When treating patients with dementia, implementing environmental modifications can increase their independence at home while simultaneously improving their physical safety and mental health. Internal or external modifications to patients’ residences may also help minimize some of the psychological and behavioral symptoms of dementia.

Have you ever had difficulty convincing your patient with dementia to brush their teeth? You are not alone!

Working in an in-patient facility, such as an acute or sub-acute rehab setting, or long-term care, you are sure to meet many wonderful patients. Some of these people will also have dementia. Working with a person with dementia can bring its own set of challenges, including communication difficulties, physical limitations, agitation, and emotionality, to name but a few.

Check out this article on improving communication when working with people with dementia!

Why can trying to brush teeth be so important in those with dementia?

The act of trying to brush the teeth of a loved one can be a particular challenge for caregivers of those with dementia, and with good reason. Firstly, poor dentition and poor oral care can come with many of its own issues. If you have a patient with poor dental hygiene, they may be experiencing oral pain- which, especially if they cannot communicate the underlying cause, can lead to agitation, aggressive, depressed mood, and other communication breakdowns. Sub-standard oral care is also linked to aspiration pneumonia in the elderly- which naturally has a massive impact on the health and quality of life. Gum disease has been linked to the development of dementia itself. Periodontal disease can cause infection, increased blood sugar (which may impact the person with diabetes), and other chronic conditions. It is clear that oral health, or disease, has a huge impact on overall health and wellness.

Poor oral health is a major issue among the elderly. According to the CDC, a staggering 96% of adults over 65 years old have a cavity and 1 in 5 have tooth decay. Over 2 in 3 (68%) of over-65s have gum disease, 1 in 5 have lost all their teeth (rising to 26% in over-75s). Oral cancer and chronic disease (such as medications that cause dry mouth, in turn increasing risk of cavities) are also much higher among the older population.

These existing correlations are only magnified in those who also have dementia, as these persons are shown to have greater rates of poor hygiene and oral disease. People with dementia are less likely to engage in thorough, regular oral care and hygiene– placing them at an even higher risk of the complications of poor dental and mouth care.

Depending on the stage and the severity of the dementia, tooth brushing can become difficult to perform- either independently or with assistance from a caregiver. It is well documented that the more cognitively intact a person is, the better their oral care will be. Conversely, decreased cognition is associated with poor clinical oral health status, tooth decay, missing teeth, and a higher rate of gum disease.

The problem of care-resistant behavior

Care-resistant behavior can be a major barrier to helping your person with dementia maintain proper oral care.

Many, if not most, persons with dementia require assistance in some aspects of activities of daily living. This can include oral care, to a greater or lesser degree. Care-resistant behavior can complicate this assistance, however. This are actions that are caused by a caregiving encounter, and involve the person with dementia opposing the actions of the caregiver.

Care-resistant behavior can present as an uncooperative, disruptive, agitated, or even aggressive response to the action initiated. Clearly, this has a huge impact on the care provided to the person. Tooth brushing/oral care are far from the only actions impacted by care-resisted behaviors in the person with dementia- bathing, dressing, taking medications, eating, and many other aspects can, and are, affected.

Agitation during a care event is usually present in those with milder and moderate dementias, and may reduce as the dementia becomes severe. The presence of care-resistant behavior, however, increases proportionally to the worsening of the dementia, and has been reported to be 8 times greater in those with severe dementia. Those who require more assistance are also more likely to exhibit this pattern of behavior.

The ‘vicious cycle’ that presents itself based on the confluence of these two factors, especially in an in-patient setting, is that patients with dementia do not receive the assistance they require. This contributes to an overall worsening of health outcomes, and generally a higher burden of care and a less content person with dementia.

The person with dementia may perceive a higher level of threat during oral care- an invasive procedure, combined with an unfamiliar and not-overly-friendly caregiver presentation is ripe to produce resistance in the person with dementia.

I have always thought that if a patient presents for an in-patient stay, perhaps to recuperate from another injury such as a fall, then we as clinicians have a golden opportunity to intervene in other aspects of care to help and support the family members. This includes oral examinations, working out ways of decreased care-resistant behaviors, and setting caregivers up for success when working with their loved one.

This wonderful article by Jablonksi et al (2011) examined interventions to reduce care-resistant behavior during oral care with people with dementia. They proposed using the MOUTh intervention, which I find to be applicable and incredibly useful for improving oral care. This breaks down the activity itself in terms of threat perception and reduction. I have included some of these strategies below. Try some of these techniques when working with your person with dementia to help in toothbrushing and oral care!

