The increasing incidence of Alzheimer’s disease (AD) has created an enormous challenge to nurses. AD is a progressive degenerative disease characterized by decline in memory and function that is sustained over months to years. As the disease advances, caregivers become increasingly involved with basic functional tasks. Nursing home placement most often occurs only after families have exhausted their financial, emotional, and physical resources in caring for their family member at home (Schulz et al., 2004; Yaffe et al., 2002). Without a clear etiology or effective medical treatment, the goal of care is to maximize cognitive and functional abilities for as long as possible. Nonpharmacological approaches that promote functional independence and improve quality of life for individuals with AD and their caregivers may be a cost-effective alternative to institutionalization (Burgener, Buettner, Beattie, & Rose, 2009; Yu, Kolanowski, Strumpf, & Eslinger, 2006).
Currently, one of the most pressing needs is developing effective nursing strategies to assist family members in caring for individuals with AD in the home setting (Burgener et al., 2009). Advancements in the study of memory suggest that those with mild to moderate AD have preserved procedural (implicit) memory (De Vreese, Neri, Fioravanti, Belloi, & Zanetti, 2001; Harrison, Son, Kim, & Whall, 2007; Sabat, 2006; van Halteren-van Tilborg, Scherder, & Hulstijn, 2007). Procedural memory is the automatic, unconscious recollection of learned motor tasks, such as combing hair, eating, and riding a bicycle, which often require practice and repetition to activate. Nursing interventions based on preserved procedural memory have the potential to enhance function in individuals with mild to moderate AD. A behavioral strategy focused on reactivating the procedural memory and relearning a procedural task by those with mild AD may be particularly effective and also address excess disability of this population in the home setting. Thus, the purpose of this study was to explore the effectiveness of a home-based skills training program on improving the function of individuals with mild AD performing a specific procedural task.
AD is the most common type of dementia. Its prevalence is estimated between 2% and 13% for adults older than 65 and almost 50% for those older than 85 (Herbert, Scherr, Bienias, Bennett, & Evans, 2003). Since age is a major risk for AD, the number of individuals afflicted with the disease will increase exponentially, having an enormous impact on society and those most involved in caring for this population (Alzheimer’s Association, 2011).
Approximately 80% of all individuals with dementia are cared for at home by family members (Alzheimer’s Association, 2011). Providing such care is one of the most challenging of family obligations, yet caregivers frequently lack support and training and often are ill equipped to deal with the symptoms and progression of the disease. They become increasingly involved with tasks such as bathing, dressing, feeding, and toileting as the disease advances (Schulz et al., 2004; Yaffe et al., 2002).
Additionally, functional decline among individuals with AD is a major risk factor for hospitalization, institutionalization, mortality, and caregiver morbidity. Although functional impairment is a major criterion for clinical diagnosis, loss of function also results in the deterioration of quality of life for individuals with AD and increases health care expenditures. Function is often defined as the ability to perform daily tasks including both basic tasks (i.e., activities of daily living [ADLs]), such as bathing, dressing, and eating, and more complex ones (i.e., instrumental ADLs [IADLs]), such as managing finances, shopping, taking medications, and preparing meals.
Behavioral strategies such as skills training programs, have been successful in improving the performance of basic tasks among nursing home residents with moderate to severe AD (Beck et al., 1997; Coyne & Hoskins, 1997; Rogers et al., 1999, Tappen, 1994; Wells, Dawson, Sidani, Craig, & Pringle, 2000). These studies have important relevance when selecting and designing nursing strategies in caring for individuals with AD in the home setting. One problem that has impeded the advances of nursing science in this area has been the lack of knowledge related to memory loss in this population.
Major advances in the study of memory suggest that memory has two distinct systems: procedural (implicit) and declarative (explicit). As mentioned above, procedural memory involves learning tasks. It is an automatic, unconscious process requiring practice and repetition to activate the particular structures involved in learning tasks. The domain of procedural memory is behavior, whereas that of declarative memory is cognition and thought. Procedural memory underlies changes in skill performance and behavior (Budson & Price, 2005; Sabat, 2006; Squire, 1987; Tulving & Schacter, 1990).
