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RESEARCH ARTICLE |
1 Research Institute on Aging of the Hebrew Home of Greater Washington, Rockville, Maryland.
2 George Washington University Medical Center, Washington, DC.
3 Department of Nursing, Tel-Aviv University, Israel.
Address correspondence to Jiska Cohen-Mansfield, PhD, Director, Research Institute on Aging, Hebrew Home of Greater Washington, 6121 Montrose Road, Rockville, MD 20852. E-mail: cohen-mansfield{at}hebrew-home.org
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Abstract |
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DEMENTIA has frequently been identified with a loss of self, mainly through the deterioration of memory and the increasing difficulty of communication. Many persons suffering from advanced dementia experience significant and frequent distress as they feel their sense of identity slipping away. Persons with dementia describe this loss of identity in poignantly articulate terms (Cohen & Eisdorfer, 1986
; McGowin, 1993), and family members and other loved ones experience their own unique painful reactions.
Identity is commonly defined as a multidimensional construct; Erikson (1980) described it as the characteristics that establish who people are and where are they heading. Different identities are produced in different historical periods and different cultures (Erikson). Because of the multidimensionality of identity and the changes it undergoes through life, identity has been described as vague, complex, and evolving (Orona, 1990).
Nevertheless, the construct of identity can be studied through its separate components. Researchers have explored a variety of identity domains, such as social, racial, gender, and ethnic identity (Santrock, 1996), as well as identity functions and status (Berrios-Allison, 2005; Rowe & Marcia, 1980). The complexity of the construct and the biomedical view of dementia as a pathology that results in a decline in cognition and increasing dependence explain the relative paucity of scientific evidence for changes of identity in persons with dementia and the inconsistencies of constructs described in the literature on identity in dementia. In the following paragraphs we review the current literature on identity in persons with dementia and illustrate the variability of approaches and definitions used with the identity construct. We follow the literature review with a short discussion of the operational definition of identity as it is utilized in this study.
There is a growing body of literature suggesting that a remarkable sense of self can indeed survive through late stages of dementia. Since Dworkin's (1986) philosophical declaration that some self-identity can survive even the most serious dementia, there has been some evidence to support his theoretical argument.
Sabat and Harre (1992) differentiated between personal identity and social identity. They suggested that whereas personal identity persists far into the end stage of dementia, social identity, which requires interaction with others in order to be materialized, can be diminished and even lost over the course of illness. Because individuals with dementia are often poorly understood, it is understandable that caregivers and loved ones are not able to provide the kind of interaction that regularly allows for social identity to be expressed. This failure is particularly tragic given McGregor and Bell's (1993) contention that the unique quality of each afflicted individual reflects the persistence of that individual's core personality and identity.
Similar concerns have been raised by Tappen, Williams, Fishman, and Touhy (1999), who cautioned that failure to recognize the person's continuing awareness can lead to low expectations for therapeutic intervention, potentially resulting in mere task-oriented interaction. In their research, they found that persons in the middle to late stages of Alzheimer's disease exhibited clear indices of personal identity; in conversation, persons referred to themselves in the first person, were able to respond to their names, or could discuss the cognitive changes that had afflicted them.
Cohen-Mansfield, Golander, and Arnheim (2000) explored four domains of role identity: profession, family role, leisure activities, and personal attributes. Although a decrease occurs in all of the identity domains as the disease progresses, these researchers found the familial role as the most likely to be recalled, even during advanced stages of progressive dementia, though people varied in the roles they maintained. Generally, more important past identity roles and connections were more likely to be maintained than were the less important identity roles.
Given the loss of verbal abilities in dementia, Hubbard, Cook, Tester, and Downs (2002) examined nonverbal behaviors in older people with dementia and showed that they used nonverbal behavior in meaningful ways for others to interpret and that they actively interpreted others' nonverbal behavior. Basting (2002) concluded that the self is "forged on a continuum of memory and creativity that exists in a social context. Therefore, the person suffering from memory loss might suffer the gradual depletion of his or her personal control over identity, but not a total loss of self" (p. 97). These findings coincide with those of other studies (Golander & Raz, 1996; Li & Orleans, 2002; Small, Geldart, Gutman, & Clarke-Scott, 1998; Vittoria, 1998).