Modify your approach.

Before ever approaching the person with dementia, check in with yourself. Are you in a rush? Irritated? Are you likely to use negative facial expressions and body language with your person- are you feeling the “burden” of care right at this moment? You may have poor associations with this task, especially if you often deal with care resistant behavior. It is vital that your tone of voice, facial expression, and body language does not communicate any negativity to the person. Not only are they less likely to trust you, but they may also sense an active threat. You must overcompensate, by ensuring that your presence is positive, approachable, calm, and unrushed.

Approach the person at eye level and within their visual field- do not look down upon the and try to attempt not to surprise or shock them with your approach. This can startle and upset the person, whose vision or hearing may not be intact.

Be calm and gentle! Using a warm, gentle hand on a non-threatening area (like the forearm or hand) can be reassuring and calming. Make sure you are smiling and relaxed in your interaction with the person throughout the entire time. Even a ‘neutral’ face is not perceived positively, so smiling during all interactions is essential.

Make sure you begin your interaction by establishing an acceptable baseline. Begin by discussing a topic you know the person will respond well to and enjoy- such as something they recognize or an interest they hold. This also helps in presenting you as a non-threatening person, who is conversational and friendly.

Modify the activity demands.

Oral care is a very sensory task, which can be overwhelming to the person. Ensure that you are making this activity as calm as possible, by reducing outside noise and creating a calmer environment.

You may need to break the activity into its components and cue the person– make sure that the cues are one-step, unambiguous commands, delivered in a kind tone of voice. Using infantilizing language should be avoided, as it can trigger care-resistant behavior and is generally disrespectful to the person.

The person with dementia may not understand verbal commands as readily as visual cues, so make sure that you demonstrate the action you require– opening your mouth, baring teeth, brush teeth with toothbrush, sticking out tongue, and so on. Make sure these actions are exaggerated and presented in a friendly way.

Position the person in front of the mirror, so they can see themselves throughout the task. This is more likely to result in mouth opening by the person with dementia, for tooth brushing or flossing.

Modify the task.

Use familiar objects, if available. The person’s own toothbrush, denture cup, rinse cup, towel, etc., can both facilitate a sense of ease with familiarity, as well as trigger implicit or procedural memories that can assist with task completion.

Use hand-over-hand or hand-under-hand motions: this can decrease the feeling of invasiveness, as well as elicit dormant automaticity on the part of the person with dementia.  You may begin the tasks with some hand-under hand activities and then be able to decrease these tactile cues as the person recognizes some of the feelings and may continue with the task more independently.

Use environmental stimuli to prime the task– such as positioning the person in front of a sink, placing a toothbrush in their hand, etc. This can access the procedural pathways of this task as well as including the person in the task at hand. Even a person who requires full assistance to clean their mouth may feel more involved in the task at hand if they are feeling the items used, and thereby be less likely to resist. This may also help remind them that they are engaging in a familiar activity, which can decrease perceived threat level.

While performing oral care, use distraction techniques, such as conversation that you know the person enjoys, verbal ping pong, singing, or playing with/holding a comforting or interesting item.

If all else fails and you wish to avoid an escalation of agitation or care-resistant behavior, make sure to have another carer on hand who can ‘swoop in’ and replace the initial caregiver. If the person with dementia has been very resistant and is not engaging positively at all with one carer, then ‘rescuing’ them with another caregiver can help to de-escalate in the moment and the person with dementia may feel safe and heard.

Providing Oral Care: Tips for a successful interaction

Approach	Activity Demands	Task modification
Check in with yourself	Calm environment	Familiar objects
Eye level/visual field	Cueing: one step commands	Hand-over-hand
Calm and gentle	Visual demonstrations	Prime task with environment
Establish acceptable baseline	Position in front of mirror	Use distraction

For a caregiver, helping someone with dementia to brush their teeth can be an intimidating task- and it may not even seem worth the conflict that it may cause.

It is true to say that employing these strategies will increase the time you spend during that interaction with the person, but the more that these approaches become second nature, the quicker they can be employed, and with better results. Caregivers are more likely to even enjoy the interaction, when care-resistant behavior is reduced.

