Clinical management of elderly persons with irreversible dementia has received increasing attention during the past several years. The emphasis on management approaches is due to the dramatically increasing numbers of elders with cognitive impairment and the concomitant impact on health care costs (Evans, 1989). As Duffy, Hepburn, Christensen, and BruggeWiger (1989) emphasize in their review of the state of research with this population, the empirical basis for clinical management approaches is often minimal or nonexistent. As expected, clinical studies that have been conducted focus on generalities rather than individual differences in elders with dementia. Studies detailing clinical staging of dementia foster the impression that the dementing process is universal, with a pattern of decline which prevails across individuals (Hughes, 1982; Reisberg, 1986). This discussion is an attempt to recognize the unique aspects of the individual displayed by elders with dementia.
The individual being cared for remains the core of health care, despite the exponential growth of health care environments into highly technical cultures, evident in longterm care settings. The individuality of the care recipient is emphasized by the ideals of the health care delivery system. The focus on individuality includes past environmental and cultural influences that affect the person's response pattern. Ideally, interventions are designed to take into account the person's individual responses.
Through observation of care delivery in institutional settings, one is impressed that this concept of individualized care is easily lost in the milieu of elderly persons experiencing dementia. The reasons underlying this loss are not always clear. As the behavior of cognitively impaired elders often varies from what is considered socially acceptable, sensitivity to individual meanings underlying the expressed behaviors may be lessened. Health care workers may also be constrained by their inability to understand the possible ways demented elders may still be able to relate to their environment. Family members can be observed struggling with similar issues as they attempt to interact with a significant other who is becoming less the person the family has known; this process is difficult, at best.
Individual Expressions of Self in Cognitively Impaired Elders
This article will begin to address the need for individualized approaches to care of institutionalized, cognitively impaired elders. In an observational study of dysfunctional elder behaviors in institutional settings, individual expressions of self were consistently noted and documented by research team members. Several months of observations of elders experiencing various stages of dementia convinced the researchers of the uniqueness of individual elders. This individualism, often hidden in routines and in the necessary regimentation of the environment, was made visible at unexpected moments. One example of individual expression was found when an elder looked up at the researcher and winked after not once acknowledging the researcher's presence during the 20 minutes of observation of a caregiving procedure.
The variety of response modes and expressions of individualism that were consistently observed will be described, followed by the implications of these observations for nursing practice. These response modes have been termed "expressed selfness," indicating the various ways cognitively impaired elders are still able to make known their unique qualities and characteristics.
REVIEW OF LITERATURE
Findings from several studies have begun to emphasize the need to look at cognitively impaired elders as individuals. Brody, Kleban, Lawton, and Silverman (1971) reported that an intervention program designed to decrease excess disabilities in demented elders was effective when it was individualized to compensate for specific functional losses. Although the positive effects of the intervention program were not evident nine months following discontinuation, the subjects' initial decrease in excess disabilities supported the importance of assessing individual differences in this population and designing nursing interventions based on specific losses and functional abilities.
In a study by Burgener and Barton (1991) focusing on the relationship between caregiver behaviors and elder behaviors in institutionalized, cognitively impaired elders, the caregivers' behaviors were not found to vary by the level of the elders' mental statuses, although the elders' behaviors and responses were different in higher- versus lower-functioning subjects. The researchers observed varying patterns of response within elders of similar levels of mental functioning, although the caregivers' interactive behaviors varied little from elder to elder.
Several descriptive writings, based mostly on clinical observations, suggest individual differences may be important in planning nursing care. Bartol (1979) described the maintenance of the elder's individuality as a central goal of nursing. In assessing and developing plans for increasing communication with demented elders, Bartol stressed the importance of identifying with the individual's abilities and patterns of response in the design of nursing care approaches. Whitney (1985) emphasized that cognitive changes, which decline in a linear pattern, are seldom uniformly evident in individuals. Variability in personality and behavioral changes from person to person were defined as expected clinical findings. Whitney described the variability in responses as being so marked that little uniformity exists in the changes that accompany Alzheimer's dementia.
Farran and Keane-Hagerty (1989) emphasized the need to understand the elder's past in order to increase understanding of the elder's present state. The authors contended that understanding past abilities and preferences may increase communication by helping caregivers understand the context of what the elder is relating. Beck and Heacock (1988) suggested an individual assessment of the elder's functional ability. An individualized approach based on assessment of functional ability would maximize maintenance of the elder's existing skill level, as caregivers currently tend to do "for" elders rather than allowing them to do as much as possible for themselves.
