The experiences of people living with dementia are at the heart of the challenge of reducing the negative impacts of the disease. To deepen our understanding of those experiences, the committee began with a close look at the reflections of a number of individuals, made available to us through the work of the advisory panel formed to support this study (see Chapter 1). The paper prepared by the members of this panel summarizes findings from a public call for commentaries that was posted on the project website and also widely distributed, and from a survey conducted by the Alzheimer’s Association (Huling Hummel et al., 2020).1 It includes anonymous first-person accounts, as well as a synthesis of the challenges the advisory panel identified as most important. We accorded these perspectives special weight as we examined the challenges of living with dementia and reviewed the available research, drawing on papers commissioned for this study,2 academic studies and reports, and presentations to the committee (see Chapter 1).
The chapter begins with a discussion of the challenges identified by the advisory panel. The remaining sections review research in several areas relevant to those challenges: diagnosis of dementia, autonomy and protection from harm, and interventions to improve the experiences of people living
with dementia. The chapter closes with a discussion of research directions for each of these areas.
Prior work offers important insights into possible gaps in research relevant to living with dementia. For example, the 2020 National Research Summit offered recommendations drafted by its Persons Living with Dementia Stakeholder Group (2020). Examples include the call for research on how disparities affect the experience of living with dementia; how finances affect choices about diagnosis, treatment, and research participation; and methods for improving the quality of end-of-life care. In addition to reviewing this prior work, the committee wished to hear directly from individuals living with dementia, and we appreciated the opportunities to integrate the advisory panel’s perspectives throughout this study. This small group of people provided us with a snapshot of their own experiences, responded to our questions, and participated in public workshop discussions. The panel also provided a thoughtful summation of the perspectives of a larger group of people living with dementia and family caregivers gathered through the call for commentaries (Huling Hummel et al., 2020). The advisory panel made an invaluable contribution to our understanding, primarily of the perspectives of individuals in the early stages of disease and family caregivers. It is important to note that insights into the experiences of individuals at advanced stages of disease are much less accessible because at those stages, dementia can limit people’s capacity to articulate their thoughts and feelings (Reuben, 2019).
The advisory panel identified four themes as primary challenges for persons living with dementia:
- problems in obtaining an accurate and timely dementia diagnosis,
- problems in obtaining needed supports and services,
- communication challenges with doctors and other health care professionals, and
- fear and loss.
The panel’s perspectives on these challenges are summarized below.
Respondents to the call for commentaries and members of the advisory panel repeatedly noted frustration with the diagnostic process. They pointed out that many primary care physicians lack the expertise to diagnose dementia accurately, an issue that may be particularly important for
the small minority of people who show signs of dementia before age 65. They suggested that many physicians believe that receiving a dementia diagnosis is either inconsequential because there is no remedy or actually harmful to patients. While there may be people who would prefer not to be told, multiple respondents reported that delays in receiving a diagnosis caused harm to themselves or loved ones. Respondents also expressed the view that delays in diagnosis reflect skepticism about reported symptoms (“My doctor did not believe me. My primary physician thought my problems were all due to the high stress of my position.”). Other delays resulted from diagnostic uncertainty (“It was difficult at first because with each new doctor I had a different diagnosis.”). One respondent reported, “I am a neurologist who retired early…. I sought medical help for my symptoms for 10 years prior to my diagnosis….” Other respondents encountered clinicians who were dismissive because of the lack of effective treatments (“When she pressed her doctor for more definitive diagnosis [after 2 years], she was told by her doctor, ‘Why bother, it won’t change your treatment approach.’”).
Errors and delays in diagnosis carried significant risks, as comments from caregivers suggested: “…Dad was confined to a psychiatric ward for a week after frightening family members with a gun because of terrifying hallucinations … a neuropsychiatrist finally diagnosed Dad with Lewy body dementia.” Delays in diagnosis also can have a significant economic impact, as one respondent noted: “It is important to receive a diagnosis as early as possible so you can leave work before you are fired due to performance issues that dementia inevitably causes. I was fired from my job, but I did not get diagnosed until 5 years later.”
Some respondents characterized the diagnostic experience as lacking in empathy: “What the doctor didn’t say out loud was, ‘Now get out of my office so I can see someone I can actually do something for.’”
Many respondents reported experiencing a disconnect between diagnosis and assessment and/or referral for services of any kind. One respondent noted, “When I first saw a neurologist he gave me a short test and a prescription, and that was that. He gave me no information about vascular dementia or any other [psychoeducational] resources at all. This is unacceptable for a terminal illness!” Others discovered that available services were inappropriate (“…support services are geared more toward care partners and not for those with the actual disease.”) or that potentially beneficial resources were unavailable: “My local ALZ Association will not allow me to participate in support groups or classes ‘without being accompanied by someone….’ I live alone and do not yet need a caregiver.”
Nevertheless, respondents reported that clinicians in some settings worked hard to avoid creating a feeling of abandonment for their clients, connecting people diagnosed with dementia to available supports. New York University, for instance, encourages referral to the Family Support Program when a person receives a diagnosis of dementia and requests permission for a staff member to follow up with patients and family in the week after diagnosis to provide any needed information or referrals. One survey respondent was able to enroll their partner and teenage children in counseling, noting the great benefit of “getting everyone on the same page as to what to expect, and … showed there was a lot more living to do.” Box 3-1 presents the perspective of an advisory panel member on the challenge of finding enrichment activities at an early stage of the disease.
Many respondents noted poor communication with health care professionals at the time of diagnosis (“The doctor did all kinds of tests that showed there was nothing wrong with his brain. She basically shrugged and sent us on our way.”); poor coordination of care (“Her doctors don’t communicate with each other and her dementia diagnosis is not flagged in her records. She has to ask her health care professionals to ‘slow down’ when giving instructions or explaining things.”); and general communication problems (“Communication is non-existent. They are not helpful or,
frankly, knowledgeable.” “My biggest frustration is communicating with my Geriatric Specialist….”).
Survey respondents described many ways in which dementia brings both fear and loss. Financial concerns were cited frequently. These concerns included worry about being preyed upon financially (“Our accountant estimated that my Dad wrote checks worth tens of thousands of dollars to charities, bogus car warranty companies, scam lotteries and gold coin merchants and nearly lost his home due to non-payment of taxes.”). Another respondent stated, “I was forced to take a medical leave because of my symptoms and lost my employee health insurance 3 days before I turned 65, so I would not be entitled to a pension.” Many respondents noted the shocking expense of care they would need in the future and their inability to pay for services of sufficient quality to maintain their safety or dignity: “I live in fear of getting worse with no financial options for assisted living or memory care.”
Social isolation has long been a problem for older Americans but is significantly exacerbated by dementia. Bias from others and embarrassment about real or potential errors related to cognitive deficits can severely limit social opportunities. Sensitivity to noise can make public gatherings jarring and unpleasant. Cognitive impairment may slow responses in conversation and make old hobbies and sports activities difficult to pursue. As one respondent noted, “I am unable to pursue my hobbies. I would love to still have the right to work in my old job and not get paid for it.”
Some respondents addressed how the COVID-19 pandemic has exacerbated the problem of isolation. One said, “I miss my family and I’m very lonely and depressed.” Other findings, such as those from a nationwide survey of nursing home residents conducted in July and August 2020 (Montgomery et al., 2020), reinforce the impression that lack of contact was especially hard on older people living away from family.
Box 3-2 describes art programs available during the COVID-19 pandemic.
Researchers have provided insights relevant to many aspects of the experience of living with dementia, including those described by the advisory panel. The committee reviewed the state of the literature to identify priorities for future research in these areas. We could not address every aspect of life with dementia but identified a set of examples that reflect the diversity of relevant research. In the medical domain, we review challenges
in making and communicating the diagnosis of dementia. In the nonmedical domain, we summarize issues related to decision making, financial vulnerability, and sexuality. A host of other issues, including driving, medication management, and housing choices, are equally important, and we hope the examples discussed here may be used as a template for further work in additional domains.
Early and accurate diagnosis of dementia can be difficult. Most types of dementia develop slowly, but different types present different symptoms, and symptoms vary even among individuals experiencing the same type of dementia. Doctors who see patients for limited appointment times in an examining room may not be certain how to interpret symptoms and their relationship to other medical issues the patient may have. The lack of clarity is often very frustrating for patients and families. Clinicians and families also wonder about the ethics of disclosing a diagnosis for which there is limited treatment.
Clinicians use guidelines to identify individuals who meet criteria that apply to a range of dementia diagnoses. The process of diagnosis often includes several steps; it may be initiated in response to concerning symptoms reported by the person or family or to the results of routine screening. Public education campaigns and tools, such as the Alzheimer’s Association’s 10 Early Signs and Symptoms of Alzheimer’s (Alzheimer’s Association, n.d.), have heightened awareness of the early signs of dementia, and anecdotal evidence suggests that screening by primary care providers has also become more common.
Although the U.S. Preventive Services Task Force (2020) currently rates the evidence for dementia screening as insufficient, clinicians may opt to screen individual patients using a variety of instruments (see Box 3-3) or through the Medicare Annual Wellness Visit. Cognitive screening is a required component of this visit, but guidelines do not specify how it should be done, and anecdotal evidence suggests that many clinicians do not adhere to the screening requirement (Jacobson and Zissimopoulos, 2020). Guidelines about what should be included in this cognitive screen are urgently needed.