Although this article seeks to focus on the much-reported issue of difficulty getting people with dementia to brush their teeth, you can apply the same principles to many areas of your daily communications with your person.

Are you interested in learning how to improve your ability to communicate with people with dementia as a caregiver? Check out our fantastic, action packed short webinar on the subject- ‘Settled and Secure- Addressing ‘challenging’ behaviors associated with dementia. This 1.5 hour CEU course provides you with skills and easy to use communications that can make all of your interactions more satisfying, and enable you to bridge the communication chasm that exists between carers and people with dementia.

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If someone close to you has ever been affected by dementia, you may know how devastating this condition can be- not only to the person themselves, but also to the family unit. Healthcare professionals such as therapists and nurses deal with these complicated family circumstances as well, when helping caregivers cope with dementia. To support caregivers of people with dementia as best you can, first we must understand what is going on…behind the scenes.

To read more about 5 tips for managing challenging behavior for your patient with dementia, read this.

The effect of dementia on the family unit

Did you know that the family members of a person with dementia are often called the ‘invisible second patients’? This speaks volumes about how all-encompassing the diagnosis of dementia can be on the family member themselves. Caring and providing support to these family members and caregivers is critical for the well-being of the person with dementia- and can make the entire process change from an immense psychological burden- to much more positive and empowering experience.

It goes without saying that the family are the main social and physical help for people with dementia. This deserves so much recognition, because it leads to much less patients entering long term care, generally indicates a better quality of life for the person themselves, and has a massive impact on the economy. With all these people being cared for at home, however, the impact on the family is intense.

Depending on the stage and the type of dementia, the person may also have their own additional challenges- like personality changes, agitation, disruptive or hard-to-understand behaviors, or even aggression.  

This situation is rife for family conflict. Members of the family might disagree on care, butt heads over how to care for the person, and fight over finances. But what makes the care of a person with dementia more high conflict than other situations?

There is, of course, the physical workload of providing more care to a person. As the dementia progresses, the person will require more and more assistance with daily tasks, may need increased levels of supervision for activities they could previously complete independently.

Families can also experience financial strain– as many primary caregivers must give up their work, or cut back on hours in order to be able to provide care to their loved one. This can create further stress in the form of financial hardship. Getting paid help into the home is an option to ease some of the physical workload but again contribute to the financial issues a family may have.

From an emotional perspective, a lot of conflict can arise because of different coping strategies. Watching your mother or father change, become less independent, or even forget your own name can be devastating. Many caregivers are dealing with a massive feeling of grief and loss, even while the person they grieve is right there in front of them. This sadness and disappointment is pervasive, and caregivers may feel depressed- which of course, will impair their ability to function at a higher level and care for their family member.

Some caregivers, like children of the person with dementia, may feel irrational anger– this is the person who took care of them, and now they are forgetful and need constant reassurance and cues to get anything done. This can be maddening to a caregiver who is sad and stressed and not coping well with the situation- particularly if they do not understand how to communicate with their person.

Frustration at the situation, and all its complex requirements, can be strongly felt by caregiver and family members and cause them to lash out at each other. Most people have their own distinct coping style, or may not be coping well with the idea of a loved one with a progressive condition. This can be heightened if some family members are seen to not be pulling their weight, or if some live far away, or if there is a disagreement as to the direction of care.

Guilt also looms large in this equation. Families can feel guilty at their own sadness, anger, or frustration toward their loved one; they may feel guilt for seeking outside help; and they certainly feel guilty if making the decision to move their person into a care facility. This guilt complicates the situation even further, and distorts the other emotional responses and coping strategies.

Although these difficult and stressful situations can arise, it is really important to understand that conflict and grief are not the default settings for caregivers of those with dementia. Many caregivers can have a rewarding and positive experience when caring for a loved one, and I personally have known families who have cherished this time with their family member.

Although the ‘burdens’ of caregiving are more widely known, caring can also have many positive effects. According to an article by Sanders (2005), between 55% and 90% of caregivers have positive experiences, such as enjoying togetherness, sharing activities, feeling a reciprocal bond, spiritual and personal growth, increased faith, and feelings of accomplishment.

Motivations can also impact the outcome: feeling more positively toward the act of caregiving has been associated with greater health and wellness, and higher general satisfaction.

As a therapist of a nurse working in an inpatient setting, understanding these situational challenges is absolutely essential. It will help inform how to proceed, what questions to ask, and what support to offer caregivers when working with a person with dementia. Keep in mind- working with your patient is the tip of the iceberg, in terms of their long term care!