Schafer (1985) reports the positive effects of modifying an institutional environment based on the elder's past routines and activities. Daily care routines were planned to simulate routines practiced in the home. Information regarding past schedules, including attendance at church, showering, and social contacts, was obtained from family members to allow for a smooth transition into the institutional setting. Individualized approaches to care were reported to produce a safer, more comfortable environment for the elder.
In summary, several studies and clinical observations have given initial support to the importance of recognizing individual differences and behavioral patterns in designing effective nursing care approaches. Individual differences in cognitively impaired elders have been recognized in functional abilities (Brody, 1971; Farran, 1989; Beck, 1988), in patterns of behavioral responses (Burgener, 1991; Bartol, 1979), in personality (Whitney, 1985), and in daily care routines (Schafer, 1985). As part of a subsequent study by Burgener and associates (1992), individual expressions of self were identified, including implications for nursing care and research. The specific purpose of this portion of the study was to identify the demented elder's perceived support and the extent to which past practices remained part of the elder's behavioral repertoire.
The results reported here were part of a larger study designed to examine interactive behaviors of caregivers and demented elders during caregiving episodes. A major portion of the study involved observation of caregiver/ elder pairs during three caregiving situations, defined by nursing staff as being most difficult: dressing, toileting, and bathing. This portion of the study represented a repeated-measures design. A fourth situation, an interpersonal contact, was included to serve as a comparison interaction as it served no specific task function. While the observations provided some of the data described in this report, unstructured interviews were also conducted with elders by the researcher and associates to obtain information about the elder's current sources of support, needs for contact with others, and use of past behaviors, such as praying.
Subjects were purposively sampled from two long-term care institutions and included 58 caregivers and 58 elders. Elder subjects were included if they had a diagnosis of either Alzheimer's or multi-infarct dementia and behavioral problems. Caregiver subjects were recruited from units housing elder subjects. Written consent for participation was obtained from the elder's legal guardian or closest family member and verbal assent was obtained from each elder subject. Written consent was also obtained from caregiver subjects, assuring all subjects of anonymity.
Elder subjects able to respond to verbal stimuli were approached by the researcher and associates to obtain information regarding the elder's perceptions of their current support and past behaviors. Elders were approached on several different occasions, both to confirm the consistency of responses given in previous contacts and to prevent tiring or increased agitation due to a prolonged contact. Contacts between elder subjects and the researcher and associates generally lasted from 15 to 25 minutes. Initially, the interview would focus on acquainting or reacquainting the elder with the researcher and then would progress to more specific questioning and content. Interviews were conducted in a quiet location whenever possible - such as the elder's room - to decrease distraction and assist the elder in focusing on the conversation.
Elder subjects ranged in age from 69 to 97 years, with a mean age of 84.5 years. The dementia diagnosis was supported for most elder subjects using the Mini-Mental State Exam, resulting in a mean mental status score of 6.9, with scores below 23 representing dementia. Caregiver subjects included 38 certified nursing assistants, 14 licensed practical nurses, and 6 registered nurses, a typical distribution of levels of practice for long-term care settings. Caregiver subjects had 9.7 mean years of nursing experience, with 7.6 mean years specifically in long-term care settings.
EXPRESSED SELFNESS ATTRIBUTES
The results addressing the relationship between caregiver and elder behaviors are described elsewhere. (Burgener, 1992) The findings described here focus on the responses of elders to the interview questions and observations made during the entire data collection process. The interviews and observations proceeded smoothly, with many elder subjects recognizing the researcher and associates and responding positively to their contacts on return visits. The varying content and relevance of responses was surprising, with elders at low levels of mental functioning often giving meaningful and consistent responses. The observations made during the contacts have provided support for the belief in individual expressions of self in cognitively impaired elders.
Retention of Predominant Skills
Retention of predominant skills from more productive stages of the elder's life frequently emerged in the everyday routines of institutionalization, despite obvious loss of functional and personal skills. This was evident when one elder, a former librarian, asked the research associate what she was doing "asking all those questions." The associate's response was, "Research (REEsearch)/' The elder immediately answered by saying, "No, you mean research (ra-SEARCH)." This correction of pronunciation occurred despite the elder's low scores on both mental and functional status exams. Another elder, with scores somewhat higher in both areas, had spoken five languages fluently during most of her adult life. The impressed research associate complimented her on this accomplishment. The elder then responded to each question in all five languages throughout the interview. Not only was retention of predominant skills obvious, but the meaningfulness of praise for competence was evident to the elder.