Since memory loss is the most prevalent and prominent feature in AD, these studies have important implications in developing strategies to enhance functional well-being and improving the quality of life of these individuals (De Vreese et al., 2001; Eslinger & Damasio, 1986; Hirono et al., 1997; Poe & Seifert, 1997; Zanetti et al., 1997). Translating this empirical evidence into practice, Harrison et al. (2007) developed a practice model of dementia care: the preserved implicit memory (PIM). The PIM model predicts that function can be sustained longer for individuals with AD through interventions and environments that activate an individual’s PIM (Harrison et al., 2007). Another model created by Son, Therrien, and Whall (2002) uses the concept of familiarity as a form of implicit memory to guide research and strategies to dementia care. Although few researchers have linked their strategies conceptually to the preserved memory of individuals with AD, the potential theoretical and therapeutic value is evident (De Vreese et al., 2001; Harrison et al., 2007; Sabat, 2006; Son et al., 2002).
Traditionally, AD has been viewed as a terminal disease with a poor prognosis and assumed to be associated with minimal restorative potential. However, empirical evidence suggests that cognitive impairment may not be an obstacle to a more functional state, and with specific interventions aimed at preserved memory abilities, the functional status of those with AD may be maintained and improved over time (Beck et al., 1997; De Vreese et al., 2001; Harrison et al., 2007; Tappen, 1994). For example, behavioral-oriented nursing strategies such as skills training may be successful in the relearning of simple motor tasks such as meal preparation, using the telephone, washing dishes, and bathing in individuals with mild to moderate AD (De Vreese et al., 2001).
Building on this empirical evidence, an intervention was designed based on preserved abilities of individuals with mild AD to relearn a specific procedural task in the home setting. Meal preparation was selected as the specific routine task, since it is a task frequently impaired in the early stages of AD and essential in the daily life of most individuals with AD (De Vreese et al., 2001). If adults with AD can improve their functional abilities despite their memory deficits with a home-based skills training program, this may have a significant impact on the rate of functional decline and postpone the need for institutionalization.
The purpose of this study was to explore the effects of an individualized skills training (IST) program on the ability of adults with mild AD to prepare a meal in the home setting. The IST program was a behavioral intervention aimed at producing a desired behavior that could be reinforced through repetition and practice (Giles & Clark-Wilson, 1993). A pretest-posttest design using direct observation and interview was used to address the following research questions:
- To what extent will 5 consecutive days of IST sessions decrease verbal, visual, and/or physical prompting in the performance of preparing a breakfast meal by a person with mild AD?
- To what extent will 5 consecutive days of caregiver-led, IST sessions maintain the necessity of verbal, visual, and/or physical prompting in a person’s performance of preparing a breakfast meal after a training program?
- What are the facilitators and obstacles encountered in implementing this program?
- What are the person’s and the primary caregiver’s perceptions on the implementation and success of the program?
A volunteer sample of 5 individuals with mild AD who lived at home with a primary caregiver was recruited from the Alzheimer’s Disease and Memory Disorder Clinic at a local hospital. The inclusion criteria were: lives at home with a primary caregiver who is present for the daily breakfast meal; age 70 or older; speaks English or Spanish; has a mild stage of AD (with written confirmation by the neurologist); reports difficulties with complex functional tasks, such as meal preparation; deemed capable by a neurologist and/or neuropsychologist to make health care decisions; and absence of concurrent severe diseases that preclude the ability to perform a functional task.
Prior to recruiting participants into the study, permission was obtained from the hospital’s and university’s Institutional Review Board on Human Subjects. Patients were identified by a neurologist and asked if they would be interested in participating in the study. If interested, the researcher (A.J.C.) contacted the patient and the patient’s primary caregiver by telephone to schedule a home visit to explain the purpose of the study and obtain consent.
Individualized Skills Training Intervention
After consent was obtained from participants, the researcher began with two consecutive home visits to observe, record, assess, and analyze the person’s physical and social environment, as well as behavior in preparing a meal. Based on this initial assessment, an IST program was developed. These initial home visits were followed by (a) 5 consecutive days of IST sessions, (b) 5 consecutive days of caregiver-led IST sessions, and (c) a semi-structured interview with the person with mild AD and her caregiver.
