Caring for people with dementia

Short description: Form of caregiving

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As populations age, caring for people with dementia has become more common. Elderly caregiving may consist of formal care and informal care. Formal care involves the services of community and medical partners, while informal care involves the support of family, friends, and local communities. In most mild-to-medium cases of dementia, the caregiver is a spouse or an adult child. Over the period of time, more professional care in the form of nursing and other supportive care may be required medically, whether at home or in a long-term care facility. There are evidences to show that case management can improve care for individuals with dementia and the experience of their caregivers.[1] Furthermore, case management may reduce overall cost and institutional care in the medium term.[1] Millions of people living in the United States take care of a friend or family member with Alzheimer’s disease or a related dementia.[2]

## Contents

* 1 Family caregivers
* 2 Respite or day care
* 3 Environmental design
* 4 Communicating
* 5 Memory strategies
* 5.1 Assistive technology
* 6 Psychological and psychosocial therapies
* 7 Nursing
* 8 Incontinence care
* 8.1 At home
* 8.2 In care homes
* 8.3 In hospitals
* 9 See also
* 10 References
* 11 Further reading

## Family caregivers

The role of family caregivers is becoming increasingly important; care in the familiar surroundings of home may delay onset of some symptoms and postpone or eliminate the need for more professional and costly levels of care. However, home-based care may entail tremendous economic, emotional costs. Family caregivers often give up time from work and forego pay in order to spend an average of 47 hours per week with an affected loved one, especially if they cannot be left alone. In a 2006 survey of patients with long-term care insurance, the direct and indirect costs of caring for an Alzheimer's disease patient averaged $77,500 per year in the United States.[3]

Caregivers themselves are subject to increased incidence of depression, anxiety, and in some cases, physical health issues.[4][5][6] According to a UK-based study, almost two out of three caregivers of those with dementia feel lonely. Most of the caregivers in the study were family members or friends.[7][8]

Research shows that African Americans face a more significant burden in Alzheimer’s care management and will face more negative life changes and health outcomes due to providing care.[9] African Americans are twice as likely to be diagnosed with dementia than other ethnic groups,[9] and caregivers often materialize as secondary patients due to the severe impact of caregiving on their health and well-being.[10] Additionally, according to the Alzheimer’s Association and NAC/AARP, 60% of Alzheimer’s disease and dementia caregivers are typically female and are 55 or older.[11] This data emphasizes that African Americans are disproportionately affected by Alzheimer’s disease and other forms of dementia.

Schulz et al. concluded in a US study that "the transition to institutional care is particularly difficult for spouses, almost half of whom visit the patient daily and continue to provide help with physical care during their visits. Clinical interventions that better prepare the caregiver for a placement transition and treat their depression and anxiety following placement may be of great benefit to these individuals."[12] Thommessen et al. found in a Norwegian study that the most common stressors reported were "disorganization of household routines, difficulties with going away for holidays, restrictions on social life, and the disturbances of sleep..." and that this was common to carers for dementia, stroke and Parkinson's disease patients.[13] In a Japanese study, Hirono et al. assessed that "the patients' functional and neuropsychiatric impairments were the main patient factors which increased the caregiver's burden."[14] Activities are important for the dementia patient because it keeps them cognitive functioning. The caregiver should aid them in their activities, but should not do it for them.[15] An Italian study by Marvardi et al. found "that patients' behavioral disturbances and disability were the major predictors of the time-dependent burden; the psychophysical burden was explained mainly by caregiver anxiety and depression."[16]

Caregivers may experience anticipatory grief and ambiguous loss,[17][18][19] and research shows that African American caregivers are less likely to seek help for grief and depression than their Caucasian counterparts.[9] Furthermore, physiological changes such as increased cortisol levels, the body’s primary stress hormone, contribute to impaired cognitive function,[20] perpetuating the problem of Alzheimer’s disease within the African American community since stress is a known causal.