How can we best support caregivers of those with dementia?

Explain dementia

Many of the family conflicts may arise from a lack of knowledge as to what is happening and how to progress with the person with dementia. By clearly explaining what kind of dementia their loved one has, and explaining what they can expect, a lot of myths may be able to be challenged. Many lay people will not realize that dementia is an ‘umbrella term’ that encompasses many presentations, each of which may have a different progression.

It will be vital to communicate to the family how their loved one will progress. Alzheimer’s type dementia has a linear downward loss of function, whereas vascular dementia will present as a stepwise loss of function. Personality changes will be most dramatic with a frontotemporal dementia, which is also complicated by a younger age of onset. Lewy Body dementia can present with hallucinations or parkinsonism- both of which impair communication, and will be very important for the family to understand.

Providing this clarity to families, along with some of the next tools, may help them feel more able to cope with the challenges and the conflict.

See the person inside; understand their best ability to function

The family member or the caregiver often feels that they have “lost” their loved one, and is grieving their loss even with the person physically beside them. We can help support our families and caregivers by teaching them about the person inside.

Educating families about the massive communication breakdown that occurs as part of dementia is paramount to a successful ongoing relationship. If a caregiver is mourning the loss of their mother, who used to always share stories and give advice but now does not seem to remember anyone’s name and sometimes does not recognize their own family members- it is easy to see why the caregiver could feel like they ‘lost’ the,’. Instead, support the caregivers to connect with their loved one through what abilities and skills remain- no matter what the level of dementia. You may teach the caregiver to reminisce about old stories, to enjoy relieving experiences through a photo album, or to companionably watch grandchildren together and gently elicit advice on their behavior.

We discuss exactly how to communicate this way in our short webinar, “Settled and Secure: Addressing Challenging Behaviors with Dementia”. Check it out!

By empowering your caregiver to communicate with their loved one in this way, you are fostering a stronger and more satisfying relationship. This is going to have knock-on effects to overall satisfaction and happiness and lessen the sense of burden and stress. All family members should be educated in this way, so that they are not trying to ‘keep the person at their current stage, or place undue stress on them by asking questions or becoming frustrated. If the family as a unit feel more empowered in their own relationships with the person, inter-familial conflict can drop.

How to communicate with their loved one

Communication is key to success in all aspects. Both communicating with their loved one, and communicating within the family unit- breakdowns and barriers in communication will cause the most strife and strain.

Communicating with the person with dementia is multi-faceted- to learn more about boosting your communication with someone with dementia, read this article!

Communication within the family is also paramount. Make sure that everyone is continuing to talk to one another, more regularly than you may think is necessary! Schedule regular meetings, conference calls, or family events; discuss what ‘worked’ with the person with dementia, and what had an adverse effect, and keep a running list of acceptable and pleasurable topics; and form a schedule that will work best for the person. Operating within this framework is going to lead to the most success for the family- which can again decrease the amount of inter familial conflict experienced.

 

How to communicate with each other

We are all more likely to be short, or less patient with our own family members. Expecting this, and encouraging the family to approach each other with compassion and an open heart is important. As mentioned before, everyone will cope with a progressive illness such as dementia in a different way- and being as empathetic as possible to this will be helpful.

Get outside help

Owing to the amount of physical help, supervision, and other assistance that the person with dementia will need, the family may need to hire outside help to ease some of the burden. Bringing in their right person to help with your loved one can also add a much needed dynamic- the hired caregivers may not have the emotionality that the family experience, and can educate and support the family on good techniques or preferred activities that they find with the person with dementia. It can also provide a supportive and social interaction for the caregiver.

There may be a transitional phase wherein the person with dementia will need a level of help greater than the family can provide. Transferring a loved one to a care facility, as mentioned before, is an emotional minefield. Guilt and trauma are expected, and this friction can also lead to what is known as “transfer trauma’ for the person with dementia.

Transfer trauma describes the high level of stress that a person with dementia can experience, when moving from one home to another. It will be more common in people at an earlier stage of dementia, or if they are moving from their lifelong home into a facility.

This can be temporary, as the person settles in and finds a new community. However, if this transfer is not handled well, there can be other complications such as isolation; depression; behavioral challenges.