Assessment of past abilities and retention of skills could provide caregivers with valuable information. Nursing care approaches designed to maximize retained skills may not only facilitate care but also provide a needed source of accomplishment for the elder. Lachman (1986) found evidence that even healthy elders feel less in control of intellectual functioning and memory than do younger persons. In an attempt to explore these control beliefs, Lachmen and Leff (1989) implemented a 5-year longitudinal study. Their results reflected that, despite findings of stability in internal controls, the belief in powerful others increases with age. Lachman and Leff concluded that elders perceive others as better able to do cognitive tasks. However, elders in the sample described here often demonstrated a determination to retain predominant skills, despite a possible concern that "another can do it better." The elder's response to the positive reinforcement by the research associate may indicate the meaningfulness of praise to the elder, despite mental impairment. Focusing on abilities, rather than disabilities, may increase maintenance of skills. Individual activities, based on the elder's past skills, may allow for a more meaningful, and possibly more therapeutic, use of time.
When asked about support and the role of prayer in their lives, the elders' responses often indicated the meaningfulness of the questions to the elder. One woman immediately said she prayed "all the time." When asked how prayer helped, she responded, "I know my mother is there. I want to see her and have her pat my head (while patting her own head), and tell me I am a good girl." Many elders talked about the meaningfulness of prayer, giving evidence of the importance of spirituality as a continuing dimension of their lives.
Clergy and rabbis are not often seen visiting elders with cognitive impairment. Nursing staff caregivers were seldom observed interacting with the elder concerning spiritual needs. Evidence exists that nursing staff members are often uncomfortable relating to the spiritual needs of cognitively intact persons (Fish, 1978). Therefore, it is not unusual to observe this same reluctance in caregivers of elders with dementia. One explanation for the lack of attention to spiritual needs in demented elders may be an assumption on the part of the religious community, caregivers, and family members that spiritual support and practices may no longer be relevant or important for an elder with dementia. The findings of this study would indicate that this assumption may not be true, and acknowledging the elder's spiritual needs may, in fact, be important and meaningful.
Enlisting the assistance of family members and friends in an effort to investigate past religious values and practices would add insight into what has been, and may well remain, important to the elder. Inviting a visit from a clergy member may provide needed support and an outlet for spiritual expression. Acknowledging the spiritual needs of this population would allow for care approaches designed to maximize individual expression and need fulfillment.
A sense of despair was evident in several of the study subjects. While despair in older persons is often thought of in the traditional Erikson sense of a developmental stage characterized by lack of integration of past accomplishments, the despair observed in several cognitively impaired elders seemed to be related more to the changes they were experiencing. One man, with a MiniMental State Exam score of 15, would consistently respond to a question concerning how he felt he received support by saying, "There is only today. There is no yesterday or tomorrow. I only have myself to count on. That's all there is." This response was given when the question was repeated on visits several weeks apart, indicating the meaning of the response to the elder. When asked about the meaning of the response, the elder would talk about all he had left behind, and how his family, work, and home were no longer part of his life. This man communicated a very real sense of despair when talking about his losses.
Despair was apparent in other elders in different ways. Some more severely mentally impaired elders would call out and continually ask for help. Often they were not able to relate what type of help was needed or why they called out, but their despair at their situation was being relayed through their remaining means of communication.
Recognizing individual losses and the resulting sense of despair experienced by some cognitively impaired elders may assist caregivers in understanding some of the difficult behaviors displayed by this population. Specific psychosocial interventions could be designed to assist elders in coping with the many losses they encounter throughout the dementing process, especially during the early stages of dementia when awareness of losses may be heightened. The man described above usually stayed in his room most of the day and ate alone during meals. With an understanding and awareness of the losses experienced, nursing staff members may be more sensitive to the elder's need for contact. Most elders interviewed in this study were able to relate their feelings of despair in some way. The communication of despair suggests the need for intervening in this area and possible benefits of individual assessments.
Several elders interviewed in this study were able to recount their experience of loneliness. One female subject talked tearfully about being left in the institution. She would relate how her "father left me in this place. He never comes to see me. He doesn't even care." Although her father was not alive and did not bring her to the institution, the feelings of loneliness from being "left behind" were evident. Other elders were able to recall past relationships and activities, often becoming more animated as they talked about the past.
