are often most easily left to the staff)
with positive reinforcement (e.g., being dressed,
bathed or pushed in a wheelchair by staff allows
for social interaction and attention that the
healthy residents don't receive).
Likewise, staff sometimes find it aversive to wait
an unpredictable amount of time for a person
with dementia to do something for themselves
(Lichtenstein, Federspiel, & Schaffner, 1985).
Consequently, staff respond by doing things for
the patient in the service of helping residents. This
“helping” behavior may be reinforced in several
ways. For example: (a) it allows staff to better
allocate and use their time because tasks get
completed more quickly; (b) getting tasks done
more quickly may be praised by supervisors or at
least avoid reprimands from supervisors; (c)
similarly, supervisors and families may view
them as more compassionate and hard working
employees; and (d) it may reduce the probability
that residents will have the opportunity to resist
care. The downside to this cycle, however, was
spelled out clearly by Lichtenstein et al. when they
noted that these interactions reduce activities of
daily living (ADLs) within the elderly population,
which were empirically shown to be related to
longevity. As noted by Baltes and Wahl (1996),
assessing the etiology of dependency might be
among the most important tasks for this genera-
tion of behavioral gerontologists.
Williams et al. (2009) also show the potential
pitfalls of adjusting patterns of communication
when interacting with the elderly suffering from
dementia. Williams and her colleagues have been
investigating a pattern of adjusted speech that
has been termed “elderspeak” by various beha-
vioral researchers (Caporael & Culbertson, 1986;
Hummert, 1994; Williams & Warren, 2009).
This pattern of “talking down” (e.g., using terms
like “sweetie,” “honey,” or using baby talk) to these
more impaired patients often has negative conse-
quences. In evaluating a large number of videotaped
sessions of staff interacting with patients in long-
term care facilities, the researchers noted a clear
pattern of resistance to care among patients when
elderspeak was used compared to when normal
speech was used. Although impaired by dementia,
these patients do have a strong awareness of who
they were (e.g., corporate president, teacher, physi-
cian) and they react negatively and defensively to
demeaning speech (e.g., “Be a good boy and eat
your pudding”).
Recent research regarding communication pat-
terns with individuals with dementia points to the
importance of other communication styles used by
caregivers that can impact patient communication
as well as the quality of patient-caregiver interac-
tions. One example is research investigating the
types of repairs used by caregivers when patients
make errors or unclear statements when communi-
cating. Using an ABAC design, Gentry and Fisher
(2007) compared two different types of listener
repair responses on the verbal behavior of three
dementia patients. Repairs were either direct (i.e.,
the listener provided corrective feedback to the
patient when an error was made) or indirect (i.e.,
the listener restated his/her understanding of what
the patient said). Results indicated that indirect
repairs were associated with more words spoken,
longer speech duration, fewer topic changes, and
fewer incomplete interactions compared to direct
repairs. This study provides some evidence that
indirect repairs reinforce patient efforts to commu-
nicate verbally while direct repairs may serve to
punish these efforts.
Improving caregiver communication skills can be
a daunting task, partly because the construct of
“communication skills” is very broad and it can be
difficult to know which specific skills to target. The
research described above helps specify effective
(e.g., using indirect repairs) and ineffective (e.g.,
reinforcing dependency, using elderspeak) skills
when communicating with persons with dementia.
Some empirical literature suggests that caregivers
can successfully be taught some of these important
skills. For example, Burgio and colleagues (2001,
 rehabilitation in dementia
2002) have demonstrated that staff training pro-
grams can result in increases in skills such as
making positive statements, informing residents
about upcoming tasks, delaying providing assis-
tance following verbal prompts to complete a task,
and using specific instructions. More importantly,
improvements in communication skills were asso-
ciated with a reduction in resident agitation during
personal cares and did not increase the amount of
time needed to deliver care. Burgio et al. (2001) also
found that a staff motivational system can increase
compliance with training and gains were main-
tained over the period of 2 months. McCallion,
Toseland, Lacey, and Banks (1999) found that a
communication training program for nursing assis-
tant resulted in reductions in patient depression,
increases in knowledge of responses to behavioral
and emotional problems, and may lower staff
turnover rates.
Despite these positive findings regarding the
effects of staff training on communication skills,
the existing literature is still relatively small. An
important area for future research will be to
determine the most effective and efficient ways to
conduct training and how to best promote mainte-
nance of gains derived from training over longer
periods of time once formal training has ended.
Improving Self-Care Skills
Few efforts have been made to improve or retrain
daily living skills that have been lost as part of the
disease process. Improving independent completion
of these skills could have several beneficial out-
comes, such as (a) reducing caregiver burden in
terms of time spent assisting patients, (b) improving
the patient's mood and sense of control over his/her
environment, and (c) delaying institutionalization.