Once cognitive concerns have been identified, the diagnostic evaluation typically involves obtaining a history of decline, usually through interviews with the patient and family and through mental status testing that identifies
at least two areas of cognition in which there has been a decline severe enough to impair social or occupational functioning (McKhann et al., 2011; American Psychiatric Association, 2013). Blood tests and neuroimaging studies are used to check for treatable conditions that may cause cognitive impairment that mimics dementia.
Although these basic approaches to diagnosis are well known, studies have suggested that cognitive impairment is significantly underdiagnosed—indeed by one estimate, roughly half the population of individuals who have Alzheimer’s disease or a related dementia receive a formal diagnosis (Alzheimer’s Association, 2019). Early-stage dementia is least likely to be diagnosed, and Hispanic and non-Hispanic Black people are less likely to receive a diagnosis of mild cognitive impairment than are non-Hispanic White people (NASEM, 2021). Moreover, the effectiveness of diagnostic evaluation is limited by linguistic, educational, and cultural factors that affect the validity of results (Lewis et al., 2021; Jervis et al., 2010, 2018).4 For example, the results of functional questionnaires are influenced by context. Patients’ responses are affected by baseline levels of function, limitations related to motor or sensory changes, and degree of insight. Family members’ observational facility and cultural expectations, as well as cultural biases in the questionnaires themselves, also affect results (Jervis et al., 2018). Similarly, scores on cognitive tests are influenced by patients’ baseline cognitive performance, mood and effort, sensory and motor changes, and comfort level (which themselves are influenced by education and culture), and by linguistic and cultural biases in the tests themselves.
Diagnosis is complex in part because cognition is not a finite or unitary capacity: the evaluation covers multiple cognitive abilities, such as episodic memory (ability to encode and recall a story and/or list of words), language or semantic memory (capacity for naming and fluency), executive function (such capacities as planning, focusing attention, and self-monitoring needed to direct one’s own cognition), and perceptual speed and working memory (ability to hold and manipulate information in short-term memory stores). Moreover, it is common for people’s cognitive capacity to decline as they age: a degree of decline is accepted as a normal part of the aging process, although it may be the result of pathologic changes in the brain (Salthouse, 2019).
Cognitive loss occurs on a continuum. Cutpoints along that continuum identify points at which the decline can be classified as impairment, beginning with mild cognitive impairment, in which objective measures of cognition are abnormal but function is preserved, and progressing through stages of severity that increasingly have clinical consequences. Thus, mild
cognitive impairment is a change in an individual’s cognition significant enough to be recognized as impairment but mild enough that the individual retains independence and functional abilities (Albert et al., 2011). A loss of cognition that impairs function is considered dementia. However, because cognitive impairment is defined primarily in terms of changes over time for the individual, clinicians use information about level of education, occupation, and other aspects of the individual’s life to set expectations for performance that can serve as the basis for assessing decline. Like the identification of a degree of decline that interferes with social or occupational functioning, these criteria are subjective and likely to be affected by cultural and other differences across populations, and thus are problematic for researchers and clinicians alike.
Today, dementia and its precursor, mild cognitive impairment, are diagnosed primarily based on clinical symptoms. Often, family members are the first to notice subtle early psychological and cognitive changes in their loved ones and bring them to a clinician’s attention. Researchers are beginning to evaluate whether information that can be collected unobtrusively (e.g., from website interactions, smartphones, and wearable devices) can be used to detect cognitive impairment or early dementia.5 There are also many tests that assess the neuropathology associated with Alzheimer’s disease and other forms of dementia, using such modalities as brain scanning technology that can reveal structural changes, deposits, or biochemical changes in the brain, or testing of cerebrospinal fluid for abnormal markers.6 These tests are valuable for research and can be used clinically to help distinguish one type of dementia from another, although they cannot be used for diagnosis of mild cognitive impairment or dementia, which is based on clinical symptoms, as discussed above. Such tests can detect signs of brain pathology even when no clinical symptoms are evident. Imaging, biomarker, and autopsy studies all indicate that many asymptomatic people have Alzheimer’s biomarkers. Not all such individuals will eventually develop dementia, and some biomarkers can be detected many years before any symptoms develop. In individuals with clinical evidence of mild cognitive impairment or dementia, these tests can be valuable in distinguishing Alzheimer’s disease from other dementias (e.g., frontotemporal degeneration, Lewy body dementia), and they can also be used to select individuals for trials of preventive strategies. Substantial progress has recently been made in the use of blood tests to measure biomarkers of Alzheimer’s disease, but the same limitations apply to these tests (Palmqvist et al., 2020).
Researchers seek to identify signs of preclinical change because of the hope that treatments offered earlier, before symptoms are apparent, can increase the chances of improving outcomes for patients. As noted in Chapter 1, however, no disease-modifying treatments have yet been approved for Alzheimer’s disease; the pharmacologic treatments that exist address symptoms but not root causes. Biomarker research is nonetheless useful for advancing understanding of the development and progression of disease, differentiating types of dementia, and guiding research to develop new interventions, both to control symptoms better and potentially to address the causes of the disease (Mangialasche et al., 2010; Tan et al., 2014). It is important to note, moreover, that biomarker studies have been conducted largely in convenience samples of predominantly White and highly educated individuals, and even the few epidemiologic studies of biomarkers have had limited representation of individuals from rural communities and minority populations, so the generalizability of their results is limited (Glymour et al., 2018).
It is important to consider as well that if biomarker screenings do become widely used clinically, they will likely raise new questions. As noted above, many people who demonstrate biomarker evidence of Alzheimer’s pathology never go on to develop clinical symptoms. Would this group, with normal cognition but positive biomarkers, be considered to have Alzheimer’s disease? If biomarker evidence were officially part of the disease definition, would people who meet the clinical criteria for dementia (progressive impairment of cognition and resultant disability) but do not show the currently measured biomarkers for disease be counted in estimates of Alzheimer’s prevalence? If biomarkers were used routinely for screening (e.g., of the adult offspring of persons with Alzheimer’s disease), what additional challenges might arise?
Perhaps most important are ethical questions about whether or when an asymptomatic individual who has biomarkers for dementia should receive that information. Being told that one may—or may not—develop a potentially devastating and ultimately fatal disease 10 or more years in the future could have profound psychological and other consequences for individuals and their families. And how could the privacy of the information be safeguarded? Would asymptomatic, biomarker-positive individuals lose access to life and long-term care insurance, housing options, employment, or other benefits? Consideration of the potential psychological, financial, and other impacts on such individuals is needed so that sound guidelines can be established. Research on these and related questions is scant; more such research is needed to support the development of guidelines, as well as important decisions regarding policy, insurance coverage, and public health messaging.
Even apart from questions about disclosure raised by screening for biomarkers, clinicians may struggle to assess the benefits and liabilities related to making and disclosing a diagnosis of dementia. An early and accurate diagnosis has benefits. A diagnosis may be an eligibility requirement for some services and provide reassurance that unexplained symptoms have a clear cause. It may allow individuals to work with loved ones to revise legal documents, anticipate needed support services, avoid medical and financial risks, and plan for future care while they can still fully participate in decision making. Yet receiving a diagnosis has potential negative ramifications as well. As noted, life and long-term care insurance could be denied to those with a preexisting condition. Access to some living options (e.g., entry into continuing care retirement communities and assisted living facilities) may be denied for those diagnosed with dementia, and even at times for those diagnosed with mild cognitive impairment. In some states, a dementia diagnosis must be disclosed to the department of motor vehicles, triggering evaluations that can lead to revocation or restriction of driving privileges. Finally, the stigma of dementia may affect how individuals feel about themselves and how they are treated in society and within health care settings.
There is relatively sparse guidance for clinicians about disclosing a diagnosis and communicating about care, symptoms, and the progress of disease. The Gerontological Society of America’s KAER toolkit7 has a section on how to disclose a diagnosis, which includes links to videos and external resources. Guidance for patient-centered communication during diagnosis has been suggested, but with variable results thus far (Zaleta and Carpenter, 2010).
Generally, clinicians are taught to balance autonomy, which would promote disclosure of diagnosis and prognosis, against beneficence, which emphasizes protection from harm. Some clinicians fear the impact of diagnosis on their patients’ mental health and well-being, particularly when cognitive deficits limit an individual’s ability to process and respond to information. The challenges of communication deepen as dementia progresses, although many people still want to be included in conversations about their care even as their ability to understand and articulate opinions declines. Indeed, supporting individuals living with dementia while protecting their autonomy—recognizing their values and right to make decisions
as other adults do while also providing appropriate and graduated levels of protection against harm—is the central ethical challenge posed by dementia.
Assessment of decision-making capacity must be tailored to individual circumstances; it cannot be based simply on the cutpoints for cognitive test results. While research has addressed how to evaluate decisional capacity for research and treatment purposes, there is no standard practice for capacity assessment (Pennington et al., 2018), and available instruments and insights have not been widely adopted in clinical practice. For decisions outside of or adjacent to the medical realm, including those related to housing, finances, and safety matters (guns, sexuality), research is extremely limited. There is a growing literature on assessment of driving capacity, but specialists who can make such assessments are not widely available (see, e.g., Wolfe and Lehockey, 2016; Schultheis et al., 2008).
The tension between autonomy and safety increases as patients’ cognitive decline continues and they become more vulnerable. A significant potential threat to dignity comes with overprotection, yet the risk of abuse and neglect grows when protection is insufficient for an individual whose capacity to make decisions that reflect personal values and interests is compromised by disease. People living with dementia, as with some other illnesses, are negatively affected by stigma, both when others see and treat them disrespectfully and when they incorporate societal bias into their own self-image. This self-stigma can diminish self-esteem and self-efficacy (Watson et al., 2007).