As a caregiver, the impulse is often to change the topic and "make things better" rather than allowing elders to discuss their feelings of loneliness. This approach may be fostered by the belief that memory impairment may make past relationships less meaningful or important to the elder. What may be more important, however, is the realization that loneliness is part of the elder's experience and needs to be recognized by nursing staff. Benner and Wrubel (1989) claim that emotions "allow the person to be engaged or involved in the situation." Benner proposes that even when the emotion is unwanted or disruptive, the very act of dealing with it is transformational and allows for reinterpretation in the context of the present. This reinterpretation implies both growth and new understanding. By accepting loneliness as a real experience for many demented, institutionalized elders, the caregiver not only validates the importance of this experience to the person, but also can assist in dealing with the experience of being left behind. Although it may not be therapeutic to dwell on feelings of loneliness, the elders in this study were able to go on to more positive activities and topics once their feelings of loneliness were validated and discussed. The recognition that loneliness was a very real part of both institutionalization and the changes they were experiencing proved to be very therapeutic for the elders in this sample.
Connecting With Others
This category embraces a variety of expressions of selfhess, although two major ways of connecting with others predominated. The first method of connecting was through physical touch, although responses to touch were varied with this sample. Several elders became increasingly upset if they were physically touched in any way, contrary to research supporting the positive effects of touch (Hollinger, 1986; Langland, 1982; McCorkle, 1974). One elder was so frightened of physical touch his family agreed to his participation in the study only if he would not be touched at all. He actually spent much of his time with his arms flexed over his chest to protect himself from touch. These negative responses to touch in cognitively impaired elders are being supported in other research as well, indicating a need to examine and to better understand the meaning of touch with this population (Burgener, 1991; Cohen-Mansfield, 1990). Other elders readily responded and even desired touch, grasping the researcher's hand or asking for hugs.
A second way of connecting was observed in elders who sought out the attention of other elders, the nursing staff, and researchers. Continuing relationships between elders were observed. Two women subjects were essentially inseparable, "protecting" one another from other elders and from intrusions by outsiders. Nursing staff members were sensitive to the need for continuing the relationship, even objecting successfully to relocation of one of the elders to another unit due to decline in functional ability. Other subjects became attached to the researcher and associates, watching them continually after they appeared on the nursing unit.
As with cognitively intact elders, the subjects observed in this study consistently made known their need to be connected with others in their environment. The importance of the responsiveness of nursing staff to this need was evident in the positive results from staff protecting a relationship valued by the involved elders. The meaning of physical touch to cognitively impaired elders needs to be explored in future studies and assessed individually. The variety of responses to touch, including distressful responses, provides evidence for the need to design individualized nursing interventions when touch is involved.
Utilizing Social Skills
Elders at varying levels of mental impairment were observed using social skills appropriately as they interacted with others. Some would graciously offer the researchers a place to sit, say "thank you," or even wish another a "good day" or "Merry Christmas." Some social skills were maintained so well that, on initial contact, an observer would have no indication that mental impairment existed. One research associate sat with two subjects involved in a discussion of past activities for over 15 minutes before realizing the events in the discussion were fabricated. The interactants' conversational and social skills were so intact, the research associate found it difficult to detect the conversation's underlying lack of reality.
Recognizing and supporting existing social skills is an important part of care of cognitively impaired elders. As some social skills are reinforced throughout the person's lifetime, they remain an integral part of the individual's behavioral repertoire. Although regimentation and routine often prevail in institutional settings, adjustments to individual behaviors may require little effort from nursing staff while providing a needed and desired reinforcement for maintaining an individual's identity. Each person's unique identity is especially important considering the devastating effects of the dementing process that render many skills inaccessible. Reinforcing and supporting the social skills that are maintained can allow the elder a needed outlet for self-expression, as well as support the individual's self-concept and self-respect.
One of the most powerful and pervasive ways elders expressed their individuality was through their sense of humor. Often at moments of both pleasure and pain, the researcher and associates were able to see a glimpse of the individual. One subject provided an example of the demented elder's ability to retain a sense of wit. This man loved coffee and apparently at one time drank dozens of cups per day. Within the institution, however, his coffee consumption was severely restricted. When a nurse, feeling empathy for his situation, gave him a cup of coffee, she told him to check to see if it was hot enough. He gladly lifted the cup to his mouth and men calmly put it back down. When asked how it was, he replied, "It's hotter than the hubs of hell!"