McEvoy and Patterson (1986) attempted to retrain
skills in 15 individuals with dementia who had been
admitted to a short-term rehabilitation program.
Procedures used to retrain skills included a number
of behaviorally oriented interventions, such as
providing and then gradually fading visual and
verbal prompts for teaching personal information,
role-playing to teach communication skills, back-
ward chaining to locate important places within the
residential facility, and verbal instruction, modeling
and reinforced practice to improve ADL deficits.
Results indicated that significant improvements
could be made in the areas of learning basic ADLs
and improving communication while moderate
improvement was found in the areas of learning
personal information and finding important places.
No improvement in the performance of more
complex ADLs was observed. Others have also
15
found that graduated prompting and reinforcement
can increase independent behaviors in persons with
dementia during dressing (e.g., Engelman, Altus, &
Mathews, 1999; Engelman, Altus, Moiser, &
Mathews, 2003).
A more recent study further supports the
conclusion that persons with mild to moderate
dementia can be taught self-care skills through the
use of behavior analytic techniques. Zanetti and
associates (2001) trained 11 dementia patients to
complete 13 ADLs such as washing face and hands,
using the telephone, and dressing. Training proce-
dures involved verbal and nonverbal prompting,
modeling, and reinforcement. Individuals receiving
training were able to complete ADLs more quickly
than an untrained control group.
These studies demonstrate that including physical
practice of skills, along with the necessary prompt-
ing, modeling, and reinforcement, can improve
ADL performance in persons with dementia.
Researchers have speculated that improvement is
more likely when physical practice is part of
training, when feedback was received from many
sensory systems, and when less cognitive effort was
required (Arkin, 1991; Camp, Foss, O'Hanlon,
Steven, 1996; Zanetti et al., 2001). It is clear,
however, that much more research is needed to
determine the degree to which ADLs can be
maintained or relearned, how long training benefits
last, and how to best train staff to support resident
autonomy.
Modification of the Physical Environment
Another component of rehabilitation with demen-
tia patients can involve rearranging physical
environments. The interplay between the physical
environment and the functioning of older people
has been recognized for many years. For example,
Lindsley (1964) used the term “prosthetic environ-
ments” to describe efforts to restructure the
physical (and social) environment to help compen-
sate for debilitations and maximize independent
functioning. Also, the competence-press model
described by Lawton and Nanemow (1973)
emphasizes the importance of the match between
a person's competencies and the demands placed on
them by the environment. This early work empha-
sized the need to examine how the qualities of the
physical environment may contribute to or hinder
the functioning of an individual given his/her
existing abilities. One important implication of
this work is that the development of more
accommodating prosthetic environments that cre-
ate less “press” is necessary for those with
dementia, who presumably have more deficient
16 buchanan et al.
physical and/or psychological competencies. An-
other implication is that environments need to be
tailored to the needs of the individual (as opposed
to the presumed needs of an entire group such as
those with dementia) to the greatest extent possible
in order to truly maximize independent functioning.
Since this pioneering theoretical and empirical
work by Ogden Lindsley and M. Powell Lawton,
the use of external aids as a means for improving
the independent functioning of persons with
dementia has become increasingly popular. There
are many desirable characteristics of such interven-
tions, including their flexibility, simplicity, and
relatively low cost. Although external aids rarely
result in negative effects, they have demonstrated
variable results in the empirical literature. The
following section will describe a variety of different
modifications to the physical environment that
have been implemented for various purposes.
enhancing safety
Safety concerns often accompany dementia. Indivi-
duals experiencing impaired decision-making abil-
ities may engage in behaviors that put them at risk
for injury. For example, one of the most common
behaviors of dementia patients is wandering (Hope
et al., 1994). The combination of excessive move-
ment and impaired cognitive functioning can
escalate safety risks. By changing aspects of one's
physical surroundings, however, these safety risks
can be minimized. These modifications may include
patterned floors to minimize wandering, door and
doorknob coverings to discourage elopement,
clearing furniture and excess décor to reduce fall
risks, posting visual cues (e.g., signs, color-coded
stickers) to indicate dangerous items and areas,
displaying emergency contact information in prom-
inent locations, using monitors to supervise from a
distance, and installing door alarms to alert
elopement attempts (Gitlin, Corcoran, Winter,
Boyce, & Marcus, 1999; Gitlin et al., 2002;
Morse & Wisocki, 1991). Visual barriers, floor
patterns, and special furnishings have effectively
reduced dangerous behaviors such as wandering,
elopement attempts, and falls (Dickinson, McLain-
Kark, & Marshall-Baker, 1995; Feliciano, Vore,
LeBlanc, & Baker, 2004; Hussian & Brown, 1987;
Mayer & Darby, 1991; Namazi, Rosner, &
Calkins, 1989). Overall, although dementia can
increase the risk of danger, environmental mod-
ifications tend to have a positive effect on safety
(Day, Carreon, & Stump, 2000).
improving orientation
Another common effect of dementia is difficulty
maintaining orientation to time, place, and person.