Thus, the need to balance respect for autonomy and beneficence, to promote self-advocacy while offering sufficient support, complicates decision making by and for people living with dementia. Adulthood brings with it the right to make decisions in risky domains, including finance, sexuality and relationships, medical care, driving, gun access, and many others. The committee cannot cover every potentially risky domain in this report, but we review issues related to finance and sexuality for persons living with dementia in order to analyze the nature of the challenges, explore potential solutions, and generate areas for research.8 These two domains represent burdens that are both common and serious for people living with dementia and their family caregivers. In addition, we perceive a gap in the research regarding how to promote independence while also providing appropriate protection. Better guidance to help clinicians, people with dementia, and families navigate these complex issues is sorely needed. Finally, we see
8 One key area in which people living with dementia are at risk is the use of physical restraints, which, although it has become less common in institutional settings such as nursing homes, remains an issue with untrained caregivers in the community. See, e.g., https://www.ncbi.nlm.nih.gov/pmc/articles/PMC7058582; https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2564468 for more on this issue.
in that evidentiary gap the potential for improvement in alleviating the challenges of dementia by developing better interventions, guidelines, and policies.
Decisional capacity is a cornerstone of autonomy. Those who can weigh risks and benefits make their own decisions, while those who cannot adequately assess risks have decisions made on their behalf by others. Prematurely limiting the decision-making authority of persons with dementia robs them of their rights and dignity. At the same time, however, protecting someone who has become vulnerable is an ethical responsibility. Two key points regarding decisional capacity are worth noting. First, a diagnosis of dementia does not automatically mean a person has lost the right or ability to make decisions. Dementia is a progressive illness, and people in earlier stages can clearly express and act upon their lifelong values and preferences. Second, capacity is decision-specific, meaning a person may be capable of making some decisions but not others. In many individuals, the capacity to make financial decisions fades earlier than other cognitive skills. People may be able to make values-based medical decisions or select a health care proxy when they can no longer handle complex financial transactions. Yet because of loss of insight, which often occurs in early stages of dementia, they may not be willing to relinquish financial decision making, with substantial consequences. Once it has been determined that a person with dementia cannot make a specific decision, it becomes the responsibility of a surrogate to support the person with dementia in decision making based on the person’s values and previously expressed preferences, if known.
Those whose cognitive impairment undermines their decisional capacity are at increased risk for abuse of various kinds. Older people hold a substantial percentage of financial assets in the United States; net worth for those older than age 65 is roughly 20 times that for those under 35 (Sawhill and Pulliam, 2019). Financial capacity, defined as “the ability to independently manage one’s financial affairs in a manner consistent with personal self-interest,” can be one of the earliest deficits of cognitive function, even before a diagnosis of dementia (Widera et al., 2011). An individual may lose a lifetime’s savings just when those funds are needed for long-term care, precisely because at that time they have become vulnerable to exploitation. In one large sample, 4.7 percent of older people reported suffering financial exploitation. The cost of such abuse in the United States is challenging to measure because much of it appears to go unreported; estimates vary from $3 billion to as much as $30 billion annually (Stanger, 2015; see also Government Accountability Office, 2020).
Financial exploitation targeting older people with cognitive impairment occurs in many forms. A typical example is a phone call in which the caller claims to represent an Internet service provider who has discovered a problem with the recipient’s computer. The caller promises to fix the problem quickly and requests bank account information for direct billing, but instead uses that information to empty the victim’s bank account.9 Older people who live alone, especially those with dementia, can be particularly vulnerable to such scams when their opportunities for human contact are limited.
Sadly, financial abuse by family members or others well known to the victim, including new “friends” who hope to extract money, is even more common than anonymous scams (Spreng et al., 2016). Financial exploitation of older people with dementia often goes unreported. In cases of abuse by family members, the person with dementia may resist reporting to the police for fear of the consequences for a loved one. Those with more advanced dementia may be unaware of the theft or unable to act on their knowledge because of isolation and inability to access help.
Making wise financial choices requires many skills, including good judgment about who is a trustworthy person, as well as basic math skills. A person needs to estimate a reasonable price for goods or services and needs sufficient memory or record keeping skills to know, for instance, whether they have recently donated to an alumni association or other philanthropy. Experts recommend that clinicians educate patients and family members about the prevalence of scams and the risks of lost financial capacity, as well as ways to identify warning signs of exploitation (Marson, 2013).
There is no single, widely used tool for measuring financial capacity. One model measures cognitive skills, such as mental math, as well as social skills, such as the ability to identify a scam (Spreng et al., 2016). This approach requires a specially trained person to administer the test and takes roughly 30 minutes to complete. An instrument for assessing the capacity to make financial decisions has also been developed (Lichtenberg et al., 2015). Assessments that require expert clinicians and take considerable time to administer may be too costly or inaccessible for many people, although many expert clinicians perform such assessments on a fee-for-service basis, which is not covered by insurance.
Financial vulnerability for older people with cognitive impairment is not a new problem; the legal system has long offered remedies, particularly through the guardianship process. The process of obtaining a guardian can be expensive, time-consuming, and stressful and therefore is used rarely relative to the frequency of dementia. The process typically requires that the
9 Catherine Christian, Chief of the Elder Abuse Unit of the NYC District Attorney’s Office, personal interview with Tia Powell, October 10, 2018.
family submit an evaluation to a judge, with a request that the person be declared incompetent and that a family member be named guardian, with authority to access all accounts and disburse funds on the person’s behalf. This has traditionally been an all-or-nothing process, in which the person with dementia either retains full decision-making rights or loses them all to a surrogate.
There are many impediments to the smooth functioning of the guardianship process. It is challenging to compel a person to undergo evaluation, and such evaluations can be expensive. The process may be traumatic for the family or disrupt relationships, particularly when dementia has brought impairment of insight or other emotional symptoms. It is not always easy to identify a suitable guardian, and not all guardians discharge their duties as hoped. The criteria for guardianship are generally quite stringent, to protect autonomy, but as one legal scholar and bioethicist has pointed out, the standard guardianship process fails to protect those in the middle, who have neither full capacity nor an utter absence of it (Arias, 2013). In practice, many families “muddle through,” relying on the support they can find from clinicians and financial and legal advisors, and adapting to circumstances. An intermediate step of limited guardianship that offers oversight but permits the person with dementia some participation in financial decision making is one recommended approach (Arias, 2013). This approach aligns well with the ethical obligation to balance freedom and supervision in a fashion that promotes inclusion where possible and permits protection as needed, matching the degree of cognitive impairment with the level of authority of the guardian.
The Consumer Financial Protection Bureau has developed educational materials for banking industry professionals, including tools for identifying unusual banking behavior, such as large money orders sent overseas (Consumer Financial Protection Bureau, 2016). Families often set up joint accounts to oversee a person with dementia’s financial affairs, but such accounts can also make exploitation easy. These accounts allow the family member or other trusted person full access, but the joint holder can use the incapacitated older person’s funds for any purpose, including ones not sanctioned by or in the interest of the person with dementia. Upon the death of one member of a joint account, the funds are owned wholly by the co-holder of the account, which may exclude other family members from an intended inheritance. The move to online banking has enabled some family members to access the account of a person with dementia using that person’s credentials; this practice is convenient but does not protect against unwarranted use of funds. Some experts recommend “convenience accounts,” in which a designated person can use the account to pay bills but will not inherit the funds. Another useful tool is “read only” access in which a third party can monitor banking activity and alert the bank about
suspicious behavior but cannot make withdrawals (Consumer Financial Protection Bureau, 2016).
Sexual intimacy in the context of dementia is overshadowed by many unhelpful cultural biases, including those involving older people, gender norms, and those with disabilities. Many younger people assume that older people either do not or should not have sexual feelings, and the same incorrect beliefs are often applied to people with disabilities, including cognitive disabilities such as dementia. Moreover, older people with a same-sex orientation may have lived closeted lives, so that even close family members are unaware of their lifelong preferences. The fact is that older people vary markedly in their sexual interests and behaviors, just as other people do, with some remaining sexually active into their 80s and beyond. Aging does not eliminate loneliness or the wish for intimacy, physical touch, and companionship—all reasons why people of any age engage in sexual behaviors. In any case, as with other decisions, a diagnosis of dementia does not in itself prove that someone lacks the capacity to make choices about sexual relationships.
It is also important to note that while most people with dementia live in the community, people with dementia represent more than half of the population of nursing homes. In these institutions, normally private behavior is rarely private.10 In the past, moreover, nursing homes often prohibited even consensual sexual activity among residents. Standards have evolved in the direction of greater freedom in this regard, although nursing facilities vary significantly in their policies and practices (Ward et al., 2005), and even when facilities have more accepting policies, family members may object and ask staff to prevent relationships among residents. Yet nursing home staff rarely receive training in how to respond to sexual approaches either among residents or to themselves by residents. Sexualized approaches to staff or female residents by male residents, either verbal or physical, are far more likely to be seen as problematic and more likely to result in punitive actions, including rejection from a facility or transfer to a more restrictive section. Women with dementia are more likely to be seen as lacking sexual impulses, and as generally more vulnerable and in need of protection (Ward et al., 2005).