The conceptualization of dementia as a dialectical interplay between neurological and social–psychological factors places special emphasis on the role of the environment in influencing the quality of life of people suffering from dementia (Cohen-Mansfield, 2000; Gilles, 2001, Kitwood, 1990). Small and colleagues (1998) found that external environmental factors have a great influence on the manifestation of self by persons with dementia. Cohen-Mansfield and colleagues demonstrated that agitated behaviors of elderly persons with dementia frequently signal discontent (Cohen-Mansfield, Marx & Werner, 1992; Cohen-Mansfield & Werner, 1995) that may not otherwise be identified, and Kitwood (1997) suggested that these behaviors could result from a devaluating environment, "malignant social psychology" (p. 17), or a misunderstanding on the part of the caregivers. Although not explicitly and directly studied, the common conclusion is therefore that an individualized, respectful, personal approach to care for persons with dementia could enhance the individuals' sense of selfhood, revive social identities and roles, and, in turn, improve their affect.
As one can see from the review of the current literature, the identity construct is variably defined and there is no consensus on the approach to studying it. In this study, the identity construct refers to roles that people assume throughout their lifetime, which are defined through peoples' attitudes toward those roles and are manifested by enactment of the roles (e.g., demonstration in talk and behavior). We chose this definition because it is intuitive and has practical applications in the care of persons with dementia. Professional, familial, and achievement roles are domains of social identity, whereas leisure time and hobbies are interests one expresses throughout one's lifetime and are considered attributes of selfhood.
In our previous study (Cohen-Mansfield et al., 2000), we elicited family and staff caregivers' responses about the potential effect of enhanced identity, as well as what could enhance a sense of self in older persons with dementia. Both family and staff members believed that most participants could achieve an enhanced sense of identity, and that enhanced self-awareness would contribute to the person's overall well-being. Surprisingly, no research has been conducted to explore whether an intervention designed to enhance self-identity actually has an impact on the well-being of those with dementia.
The current study builds on this prior research and fills the gap in knowledge related to identity-specific interventions and their effect on the well-being, involvement in activities, affect, and agitated behaviors of elderly persons suffering from dementia. We hypothesized that interventions incorporating information about a person's self-identity would have a greater positive impact on that person's affect, well-being, and involvement in activities, and more significantly decrease the person's agitated behaviors, than would the usual activities and care.
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METHODS |
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) was 10.58, and there was a fairly equal distribution between severe dementia (MMSE < 10; 52.7% of participants) and moderate dementia (47.3%). The composition of the sample of participants by treatment group is presented in Table 1. We found no statistically significant differences between participants in the control group and those in the treatment group on demographic and clinical characteristics or on the outcome variables as determined by chi-square and t-test statistics.
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). Given the influence of dementia on a person's ability to communicate and recall information, we assessed role identity by interviewing participants as well as their family members and staff caregivers. Although there may be differences in the absolute ratings of role identities across informants, previous studies found reasonable agreement among sources of information regarding role identities (Cohen-Mansfield et al., 2000; Cohen-Mansfield, Parpura-Gill, & Golander, 2006), and thus the multi-informant approach presents a reasonable strategy for obtaining information. We gathered the information regarding self-identity for all participants, control and experimental, in the same way. However, we used the information to design individual, personal interventions for each participant in the treatment group only. If a participant, her or his family, or the staff disagreed about which role identity to choose, we placed greater weight on the participant's responses, especially if her or his cognitive performance reflected only mild to moderate dementia. Prior to treatment initiation, baseline assessment included informant questionnaires and 5 days of structured observations for both groups of participants. Following baseline, treatments were delivered for 5 days for 30 min a day to treatment group participants. The treatments were provided by trained research assistants in the participants' natural setting (e.g., day care center or nursing home unit).
Interventions
We designed interventions with regard to the salience of the identity roles and the severity of the dementia. The purpose of the interventions was to engage the participants in interactions related to their role identities and to determine the effect of these interactions on their well-being (affect and behavior) and awareness of identity. The steps we took to design individualized interventions are as follows.
The first step was the determination of role-identity salience. This determination involved a review of the answers from all three informants and prioritization of the role based on specified guidelines. First, the role rated as the most important lifetime role received the highest priority. Second, an identity role that was very important in both the past and present received a higher priority than one that was important in only one time frame. Third, participants' cognitive function influenced the priority of the ratings so that (a) participants' ratings received higher priority if their level of cognitive decline was moderate or mild (rather than severe), or if their responses were relatively complete and consistent; and (b) when participants had severe dementia and were not able to answer the whole or large portions of the questionnaire, or when their responses lacked consistency, priority was given to family members' ratings over participant and staff member ratings. Fourth, when two informants agreed and the third did not, the discrepant ratings were not utilized.