Orientation difficulties are manifested in indivi-
duals' inability to remember the date, navigate in
their environment, or have insight into their own
identity. Clearly, even the most basic ADLs require
some degree of orientation.
Care providers and researchers have identified
several environmental interventions that are
designed to improve orientation. One option
involves displaying large-faced and easily readable
clocks in conspicuous locations. Another recom-
mendation is to post a large, master calendar that
highlights the date, month, and year. A third
environmental modification is to display signs or
pictures that remind a person who and where they
are. These orienting devices and others like them
can be utilized or modified depending on the
individual's skills and needs.
Despite the intuitive appeal of these interven-
tions, the effects of external cues on orientation and
related functioning have shown limited success in
empirical literature. Short-term improvements have
been recorded (e.g., Camp et al., 1996), but these
improvements rarely generalize across time or
location (Bird, 2000). In other words, an individual
with dementia may be able to accurately identify
the date when he or she is in the presence of a
calendar, but the chances that he or she will know
the correct date one hour later is greatly diminished.
Similarly, the effects of sign-posting and other
external navigational cues have shown limited
success. For example, Hanley, McGuire, and Boyd
(1981) demonstrated that posting directional signs
improved way-finding only when combined with
orientation training.
directing attention
Everyday functioning involves task completion;
task completion requires organized attention. The
cognitive effects of dementia affect one's ability to
attend to and eventually complete tasks. For
persons with dementia, daily tasks can become
too overwhelming or complicated to complete.
Changes to external stimuli can simplify tasks and
make them appear more manageable. Such altera-
tions function in two complimentary ways: (a)
reducing distractions and (b) directing attention.
Reducing distractions may involve removing
clutter and clearing areas of all items except those
related to the present task. Similarly, limiting excess
auditory stimuli can help reduce distractions. To
assist in directing attention, a care provider can set
up the remaining items in a logical sequence. Other
options include using brightly colored labels or
signs, developing simple coding systems, or direct-
ing light to specific objects, tasks, or locations
(Alzheimer's Association, 2002). To illustrate, an
 rehabilitation in dementia
individual may become overwhelmed by a closet
full of clothing. However, the task of dressing seems
much more manageable if clothing items are (a)
limited to only in-season items, (b) organized into
matching outfits, and (c) clearly labeled with
matching symbols or colors. Gitlin et al. (2006)
demonstrated that these strategies have positive
effects on elderly individuals with functional
difficulties. Home interventions not only improved
daily functioning but also enhanced participant's
self-efficacy—and benefits were still present after
12 months (Gitlin et al.).
increasing socialization
Because of difficulties with memory and communi-
cation, individuals with dementia may become
socially withdrawn, thereby increasing excess
disability due to reductions in environmental
stimulation. Relatively simple environmental mod-
ifications have been successfully used to increase
socialization. One idea is to encourage social
interaction through the addition of décor and
rearrangement of furniture. Melin and Gotestam
(1981) demonstrated that grouping and positioning
chairs effectively increased the frequency of social
interactions. Altus, Engelman, and Mathews (2002)
found that simply serving meals in a different
manner (i.e., serving “family style”) can increase
appropriate communication as well as participation
in the mealtime routine when desired behavior was
prompted and praised by staff.
Increasing Physical Exercise and Activity
Recent research with normally aging older adults
has clearly demonstrated that exercise is important
for increasing strength, balance, and endurance
(Colcombe & Kramer, 2003). Other studies suggest
that physical activity may also reduce the risk of
developing dementia (Dik et al., 2003; Larson et al.,
2006; Rovio et al., 2005). Given that physical
activity benefits older adults without cognitive
impairment, it can be expected that physical activity
would maintain or perhaps even improve function-
ing in individuals who have dementia. Remarkably,
less is known about the benefits of physical activity
in individuals with cognitive impairments.
characteristics of exercise programs
Patients with cognitive impairments face more
limitations, have fewer opportunities to participate
in physical activities, and require more supervision
by caregivers during physical activities. These
challenges can reduce access to regular physical
activity and result in increased dependence. Despite
these challenges, recent research has investigated
17
the benefits of structured exercise programs specif-
ically designed for the unique needs of persons with
dementia. These exercise programs most often
include aerobic training (e.g., walking, running,
bicycling, or elliptical training) or anaerobic train-
ing (e.g., weight/resistance training, stretching, or
somatic relaxation). Duration of exercise sessions is
typically at least 30 minutes. The frequency of
sessions across studies has varied greatly (ranging
from 1 to 3+ sessions per week) as has the total
duration of exercise interventions (ranging from 3
to 12 weeks). Exercise programs have also been
successfully implemented in a variety of settings,
such as institutional settings (Friedman & Tappen,
1991; Lindenmuth & Moose, 1990; Powell, 1974),
outpatient facilities (Arkin, 1999), and residential
homes (Rolland et al., 2000; Teri et al., 2003).