Certainly, sexual behaviors can include risks to both physical safety and dignity for any person, but it is possible, indeed obligatory, to assess risks in individual cases. The presumption should be that sexual behavior among adults, irrespective of a diagnosis of dementia, is a normal and expected expression of self, and that willing and capable participation can
be assessed. These decisions are of an essentially private nature, and the intervention of others poses a significant threat to dignity and the freedom to act as other adults do. Thus, the starting point for decisions about sexual behavior is that they remain the province of the person with dementia unless there are compelling reasons, not based on bias, to think otherwise. When sexual behavior is unwanted by the person to whom it is directed, such as a staff member at a nursing home, respectful, nonpunitive reactions, such as distraction and redirection, are appropriate. If the person with dementia is viewed as being unwilling or otherwise at risk—for instance, because of a predatory or disinhibited partner—intervention by family members, institutions, or even legal authorities may be appropriate, yet must still be approached in a way that preserves dignity. Dementia also can result in uninhibited sexual self-stimulation, which can be disturbing for staff and other residents, as well as undermine the dignity of the person. Distracting and removing the person to a private setting are the best options; restraints and sedation should be avoided unless strictly necessary. Little research or evidence-based training is available to help address this issue.
Possible and appropriate interventions regarding the sexual behavior of persons with dementia fall on a spectrum. When both participants have full capacity, no intervention is ethically justifiable within this intensely private domain. A next step along the spectrum would resemble the sort of inquiry a concerned friend would make of a person who does not have cognitive impairment but appears to be making an unwise choice. For persons with cognitive impairment associated with dementia, an assessment of their decisional capacity is warranted and is indeed a mark of excellence in nursing homes. As the cognitive deficits of dementia advance, a person may no longer be capable of expressing or acting upon a choice. At this stage, a protective role is ethically justified and comes to the fore.11
Although dementia can undermine a person’s ability to make decisions based on lifelong values, this decline in capacity occurs gradually and affects domains unevenly. As in many aspects of living with dementia, a person may be able to extend autonomy by learning about challenges that dementia is likely to bring as the disease progresses and recording advance directives about medical choices, finances, sexual relationships, and other
11 An issue that touches on both sexual and financial decision making is marriage undertaken by or with a person who has cognitive impairment. Such a marriage offers the possibility of support in the face of the isolation and loneliness that are common among older people and those living with dementia, but there is also the possibility of exploitation, as well as distress for adult children and other family members. This is another area that has not been well studied.
issues. Such documents as the MOLST (Medical Orders for Life-Sustaining Treatment) are important for directing medical care after a person loses capacity. Unfortunately, no one can realistically predict every challenge or devise an advance directive that will provide adequate guidance for every situation that may arise.
As dementia progresses, a person may still retain a strong sense of self but lose insight or have impaired judgment about risks. Risks associated with driving and gun safety may be misjudged by a person with advancing cognitive impairment. These two activities involve risks not only to the person with dementia but also to others, both in the family and in the local community. The ethical viability of removing a person’s right to make decisions increases as the danger to self and others increases and as the judgment of the person declines.
Clinicians are often asked by family members for help in assessing various types of decisional capacity (including for financial decisions, as discussed above). Yet many physicians lack the appropriate expertise to fill this role, and a comprehensive exam cannot be accomplished during a brief medical appointment. Assessments of capacity also can be quite variable (Stocking et al., 2008). Neuropsychological evaluations can elucidate the impact of impaired cognition on decisions but require considerable time, expense, and expertise (Gurrera et al., 2006). Although most clinicians cannot perform a detailed neuropsychological evaluation—or an assessment of driving skills or financial capacity—they should be able to determine when such evaluations are needed and refer the patient to a professional with the requisite skills. Unfortunately, no single evaluation or type of specialist can assess a person’s capacity to make choices about money, sexual contact, driving, and the wide range of important challenges a person with dementia faces. And as noted, at a given stage of disease, a person may retain the ability to make choices that reflect lifelong values and interests in some domains but not others. This complexity greatly increases the difficulty of finding the right resources to help guide those with dementia and their family caregivers as they navigate potentially risky life choices.
Limited research has been conducted to establish standard tools and methods for assessing different sorts of capacity or to identify ways of making such resources broadly available and easy to administer. The assessment resources available today are not standardized, can be difficult to obtain, and are often expensive and time-consuming. Additional research to develop tools for assessing and supporting decision-making capacity for people living with dementia, aimed at primary care providers, social workers, and others involved in providing care, could help address this gap. Readily accessible educational programs about challenges in decision making for people with dementia and family caregivers, adapted for different cultural groups and languages, might also be helpful.
Although the clinical manifestations of different types of dementia vary, particularly at early stages of disease, the similarities are more pronounced as the diseases progress in severity and patients develop more complications. Characteristic symptoms appear during the various stages of the disorder, especially among those with Alzheimer’s disease, as shown in Table 3-1. However, biological, sociodemographic, and clinical markers that predict disease progression and the rate of decline are lacking and are a topic for future research.
TABLE 3-1 Progression of Dementia Symptoms
|Functional Status||Cognitive Changes||Behavioral Issues||Complications|
|Mild Cognitive Impairment (preclinical)|
|Report by patient or caregiver of memory loss; objective signs of memory impairment; mild construction, language, or executive dysfunction|
|Early, Mild Dementia (typically 1 to 3 years from onset of symptoms)|
|Impairment that affects capacity to manage finances, driving, and medications||Decreased insight, short-term memory deficits, poor judgment||Social withdrawal, mood changes: apathy, depression||Poor financial decisions, adverse effects related to medication errors|
|Middle Stage, Moderate Impairment (typically 2 to 8 years from onset)|
|Difficulty with instrumental activities of daily living and some activities of daily living (ADLs), changes in gait and balance||Further declines in memory, getting lost in familiar areas, repeating questions||Apathy, depression, restlessness, anxiety, wandering||Need for assisted living facility, weight loss due to inability to prepare meals, falls|
|Late, Severe Impairment (typically 6 to 12 years from onset)|
|Severe difficulty with ADLs, including continence; problems with mobility, swallowing||Little or unintelligible verbal output, loss of remote memory, inability to recognize family/friends||Motor or verbal agitation, aggression, apathy, depression, sundowning||Pressure sores, contractures, aspiration, pneumonia, weight loss due to forgetting to or refusing to eat|
Clinicians often use medicines to try to decrease the symptoms of certain dementias or reduce the emotional and psychological complications, with results that are modest at best (Gaugler et al., 2020; Fink et al., 2020). These medications, whose indications vary by type of dementia, are not addressed in this report because they fall outside the realm of social and behavioral approaches to reducing the impacts of dementia.
Nonpharmacologic interventions include both single- and multicomponent approaches. Although some types of dementia (e.g., frontotemporal degeneration) and situations (e.g., early-onset dementia) may require specific nonpharmacologic interventions, most general interventions are applicable to the majority of persons with dementia and their family caregivers, particularly in the more advanced stages of disease. Interventions may focus on persons living with dementia, caregivers (see Chapter 4), or both. Others are directed at helping the community better support families living with dementia and may be provided by community-based organizations or by health systems, as discussed in Chapter 5. This section reviews objectives for the care of people living with dementia and the evidence for approaches to some of the key challenges.
Individuals at each stage of dementia have distinct needs, abilities to respond to interventions, and potential quality-of-life outcomes. For example, a positive outcome for people living with mild dementia might be that with added support, they can continue to work or volunteer for longer than would otherwise have been the case. For those living with severe dementia, the goal may be to identify in-home care that allows them to live with family and avoid moving to a nursing home. Needs vary with stage of disease and circumstances, but the areas in which persons living with dementia are likely to need care and support include (NASEM, 2021, p. 9)
- detection and diagnosis;
- assessment of symptoms to inform planning and deliver care, including financial and legal planning;
- information and education;
- medical management;
- support in activities of daily living;
- support for care partners and caregivers;
- communication and collaboration;
- coordination of medical care, long-term services and supports, and community-based services and supports;
- a supportive and safe environment; and
- advance care planning and end-of-life care.
A taxonomy of goals for dementia care (Table 3-2) provides a closer look at what is needed in some of these areas. Derived from focus groups of persons living with dementia and caregivers, this taxonomy has been used to guide care (Jennings et al., 2018). Setting goals and measuring attainment of these goals can serve several purposes that improve the care and lives of persons living with dementia. First, this exercise helps individuals identify and work toward personal goals that are meaningful to them. It also facilitates their providers’ efforts to plan and organize care to achieve those goals. Defining outcome measures is another important tool for assessing how well a health system is meeting the needs of persons living with dementia (Reuben and Jennings, 2019). Yet while setting goals and measuring their attainment show promise for improving patient-centered outcomes, additional research is needed on such questions as the frequency of such assessments, the added value of integrating them into dementia care interventions, and appropriate responses when the goals of persons with dementia and those of their caregivers are not aligned.