The second step was the determination of the intervention. The details of the most important role were provided in the self-identity questionnaire, and included information such as the particular job that was important to the participant, the particular family member who was the most important to the participant, and what specific activities or hobbies the participant enjoyed. We designed the intervention so that (a) it was directly related to the detailed content or context of the role identity; (b) it was appropriate for the cognitive, physical, and sensory abilities of the participant; (c) it considered the demographics of the participant (e.g., gender, educational level, primary language); and (d) the intervention provided a sense of purpose (e.g., helping or providing something valuable to others).
Sometimes two roles could be accommodated (e.g., a family-role identity was addressed through a craft project centered on a family theme if the participant's interest in hobbies included crafts). The choice of intervention was at times affected by the availability of materials for the specific activities chosen. For example, if a project involved family photos, usually the family member had to supply them, and so the cooperation of the family member determined the practicability of this intervention.
We list examples of experimental activities, grouped by the role identity addressed, here. Naturally, some of the activities address more than one role.
Family–social role
A male participant was encouraged to create a family tree, using family photographs. The participant was motivated to work on this project because he believed it would be invaluable to his sons and grandchildren. Although he was doing little of the work himself, he exerted firm control over the design of the project. He also insisted that his son be consulted before he presented the completed tree to his grandchildren. Significantly, the participant continued to think about various aspects of the project even during nonintervention times, looking for the research assistant to discuss his ideas. Other participants who received an intervention based on the family–social role listened to audiotapes prepared by the participants' family, made a family tree for the grandchildren, watched videos of babies, discussed family-related experiences (prompted by question cards and article reading), and the like.
Professional role
A former aviation engineer was asked to help construct a model plane. Although he was not able to put the airplane together, he was very interested in its construction, and he enjoyed looking through the instructions and model pieces. He responded with smiles and was engaged in a simple conversation related to his profession. Other participants baked cookies, made an alphabet scrapbook for teachers, gave tax advice, read through contracts, gave legal advice, and the like.
Leisure time and hobbies
Participants listened to music, expressed preferences for specific artists and songs, sang along with a tape, tapped their feet and moved their heads to the rhythm of the music, read and looked at pictures from travel magazines, took photographs of others, played golf with research assistants on the nursing home lawn, danced, played the piano, listened to Bible audiotapes, reminisced about past vacations (prompted by looking at pictures), told stories to research assistants, and the like.
Achievements and traits
A participant with a great sense of professional accomplishment enjoyed looking at his awards, and he requested that someone read aloud the newspaper articles honoring him and his professional achievements. Other participants were engaged in activities that were labeled as volunteering, such as stamping envelopes. Some participants were interviewed by the research assistant about important events in their lives. The research assistant acknowledged a resident's artistic achievement by attending an "exhibition of his paintings in the resident's room."
Assessments
Self-identity retention and importance
A trained research assistant interviewed participants, their families, and their staff caregivers of both experimental and control group participants using the Self-Identity in Dementia Questionnaire, as previously described in Cohen-Mansfield and colleagues (2000). The questionnaire explores four role identity domains (professional; family–social; leisure time, hobbies, or activities; and attributes, achievements, or traits); the importance of these roles or attributes; the attitude toward the role identity; and the demonstration of the roles in behavior. We calculated the internal consistency reliability (scale reliability) of each of the four role-identity subscales for family and staff informants on the basis of the four items of importance, attitudes, talks about role, and demonstration of the role in behavior. For family informants, Cronbach's alpha for professional, familial, hobbies–leisure time, and achievements role-identity scales was 
= 0.82, 0.83, 0.82, and 0.84, respectively; for staff informants, the corresponding values were = 0.85, 0.67, 0.84, and 0.87. We performed test–retest reliability of the questionnaire for a subset of family members (n = 10), and it averaged an exact agreement of 86.2%. Research assistants asked participants and family caregivers about these domains in both past and present contexts and asked staff caregivers to focus exclusively on the present. Research assistants interviewed participants and staff in person, and family members over the phone. Interviews typically took 30–45 min. In addition, the assistants asked more specific questions for each role-identity domain such as the specific professional role, the closest family member, specific hobbies and leisure time activities, and specific achievements and traits.