Furthermore, although many exercise programs are
led by professionals, some programs have utilized
the assistance of student partners (Arkin) and
family caregivers (Rolland et al.; Teri et al.).
Overall, the existing literature demonstrates that
exercise programs for persons with dementia can be
conducted and delivered in a wide variety of ways.
benefits of exercise programs
A growing body of empirical literature provides
support for not only the feasibility of implementing
physical exercise programs with persons with
dementia, but also for their effectiveness on a
variety of outcome measures. For example, indivi-
duals who participated in regular exercise demon-
strated an increase in physical health and
functioning as indicated by increased walking
distance and mobility, improved balance and
flexibility, increased strength, increased minutes of
aerobic activity, decreased restricted activity days,
and increased weight training over the course of the
intervention (Arkin, 1999; Lazowski et al., 1999;
Teri et al., 2003). It should be noted that these
studies have included patients with cognitive
impairment ranging in severity from mild to severe.
Studies have also demonstrated the positive
effects of exercise in terms of maintaining and
improving cognitive functioning. For example,
Powell (1974) found significant improvements on
recall, logical thinking, and reality orientation for an
exercise group compared to a social interaction only
and control group after 12 weeks. Aerobic training
and hand/face exercises have been found to result in
significant improvements from pre- to posttesting
on cognitive outcome measures, specifically execu-
tive functioning (Palleschi et al., 1996; Scherder et
al., 2005). Friedman and Tappen (1991) observed
significant improvements in communication in
nursing home residents with AD following a
18 buchanan et al.
program designed to increase walking. In general,
results from a recent meta-analysis suggests that
both aerobic and anaerobic training programs
resulted in moderate effects on cognitive functioning
compared to control groups (Heyn, Abreu, &
Ottenbacher, 2004). In addition, larger effects
sizes were associated with low intensity (e.g., few
minutes per session), low duration, and higher
frequency (e.g., several sessions per week) exercise
and for patients with moderate or severe dementia.
Other studies suggest that physical activity can
potentially have positive effects on a patient's
behavioral and emotional functioning. For exam-
ple, the Reducing Disability in Alzheimer's Disease
program resulted in drastically fewer institutional
placements due to behavioral problems and de-
creased symptoms of depression after 3 months
(Teri et al., 2003). Rolland and colleagues (2000)
also found that caregivers reported fewer behav-
ioral problems and no significant change in burden,
indicating that fitness interventions may be imple-
mented without increasing burden for family
caregivers.
It is encouraging to see that structured exercise/
fitness programs can be implemented successfully
and can produce positive results in terms of
improving physical health, maintaining or improv-
ing cognitive functioning, and reducing behavior
problems. Future research has yet to address some
important issues, however. For example, few
studies included follow-up measurement and only
one study (Teri et al., 2003) investigated the long-
term maintenance (24 months) of treatment effects.
Also, the required frequency, duration, and inten-
sity needed to produce improvement and/or main-
tenance of cognitive functioning in both the short
and long term for persons with dementia is still
unknown. Further research is also needed to
examine the appropriateness, generality, and social
validity of implementing exercise interventions
within this population (Heyn et al., 2004; Kramer,
Hahn, & McAuley, 2000). Finally, it should be
noted that despite clear implications of positive
outcomes, outside of Hoyer (1973) and Burgio,
Burgio, Engel, and Tice (1986), there is a relative
dearth of behavior modification and therapy
techniques described in the literature directed at
increasing activity in elderly populations with
dementia.
Summary and Conclusions
The projected increase in the number of cases of
dementia over the next 40 years makes it essential
that we take a comprehensive rehabilitation ap-
proach with those afflicted with dementia. In this
paper, we described a comprehensive rehabilitation
strategy that targets five domains (i.e., cognitive
functioning, the social environment, self-care skills,
physical activity, and the physical environment). In
addition, examples of effective interventions that
target these domains were presented. We feel this
five-domain rehabilitation strategy could potentially
provide a framework for future rehabilitation
efforts (see Arkin, 2001 for an excellent example
of a rehabilitation program that targets three of
these domains). Comprehensive rehabilitation pro-
grams must be both community-based for those
living at home (such as in adult day care centers or
senior centers) as well as those living in long-term
care facilities. Rehabilitation efforts may translate
into positive outcomes for patients and families and
result in substantial cost savings in terms of fewer
nursing home placements. Taking a rehabilitation
approach will clearly require a shift in the way
many people think of caring for persons with
progressive dementia. This shift, however, appears
to be necessary given the expected growth in cases
of dementia and the limited benefits of currently
available medications. As described throughout this
paper, many innovative behavioral interventions
consistent with a rehabilitation approach have been
developed and evaluated, but it is also clear that
more research is needed to find additional methods
to help caregivers and patients in the fight against
the deterioration in physical and cognitive func-
tioning associated with dementia.