As a therapist or nurse, you may be meeting the family during this difficult time. Perhaps you were caring for their loved on who fell ill or was in in-patient care, and with their new level of need, the family are unable to care for them. Or maybe, you are a clinician in the inpatient subacute facility that they are moving their mother/father/husband/sibling in to. Having an acute sense of the conflicts that may arise can help you best support the person, and their family.

Transfer trauma can be just as real for the caregiver- families may experience stress and guilt. This might be compounded by any insight their loved one has into the situation, perhaps asking them “why have you done this to me?”. Our role as clinicians here can be powerful- enabling communication and healthy emotional exchange between the family and their loved one.

Support groups

Community support at a wider level is also going to be vital for us as clinicians to be aware of, and empower families and caregivers of those with dementia to seek out. Both live and online support groups are available, as well as counselors, patient advocates, and websites with lots of useful information for carers.

Here are a few links that list live and online support groups that you can draw attention to:

• https://www.alzheimers.net/best-alzheimers-support-groups
• https://www.alz.org/help-support/community/support-groups
• https://dailycaring.com/support-groups-for-caregivers-on-facebook/

Family conflict is almost inevitable when trying to cope with caring for a person with dementia. Many complicated factors are at play, and this condition is multi-faceted. For clinicians or caregivers, being aware of these issues and being ready to provide support and understanding is going to be one of the most empowering things we can do. We want to set both our caregivers and our patients up for success at every level!

We talk much more about communication techniques, coping, and boosting your skills in connecting with your person and family members in our fantastic one-hour webinar, ‘Settled and Secure: addressing ‘challenging’ behaviors associated with dementia’. Check it out, or get our free Care Approaches cheat sheet right here!

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂

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Do you have experience working with someone with dementia, who had family conflict? We always love hearing from you! Comment in the section below!

Whether you are a PT, OT, SLP, Nurse or nursing tech- you will invariably be working with dementia patients over the course of your career. Feeling comfortable and capable caring for dementia patients is crucial no matter whether you’re working in acute, sub acute or a long term setting. A huge fear for caregivers is not knowing how to deal with a dementia patient who is becoming aggressive, or even worsening the situation.

Dementia can be an extremely intimidating and challenging condition to treat.

It can be unpredictable, heartbreaking, and the breakdowns in communication are intensely frustrating both to the person with dementia and to the person caring for them. Check out our (free!) Tips for Effective Interactions here for some guidelines on managing interactions with patients with any altered cognitive status.

Effective communication is becoming all the more relevant with each passing year- we all know the population is rapidly expanding and aging, and with that has come a massive increase in those with dementia. Right now, 1 in 3 people over 65 are affected by dementia- totaling about 5.3 million Americans. By 2050, that number is expected to increase to 14-16 MILLION! (and just to help wrap your head around that- 2050 is closer to us right now than 1989!)

There are many behaviors that a patient with dementia can have that can be ‘challenging’ to us as caregivers. How do we deal with a dementia patient who is aggressive? Agitated? Constantly repeating questions, wandering, or any number of other behaviors that we cannot figure out?

First, we should understand that behavior is just a way of trying to communicate, when other channels (like language, memory, problem-solving, orientation) have failed.

By being able to communicate better with these patients, we are going to exponentially increase their happiness and satisfaction, as well as our own. Bridging the chasm of broken communication will be one of the most effective ways we can reach our patients and help manage these disruptive behaviors.

How can we boost our communication with this vulnerable population?

 

1. Don’t ask Questions

Remember those cartoons where the hero got stuck in quicksand? A person with dementia is constantly trying to find their footing on a ground that is always shifting beneath them. Their fundament of understanding of themselves and the world around them is moving or slipping away- and when they try to figure out what they are “missing”, it causes, understandably, great upset. Any question we ask them, no matter how casual, will trigger this sense of worry and discombobulation. Think about it- If I ask you: “How was lunch?”, it requires of you to know: that you had lunch in the first place; what it was; if you ate it; if you enjoyed it; why you can’t remember it; whether you have even eaten today; in fact, whether you have eaten at all in weeks? These fleeting thoughts are impossible to hold onto and the fact that the answers may not come readily is extremely upsetting to someone with dementia. Essentially, it forces them to face the fact that they CANNOT REMEMBER LUNCH. This can cause a cascade of anxiety and emotion that can trigger behaviors like agitation, or eventually aggression. When you are working with someone with dementia, never, ever ask questions!