While family caregivers often care for patients with dementia at home, they also provide a helpful function within nursing or residential aged care facilities. Findings from a 2021 systematic review found caregivers of these patients in nursing homes with dementia do not have sufficient tools or clinical guidance for helping to manage multiple interventions, such as behavioral and psychological symptoms of dementia (BPSD) and medication use.[21] Nurses should provide information to the caregiver on how to take care of the dementia patient so the caregiver does not neglect them.[22]

## Respite or day care

Caring for someone with dementia is accompanied by many emotional and physical challenges.[23] Respite care is designed to give rest or relief to caregivers and can take place in many different settings depending on the needs of those involved. Respite services are offered at adult daycare facilities, nursing homes, or in-home.[24] A 2014 study did not report any benefits or detrimental effects from the use of these interventions.[23] However, these results may be due to the lack of high quality studies in this field.[23]

According to a more recent 2016 review, respite services provided to families caring for a family member with dementia had positive effects such as stress reduction, increased time for relaxation, socialization, and focusing on personal tasks. This is an important finding as caregivers often experience burnout.[24] See also Caregiver stress and Memory and aging. The review also found that respite services provided by a nursing home (or other similar facility) increased the likelihood of the patient being transferred into an institution,[25] while early utilization of in-home help services often delayed institutionalization.[26]

## Environmental design

A 2010 review summarizes what is known about best practices for safe and stimulating environments for dementia.[27] Architects in designs for aging in place can consider the relationship of the built environment to the functioning and well-being of seniors.

The environment that a person with dementia lives in is very important. Nurses should help to provide a healthy environment for people with dementia. A negative frustrated atmosphere from the nurses could lead to emotional neglect to the patients.[28] Nursing home managers do not understand how to take care of their dementia patients either, which could lead to a chaotic and hostile environment.[29] It should be conducive to relaxation, stimulating, and engaging. A 2014 cross sectional quantitative study showed that while the nurses were less stressed, so were the residents. Nurses who were working in a calm environment decreased stress levels.[28] The environment in which those with dementia live should foster their ability to be a participant and not just an observer in their life and include opportunities for independence. Their environment should allow them to keep their identity. Including things that are personal to them and that serve as reminders of their identity are important and meaningful. This personal environment should also be a place where if needed they can have privacy. The areas should also be well lit with minimal items on the ground to reduce risks of falling or injury.[30]

The environment where those with dementia eat their meals should be inviting and foster conversation and socialization.[30] Items designed specifically to help individuals with dementia can also be helpful, such as industrial designer Sha Yao's tableware that both has the colorful and unique design that stimulate people with dementia and has other features that address cognitive, motor, and physical impairments that often arise.[31][32][33]

Things to do for people with dementia would be:[2]

* Try to keep a routine, such as bathing, dressing, and eating at the same time each day.
* Help the person write down to-do lists, appointments, and events in a notebook or calendar.
* Plan activities that the person enjoys and try to do them at the same time each day.
* Consider a system or reminders for helping those who must take medications regularly.
* When dressing or bathing, allow the person to do as much as possible.
* Buy loose-fitting, comfortable, easy-to-use clothing, such as clothes with elastic waistbands, fabric fasteners, or large zipper pulls instead of shoelaces, buttons, or buckles.
* Use a sturdy shower chair to support a person who is unsteady and to prevent falls. You can buy shower chairs at drug stores and medical supply stores.
* Be gentle and respectful. Tell the person what you are going to do, step by step while you help them bathe or get dressed.
* Serve meals in a consistent, familiar place and give the person enough time to eat.

## Communicating

Caring for someone with dementia is especially challenging due to the fact that dementia patients soon lose the ability to speak or otherwise communicate and seem unable to understand what's said to them.[34] Since dementia patients have trouble communicating their needs, this can be frustrating for the nurse. Nurses may have a hard time making relationships with their dementia patients because of the communication barrier. How the dementia patient feels is based on their social interactions and they may feel neglected because of this barrier.[35] Nurses feel pain and helpless when caring for a dementia patient.[28] Care approaches known variously as patient-centered care or comfort-centered care attempt to address the difficulty in communication between caregiver and patient. These terms are used in reference to all patient populations, not just dementia patients.[36]

To communicate with dementia patients who have lost their ability to communicate in traditional ways, nontraditional forms of communication are used. Paying attention to eye movements, facial expressions and body movements can help caregivers understand them a little better. In the study by Ellis and Astell it was found that as researchers imitated the sounds and body language of the dementia patients, they engaged even more with the researcher. As each person is affected by dementia differently, a unique form of communication may need to be established. Nurses must use therapeutic communication while talking to patients. Therapeutic lying is a tool that nurses use to re ensure the patient that they are okay and it's used in situations that would not harm the patient in any way.[37] Even though they may be nonverbal that does not always conclude they no longer wish to participate in the world around them.[38]

## Memory strategies

Some studies have demonstrated emotional memory enhancement in Alzheimer's patients suggesting that emotional memory enhancement might be used in the daily management of Alzheimer's patients.[39][40][41][42] One study found that objects are recalled significantly better in Alzheimer's patients if they were presented as birthday presents to AD patients.[43]

### Assistive technology

A 2017, Cochrane Review highlighted the current lack of high-quality evidence to determine whether assistive technology effectively supports people with dementia to manage memory issues.[44] Thus, it is not presently sure whether or not assistive technology is beneficial for memory problems.