Not only did elder subjects in this study express themselves through humor, but they also responded positively to humor. One nurse would continually joke and playfully interact with the elders. This type of interaction seemed to relax both the elders and the nursing staff. One subject even enjoyed giving this nurse a ride on the front of his wheeled walker! By recognizing and responding to the elder's use of humor, the nurse may make interactions more positive for both caregivers and elders. Acknowledging the elder's receptivity to humorous or playful interactions can ease otherwise tense situations, allowing for more pleasant and less stressful care routines. Care needs to be given, however, to individual style and responses to humor.
Sense of Mastery
Maintaining a sense of mastery is not only something caregivers can effectively help cognitively impaired elders to achieve, but is also something the elders were observed to seek for themselves. A striking example was seen when a subject was being showered by a young nurse. The woman was upset and crying. The nurse remained pleasant and tried talking with her, but the elder's behavior remained unchanged. After several minutes, the nurse handed the distressed woman a washcloth and asked her to wash her face. The change that followed was immediate and dramatic; the woman stopped crying and began to wash her face and body. Even without the aid of nursing staff, many elders readily expressed their need for mastery. One 82-year old subject with a MiniMental State Exam score of 4, shouted, "I'll do it myself," after her caregiver mentioned she was going to clean the subject's room. Another subject was attempting to put on a bib before his meal when the nursing assistant took it from him and hurriedly placed it around his neck. After she walked away, he took another bib and placed it around his neck, over the one she had tied for him. These individuals expressed, in their own way, a need for selfefficacy, a sense of mastery in their lives, even in a situation that didn't foster or support this type of mastery.
Although all elders may not respond as positively to being allowed to "do for self" as the subjects in these examples, potential positive effects are evident if elders are allowed to master whatever tasks are within their realm. In this study, less compensation for disabilities, or allowing elders to do more for themselves, was consistently related to calmer, more functional behaviors (Burgener, 1992). Teri, Borson, Kiyak, and Yamagishi (1989) also found a significant relationship between decreased ability to perform activities of daily living and increased behavioral problems. Increased attention by caregivers to the effects of allowing elders to do as much as possible for themselves may allow elders to fulfill their needs for mastery, as well as result in a more positive experience for the caregiver.
Recognition of "Logical, Expected Behaviors"
Even in the presence of relatively severe cognitive impairment, elders were, at times, obviously aware of what behaviors were expected of them. One man, when asked if he objected to being observed, replied, "Okay, but I'm not going to do much," recognizing that certain behaviors might be expected by the observer. Elders were also aware of the consequences of their actions. One woman, suffering from several physical problems, began holding her lips tightly closed as soon as she saw the medication cup. Although she could barely speak, she immediately identified the potential results of the situation and took an action that expressed her response to it.
Nursing staff may better attend to an individual's needs if attempts are made to find meaning in behaviors. Although elders may not be completely aware of or fully understand their environment, elders in this study continually reacted in individual ways to what was happening and what they knew was expected of them. Elders, at times, seemed to become more agitated when they recognized they could not or did not want to do what was expected, such as taking medication. Attempting to find the meaning of individual responses or variations from "what is expected" may assist caregivers in identifying approaches for soothing the distress displayed by elders when expected behaviors are not possible or desired.
This presentation is intended to sensitize the reader to some of the many ways elders with irreversible dementia express their individuality, despite the effects of the dementing process. Recognizing and attending to expressed selfness has implications for planning nursing care, both to meet specific needs and to support existing characteristics and behaviors. The nursing staff may make family members aware of ways the elder has retained past behaviors and needs, facilitating the family's participation in supporting the elder in a positive manner. Although individualized care approaches have been used previously with this population, they were focused mostly around supporting functional abilities rather than characteristics and interpersonal behaviors. As few systematic studies have been conducted examining the effect of planned care based on other retained abilities and skills, the possible positive effects of an individualized approach can only be postulated. Observations in this study do suggest, however, that when individual expressions of self are recognized and attended to, elders may respond positively. Additional study is needed to explore the relationship between individual approaches to care based on the elder's expressions of self and positive outcomes. The Figure summarizes the varied ways elders expressed their individuality in this study and suggests nursing implications relevant to planning care.
The study findings support the effectiveness of interacting with elders on a personal level. Often the meaning of verbal communication and behaviors is not obvious to the observer or caregiver. At these times, it is easy to assume that interpersonal contact would not be meaningful. However, the semi-structured interview format used in this study did provide meaningful interactions and responses, which suggests that this approach would be useful to obtain the elder's perspective. Studies to date have used objective measures to assess the effectiveness of nursing interventions, and are based on the assumption that subjective information would not be obtainable or relevant. Obtaining both subjective and objective information is not only possible with this population, but also may provide for more valid outcome measures.