References
Abrahams, J. P., & Camp, C. J. (1993). Maintenance and
generalization of object name training in anomia associated
with degenerative dementia. Clinical Gerontologist, 12,
57–72.
Altus, D. E., Engelman, K. K., & Mathews, R. M. (2002). Using
family style meals to increase participation and communi-
cation in persons with dementia. Journal of Gerontological
Nursing, September, 47–53.
Alzheimer's Association. (2002). Planning guide for dementia
care at home: A reference tools for care managers. Retrieved
17 July, 2008 from dhs.wisconsin.gov/Aging/dementia/
environment.pdf.
Alzheimer's Disease International. (2009). World Alzheimer's
report 2009: Executive summary. Retrieved December 30,
2009, from http://www.alz.co.uk/research/files/World%
20Alzheimer%20Report%20Executive%20Summary.pdf.
Arkin, S. M. (1991). Memory training in early Alzheimer's
disease: An optimistic look at the field. The American
Journal of Alzheimer's Care and Related Disorders and
Research, 6, 17–25.
Arkin, S. M. (1992). Audio-assisted memory training with early
Alzheimer's patients: Two single subject experiments.
Clinical Gerontologist, 12, 77–96.
Arkin, S. M. (1999). Elder rehab: A student-supervised exercise
program for Alzheimer's patients. The Gerontologist, 39,
729–735.
 rehabilitation in dementia
Arkin, S. M. (2001). Alzheimer rehabilitation by students:
Interventions and outcomes. Neuropsychological Rehabili-
tation, 11, 273–317.
Baltes, M. M. (1995). Dependency in old age: Gains and losses.
Current Directions in Psychological Science, 4, 14–19.
Baltes, M. M., & Wahl, H.-W. (1996). Patterns of commu-
nication in old age: The dependence-support and
independence-ignore script. Health Communication, 8,
217–231.
Baltes, P. B., & Baltes, M. M. (1990). Psychological perspec-
tives on successful aging: The model of selective optimiza-
tion with compensation. In P. B. Baltes & M. M. Baltes
(Eds.), Successful aging: Perspectives from the behavioral
sciences. New York: Cambridge University Press.
Bird, M. (2000). Psychosocial rehabilitation for problems
arising from cognitive deficits in dementia. In R. D. Hill,
L. Backman, & A. S. Neely (Eds.), Cognitive rehabilitation
in old age (pp. 249–269). New York: Oxford University
Press.
Bourgeois, M. S. (1991). Communication treatment for adults
with dementia. Journal of Speech and Hearing Research, 34,
831–844.
Bourgeois, M. S. (1992). Evaluating memory wallets in
conversations with persons with dementia. Journal of
Speech & Hearing Research, 35, 1344–1357.
Bourgeois, M. S. (1993). Effects of memory aids on the dyadic
conversations of individuals with dementia. Journal of
Applied Behavior Analysis, 26, 77–87.
Bourgeois, M. S., Camp, C. J., Rose, M., White, B., Mai-one,
M., Carr, J., & Rovine, M. (2003). A comparison of training
strategies to enhance use of external aids by persons with
dementia. Journal of Communication Disorders, 36,
361–378.
Buchanan, J. A. (2006). A review of behavioral treatments for
persons with dementia. The Behavior Analyst Today, 7,
521–537.
Burgio, L. D., Allen-Burge, R., Roth, D. L., Bourgeois, M. S.,
Dijkstra, K., Gerstle, J., et al. (2001). Come talk with me:
Improving communication between nursing assistants
and nursing home residents during care routines. The
Gerontologist, 41, 449–460.
Burgio, L. D., Burgio, K. L., Engel, B. T., & Tice, L. M. (1986).
Increasing distance and independence of ambulation in
elderly nursing home residents. Journal of Applied Behavior
Analysis, 19, 357–366.
Burgio, L. D., Stevens, A., Burgio, K. L., Roth, D. L., Paul, P., &
Gerstle, J. (2002). Teaching and maintaining behavior
management skills in the nursing home. The Gerontologist,
42, 487–496.
Camp, C. J. (1998). Memory interventions for normal and
pathological older adults. In R. Schulz, G. Maddox, & M. P.