TABLE 3-2 Goals for Dementia Care Identified by Persons with Dementia and Caregivers
|Medical Care and End-of-Life Care||
Receive needed dementia care
Have doctors who work with us
Have providers who understand our cultural background and speak our primary language
Do not take medications with side effects
Get adequate sleep at night
Maintain adequate nutrition
Do not get burdensome medical care
Stay out of the hospital
Live as long as possible
Not be a burden to family
|Quality of Life—Physical||
Be physically safe (e.g., avoids falls, household hazards, or getting lost)
Not taken advantage of by others
Do self-care and household activities
Be in charge of household activities
Be physically active
Continue to drive or use other transportation
Continue to live at home
Move to a more supportive setting (e.g., move in with family, assisted living, or nursing home)
Find acceptable long-term care
|Quality of Life—Social and Emotional||
Socialize with family and friends
Maintain relationship with spouse/partner
Continue to work or volunteer
Do recreational activities
Keep mind stimulated; be alert
Control agitation or aggression; manage behavioral symptoms of dementia
Respected for spiritual preferences
|Accessing Services and Supports||
Feel financial resources are not a barrier to care; find assistance with managing finances
Have legal issues in order
Have adequate caregivers
Find community resources for dementia that offer what I need
Find culturally appropriate services for dementia
Increase community awareness and education about dementia
Control caregiver’s frustration and manage stress
Receive caregiver support
Feel confident in managing dementia-related problems
Have more free time for caregiver; respite care
Minimize family conflict with managing dementia care
Maintain caregiver’s health
SOURCE: Reprinted with permission from Springer Nature, Quality of Life Research, Jennings et al. (2016).
A recent National Academies’ report on the challenges of caregiving has also identified a set of principles to guide care and support for people living with dementia (NASEM, 2021, p. 8):
- Person-centeredness: Recognition of persons living with dementia as individuals with their own goals, desires, interests, and abilities.
- Promotion of well-being: The use of social, behavioral, and environmental interventions that holistically address the needs of persons living with dementia, care partners, and caregivers to enhance well-being.
- Respect and dignity: Attention to each person’s particular needs and values, which can be achieved by following models for identifying preferences and values, such as values elicitation, shared decision making, respect for dissent, or seeking either assent or informed consent.
- Justice: Treating people with equal need equally so that, for example, all critically ill persons receive critical care, all expectant
- mothers receive prenatal care, and the dying receive palliative care. By extension, all persons living with dementia, care partners, and caregivers have equal access and can receive care, supports, and services according to their needs.
- Racial/ethnic, sexual, cultural, and linguistic inclusivity: The availability of racially, ethnically, sexually, culturally, and linguistically appropriate services for all who may need them, especially underserved and underrepresented populations, such as racial/ethnic minorities and LGBTQ individuals.
- Accessibility and affordability: Care, services, and supports for persons living with dementia, care partners, and caregivers that do not impose an unmanageable financial burden on individuals or their families and are available and accessible to all who may need them, including those living in rural communities.
The authors acknowledge that more research is needed to provide more explicit guidance regarding dementia care but note that following these guidelines would “represent a significant advance” over care that is currently widely available (p. 8).
Researchers have explored a variety of strategies for improving the experiences of people living with dementia, including forms of cognitive training; therapies incorporating music, animal companionship, and other approaches; exercise; environmental modification; and others. The committee commissioned a paper that provides an overview of this body of work, based on systematic reviews published from 2016 to 2019 (Gaugler et al., 2020). The authors report that while some interventions may have potential, “conclusions as to efficacy or effectiveness are challenging if not impossible due to how control groups are defined, incomplete reporting of protocols and key intervention characteristics, heterogeneous outcome measures, and lack of clarity related to effect sizes or … the clinical relevance of reported effects.” The authors characterize the lack of conclusive evidence for nonpharmacologic interventions as “frustrating.” Described below are some approaches that may hold promise for addressing key dementia symptoms: cognitive decline, functional decline, and behavioral and psychological symptoms.12
Addressing cognitive decline
Approaches for addressing cognitive decline include forms of cognitive training, as well as exercise and other lifestyle
modifications (Gaugler et al., 2020). In general, cognitive interventions, including cognitive training, cognitive rehabilitation, and cognitive stimulation therapy, appear to produce moderate benefits for cognition. Cognitive training includes guided tasks designed to improve memory and thinking. There is evidence that training targeted at specific domains of cognition, such as speed of processing or attention, can bring improvement in that domain. Cognitive rehabilitation is designed to enhance daily living using memory activities and memory-boosting approaches. It has shown limited benefit, particularly compared with other approaches designed to maintain or improve cognition for persons living with dementia. Overall, these approaches appear to have the capacity to strengthen people’s capacity for the task they are practicing, but the benefits do not extend to other cognitive challenges.13
The evidence for cognitive stimulation training (CST) is stronger, and it is the only nonpharmacologic therapy recommended by the National Institute for Health and Clinical Excellence in the United Kingdom. Designed to enhance cognitive and social function, CST is often presented in group settings using such approaches as reminiscence and reality orientation (orienting individuals to the day, date, and weather to place them in “reality”). Reality orientation appears to have moderate benefits for cognition (Chiu et al., 2018). Systematic reviews have shown that CST can help improve cognition and memory, usually for persons with less severe dementia (Aguirre et al., 2013; Bahar-Fuchs et al., 2013; Woods et al., 2012). However, researchers have not yet established whether it is effective in community-based settings (as opposed to residential environments). Moreover, the cognitive benefits do not appear to be lasting, and CST does not affect other important domains, such as mood, behavioral symptoms, or daily function.
A fair amount of research supports the idea that physical activity (including both aerobic and nonaerobic exercise) also has the potential to maintain or enhance cognitive function for people with dementia, or possibly delay dementia symptoms (see, e.g., Duan et al., 2018; Farina et al., 2014; Groot et al., 2016; Karssemeijer et al., 2017; Liang et al., 2018; Lim et al., 2019). Although existing research does not provide a clear picture as to which interventions are most consistently efficacious at preventing cognitive decline, emerging work points to the possible benefits of a multicomponent approach that takes advantage of several mechanisms, such as nutrition, exercise, cognitive training, and social activity (Kivipelto et al., 2018).
Addressing functional decline
Decline in such functions as self-care activities is a core symptom of dementia and is directly linked to such adverse
events as falls and greater dependence on help from others. Functional decline that results in dependence is caused in part by neuropathological changes, but contextual factors also play a role. For example, cluttered, loud, or poorly lighted environments; information that is communicated ineffectively; lack of structures to support medication management; and overly complex tasks all may increase challenges for people living with dementia (Gitlin et al., 2020). These contextual factors are modifiable.
The available evidence suggests that several types of interventions are modestly beneficial in ameliorating functional decline. These include occupation-based and cognitive interventions; physical activity that features aerobic exercise, resistance training, or flexibility training or activities that combine all three; modification of the home environment; and family caregiver skills training programs. Approaches that provide education for caregivers and equip them with strategies for managing behavioral challenges, offer physical activity, and modify the home environment show promise (Gaugler et al., 2020).
There is also some evidence that technological assists can be beneficial. Remaining in their homes through the course of their illness is important to many persons with dementia. Such emerging tools as assessment and monitoring technologies, assistive devices, therapeutic devices, and caregiver supportive technologies show promise for supporting these individuals (Moyle, 2019) (see also the discussion of the use of technology to support caregiving in Chapter 5). Currently, many of these technologies (e.g., smart home technologies; artificial intelligence, including the Internet of Things; wearable devices that monitor activities; robotics; medication reminders) are most appropriate for those in the early stages of disease, but some facilitate physical functions, such as feeding and transferring from bed to chair, and may be helpful for those who are in more advanced stages. Some of these technologies are currently available, while others (e.g., self-driving cars) are in development or being tested.
Addressing behavioral and psychological symptoms
Behavioral and psychological symptoms can be very distressing for people living with dementia and their families, and often drive the decision to seek residential care (Gaugler et al., 2009). Interventions to alleviate these symptoms include tailoring activities to the interests of the individual and providing education, skill building, and support to family caregivers (Gaugler et al., 2020) (see also the discussion of approaches for addressing these symptoms in Chapter 4). Emerging evidence points to possible benefits of multidisciplinary care and to the possible reduction of aggressive and agitated behaviors through massage, music therapy, and touch therapy. Cognitive and sensory stimulation, music therapy, animal therapy, and psychotherapeutic approaches (e.g., cognitive-behavioral therapy) show potential for reducing depressive
symptoms and anxiety, as well as enhancing overall quality of life and mood (e.g., Kishita et al., 2020; Hu et al., 2018; Liang et al., 2018; Lorusso and Bosch, 2018; Peluso et al., 2018; Tay et al., 2019; van der Steen et al., 2018; Wood et al., 2017; Yen and Lin, 2018; Zhang et al., 2017; Aguirre et al., 2013; Fukushima et al., 2016; Garcia-Casal et al., 2017). In general, these approaches appear to be more beneficial than pharmacologic treatment in managing behavioral and psychological symptoms and to have fewer negative consequences (Watt et al., 2019).
The committee’s exploration of research intended to improve the experiences of individuals living with dementia points to key gaps in knowledge across the areas discussed in this chapter. Looking first at screening and diagnosis, we identified needs related to disclosure of diagnostic information and predictive measures, as well as the use of biomarkers and their value in clinical practice, including the ramifications, both positive and negative, for asymptomatic persons who could be notified that they have these specific markers of disease. There is a need for psychometric research on the accuracy of screening and diagnostic tools and approaches (e.g., what combinations of historical information about the person’s symptoms, cognitive testing, laboratory tests, and neuroimaging are most accurate), as well as qualitative research on the impact on persons receiving a dementia diagnosis.
We also reviewed research needs related to the support and dignity of people living with dementia. We examined decision making from varied perspectives and identified needs for both qualitative and quantitative research related to the needs of persons at all stages of dementia. Research on how to strengthen protections while respecting autonomy will need to be interdisciplinary, including both ethicists and legal experts along with clinicians and researchers. Research to examine the impact of dementia on decision-making capacity can support the development and testing of interventions with the potential to mitigate such adverse consequences as stigma and improve protection from abuse.