## Psychological and psychosocial therapies

A 2018, Cochrane Review found that offering personally tailored activity sessions to people with dementia in long-term care homes may help manage challenging behavior.[45][needs update] No evidence supported the idea that activities were better if they matched the individual interests of people. The findings are based on low-certainty evidence from eight studies. At the same time a program showed that simple measures like talking to people about their interest can improve the quality of life for care home residents living with dementia. The program showed that such simple measures reduced residents' agitation and depression. They also needed fewer GP visits and hospital admissions, which also meant that the program was cost-saving.[46][47]

## Nursing

In the acute care setting a fair number of individuals diagnosed with dementia suffer from hip fractures. For that reason, nurses are in high demand to care for this population.[48] When taking care of the elderly who are cognitively impaired it is challenging to assess if one is experiencing pain. Missed nursing care is common when taking care of patients with dementia. Some nurses may prioritize other patients based on the stage of their dementia and their age. Missed care could lead to complications such as falls, infections, and incontinence.[49] Pain is commonly defined as a subjective feeling that is best understood by the patient. Because of this, nurses tend to rely on verbal statements from patients to detect whether one is hurting.[50] Due to diminished verbal skills in this population it can increase the risk of inadequately assessing ones' needs, including if they are in pain. Research has shown that patients not being able to express themselves is the number one barrier when it comes to caring for the elderly.

As the population continues to age, the numbers of patients in hospital settings with dementia will most likely increase. To prevent the elderly with dementia from receiving inadequate recognition of pain nurses should use common sense to aid in assessments.[48] Interpreting body language has been shown effective in relieving discomfort. Another way to improve perception of pain is getting to know the patient better through family members’ eyes. Obtaining further information about the patient from family members helps make the connection to normal behaviors.[50] Although some of these pain-relieving strategies are beneficial there still is a lack of research focused on dementia patients in the acute care setting.Unfortunately many nurses are not taught on how to take care of patients with dementia. Many programs that nurses go through that are provided by their facilities, a little less than half of nurses do not feel comfortable actually using that training on their patients.[51] As a result, this puts an increased risk of strain on nurses and patients.

In general, however, the unfamiliar environment and routinized practices of the acute care setting can be particularly challenging for people living with dementia. The absence of family and familiar surroundings, on top of the physical issue leading to the admission, heightens anxieties, confusion and distress. Challenges in communication not only impact effective pain medication, but also affect hydration, nutrition and all aspects of physical and emotional care. Whilst these challenges have long been recognized, it remains an ongoing issue,[52] and has been further impacted by the COVID-19 pandemic.[53] A person-centered care approach helps alleviate some of the unfamiliar stress from being in the acute care environment,[54] and can also benefit those caring for people with dementia in this setting.[55] Implementing best practice in dementia care needs a hospital wide approach. Increases to workforce capacity, physical environments that support familiarisation, social interaction and activities, inclusive carer policies and cultures of sharing knowledge have all shown promise in improving dementia care in the acute-care setting.[56][57]

## Incontinence care

People with dementia are more likely to have problems with incontinence: they are three times more likely to have urinary and four times more likely to have fecal incontinence compared to people of similar ages.[58][59] This can have a profound impact on the dignity and quality of life on people with dementia and their carers.[58][60]

There is a general lack of understanding and stigma around incontinence.[61] Professionals also lack knowledge and training when it comes to incontinence in people with dementia.[58][62] Poorly-managed incontinence also has severe negative impact physically, psychologically, economically and socially on people with dementia living at home and their informal carers.[58][62]

Guidelines suggest that treatment should always be preferred to containment as pads and catheterisation can be uncomfortable and negatively affect the person's dignity.[58] However the continence problems of people with dementia are different than of those without[62] and the care strategy should take their and their carers' different perspectives into account.[63] There are guidelines for the continence care needs of people with complex health conditions such as the Continence Care Framework.[64]