2. Never Contradict

Contradiction also challenges the dementia patient’s world view, and can throw them into unpleasant anxiety or confusion. Re-orienting the patient forcefully can also be extremely uncomfortable. At times, we want to be contradictory if we feel our patient is upset, for example “I want to go home” “But Mary, you can’t go home, remember, your daughter can’t take care of you anymore”, or “I need to get the train now” “What do you mean, there isn’t any train here!”. However, we can see that by explaining these realities to our patient, they are again forced to try to examine why their version of reality is not matching up to what they are being told. This can again lead to disruptive behaviors and a very unsettled person. Instead, we should nod and agree, smile and be comforting, and if necessary, try to redirect the person.

3. Redirect

Redirection is going to be one of the most effective tools in your chest, as you will be able to meet your own care goals, while keeping your patient from getting upset or agitated. Key to being able to redirect your person is being able to meet them where they are at. If your patient is convinced that they are “late”, then you should be focused on ‘helping them’ where you may begin by ‘taking them’ somewhere, and as you are walking with them, that you can start to discuss something you know to be a topic that they love to engage in. Similarly, if your patient is asking you where their husband/wife/son/daughter is, you can engage at that level, “hmm, I think he is still at work, but he should be home soon”, and then begin to redirect into a favorite topic or an experience you know they find enjoyable.

4. Learn from the Expert

Knowing information about your patient with dementia is going to be crucial to being able to skillfully redirect them or engage in their favorite activities. Think about what you know about them- at the very least you will know that they are an adult with a lifetime of experiences, who will expect a certain level of social respect (and believe me, will know if they are not receiving it!). You may also know if they are a parent, grandparent, perhaps their kids names, or their profession. You may know some hobbies or activities they love to do/talk about, places they have lived or communities they are a part of. Communication between all the people who are caring for this person is going to be really helpful to build a more comprehensive picture, and be able to summon up some of these topics of conversation for redirection or in order to be able to meet other care goals.

5. Recycle Acceptable Experiences

If your person enjoys flipping through their photo album, watching their favorite performer on TV, or talking about their garden, we should never stop doing it! A person with dementia will continue to derive a lot of satisfaction out of the exact same tasks again and again, without any need for novelty or newness. This can’t be undervalued! If we have a deck of acceptable experiences that we know our person is going to love, we should be willing to dip into them frequently and understand that every time is going to be comforting and enjoyable each time. Keep ‘acceptable’ activities, which you know makes your person happy, near to you. Use these acceptable experiences to help meet your therapeutic goals in other ways- such as, if you are leafing through the wedding album with your dementia patient, you can layer in breaks for drinking water and having a snack; or cutting their nails; etc.

Many of the ‘challenging’ behaviors that are associated with dementia are related to poor communication. Improving our communication with dementia patients is going to help them feel much safer and more comfortable, and help us to feel more effective and less intimidated.

We talk much more about communication techniques, how to deal with dementia patients who display aggressive behavior, and how your language and perspective may be holding you back in our fantastic one-hour webinar, ‘Settled and Secure: addressing ‘challenging’ behaviors associated with dementia’. Check it out, or get our free Care Approaches cheat sheet right here!

Interested in more clinical tips, articles, and resources for your practice? Sign up for our bi-weekly mailing list below! We promise to treat your inbox with the respect and love it deserves 🙂

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More great resources for further reading about how to deal with aggressive or challenging behavior with your patients with dementia:

1. Contented Dementia: by Oliver James.
2. Spencer, S; Johnson, P. (2016) De-escalation techniques for managing aggression. Cochrane Database of Systematic Reviews 2016, Issue 1
3. Jablonski, R et al (2011) An intervention to reduce care-resistant behavior in persons with dementia during oral hygiene: a pilot study. Spec Care Dentist 31(3):77-87
4. Kaufmann, E; Engel, S. (2016) Dementia and well-being: A  conceptual framework based on Tom Kitwood’s model of needs. Dementia, 15(4):774-788
5. McCrae et al (2019) The Specialized  Early Care for Alzheimer’s method of caring for people with dementia: an investigation of what works and how. Scandinavian Journal of Caring Sciences, 2019 (12)
6. Wong et al (2018) Applying the Person-Environment-Occupation Model to Improve Dementia Care. AOTA Continuing Education Article, May 2018