Gaps in the development of nonpharmacologic interventions to slow or prevent cognitive decline, decrease behavioral and psychological symptoms, and increase comfort and well-being for those living with dementia were also evident from our review. Although several interventions (e.g., exercise and cognitive stimulation therapy) have shown promise, few have been studied in adequately powered or pragmatic trials and with diverse groups. Such research is needed to justify broad dissemination.
Finally, we reflected on the nature of the research available in these domains. Much of the research on interventions for people living with dementia is primarily observational or conducted using conventional rather
than pragmatic trials. As discussed in Chapter 2 (see the section on “Interpreting the Evidence”), observational studies provide insight but are not conclusive in determining the effectiveness of interventions. Interpreting observational data is challenging because it can be difficult to disentangle factors that may confound evidence about the factor under study or to identify causation. For example, the effect of physical activity on cognitive decline may depend on when in the life course exercise is initiated, when it is assessed, and the type and amount of exercise involved. Clinical trials are needed to provide more valid answers to such questions. However, conventional clinical trials aimed at demonstrating efficacy may not provide sufficient insight into what is achievable in real-world settings, such as health care systems.
Related is the need for improved measures that can be used in assessing outcomes relevant to persons living with dementia and their family caregivers throughout the course of the disease. Consistent, shared definitions of outcomes of interest and ways to measure them can support efforts to synthesize research from varied domains in this complex area. For example, the goal of supporting people living with dementia in remaining at home through as much of their illness as possible is valued by clinicians, social workers, and families, and a wide array of interventions may contribute to meeting that goal. Use of consistent measures, such as number of days spent at home, across studies would be a valuable aid to harmonizing research, thereby increasing the ability to compare the effectiveness of interventions implemented in different studies. Psychometric research, including qualitative studies to identify meaningful goals for measurement, as well as validation studies, are needed to create instruments that are patient-centered and capture what matters most to those living with dementia and their caregivers over the course of disease. These issues are discussed further in Chapter 8.
The committee identified priority areas for research related to the experiences of individuals living with dementia in two domains: diagnosis and decision-making support, and support for well-being and quality of life. The priority areas for research in each of these domains are summarized in Conclusions 3-1 and 3-2; Tables 3-3 and 3-4, respectively, provide detailed directions for research in each area of these domains.
CONCLUSION 3-1: Research in the following areas related to diagnosis and decision-making support has the potential to substantively improve the experience of individuals living with dementia by supporting their dignity and well-being:
- Improved screening and diagnosis to identify persons living with dementia, including guidance for clinicians that also addresses issues related to disclosure.
- Development of guidance to support ethical and responsible decision making by and for people living with dementia.
TABLE 3-3 Detailed Research Needs: Diagnosis and Decision-Making Support
|1: Improved Screening and Diagnosis||
|2: Support for Ethical and Responsible Decision Making||
CONCLUSION 3-2: Research in the following areas has the potential to advance the development of interventions to support the well-being and quality of life of people living with dementia.
- Development and validation of outcome measures that reflect the perspectives of people living with dementia, their family caregivers, and communities.
- Improved design and evaluation of nonpharmacologic interventions to slow or prevent cognitive and functional decline, reduce or ameliorate behavioral and psychological symptoms, improve comfort and well-being, and adequately and equitably serve diverse populations.
TABLE 3-4 Detailed Research Needs: Support for Well-Being and Quality of Life
|1: Development and Validation of Outcome Measures||
|2: Improved Design and Evaluation of Nonpharmacologic Interventions||
Research focused on the priorities identified above has the potential to substantially improve the comfort and dignity of the experience of living with dementia. However, we close this chapter with the observation that the need is great and that it was not possible to explore adequately every possible opportunity for meaningful improvement. Among the important areas for which we were unable to establish the basis for explicit conclusions within the time allotted for this study are the impact of implicit and explicit bias and stigma against people living with dementia and their family caregivers on their well-being; the needs of people living with dementia who do not have family caregivers; and the needs of specific subpopulations of people living with dementia, including LGBTQ, African American, Latinx, and America Indian/Alaska Native populations. We emphasize that we in no way wish to discourage research in these areas.
Aguirre, E., Woods, R., Spector, A., and Orrell, M. (2013). Cognitive stimulation for dementia: A systematic review of the evidence of effectiveness from randomised controlled trials. Ageing Research Reviews, 12(1), 253–262. https://doi.org/10.1016/j.arr.2012.07.001
Albert, M.S., DeKosky, S.T., Dickson, D., Dubois, B., Feldman, H.H., Fox, N.C., Gamst, A., Holtzman, D.M., Jagust, W.J., Petersen, R.C., Snyder, P.J., Carrillo, M.C., Thies, B., and Phelps, C.H. (2011). The diagnosis of mild cognitive impairment due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7(3), 270–279. https://doi.org/10.1016/j.jalz.2011.03.008
Alzheimer’s Association. (n.d.). 10 Early Signs and Symptoms of Alzheimer’s. https://www.alz.org/alzheimers-dementia/10_signs
———. (2019). 2019 Alzheimer’s Disease Facts and Figures. https://www.alz.org/media/documents/alzheimers-facts-and-figures-2019-r.pdf
American Geriatrics Society. (2020). Geriatrics at Your Fingertips. https://geriatricscareonline.org/ProductAbstract/geriatrics-at-your-fingertips-2020/B052
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders (5th ed.). https://doi.org/10.1176/appi.books.9780890425596
Arevalo‐Rodriguez, I., Smailagic, N., Roqué i Figuls, M., Ciapponi, A., Sanchez‐Perez, E., Giannakou, A., Pedraza, O.L., Bonfill Cosp, X., and Cullum, S. (2015). Mini‐Mental State Examination (MMSE) for the detection of Alzheimer’s disease and other dementias in people with mild cognitive impairment (MCI). Cochrane Database of Systematic Reviews, 2015(3), CD010783. https://doi.org/10.1002/14651858.CD010783.pub2
Arias, J. (2013). A time to step in: Legal mechanisms for protecting those with declining capacity. American Journal of Law and Medicine, 39, 134–159.
Bahar-Fuchs, A., Clare, L., and Woods, B. (2013). Cognitive training and cognitive rehabilitation for mild to moderate Alzheimer’s disease and vascular dementia. Cochrane Database of Systematic Reviews, 2013(6), CD003260. https://doi.org/10.1002/14651858.CD003260.pub2
Beishon, L.C., Batterham, A.P., Quinn, T.J., Nelson, C.P., Panerai, R.B., Robinson, T., and Haunton, V.J. (2019). Addenbrooke’s Cognitive Examination III (ACE-III) and mini-ACE for the detection of dementia and mild cognitive impairment. Cochrane Database of Systematic Reviews, 12(12):CD013282. https://doi.org/10.1002/14651858.CD013282.pub2
Bennett, D.A. (2020). Defining Different Types of Dementia. Paper prepared for the National Academies of Sciences, Engineering, and Medicine’s Committee on Decadal Survey of Behavioral and Social Science Research on Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias. https://www.nationalacademies.org/event/10-17-2019/meeting-2-decadal-survey-of-behavioral-and-social-science-research-on-alzheimers-disease-and-alzheimers-disease-related-dementias#sectionEventMaterials
Chan, Q.L., Xu, X., Shaik, M.A., Chong, S.S., Hui, R.J., Chen, C.L., and Dong, Y. (2016). Clinical utility of the informant AD8 as a dementia case finding instrument in primary healthcare. Journal of Alzheimer’s Disease, 49(1), 121–127. https://doi.org/10.3233/jad-150390
Chiu, H.Y., Chen, P.Y., Chen, Y.T., and Huang, H.C. (2018). Reality orientation therapy benefits cognition in older people with dementia: A meta-analysis. International Journal of Nursing Studies, 86, 20–28. https://doi.org/10.1016/j.ijnurstu.2018.06.008