As institutional environments often stress conformity and regimentation, individualized care is easily lost or underemphasized. Several months of observations of and interactions with elders experiencing various stages of dementia has provided convincing support for the uniqueness that remains in individual elders. Without intentional observation, this uniqueness is often not evident, especially in an environment designed for conformity. Nursing staff members may tend to weigh the value of assessing and meeting individual needs in terms of facilitating nursing care, but the potential benefit to the elder should not be neglected. With the multiple losses encountered in dementia, supporting expressions of the self accessible to the individual can enhance the quality of the individual's living experience. Although this second outcome may not be easily measured, it is an outcome worth considering in planning care for this population.
- Bartol, M.A. Dialogue with dementia: Nonverbal communication with patients with Alzheimer's disease. Journal of Gerontological Nursing 1979; 5(4):21-31.
- Beck, C, Heacock, P. Nursing interventions for patients with Alzheimer's Disease. Nurs Clin North Am 1988; 23:95-124.
- Benner, P., Wrubel, J. The primacy of caring. Menlo Park: Addison-Wesley, 1989.
- Brody, E.M., Kleban, M.H., Lawton, M.P., Silverman, H. Excess disabilities of mentally impaired aged: Impact of individualized treatment. Gerontologist 1971; 21:124-133.
- Burgener, S. Environmental and caregiver variables related to difficult behaviors in cognitively impaired elderly persons. Paper presented at the Annual Robert Wood Johnson Clinical Nurse Scholars Meeting, April 1991. Scottsdale, AZ.
- Burgener, S.C., Barton, D. Nursing care of cognitively impaired, institutionalized elderly. Journal of Gerontological Nursing 1991; 17(4):37-43.
- Burgener, S., Jirovec, M., Murrell, L., Barton, D. Caregiver and environmental variables related to difficult behaviors in institutionalized, demented elderly persons, foumal of Gerontological Nursing 1992; 47:242249.
- Cohen-Mansfield, J., Werner, P., Marx, M.S. Screaming in nursing home residents. J Am Gerktr Soc 1990; 38:785-792.
- Duffy, L.M., Hepburn, K., Christensen, R., Brugge-Wiger, P. A research agenda in care for patients with Alzheimer's Disease. Image 1989; 21:254-257.
- Evans, D.A., Frankenstein, H., Albert, M.S., Scheer, P.A., Cook, N.R., Chown, M.J., Hebert, L.E., Henneken, C.H., Taylor, J.O. Prevalence of Alzheimer's Disease in a community population of older persons. JAMA 1989; 262:2551-2556.
- Farran, C.J., Keane-Hagerty, E. Communicating effectively with dementia patients. / Psychosoc Nurs Ment Health Serv 1989; 27(5):13-16.
- Fish, S., Shelly, J. Spiritual care: The nurses role. Downers Grove, IL: Intervarsity Press, 1978.
- Hollinger, L.M. Communicating with the elderly. Journal of Gerontological Nursing 1986; 12(3):9-13.
- Hughes, CP, Berg, L., Danziger, W.L., Cohen, L.A., Martin, R.L. A new clinical scale for the staging of dementia. Br J Psychiatry 1982; 140:566-572.
- Lachman, M., Leff, R. Perceived control and intellectual functioning in the elderly: A five-year longitudinal study. Developmental Psychology 1989; 25:722-728.
- Lachman, M. Locus of control in aging research: A case for multidimensional and domain-specific assessment. Psychology of Aging 1986; 1:34-40.
- Langland, R.M., Panicucci, CL. Effects of touch on communication with elderly confused clients. Journal of Gerontological Nursing 1982; 8(3):152-155.
- McCorkle, R. Effects of touch on seriously ill patients. Nurs Res 1974; 23:125-131.
- Reisberg, B. Dementia: A systematic approach to identifying reversible causes. Geriatrics 1986: 41(4):30-46.
- Schafer, S.C. Modifying the environment. Geriatr Nurs 1985; 5/6:157-159.
- Teri, L., Borson, S., Kiyak, A., Yamagishi, M. Behavioral disturbance, cognitive dysfunction, and functional skill. / Am Geriatr Soc 1989;37:109-116.
- Whitney, EW. Alzheimer's Disease: Toward understanding and management. Nurse Pract 1985; 10(9):25-35.
Individual Expressions of Self in Cognitively Impaired Elders