Lawton (Eds.), Annual Review of Gerontology and Geriatric,
volume 18. New York: Springer.
Camp, C. J., Bird, M. J., & Cherry, K. E. (2000). Retrieval
strategies as a rehabilitation aid for cognitive loss in
pathological aging. In R. D. Hill, L. Backman, & A. S.
Neely (Eds.), Cognitive rehabilitation in old age
(pp. 224–248). New York: Oxford University Press.
Camp, C. J., Foss, J. W., O'Hanlon, A. M., & Stevens, A. B.
(1996). Memory interventions for persons with dementia.
Applied Cognitive Psychology, 10, 193–210.
Camp, C. J., & Schaller, J. R. (1989). Epilogue: Spaced-retrieval
memory training in an adult day-care center. Educational
Gerontology, 15, 641–648.
Camp, C. J., & Stevens, A. B. (1990). Space retrieval: A memory
intervention for dementia of the Alzheimer's type (DAT).
Clinical Gerontologist, 10, 58–60.
19
Caporael, L. R., & Culbertson, G. H. (1986). Verbal response
modes of baby talk and other speech at institutions for the
aged. Language & Communication, 6, 99–112.
Clare, L., Wilson, B. A., Breen, K., & Hodges, J. R. (1999).
Errorless learning of face-name associations in early
Alzheimer's disease. Neurocase, 5, 37–46.
Clare, L., Wilson, B. A., Carter, G., Breen, K., Gosses, A., &
Hodges, J. R. (2000). Intervening with everyday memory
problems in dementia of Alzheimer's type: An errorless
learning approach. Journal of Clinical and Experimental
Neuropsychology, 22, 132–146.
Colcombe, S. J., & Kramer, A. F. (2003). Fitness effects on the
cognitive functioning of older adults: A meta-analytic study.
Psychological Science, 14, 125–130.
Dawson, P., Wells, D. L., & Kline, K. (1993). Enhancing the
abilities of persons with Alzheimer's disease and related
dementias: A nursing perspective. New York: Springer.
Day, K., Carreon, D., & Stump, C. (2000). The therapeutic
design of environments for people with dementia: A review
of the empirical research. The Gerontologist, 40, 397–416.
Dickinson, J. I., McLain-Kark, J., & Marshall-Baker, A. (1995).
The effects of visual barriers on exiting behavior in a
demented care unit. The Gerontologist, 35, 127–130.
Dik, M. G., Deeg, D. J. H., Visser, M., & Jonker, C. (2003).
Early life activity and cognition in old age. Journal of
Clinical and Experimental Neuropsychology, 25, 643–653.
Einstein, G. O., & McDaniel, M. A. (2004). Memory fitness: A
guide for successful aging. London: Yale University Press.
Engelman, K. K., Altus, D. E., & Mathews, R. M. (1999).
Increasing engagement in daily activities by older adults with
dementia. Journal of Applied Behavior Analysis, 32,
107–110.
Engelman, K. K., Altus, D. E., Mosier, M. C., & Mathews, R.
M. (2003). Brief training to romote the use of less intrusive
prompts by nursing assistants in a dementia care unit.
Journal of Applied Behavior Analysis, 36, 129–132.
Feliciano, L., Vore, J., LeBlanc, L. A., & Baker, J. C. (2004).
Decreasing entry into a restricted area using a visual barrier.
Journal of Applied Behavior Analysis, 37, 107–110.
Fillit, H. M., Butler, R. N., O'Connell, A. W., Albert, M. S.,
Birren, J. E., Cotman, C. W., et al. (2002). Achieving and
maintaining cognitive vitality with aging. Mayo Clinic
Proceedings, 77, 681–696.
Friedman, R., & Tappen, R. M. (1991). The effect of planned
walking on communication in Alzheimer's disease. Journal
of the American Geriatrics Society, 39, 650–654.
Geldmacher, D. S., Frolich, L., Doody, R. S., Erkinjuntti, T.,
Vellas, B., Jones, R. W., et al. (2006). Realistic expectations
for treatment success in Alzheimer's disease. The Journal of
Nutrition Health and Aging, 10, 417–429.
Gentry, R. A., & Fisher, J. E. (2007). Facilitating conversation
in elderly persons with Alzheimer's disease. Clinical
Gerontologist, 31, 77–99.
Gitlin, L. N., Corcoran, M., Winter, L., Boyce, A., & Marcus, S.
(1999). Predicting participation and adherence to a home
environment intervention among family caregivers of
persons with dementia. Family Relations, 48(4), 363–372.
Gitlin, L. N., Schinfeld, S., Winter, L., Corcoran, M., & Hauck,
W. (2002). Evaluating home environments of person with
dementia: Interrater reliability and validity of the home
environmental assessment protocol (HEAP). Disability and
Rehabilitation, 24, 59–71.