Consumer Financial Protection Bureau. (2016). Recommendations and Report for Financial Institutions on Preventing and Responding to Elder Financial Exploitation. https://201603_cfpb_recommendations-and-report-for-financial-institutions-on-preventing-and-responding-to-elder-financial-exploitation.pdf
Davis, D.H., Creavin, S.T., Yip, J.L., Noel‐Storr, A.H., Brayne, C., and Cullum, S. (2015). Montreal Cognitive Assessment for the diagnosis of Alzheimer’s disease and other dementias. Cochrane Database of Systematic Reviews, 2015(10), CD010775. https://doi.org/10.1002/14651858.CD010775.pub2
Droogsma, E., van Asselt, D., and De Deyn, P.P. (2015). Weight loss and undernutrition in community-dwelling patients with Alzheimer’s dementia. From population based studies to clinical management. Zeitschrift fur Gerontologie und Geriatrie, 48(4), 318–324. https://doi.org/10.1007/s00391-015-0891-2
Duan, Y., Lu, L., Chen, J., Wu, C., Liang, J., Zheng, Y., Wu, J., Rong, P., and Tang, C. (2018). Psychosocial interventions for Alzheimer’s disease cognitive symptoms: A Bayesian network meta-analysis. BMC Geriatrics, 18(1), 175. https://doi.org/10.1186/s12877-018-0864-6
Farina, N., Rusted, J., and Tabet, N. (2014). The effect of exercise interventions on cognitive outcome in Alzheimer’s disease: A systematic review. International Psychogeriatrics, 26(1), 9–18. https://doi.org/10.1017/S1041610213001385
Fink, H.A., Linskens, E.J., MacDonald, R., Silverman, P., McCarten, R., Talley, K., Forte, M., Desai, P., Nelson, V., Miller, M., Hemmy, L., Brasure, M., Taylor, B., Ng, W., Ouellette, J., Sheets, K., Wilt, T., and Butler, M. (2020). Benefits and harms of prescription drugs and supplements for treatment of clinical Alzheimer-type dementia. Annals of Internal Medicine, 172(10), 656–668. https://doi.org/10.7326/M19-3887
Fukushima, R.L.M., do Carmo, EG., Pedroso, R.D.V., Micali, P.N., Donadelli, P.S., Fuzaro Junior, G., Venancio, R.C.dP., Viola, J., and Costa, J.LR. (2016). Effects of cognitive stimulation on neuropsychiatric symptoms in elderly with Alzheimer’s disease: A systematic review. Dementia & Neuropsychologia, 10(3), 178–184. https://doi.org/10.1590/S1980-5764-2016DN1003003
Garcia-Casal, J.A., Loizeau, A., Csipke, E., Franco-Martin, M., Perea-Bartolome, M.V., and Orrell, M. (2017). Computer-based cognitive interventions for people living with dementia: A systematic literature review and meta-analysis. Aging & Mental Health, 21(5), 454–467. https://doi.org/10.1080/13607863.2015.1132677
Gaugler, J.E., Fang, Y., Krichbaum, K., and Wyman, J. (2009). Predictors of nursing home admission or persons with dementia. Medical Care, 47(2), 191–198. https://doi.org/10.1097/MLR.0b013e31818457ce
Gaugler, J., Jutkowitz, E., and Gitlin, L.N. (2020). Non-Pharmacological Interventions for Persons Living with Alzheimer’s Disease: Decadal Review and Recommendations. Paper prepared for the National Academies of Sciences, Engineering, and Medicine’s Committee on Decadal Survey of Behavioral and Social Science Research on Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias. https://www.nationalacademies.org/event/10-17-2019/meeting-2-decadal-survey-of-behavioral-and-social-science-research-on-alzheimers-disease-and-alzheimers-disease-related-dementias
Gitlin, L., Jutkowitz, E., and Gaugler, J.E. (2020). Dementia Caregiver Intervention Research Now and into the Future: Review and Recommendations. Paper prepared for the National Academies of Sciences, Engineering, and Medicine’s Committee on Decadal Survey of Behavioral and Social Science Research on Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias. https://www.nationalacademies.org/event/10-17-2019/meeting-2-decadal-survey-of-behavioral-and-social-science-research-on-alzheimers-disease-and-alzheimers-disease-related-dementias
Glymour, M.M., Brickman, A.M., Kivimaki, M., Mayeda, E.R., Chêne, G., Dufouil, C., and Manly, J.J. (2018). Will biomarker-based diagnosis of Alzheimer’s disease maximize scientific progress? Evaluating proposed diagnostic criteria. European Journal of Epidemiology, 33(7), 607–612. https://doi.org/10.1007/s10654-018-0418-4
Government Accountability Office. (2020). Elder Justice: HHS Could Do More to Encourage State Reporting on the Costs of Financial Exploitation. https://www.gao.gov/assets/gao-21-90.pdf
Groot, C., Hooghiemstra, A.M., Raijmakers, P.G., van Berckel, B.N., Scheltens, P., Scherder, E.J., van der Flierad, R., and Ossenkoppele, R. (2016). The effect of physical activity on cognitive function in patients with dementia: A meta-analysis of randomized control trials. Ageing Research Reviews, 25, 13-23. https://doi.org/10.1016/j.arr.2015.11.005
Gurrera, R., Moye, J., Karel, M., Azar, A., and Armesto, J. (2006). Cognitive performance predicts treatment decisional abilities in mild to moderate dementia. Neurology, 66(9), 1367–1372. https://doi.org/10.1212/01.wnl.0000210527.13661.d1
Harrison, J.K., Stott, D.J., McShane, R., Noel‐Storr, A.H., Swann‐Price, R.S., and Quinn, T.J. (2016). Informant Questionnaire on Cognitive Decline in the Elderly (IQCODE) for the early diagnosis of dementia across a variety of healthcare settings. Cochrane Database of Systematic Reviews, 2016(11). https://doi.org/10.1002/14651858.CD011333.pub2
Hu, M., Zhang, P., Leng, M., Li, C., and Chen, L. (2018). Animal-assisted intervention for individuals with cognitive impairment: A meta-analysis of randomized controlled trials and quasi-randomized controlled trials. Psychiatry Research, 260, 418–427. https://doi.org/10.1016/j.psychres.2017.12.016
Huling Hummel, C., Pagan, J.R., Israelite, M., Patterson, E., Van Buren, B., and Woolfolk, G. (2020). A Summary of Commentaries Submitted by Those Living with Dementia and Care Partners. Paper prepared for the National Academies of Sciences, Engineering, and Medicine’s Committee on Decadal Survey of Behavioral and Social Science Research on Alzheimer’s Disease and Alzheimer’s Disease-Related Dementias. https://www.nationalacademies.org/our-work/decadal-survey-of-behavioral-and-social-science-research-on-alzheimers-disease-and-alzheimers-disease-related-dementias#sl-three-columns-b93dcbe8-e082-4170-9bfca8cae8ef0445
Jacobson, M., and Zissimopoulos, J. (2020). The Role of Medicare’s Annual Wellness Visit in the Assessment of Cognitive Health. Pilot project, Center for Aging and Health Research, National Bureau of Economic Research. https://www.nber.org/programs-projects/projects-and-centers/center-aging-and-health-research/7783-role-medicares-annual-wellness-visit-assessment-cognitive-ealth?page=1&perPage=50
Jennings, L.A., Palimaru, A., Corona, M., Cagigas, X., Ramirez, K., Zhao, T., Hays, R.D., Wenger, N.S., and Reuben, D.B. (2016). Patient and caregiver goals for dementia care. Quality of Life Research, 3, 685–693.
Jennings, L.A., Ramirez, K., Hays, R.D., Wenger, N.S., and Reuben, D.B. (2018). Personalized goal attainment in dementia care: Measuring what persons with dementia and their caregivers want. Journal of the American Geriatrics Society, 66(11), 2120–2127. https://doi.org/10.1111/jgs.15541.PMID:30298901
Jervis, L.L., Fickenscher, A., Beals, J., Manson, S.M., and Arciniegas, D. (2010). Predictors of performance on the MMSE and the DRS-2 among American Indian elders. Journal of Neuropsychiatry and Clinical Neurosciences, 22(4), 417–425. https://doi.org/10.1176/jnp.2010.22.4.417
Jervis, L.L., Cullum, C.M., Cox, D., and Manson, S.M. (2018). Dementia assessment in American Indians. In G. Yeo, L.A. Gerdner, and D. Gallagher-Thompson (Eds.), Ethnicity and the Dementias (3rd ed., pp. 108–123). New York: Routledge.
Karssemeijer, E.G.A., Aaronson, J.A., Bossers, W.J., Smits, T., Olde Rikkert, M.G.M., and Kessels, R.P.C. (2017). Positive effects of combined cognitive and physical exercise training on cognitive function in older adults with mild cognitive impairment or dementia: A meta-analysis. Ageing Research and Reviews, 40, 75–83. https://doi.org/10.1016/j.arr.2017.09.003
Kishita, N., Backhouse, T., and Mioshi, E. (2020). Nonpharmacological interventions to improve depression, anxiety, and quality of life (QoL) in people with dementia: An overview of systematic reviews. Journal of Geriatrics Psychiatry and Neurolology, 33, 28–41. https://doi.org/10.1177/0891988719856690
Kivipelto, M., Mangialasche, F., and Ngandu, T. (2018). Lifestyle interventions to prevent cognitive impairment, dementia and Alzheimer disease. National Review of Neurology, 14(11), 653–666. https://doi.org/10.1038/s41582-018-0070-3. PMID: 30291317
Larner, A.J., and Mitchell, A.J. (2014). A meta‐analysis of the accuracy of the Addenbrooke’s Cognitive Examination (ACE) and the Addenbrooke’s Cognitive Examination-Revised (ACE‐R) in the detection of dementia. International Psychogeriatrics/IPA, 26(4), 555–563.