The participants’ desired breakfast meal task was selected and analyzed based on the initial assessment. Analysis of the task involved a process of dividing the task into subtasks, which provided a method of organizing behaviors to make them easier to learn. Task analysis emerged from the behaviorist tradition and is often applied by rehabilitation therapists in practice. For example, the analysis of the poached eggs and toast task in Participant #2 included 26 subtasks—18 subtasks to prepare the poached eggs (e.g., obtains eggs from refrigerator, obtains skillet from cupboard, puts water in skillet, puts skillet on stove) and eight to prepare the toast (e.g., obtains bread from refrigerator, puts bread in toaster oven, turns on toaster oven). The number of subtasks identified in this study ranged from 15 subtasks for preparing pudding to 42 subtasks for preparing blueberry muffins.
Using a highly structured, repetitive approach, a training program was developed from this assessment and aimed at the person’s completion of each subtask. At each 45-minute nurse training session, verbal, visual, and physical prompts were used when necessary to assist the person in completing the subtasks. A precise sequence of subtasks was followed to maximize the person’s learning. As the person completed each subtask with greater competence, the prompts were gradually decreased.
The caregiver-led IST sessions were conducted 5 consecutive days after the initial IST sessions. The caregiver continued the level of graded assistance (verbal, visual, and physical prompting) for the person with mild AD to complete the specific sequence of subtasks. On the fifth session, the researcher recorded structured observations of the participants’ performance, including the number and type of prompts and their behavior.
Additionally, a semi-structured interview was conducted with all participants and their caregivers after completion of the final program session. The intent of the interview was to ask general questions to explore both participants’ and caregivers’ perceptions of the program.
Data Collection and Analysis
First, demographic data (age, gender, educational level, and medical diagnoses) were gathered on each participant. This was followed by three phases of data collection. The first phase included the recording of direct observations of the physical and social context in which the participant carried out the particular task, the selection of the meal task, and the initial analysis of the task. These data were used to create the IST programs. The second phase included observations of the participant’s behavior (a) at baseline, (b) following the nurse IST sessions, and (c) at the caregiver-led IST sessions. These observations were recorded as field notes and consisted of notations regarding the specific assistance necessary, description of the problems observed, and facilitators used to complete the task. The final phase of data collection included an open-ended, semi-structured, audiorecorded interview with the participants and their caregivers.
The data generated were used to evaluate the effects of the IST program on the task performance of each participant. A descriptive profile was developed for each participant and included baseline observations of her behavior, her physical and social environment, her progression in performance, and both problems and successes encountered. In addition, a mapping of the data for each participant was used to provide a visual record of change and level of assistance from the baseline to the final nurse IST and final caregiver-led IST sessions. Lastly, the responses from the semi-structured interview were transcribed verbatim and underwent content analysis.
Five English-speaking Caucasian women (age range = 71 to 85) diagnosed with late-onset mild AD completed the study. All five women had a Clinical Dementia Rating scale (Hughes, Berg, Danziger, Coben, & Martin, 1982) score of 1, indicating mild dementia, and Mini-Mental State Examination (MMSE, Folstein, Folstein, & McHugh, 1975) scores for 4 of the participants ranged from 20 and 23, indicating mild cognitive impairment. Participant #4 had expressive aphasia, a symptom of her AD, which accounted for her lower score of 14 on the MMSE. Two of the participants had finished 8 years of education and 3 had completed 12 years, one of whom had an additional 2 years of secretarial training (Table). The sample had many similar characteristics regarding presentation of the disease state, but there was variability in disease symptomatology, functional limitations, and behavioral symptoms. These variations necessitated minor modifications in implementation of the intervention but did not preclude completion of the training program.
Table: Demographic Characteristics of the Sample
For 3 of the women, the husband was the primary caregiver living at home with the participant. One woman’s daughter did not live with the participant but visited her mother at least twice per day. For Participant #5, the caregiver was a hired, live-in companion. All primary caregivers were present for the breakfast meal each day. Personal meal tasks in this study ranged from preparing pancakes, oatmeal, and poached eggs and toast to making pudding and blueberry muffins.
Results of the IST Program
All 5 participants and their caregivers completed the skills training sessions. The findings at the final nurse and caregiver-led IST sessions demonstrated a significant improvement from baseline assessments. All participants required modifications in some aspect of the procedure. These modifications were minor but necessary to enhance their ability to perform the task. The participants themselves, the caregivers, and the researcher all acted at times as facilitators and obstacles to the implementation of the skills program.