Self-identity awareness
For this study, we developed one additional question to help examine a participant's awareness of her or his self-identity. This question assessed how frequently a participant showed an awareness of self-identity during the preceding week on a 6-point scale, ranging from never to several times an hour.
Affect
We observed five emotional responses, measured by Lawton's Modified Behavior Stream (LMBS; Lawton, Van Haitsma, & Klapper, 1996), adapted for use on a Palm pilot. Emotional responses measured by LMBS include pleasure, interest, sadness, anxiety, and anger.
Involvement
We measured involvement in activities that were taking place around the participants. These included both structured activities such as activities programs and unstructured activities such as watching television, listening to music, or engaging in social contact. We measured involvement level by using one item on the Agitation Behavior Mapping Instrument (ABMI; Cohen-Mansfield & Libin, 2004; Cohen-Mansfield, Werner, & Marx, 1989), modified for use on a Palm pilot, which we rated as either involved or not involved. We coded these ratings as 1 and 0, respectively. For example, when music was played, and the participant manifested attending to it (e.g., tapping toes, humming along), we would rate that involvement level as involved and we would code it as 1. If the participant was not responding, was withdrawn, or just sat in the activity area, we would rate the involvement level as not involved and we would code it as 0. Involvement in agitated behaviors is not included in this measure (e.g., pacing, picking at clothing). The final involvement level score was an average level of involvement coding in all observations for the phase (baseline, treatment).
Agitated behaviors
We measured agitated behaviors and their frequency by using the modified ABMI (Cohen-Mansfield & Libin, 2004; Cohen-Mansfield et al., 1989), adapted for use on a Palm pilot. Trained research assistants observed residents at baseline and during treatment, recording three 3-min observations within the same 30-min period each day. We calculated interrater agreement for all research assistants. The average agreement rate for the ABMI (calculated within 1 unit difference) for all of the items was 97.3%, with a range from 94.9% to 100%.
Well-being
We assessed four dimensions of well-being with 14 items from the Multidimensional Observation Scale for Elderly Subjects (MOSES; Helmes, Csapo, & Short, 1987). These items assessed participants' disorientation (coherence of speech—1 item), depression or anxiety (7 items), irritability (4 items), and withdrawal (2 items). Research assistants who observed the participants and staff caregivers completed these questions at the end of the baseline phase and at the end of the treatment phase.
Cognitive functioning
We assessed participants' cognitive performance by using the MMSE (Folstein et al., 1975) and the BCRS (Reisberg et al., 1983).
Provision of activities
We determined the actual availability and provision of activities during the observation times by means of direct observations. We calculated the provision of activities by using one item of the ABMI (Cohen-Mansfield & Libin, 2004; Cohen-Mansfield et al., 1989), noting the present activity and using a comment section of the same instrument that provided additional detail about each observation. We dichotomized the provision of the activities variable into categories of activities provided and activities not provided. Present activity was a coded item of the instrument and included 10 activities, namely doing nothing, sleeping, grooming or dressing, bathing or toileting, transferring or ambulating, eating or drinking, watching or listening to TV, music, or radio, socializing, engaging in structured activities, and other. We recoded the first six categories as no activities provided. We coded activities such as watching or listening to TV, music, or radio, socializing, and engaging in structured activities as activities provided. To determine whether there were activities for those coded as "other," we utilized the comments item of the ABMI. Examples of other activities that we coded as activities provided are "visit with a dog," "doing exercise," and "reading a magazine." Examples of the activities we coded as activities not provided were receiving medical care (e.g., waiting for the doctor, having blood pressure checked), "sitting in the wheelchair while nursing assistant is making the bed," and receiving activity of daily living care (a person was trying to feed the participant).
Data Management and Analysis
We downloaded observational data from the palm pilot to a personal computer and converted the data into an SPSS file. We had questionnaire data entered into the computer via MedQuest software. We had data entered twice by two independent staff members. We compared the data sets by using the IQC module of MedQuest, and we corrected all discrepancies. We performed data analysis by using SPSS.