### At home

THE EVIDEM-C research program looked at how to improve care for people with dementia living at home. They identified priorities for action: the importance of early clinical assessment (rather than using pads); promoting continence through a balanced diet, exercise and hand hygiene; encouraging and helping toilet use; and a sensitive management of incontinence to secure the person's dignity.[65]

### In care homes

Among people with dementia living in care homes the rates of fecal incontinence are between 30% and 50%.[66] This generally occurs alongside urinary incontinence but around 30% of people in care homes have only urinary incontinence.[58][67] According to research in the UK, continence care should be individualized with the aim of promoting personal dignity. New measures should take into account the preferences and personal history of the affected person. Appropriate diet and mobility can help and prompts to go to the toilet should be preferred over using pads. For supporting and encouraging toilet use, staff needs practical training and an understanding of how dementia affects continence.[66]

### In hospitals

In a hospital context, the care of continence is often poor.[58][68] This can lead to worse clinical outcomes for people with dementia, a higher risk of infection and the development of urinary and fecal incontinence.[69] After clinical assessment, a personalized continence plan should be created which includes identifying reversible causes and contributing factors. Continence problems in people with dementia are at the same time communication challenges. Staff need to be sensitive to the affected people's specific, verbal and non-verbal cues as they might have difficulties expressing their needs around continence. The language used should respect dignity and shouldn't cause embarrassment.[69] An ethnographic study in the UK pointed out the existence of "pad culture" which means that the main care strategy was the use of continence pads even in cases where people were continent. The main reasons for this strategy were fears about safety and falls which kept people in their beds and did not support independence. This mode of caring often lead to undignified situations and the use of demeaning language.[70]

## See also

* Clinical Geropsychology
* Carers rights movement
* Direct support professional
* Personal Care Assistant