Final Nurse IST Session. Between the baseline assessment and the final nurse IST session, a decrease in the number and type of prompts provided was noted across all 5 participants. For example, Participant #2 selected poached eggs and toast as her meal task, requiring 26 subtasks (e.g., obtains eggs from refrigerator, obtains skillet from cupboard, puts water in skillet) to complete. At baseline, the participant required 18 verbal prompts, two visual prompts, and one physical prompt in completing the task. After 5 consecutive days of training, the participant only needed 7 verbal prompts, and no visual or physical prompts were needed to complete the task. Similar trends occurred in the remaining 4 participants, yet Participant #3 required some verbal, visual, and physical prompting to complete the task at the end of the nurse IST sessions. All 5 increased their level of independence in completing the task between the baseline assessment and the final nurse IST session (Figures 1 to 5).
Figure 1. Frequency of verbal, visual, and physical prompting needed for Participant #1’s task (preparing pudding; 15 subtasks) at baseline, final nurse individualized skills training (IST) and final caregiver-led IST sessions.
Figure 5. Frequency of verbal, visual, and physical prompting needed for Participant #5’s task (preparing oatmeal; 19 subtasks) at baseline, final nurse individualized skills training (IST) and final caregiver-led IST sessions.
Final Caregiver-Led IST Session. For 3 of the 5 participants, the number of verbal prompts actually decreased between the final nurse IST session and final caregiver-led IST session. For example, Participant #2 required seven verbal prompts at the final training session and only three at the final maintenance session in completing the poached eggs and toast task (Figure 2). Interestingly, the three verbal prompts needed for this participant were for subtasks added for safety reasons. For 2 participants, the number of verbal prompts remained consistent. The caregivers were able to maintain or improve the level of independence in the participants’ performance at the end of the IST sessions, although none of the participants achieved total independence. The caregivers understood the importance of a highly structured, repetitive approach and used prompting only when necessary (Figures 1 to 5).
Figure 2. Frequency of verbal, visual, and physical prompting needed for Participant #2’s task (preparing poached eggs and toast; 26 subtasks) at baseline, final nurse individualized skills training (IST) and final caregiver-led IST sessions.
Facilitators and Obstacles
Four factors were identified as facilitators: the presence of a supportive caregiver, the person with mild AD’s insight into her memory loss, the presence of the researcher, and the individualization of the skills training program.
The most important facilitator was the presence of a supportive caregiver. The caregivers played an instrumental role in reassuring the participants, integrating the home visits into their daily schedule, and carrying out the IST sessions. Second, the willingness of the individuals with mild AD to participate, their insight into their own memory problems, and their supportive living situations were factors that facilitated their completion of the study intervention. All 5 participants had some level of awareness of their need for assistance, despite their lack of insight into the severity of their memory loss. Such awareness made these individuals more receptive to participating in the program. The third factor was the researcher, whose flexibility with schedule changes, knowledge of the disease, and interest in the lives of the participants and their caregivers facilitated implementation of the study intervention.
The fourth and very important facilitating factor was individualization of the program. Minor modifications were made for all participants in implementing the assessment, nurse IST sessions, or caregiver-led IST sessions. During the assessments, the number of sessions was altered for 3 participants, the time of day adjusted for 2 other participants, and the selection of a meal task was individualized for all 5 participants. Accommodations were also made in the scheduling of home visits to integrate the intervention into daily routines.
At times, three of the facilitators (the caregiver, the person with mild AD, and the researcher) were identified as obstacles to the program’s implementation. For example, when caregivers were overly helpful, they would distract the participants from performing the task. The caregivers learned to provide verbal prompts rather than directly assist the person with the task. Participants with certain behavioral symptoms (e.g., wandering, delusional behavior, mild apraxia) also posed a challenge in implementation of the program. A third obstacle was the presence of the researcher, especially at the beginning of the program when all 5 participants exhibited some mild anxiety and apprehension. The caregivers were especially helpful in overcoming these obstacles by reassuring the participants and encouraging them to participate.
Participants’ and Caregivers’ Perceptions of the IST Program
All 5 participants and their caregivers agreed to be interviewed. For 3 of the 5 women, their caregivers requested not to be interviewed in the presence of the participants, in part because these “experienced” caregivers knew that these individuals would become upset, angry, or irritated if confronted with the caregivers’ comments.