Gitlin, L. N., Winter, L., Dennis, M. P., Corcoran, M.,
Schinfeld, S., & Hauck, W. (2006). A randomized trial of
a mulitcomponent home intervention to reduce functional
difficulties in older adults. Journal of the American
Geriatrics Society, 54(5), 809–816.
20 buchanan et al.
Hanley, I. G., McGuire, R. J., & Boyd, W. D. (1981). Reality
orientation and dementia: A controlled trial of two
approaches. The British Journal of Psychiatry, 138, 10–14.
Hebert, L. E., Scherr, P. A., Bienias, J. L., Bennett, D. A., &
Evans, D. A. (2003). Alzheimer's disease in the U.S.
population: Prevalence estimates using the 2000 Census.
Archives of Neurology, 60, 1119–1122.
Heyn, P., Abreu, B. C., & Ottenbacher, K. J. (2004). The effects
of exercise training on elderly persons with cognitive
impairment and dementia: A meta-analysis. Archives of
Physical Medicine and Rehabilitation, 85, 1694–1704.
Hoerster, L., Hickey, E. M., & Bourgeois, M. S. (2001). Effects
of memory aids on conversations between nursing home
residents with dementia and nursing assistants. Neuropsy-
chological Rehabilitation, 11, 399–427.
Hope, T., Tilling, K. M., Gedling, K., Keene, J. M., Cooper, S.
D., & Fairburn, C. G. (1994). The structure of wandering
in dementia. International Journal of Geriatric Psychiatry,
9, 149–155.
Hoyer, W. J. (1973). Application of operant techniques to the
Modification of Elderly Behavior. The Gerontologist, 13,
18–22.
Hummert, M. L. (1994). Stereotypes of the elderly and
patronizing speech. In M. L. Hummert, J. M. Wiemann,
& J. F. Nussbaum (Eds.), Interpersonal communication and
older adulthood: Interdisciplinary research (pp. 162–184).
Thousand Oaks, CA: Sage Publications.
Hussian, R. A., & Brown, D. C. (1987). Use of two-dimensional
grid to limit hazardous ambulation in demented patients.
Journal of Gerontology, 42, 558–560.
Kramer, A. F., Hahn, S., & McAuley, E. (2000). Influence of
aerobic fitness on the neurocognitive function of older
adults. Journal of Aging and Physical Activity, 8, 379–385.
Larson, E. B., Wang, L., Bowen, J. D., McCormick, W. C., Teri,
L., Crane, P., & Kukull, W. (2006). Exercise is associated
with reduced risk for incident dementia among persons 65
years of age or older. Annals of Internal Medicine, 144,
73–81.
Lawton, M. P., & Nanemow, L. (1973). Ecology and the aging
process. In C. Eisdorfer & M. P. Lawton (Eds.), The
psychology of adult development and aging (pp. 619–674).
Washington, DC: American Psychological Association.
Lazowski, D. A., Ecclestone, N. A., Myers, A. M., Paterson, D.
H., Tudor-Locke, C., Fitzgerald, C., Jones, G., Shima, N., &
Cunningham, D. A. (1999). A randomized outcome
evaluation of group exercise programs in long-term care
institutions. Journals of Gerontology, 54A, M621–M628.
Lichtenstein, M. J., Federspiel, C. F., & Schaffner, W. (1985).
Factors associated with early demise in nursing home
residents: a case control study. Journal of the American
Geriatrics Society, 33, 315–319.
Lindenmuth, G. F., & Moose, B. (1990). Improving cognitive
abilities of elderly Alzheimer's patients with intense exercise
therapy. American Journal of Alzheimer's Disease and
Other Dementias, 44, 175–180.
Lindsley, O. R. (1964). Geriatric behavioral prosthetics. In R.
Kastenbaum (Ed.), New thoughts on old age (pp. 41–60).
New York: Springer.
Lowenstein, D. A., Acevedo, A., Czaja, S. J., & Duara, R.
(2004). Cognitive rehabilitation of mildly impaired Alzhei-
mer's disease patients on cholinesterase inhibitors. American
Journal of Geriatric Psychiatry, 12, 395–402.
Mayer, R., & Darby, S. J. (1991). Does a mirror deter
wandering in demented older people? International Journal
of Geriatric Psychiatry, 6, 607–609.
McCallion, P., Toseland, R. W., Lacey, D., & Banks, S.
(1999). Educating nursing assistants to communicate more
effectively with nursing home residents with dementia. The
Gerontologist, 39, 546–558.
McEvoy, C. L., & Patterson, R. L. (1986). Behavioral treatment
of deficit skills in dementia patients. The Gerontologist, 26,
475–478.