Lewis, J.P., Manson, S.M., Jernigan, V., and Noonan, C. (2021). Making sense of a disease that makes no sense: Understanding Alzheimer’s disease and related disorders among caregivers and providers in Alaska. Gerontologist, 61(3), 363–373. https://doi.org/10.1093/geront/gnaa102
Liang, J.H., Xu, Y., Lin, L., Jia, R.X., Zhang, H.B., and Hang, L. (2018). Comparison of multiple interventions for older adults with Alzheimer disease or mild cognitive impairment: A PRISMA-compliant network meta-analysis. Medicine, 97(20), e10744. https://doi.org/10.1097/md.0000000000010744
Lichtenberg, P., Stoltman, J., and Flicker, L. (2015). A person-centered approach to financial capacity assessment: Preliminary development of a new rating scale. Clinical Gerontologist, 38, 49–67. http://doi.org/10.1080/07317115.2014.970318
Lim, K.H., Pysklywec, A., Plante, M., and Demers, L. (2019). The effectiveness of Tai Chi for short-term cognitive function improvement in the early stages of dementia in the elderly: A systematic literature review. Clinical Interventions in Aging, 14, 827–839. https://doi.org/10.2147/cia.s202055
Lorusso, L.N., and Bosch, S.J. (2018). Impact of multisensory environments on behavior for people with dementia: A systematic literature review. Gerontologist, 58(3), e168–e179. https://doi.org/10.1093/geront/gnw168
Mangialasche, F., Solomon, A., Winblad, B., Mecocci, P., and Kivipelto, M. (2010). Alzheimer’s disease: Clinical trials and drug development. Lancet Neurology, 9(7), 702–716. https://doi.org/10.1016/S1474-4422(10)70119-8
Marson, D. (2013). Clinical and ethical aspects of financial capacity in dementia: A commentary. American Journal of Geriatric Psychiatry, 21(4), 382–390. https://doi.org/10.1097/JGP.0b013e31826682f4
McKhann, G.M., Knopman, D.S., Chertkow, H., Hyman, B.T., Jack, Jr., C.R., Kawas, C.H., Klunk, W.E., Koroshetz, W.J., Manly, J.J., Mayeux, R., Mohs, R.C., Morris, J.C., Rossor, M.N., Scheltens, P., Carrillo, M.C., Thies, B., Weintraub, S., and Phelps, C.H. (2011). The diagnosis of dementia due to Alzheimer’s disease: Recommendations from the National Institute on Aging-Alzheimer’s Association workgroups on diagnostic guidelines for Alzheimer’s disease. Alzheimer’s & Dementia, 7(3), 263–269. https://doi.org/10.1016/j.jalz.2011.03.005
Montgomery, A., Slocum, S., and Stanik, C. (2020). Experiences of Nursing Home Residents during the COVID-19 Pandemic. Altarum. https://altarum.org/sites/default/files/uploaded-publication-files/Nursing-Home-Resident-Survey_Altarum-Special-Report_FINAL.pdf
Moyle, W. (2019). The promise of technology in the future of dementia care. Nature Reviews Neurology, 15, 353–359. https://doi.org/10.1038/s41582-019-0188-y
National Academies of Sciences, Engineering, and Medicine. (2021). Meeting the Challenge of Caring for Persons Living with Dementia and Their Care Partners and Caregivers: A Way Forward. Washington, DC: The National Academies Press. https://doi.org/10.17226/26026
Palmqvist, S., Janelidze, S., Quiroz, Y.T., Zetterberg, H., Lopera, F., Stomrud, E., Su, Y., Chen, Y., Serrano, G.E., Leuzy, A., Mattsson-Carlgren, N., Strandberg, O., Smith, R., Villegas, A., Sepulveda-Falla, D., Chai, X., Proctor, N.K., Beach, T.G., Blennow, K., Dage, J.L., Reiman, E.M., and Hansson, O. (2020). Discriminative accuracy of plasma phospho-tau217 for Alzheimer disease vs other neurodegenerative disorders. Journal of the American Medical Association, 324(8), 772–781. https://doi.org/10.1001/jama.2020.12134
Peluso, S., De Rosa, A., De Lucia, N., Antenora, A., Illario, M., Esposito, M., and De Michele, G. (2018). Animal-assisted therapy in elderly patients: Evidence and controversies in dementia and psychiatric disorders and future perspectives in other neurological diseases. Journal of Geriatric Psychiatry and Neurology, 31(3), 149–157. https://doi.org/10.1177/0891988718774634
Pennington, C., Davey, K., Meulen, R., Coulthard, E., and Kehoe, P. (2018). Tools for testing decision-making capacity in dementia. Age and Ageing, 47(6), 778–784. https://doi.org/10.1093/ageing/afy096
Persons Living with Dementia Stakeholder Group. (2020). National Research Summit on Care, Services and Support for Persons Living with Dementia. https://aspe.hhs.gov/system/files/pdf/263846/PLwDRecom20.pdf
Rajan, K., Barnes, L., Wilson, R., Weuve, J., McAninch, E., and Evans, D. (2019). Apolipoprotein E genotypes, age, race, and cognitive decline in a population sample. Journal of the American Geriatric Society, 67(4), 734–740. https://doi.org/10.1111/jgs.15727
Reuben, D.B. (2019). The voices of persons living with dementia. American Journal of Geriatric Psychology, 28(4), 443–444. https://doi.org/10.1016/j.jagp.2019.11.005
Reuben, D.B., and Jennings, L.A. (2019). Putting goal-oriented patient care into practice. Journal of the American Geriatrics Society, 67(7), 1342–1344. https://doi.org/10.1111/jgs.15885
Salthouse, T.A. (2019). Trajectories of normal cognitive aging. Psychology and Aging, 34(1), 17–24. https://doi.org/10.1037/pag0000288
Sawhill, I., and Pulliam, C. (2019). Six facts about wealth in the United States. Middle Class Memos. Brookings Institution. https://www.brookings.edu/blog/up-front/2019/06/25/six-facts-about-wealth-in-the-united-states
Schultheis, M., DeLuca, J., and Chute, D., Eds. (2008). Handbook for the Assessment of Driving Capacity. Elsevier Academic Press. https://doi.org/10.1016/B978-0-12-631255-3.X0001-X
Spreng, R.N., Karlawish, J., and Marson, D.C. (2016). Cognitive, social and neural determinants of diminished decision-making and financial exploitation risk in aging and dementia: A review and new model. Journal of Elder Abuse and Neglect, 28(45), 320–344.
Stanger, T. (2015, September 29). Financial elder abuse costs $3 billion a year. Or is it $36 billion? Consumer Reports. https://www.consumerreports.org/cro/consumer-protection/financial-elder-abuse-costs--3-billion-----or-is-it--30-billion-
Stocking, C., Hougham, G., Danner, D., Patterson, P., Whitehouse, P., and Sachs, G. (2008). Variable judgments of decisional capacity in cognitively impaired research subjects. Journal of the American Geriatrics Society, 56(10), 1893–1897. https://doi.org/10.1111/j.1532-5415.2008.01922.x
Tan, C.C., Yu, J.T., and Tan L. (2014). Biomarkers for preclinical Alzheimer’s disease. Journal of Alzheimer’s Disease, 42(4), 1051–1069. https://doi.org/10.3233/JAD-140843
Tay, K.W., Subramaniam, P., and Oei, T.P. (2019). Cognitive behavioural therapy can be effective in treating anxiety and depression in persons with dementia: A systematic review. Psychogeriatrics, 19(3), 264–275. https://doi.org/10.1111/psyg.12391
U.S. Preventive Services Task Force. (2020, February 25). Cognitive Impairment in Older Adults: Screening. Final Recommendation Statement. https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/cognitive-impairment-in-older-adults-screening
van der Steen, J.T., Smaling, H.J., van der Wouden, J.C., Bruinsma, M.S., Scholten, R.J., and Vink, A.C. (2018). Music-based therapeutic interventions for people with dementia. Cochrane Database of Systematic Reviews, 7, Cd003477. https://doi.org/10.1002/14651858.CD003477.pub4
Ward, R, Vass, A., Aggarwal, N., Garfield, C., and Cybyk, B. (2005). A kiss is still a kiss? The construction of sexuality in dementia care. Dementia, 4(1), 49–72.
Watson, A.C., Corrigan, P., Larson, J.E., and Sells, M. (2007). Self-stigma in people with mental illness. Schizophrenia Bulletin, 33(6), 1312–1318. https://doi.org/10.1093/schbul/sbl076
Watt, J.A., Goodarzi, Z., Veroniki, A.A., Nincic, V., Khan, P.A., Ghassemi, M., Thompson, Y., Tricco, A.C., and Straus, S.E. (2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: A systematic review and network meta-analysis. Annals of Internal Medicine. https://doi.org/10.7326/M19-0993
Widera, E., Steenpass, V., Marson, D., and Sudore, R. (2011). Finances in the older patient with cognitive impairment. Journal of the American Medical Association, 305(7), 698–706. https://doi.org/10.1001/jama.2011.164
Wolfe, P.L., and Lehockey, K.A. (2016). Neuropsychological assessment of driving capacity. Archives of Clinical Neuropsychology, 31(6), 517–529. https://doi.org/10.1093/arclin/acw050
Wood, W., Fields, B., Rose, M., and McLure, M. (2017). Animal-assisted therapies and dementia: A systematic mapping review using the Lived Environment Life Quality (LELQ) Model. American Journal of Occupational Therapy, 71(5), 7105190030. https://doi.org/10.5014/ajot.2017.027219
Woods, B., Aguirre, E., Spector, A.E., and Orrell, M. (2012). Cognitive stimulation to improve cognitive functioning in people with dementia. Cochrane Database of Systematic Reviews, 2, CD005562. https://doi.org/10.1002/14651858.CD005562.pub2
Yen, H.Y., and Lin, L.J. (2018). A systematic review of reminiscence therapy for older adults in Taiwan. Journal of Nursing Research, 26(2), 138–150. https://doi.org/10.1097/jnr.0000000000000233
Zaleta, A.K., and Carpenter, B.D. (2010). Patient-centered communication during the disclosure of a dementia diagnosis. American Journal of Alzheimer’s Disease & Other Dementias, 25(6), 513–520. https://doi.org/10.1177/1533317510372924
Zhang, Y., Cai, J., An, L., Hui, F., Ren, T., Ma, H., and Zhao, Q. (2017). Does music therapy enhance behavioral and cognitive function in elderly dementia patients? A systematic review and meta-analysis. Ageing Research Reviews, 35, 1–11. https://doi.org/10.1016/j.arr.2016.12.003
This page intentionally left blank.