Overall, the caregivers reported that they enjoyed the intervention. They reported that the participants became more self-confident and self-reliant during the intervention. They believed the participants enjoyed the social interaction and came to expect the daily visits by the researcher. The caregivers were committed and devoted to the care of their spouse, mother, and employer. They did not report feelings of stress, but rather frustration with the behavioral symptoms related to the disease.
The caregivers reported that in the presence of a “stranger” the participants were more agreeable to engage in a breakfast activity than they might have been with someone familiar to them. The caregivers reported that the researcher’s gentle approach and calming personality were factors that added to the implementation of the program. In addition, the program validated the caregiver’s approach in promoting functional independence. Although four of the five caregivers initially appeared “to do for” the individuals with mild AD, they also learned the importance of encouraging independence with routine activities.
This intervention builds on previous research by providing further support for the effectiveness of behavioral strategies for individuals with mild AD in the home setting and by linking the intervention conceptually with preserved memory function (Beck et al., 1997; Coyne & Hoskins, 1997; Rogers et al., 1999; Tappen, 1994; Wells et al., 2000). This study also provides support for developing interventions based on preserved procedural memory to enhance function of a previously learned task among individuals with mild AD living at home. Procedural memory is the demonstration of the effects of prior experiences. Procedural memory underlies changes in skill performance, as observed in the changes in the person’s performance in preparing a meal.
Moreover, the findings support the idea that a behavioral strategy can be used successfully to reactivate the procedural memory of individuals with mild AD so they may relearn a specific procedural task (Harrison et al., 2007; Son et al., 2002). However, tasks based on new learning versus tasks that only require relearning need to be differentiated. Procedural tasks based on new learning may require longer periods of training to achieve sustained performance.
These findings have significance for both individuals with AD and their caregivers. With this nursing strategy, adults with mild AD may be able to maintain their ability to perform simple routine tasks with caregiver prompting and potentially experience a higher level of meaning and sense of well-being in their lives. Similarly, caregivers may find that improving the person’s function may decrease their need to provide total assistance and delay the person’s functional decline and need for nursing home placement. During implementation of the program, it became clear that caregivers were benefiting from participation; however, the nature of that benefit and its potential impact on their caregiving was not determined.
Future research is needed to address the intervention’s long-term effectiveness and the need for a research design capable of accommodating the individualization of personalized programs. Three of the 5 women with mild AD participated in a follow-up study 1 year later. These individuals needed only minimal prompting to complete the original meal task after one to two training sessions. The need to explore more substantial outcomes, such as quality of life, well-being, and behavioral symptoms, as well as unexpected outcomes for both the individuals with mild AD and their caregivers, is important in designing future studies.
As noted earlier, this study was designed to explore the effects of an IST program based on procedural memory function. The results are encouraging even though the findings lack generalizability and are limited by the nature of the sample and certain aspects of the design and implementation of the study intervention.
The sample was small and limited to Caucasian women. The original intent was to include both genders; however, it may be that women self-selected to participate due to the “gender bias” of the task selected. At the same time, with the exception of age, the sample does reflect the typical AD population in regard to gender and ethnic origin.
The individualization of the program may be seen as limiting replication of the study, although the need for this was readily apparent early in the program’s implementation. For example, the selection of the task needed to be individualized for each participant and caregiver to sustain the participant’s interest in performing the task and to enhance each person’s successful completion of the program.
Lastly, the observational period needs to be extended to explore whether individuals are able to maintain their level of function over time and identify levels of adequate “dosages” of treatment necessary to maintain each person’s level of independence in performing the task.
These findings have significance for nursing practice. With this nursing strategy, individuals with mild AD may be able to maintain their ability to perform simple routine tasks at home with minimal support from a caregiver. Nursing interventions based on behavioral strategies that draw on the preserved procedural memory of individuals with mild AD may be most effective in preserving function in the home setting.
The need for nurses to assess previous learned tasks and psychomotor activities among individuals with AD is an important first step in developing an individualized skills training program. With a broader perspective, interventions can be designed to focus not only on ADLs and IADLs, but also other pleasurable activities to improve the quality of life and well-being of the person with AD and his or her caregiver.