McKitrick, L. A., & Camp, C. J. (1993). Relearning the names
of things: The spaced-retrieval intervention implemented by
a caregiver. Clinical Gerontologist, 14, 60–62.
Melin, L., & Gotestam, K. G. (1981). The effects of rearranging
ward routines on communication and eating. Journal of
Applied Behavior Analysis, 14, 47–51.
Moore, S., Sandman, C. A., McGrady, K., & Kesslak, J. P.
(2001). Memory training improves cognitive ability in
patients with dementia. Neuropsychological Rehabilitation,
11, 245–261.
Morse, C., & Wisocki, P. A. (1991). Residential factors in
behavioral programming for elderly. In P. A. Wisocki (Ed.),
Handbook of clinical behavior therapy (pp. 97–120). New
York: Plenum Press.
Namazi, K. H., Rosner, T. T., & Calkins, M. P. (1989). Visual
barriers to prevent ambulatory Alzheimer's patients from
exiting through an emergency door. The Gerontologist, 29,
699–702.
Palleschi, L., Vetta, F., DeGennaro, E., Idone, G., Scottosanti,
G., Gianni, W., & Marigliano, V. (1996). Effect of aerobic
training on the cognitive performance of elderly patients
with senile dementia of Alzheimer type. Archives of
Gerontology and Geriatric Supplements, 5, 47–50.
Powell, R. R. (1974). Psychological effects of exercise therapy
upon institutional geriatric mental patients. Journal of
Gerontology, 29, 157–161.
Rolland, Y., Rival, L., Pillard, F., Lafont, C. H., Riviere, D.,
Albarede, J.-L., & Vellas, B. (2000). Feasibility of regular
physical exercise for patients with moderate to severe
Alzheimer disease. Journal of Nutrition, Health, and
Aging, 4, 109–113.
Rovio, S., Helkala, E. L., Viitanen, M., Winblad, B., Tuomi-
lehto, J., Soininen, H., Nissinen, & Kivipelto, A. M. (2005).
Leisure time physical activity at midlife and the risk of
dementia and Alzheimer's disease. Lancet Neurology, 4,
705–711.
Scherder, E. J. A., Paasschen, J., Deijen, J.-B., Van der Knokke,
S., Orlebeke, J. F. K., Burgers, I., Devriese, P.-P., Swaab, D.
F., & Sergeant, J. A. (2005). Physical activity and executive
functions in the elderly with mild cognitive impairments.
Aging and Mental Health, 9, 272–280.
Spira, A. P., & Edelstein, B. A. (2006). Behavioral interven-
tions for agitation in older adults with dementia: An
evaluative review. International Psychogeriatrics, 18,
195–225.
Stevens, A. B., O'Hanlon, A., & Camp, C. (1993). The spaced-
retrieval method: A case study. Clinical Gerontologist, 13,
106–108.
Teri, L., Gibbons, L. E., McCurry, S. M., Logsdon, R. G.,
Buchner, D. M., Barlow, W. E., Kukull, W. A., LaCroix,
A. Z., McCormick, W., & Larson, E. B. (2003). Exercise
plus behavioral management in patients with Alzheimer's
disease. Journal of the American Medical Association, 290,
2015–2022.
Terrace, H. S. (1963). Discrimination learning with and without
“errors.” Journal of the Experimental Analysis of Behavior,
6, 1–27.
U.S Census Bureau – Census (2000). Profile of General
Demographic Characteristics for the United States 2000.
Valliant, G. (2002). Aging well: Surprising guideposts to a
happier life from the landmark Harvard Study of Adult
Development. London: Little, Brown & Company.
 rehabilitation in dementia
Wei, J., & Levkoff, S. (2001). Aging well: The complete
guide to physical and emotional health. New York: John
Wiley.
Wilson, B. A., Baddeley, A., Evans, J., & Shiel, A. (1994).
Errorless learning in the memory rehabilitation of memory
impaired people. Neuropsychological Rehabilitation, 4,
307–326.
Williams, K. N., Herman, R., Gajewski, B., & Wilson, K.
(2009). Elderspeak communication: Impact on dementia
care. American Journal of Alzheimer's Disease & Other
Dementias, 24, 11–20.
21
Williams, K. N., & Warren, C. A. B. (2009). Communication in
assisted living. The Journal of Aging Studies, 23, 24–36.
Zanetti, O., Zanieri, G., Di Giovanni, G., Di Vreese, L. P.,
Pezzini, A., Metitieri, T., et al. (2001). Effectiveness of
procedural memory stimulation in mild Alzheimer's disease
patients: A controlled study. Neuropsychological Rehabili-
tation, 11, 263–272.
R E C E I V E D : November 3, 2009
A C C E P T E D : January 18, 2010
Available online 21 September 2010