## References

1. ↑ 1.0 1.1 "Case management approaches to home support for people with dementia". The Cochrane Database of Systematic Reviews 1 (1): CD008345. January 2015. doi:10.1002/14651858.CD008345.pub2. PMID 25560977.
2. ↑ 2.0 2.1 "Tips for Caregivers and Families of People With Dementia | National Institute on Aging" (in en). http://www.nia.nih.gov/life-with-dementia/tips-caregivers.
3. ↑ [|permanent dead link|dead link}}]MetLife Mature Market Institute (August 2006). "The MetLife Study of Alzheimer's Disease: The Caregiving Experience". http://www.metlife.com/WPSAssets/14050063731156260663V1FAlzheimerCaregivingExperience.pdf.
4. ↑ "Psychiatric and physical morbidity effects of dementia caregiving: prevalence, correlates, and causes". The Gerontologist 35 (6): 771–791. December 1995. doi:10.1093/geront/35.6.771. PMID 8557205.
5. ↑ "A systematic review of the prevalence and covariates of anxiety in caregivers of people with dementia". International Psychogeriatrics 19 (2): 175–195. April 2007. doi:10.1017/S1041610206004297. PMID 17005068.
6. ↑ "Specific effects of caring for a spouse with dementia: differences in depressive symptoms between caregiver and non-caregiver spouses". International Psychogeriatrics 20 (3): 508–520. June 2008. doi:10.1017/S1041610207006278. PMID 17937825.
7. ↑ "Most people caring for relatives with dementia experience loneliness" (in en). NIHR Evidence. 2020-07-22. doi:10.3310/alert_40575. https://evidence.nihr.ac.uk/alert/most-people-caring-for-relatives-with-dementia-experience-loneliness/.
8. ↑ "The prevalence and predictors of loneliness in caregivers of people with dementia: findings from the IDEAL programme". Aging & Mental Health 25 (7): 1232–1238. July 2021. doi:10.1080/13607863.2020.1753014. PMID 32306759.
9. ↑ 9.0 9.1 9.2 "Experiences and Learning Needs of African American Family Dementia Caregivers". American Journal of Alzheimer's Disease and Other Dementias 31 (6): 492–501. September 2016. doi:10.1177/1533317516628518. PMID 26953236.
10. ↑ "Caregiver health: health of caregivers of Alzheimer's and other dementia patients". Current Psychiatry Reports 15 (7): 367. July 2013. doi:10.1007/s11920-013-0367-2. PMID 23712718.
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44. ↑ "Assistive technology for memory support in dementia". The Cochrane Database of Systematic Reviews 2017 (6): CD009627. June 2017. doi:10.1002/14651858.cd009627.pub2. PMID 28602027.
45. ↑ "Personally tailored activities for improving psychosocial outcomes for people with dementia in long-term care". The Cochrane Database of Systematic Reviews 2018 (2): CD009812. February 2018. doi:10.1002/14651858.cd009812.pub2. PMID 29438597.
46. ↑ "The WHELD programme for people with dementia helps care home staff deliver person-centred care" (in en). NIHR Evidence. 2020-11-26. doi:10.3310/alert_42713. https://evidence.nihr.ac.uk/alert/wheld-dementia-care-homes-person-centred-care/.
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48. ↑ 48.0 48.1 "Barriers to postoperative pain management in hip fracture patients with dementia as evaluated by nursing staff". Pain Management Nursing 15 (1): 208–219. March 2014. doi:10.1016/j.pmn.2012.08.007. PMID 24602437.
49. ↑ "Implementation of a training program to increase knowledge, improve attitudes and reduce nursing care omissions towards patients with dementia in hospital settings: a mixed-method study protocol". BMJ Open 9 (7): e030459. July 2019. doi:10.1136/bmjopen-2019-030459. PMID 31326938.
50. ↑ 50.0 50.1 "Pain relief at the end of life: nurses' experiences regarding end-of-life pain relief in patients with dementia". Pain Management Nursing 15 (1): 315–323. March 2014. doi:10.1016/j.pmn.2012.10.005. PMID 23453467.
51. ↑ "The barriers and facilitators to implementing dementia education and training in health and social care services: a mixed-methods study". BMC Health Services Research 20 (1): 512. June 2020. doi:10.1186/s12913-020-05382-4. PMID 32503536.
52. ↑ "Perceptions of Care Quality during an Acute Hospital Stay for Persons with Dementia and Family/Carers". Healthcare 9 (9): 1176. September 2021. doi:10.3390/healthcare9091176. PMID 34574951.
53. ↑ "Care homes: averting market failure in a post-covid-19 world". BMJ 372 (2): n118. January 2021. doi:10.1177/14713012211053971. PMID 33461971.
54. ↑ "Understanding and improving experiences of care in hospital for people living with dementia, their carers and staff: three systematic reviews" (in EN). Health Services and Delivery Research 8 (43): 1–248. 2020-11-23. doi:10.3310/hsdr08430. PMID 33237687.
55. ↑ "The experiences of hospital staff who provide care for people living with dementia: A systematic review and synthesis of qualitative studies". International Journal of Older People Nursing 15 (4): e12325. December 2020. doi:10.1111/opn.12325. PMID 32412167.
56. ↑ "Can person-centred care for people living with dementia be delivered in the acute care setting?". Age and Ageing 50 (4): 1077–1080. June 2021. doi:10.1093/ageing/afab065. PMID 33890625.
57. ↑ Royal College of Nursing (2011). "Commitment to the care of people with dementia in general hospitals (SPACE principles).". https://dementiapartnerships.com/wp-content/uploads/sites/2/rcnhospitalcare.pdf.
58. ↑ 58.0 58.1 58.2 58.3 58.4 58.5 58.6 "Continence, dementia, and care that preserves dignity". NIHR Evidence. 21 June 2022. doi:10.3310/nihrevidence_51255. https://evidence.nihr.ac.uk/themedreview/continence-dementia-and-care-that-preserves-dignity/.
59. ↑ "First diagnosis and management of incontinence in older people with and without dementia in primary care: a cohort study using The Health Improvement Network primary care database". PLOS Medicine 10 (8): e1001505. August 2013. doi:10.1371/journal.pmed.1001505. PMID 24015113.
60. ↑ "A qualitative study and preliminary model of living with dementia and incontinence at home: beyond containment". Age and Ageing 51 (1): afab221. January 2022. doi:10.1093/ageing/afab221. PMID 34888621.
61. ↑ "My bladder and bowel own my life." A collaborative workshop addressing the need for continence research.. Age UK. 2018. https://gutscharity.org.uk/wp-content/uploads/2018/08/Continence-needs-report-C402-August-2018.pdf.
62. ↑ 62.0 62.1 62.2 "Problems faced by people living at home with dementia and incontinence: causes, consequences and potential solutions". Age and Ageing 50 (3): 944–954. May 2021. doi:10.1093/ageing/afaa262. PMID 33320926.
63. ↑ "A taboo within a stigma? a qualitative study of managing incontinence with people with dementia living at home". BMC Geriatrics 11 (1): 75. November 2011. doi:10.1186/1471-2318-11-75. PMID 22081876.
64. ↑ "Reframing continence care in care-dependence". Geriatric Nursing 38 (6): 520–526. 23 April 2017. doi:10.1016/j.gerinurse.2017.03.014. PMID 28442175.
65. ↑ "Meeting the needs of older people living at home with dementia who have problems with continence". Quality in Ageing and Older Adults 18 (4): 246–253. 2017-01-01. doi:10.1108/QAOA-06-2017-0020. ISSN 1471-7794. https://doi.org/10.1108/QAOA-06-2017-0020.
66. ↑ 66.0 66.1 "Managing Faecal INcontinence in people with advanced dementia resident in Care Homes (FINCH) study: a realist synthesis of the evidence". Health Technology Assessment 21 (42): 1–220. August 2017. doi:10.3310/hta21420. PMID 28805188.
67. ↑ "Supporting people living with dementia and faecal incontinence". British Journal of Community Nursing 22 (3): 110–114. March 2017. doi:10.12968/bjcn.2017.22.3.110. PMID 28252330. http://openaccess.sgul.ac.uk/110998/1/Drennan-V-37760-AAM.pdf.
68. ↑ "'We tend to get pad happy': a qualitative study of health practitioners' perspectives on the quality of continence care for older people in hospital". BMJ Open Quality 10 (2): e001380. April 2021. doi:10.1136/bmjoq-2021-001380. PMID 33837091.
69. ↑ 69.0 69.1 "Understanding how to facilitate continence for people with dementia in acute hospital settings: a mixed methods systematic review and thematic synthesis". Systematic Reviews 10 (1): 199. July 2021. doi:10.1186/s13643-021-01743-0. PMID 34229762.
70. ↑ "Understanding approaches to continence care for people living with dementia in acute hospital settings: an ethnographic study". Health and Social Care Delivery Research 10 (14): 1–142. June 2022. doi:10.3310/QUVV2680. PMID 35737814.