Finally, with increasing state budget constraints, there will be greater need for home-based rather than institutional care, along with a desire to transition patients from the nursing home setting to the home environment. Providing support and hands-on training for caregivers is essential if individuals with AD are to remain in the home. Caregiving is a complex task requiring knowledge and practice to achieve a level of skill. A home-based, skills training program may be most effective in supporting the caregiver while enhancing the function of individuals with mild AD.
Considerable support was found for the applicability and effectiveness of an IST program that drew on the preserved memory of individuals with AD to improve their performance of a specific meal task in the home setting. Adults with mild AD who were once dependent in meal preparation were now making pudding, pancakes, poached eggs and toast, blueberry muffins, and oatmeal with minimal verbal prompting. Despite significant declarative memory impairment, all 5 participants were able to relearn a procedural task with a highly structured, repetitive approach using verbal, visual, and physical prompting. At the same time, none of the participants achieved total independence in performing the task. It may be that the goal for this population needs to be preserving and encouraging a more functional state rather than achieving total independence. Finally, the implementation of this program highlighted the vital role of the caregiver and the importance of the relationship between the researcher and the caregiver-participant dyad. Nonpharmacological approaches that provide support and hands-on training for the caregiver to maximize function may be most beneficial in enhancing the care of individuals with mild AD in the home setting.
- Alzheimer’s Association. (2011). 2011 Alzheimer’s disease facts and figures. Retrieved from http://www.alz.org/alzheimers_disease_facts_and_figures.asp
- Beck, C., Heacock, P., Mercer, S.O., Walls, R.C., Rapp, C.G. & Vogelpohl, T.S. (1997). Improving dressing behavior in cognitively impaired nursing home residents. Nursing Research, 46, 126–132. doi:10.1097/00006199-199705000-00002 [CrossRef]
- Budson, A.E. & Price, B.H. (2005). Memory dysfunction. New England Journal of Medicine, 352, 692–699. doi:10.1056/NEJMra041071 [CrossRef]
- Burgener, S.C., Buettner, L.L., Beattie, E. & Rose, K.M. (2009). Effectiveness of community-based, nonpharmacological interventions for early-stage dementia: Conclusions and recommendations. Journal of Gerontological Nursing, 35(3), 50–57. doi:10.3928/00989134-20090301-03 [CrossRef]
- Coyne, M.L. & Hoskins, L. (1997). Improving eating behaviors in dementia using behavioral strategies. Clinical Nursing Research, 6, 275–290. doi:10.1177/105477389700600307 [CrossRef]
- De Vreese, L.P., Neri, M., Fioravanti, M., Belloi, L. & Zanetti, O. (2001). Memory rehabilitation in Alzheimer’s disease: A review of progress. International Journal of Geriatric Psychiatry, 16, 794–809. doi:10.1002/gps.428 [CrossRef]
- Eslinger, P.J. & Damasio, A.R. (1986). Preserved motor learning in Alzheimer’s disease: Implications for anatomy and behavior. The Journal of Neuroscience, 6, 3006–3009.
- Folstein, M.F., Folstein, S.E. & McHugh, P.R. (1975). “Mini-mental state.” A practical method for grading the cognitive state of patients for the clinician. Journal of Psychiatric Research, 12, 189–198. doi:10.1016/0022-3956(75)90026-6 [CrossRef]
- Giles, G.M. & Clark-Wilson, J. (1993). Brain injury rehabilitation. A neurofunctional approach. New York: Chapman & Hall.
- Harrison, B.E., Son, G.R., Kim, J. & Whall, A.L. (2007). Preserved implicit memory in dementia: A potential model for care. American Journal of Alzheimer’s Disease and Other Dementias, 22, 286–293. doi:10.1177/1533317507303761 [CrossRef]
- Herbert, L.E., Scherr, P.A., Bienias, J.L., Bennett, D.A. & Evans, D.A. (2003). Alzheimer’s disease in the U.S. population: Prevalence estimates using the 2000 Census. Archives of Neurology, 60, 1119–1122. doi:10.1001/archneur.60.8.1119 [CrossRef]
- Hirono, N., Mori, E., Ikejiri, Y., Imamura, T., Shimomura, T., Ikeda, M. & Yamadori, A.,… (1997). Procedural memory in patients with mild Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders, 8, 210–216. doi:10.1159/000106633 [CrossRef]
- Hughes, C.P., Berg, L., Danziger, W.L., Coben, L.A. & Martin, R.L. (1982). A new clinical scale for the staging of dementia. British Journal of Psychiatry, 140, 566–572. doi:10.1192/bjp.140.6.566 [CrossRef]
- Poe, M.K. & Seifert, L.S. (1997). Implicit and explicit tests: Evidence for dissociable motor skills in probable Alzheimer’s dementia. Perceptual and Motor Skills, 85, 631–634.