## Further reading

* Next Step in Care: free, downloadable resources for family caregivers and health care providers
* Always On Call: When Illness Turns Families into Caregivers (2nd ed.). Vanderbilt University Press for the United Hospital Fund. 2004. ISBN 978-0-8265-1461-5.
* Hidden Carers. Edinburgh: Dunedin Press. 2006. ISBN 978-1-903765-66-1.
* "Investigating Caregivers' Attitudes and Needs (I CAN) Survey". Alzheimer's Foundation of America. http://www.alzfdn.org/survey.shtml.
* "Investigating Caregivers' Attitudes and Needs (I CAN 2) Survey". Alzheimer's Foundation of America. http://www.alzfdn.org/surveys/index.shtml.
* "The MetLife Market Survey of Adult Day Services & Home Care Costs". MetLife. September 2007. http://www.metlife.com/WPSAssets/18746211091190810760V1F2007ADSHCCStudy.pdf.
* The 36-Hour Day (4th ed.). Baltimore: Johns Hopkins University Press. 2006. pp. 324. ISBN 978-0-8018-8509-9. https://archive.org/details/36hourday00nanc_0/page/324.
* Caring for a Person with Alzheimer's Disease: Your Easy-to-Use Guide from the National Institute on Aging. US Department of Health and Human Services, National Institute on Aging, National Institutes of Health. 2009. http://www.nia.nih.gov/alzheimers/publication/caring-person-alzheimers-disease/about-guide.
* "Living With Alzheimer's Disease". Visiting Nurse Service of New York. http://www.vnsny.org/caregivers/caregiving-basics/living-with-alzheimers-disease/.
* "Effective Communication with Alzheimer's Patients". Care Communities. http://www.carecommunities.net/blog/effective-communication-with-alzheimers-patients/.

* Norbergh, K.-G., Helin, Y., Dahl, A., Hellzén, O., & Asplund, K. (2006). Nurses’ Attitudes Towards People with Dementia: the semantic differential technique. Nursing Ethics, 13(3), 264–274. https://doi.org/10.1191/0969733006ne863oa

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