- Rogers, J.C., Holm, M.B., Burgio, L.D., Granieri, E., Hsu, C., Hardin, J.M. & McDowell, B. (1999). Improving morning care routines of nursing home residents with dementia. Journal of the American Geriatrics Society, 47, 1049–1057.
- Sabat, S.R. (2006). Implicit memory and people with Alzheimer’s disease: Implications for caregiving. American Journal of Alzheimer’s Disease and Other Dementias, 21, 11–14. doi:10.1177/153331750602100113 [CrossRef]
- Schulz, R., Belle, S.H., Czaja, S.J., McGinnis, K.A., Stevens, A. & Zhang, S. (2004). Long-term care placement of dementia patients and caregiver health and well-being. Journal of the American Medical Association, 292, 961–967. doi:10.1001/jama.292.8.961 [CrossRef]
- Son, G.R., Therrien, B. & Whall, A. (2002). Implicit memory and familiarity among elders with dementia. Journal of Nursing Scholarship, 34, 263–267. doi:10.1111/j.1547-5069.2002.00263.x [CrossRef]
- Squire, L.R. (1987). Memory and brain. New York: Oxford University Press.
- Tappen, R.M. (1994). The effect of skill training on functional abilities of nursing home residents with dementia. Research in Nursing & Health, 17, 159–165. doi:10.1002/nur.4770170303 [CrossRef]
- Tulving, E. & Schacter, D.L. (1990). Priming and human memory systems. Science, 247, 301–306. doi:10.1126/science.2296719 [CrossRef]
- van Halteren-van Tilborg, I.A., Scherder, E.J. & Hulstijn, W. (2007). Motor-skill learning in Alzheimer’s disease: A review with an eye to the clinical practice. Neuropsychology Review, 17, 203–212. doi:10.1007/s11065-007-9030-1 [CrossRef]
- Wells, D.L., Dawson, P., Sidani, S., Craig, D. & Pringle, D. (2000). Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers. Journal of the American Geriatrics Society, 48, 442–449.
- Yaffe, K., Fox, P., Newcomer, R., Sands, L, Lindquist, K., Dane, K. & Covinsky, K.E. (2002). Patient and caregiver characteristics and nursing home placement in patients with dementia. Journal of the American Medical Association, 287, 2090–2097. doi:10.1001/jama.287.16.2090 [CrossRef]
- Yu, F., Kolanowski, A.M., Strumpf, N.E. & Eslinger, P.J. (2006). Improving cognition and function through exercise intervention in Alzheimer’s disease. Journal of Nursing Scholarship, 38, 358–365. doi:10.1111/j.1547-5069.2006.00127.x [CrossRef]
- Zanetti, O., Binetti, G., Magni, E., Rozzini, L., Bianchetti, A. & Trabuchi, M. (1997). Procedural memory stimulation in Alzheimer’s disease: Impact of a training programme. Acta Neurologia Scandinavica, 95, 152–157. doi:10.1111/j.1600-0404.1997.tb00087.x [CrossRef]
Figure 3. Frequency of verbal, visual, and physical prompting needed for Participant #3’s task (making pancakes; 23 subtasks) at baseline, final nurse individualized skills training (IST) and final caregiver-led IST sessions.
Figure 4. Frequency of verbal, visual, and physical prompting needed for Participant #4’s task (making blueberry muffins; 42 subtasks) at baseline, final nurse individualized skills training (IST) and final caregiver-led IST sessions.
Demographic Characteristics of the Sample
||Years of Education
||Daughter (age 50)
||Husband (age 86)
||Husband (age 83)
||Husband (age 79)
||Hired companion (age 54)