To determine the main effect of the experimental treatment, we performed two-way repeated-measures analyses of covariance (ANCOVAs). The dependent variables were the LMBS affect variables (interest, pleasure, anger, sadness, and anxiety), involvement in activities, the MOSES dimension subscale scores (disorientation, depression or anxiety, irritability, and withdrawal), and agitation scores (ABMI), with baseline and intervention phase as the repeated-measures factor. The between-subject factor was treatment group versus control group, and covariate variables were cognitive functioning (MMSE score) and type of facility. We calculated all scores for dependent variables as an average score across all observations to control for variability in number of observations. The hypothesis calls for a significant interaction term, where changes between baseline and intervention phases will be evident in the treatment group, but not in the control group.
In addition, we performed a series of two-way repeated-measures ANCOVAs for a subset of observations that captured participants only when they were provided with activities. We performed this selection of observations for both baseline and treatment phase observations. We performed the determination of provision of activities for each observation, and this is described in the Assessments section. The dependent variables were the LMBS affect variables (interest, pleasure, anger, sadness, and anxiety), involvement in activities level, and agitation scores (ABMI).
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RESULTS |
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Involvement Level
A repeated-measures ANCOVA revealed a significant interaction between the within-subject factor (baseline phase vs intervention phase) and the between-subject factor (treatment vs control group) for involvement in activities, F(1, 89) = 142.65, p <.001 (Table 2 and Figure 4), showing that treatment group participants manifested greater involvement with self-identity interventions than control group participants did with regular activities.
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Well-Being
We measured well-being by using four subscales of the MOSES, which were completed by research assistants and staff caregivers at the end of both the baseline and intervention phases. The repeated-measures ANCOVA revealed a significant interaction between the repeated-measures factor (baseline vs intervention phase) and the between-subject factor (treatment vs control group) for disorientation (measured by the item asking about coherence of talk) as reported by research assistants, F(1, 74) = 14.33, p <.001 (Table 2 and Figure 5), and staff caregivers, F(1, 84) = 7.53, p =.007 (Figure 6). This demonstrated a decreased disorientation for the treatment group and a slight yet nonsignificant increase in disorientation for the control group. We detected no significant interaction effects for the other three MOSES subscales (see Table 2).
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Self-Identity Awareness
A repeated-measures ANCOVA revealed a significant interaction between the within-subject factor (baseline phase vs intervention phase) and the between-subject factor (treatment vs control group) for identity awareness rated by research assistants, F(1, 57) = 148.84, p <.001. This showed that treatment group participants manifested a greater increase in awareness of their identity during the intervention phase than during the baseline phase, whereas control group participants' identity awareness remained the same over time. We found a significant relationship with the covariate of facility type, F(1, 57) = 9.37, p =.003, where adult day center participants had higher levels of self-identity awareness than nursing home residents did (Figure 8). No significant changes were revealed for results reported by staff members (Table 2).
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DISCUSSION |
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Prior to this study, the individualization of treatments for persons with dementia was limited, with treatment designs individualized to address a particular person's needs or preferences, without considering the person's self-identity. For example, individualized treatments aimed at addressing various medical conditions, and taking into consideration a person's disabilities, resulted in significant improvements of targeted disabilities (Kleban, Lawton, Brody, & Moss, 1975). Music activities individualized to match personal preferences have been more effective than general relaxing music in reducing agitated behaviors in elderly people with dementia (Cohen-Mansfield, 2001; Gerdner, 2000). We based our work on the theoretical frameworks of individualized care (Cohen-Mansfield, 2000; Rader, 1995) and the unmet needs model (Cohen-Mansfield, 2000; Cohen-Mansfield & Deutsch, 1996; Cohen-Mansfield & Taylor, 1998). The premises underlying our work are similar to those behind person-centered care (Kitwood, 1997), "need-driven dementia-compromised behavior" (Algase et al., 1996), and "best friends" (Bell & Troxel, 1997) approaches to dementia care.
The current study represents what we believe is the first attempt to systematically utilize self-identity roles to develop individualized treatments for persons with dementia. The findings suggest that designing treatments around an individual's sense of self-identity can be highly effective in decreasing agitation, increasing positive emotional responses and levels of involvement in activity, and reducing disorientation. Future research should examine this issue and compare the effectiveness of this approach for persons with different types of dementia, and other personal characteristics. These findings also support the importance of the environment on influencing the quality of life of people with dementia (Cohen-Mansfield, 2000; Gilles, 2001; Kitwood, 1990). Furthermore, it confirms researchers' concerns regarding the general failure to recognize the persistence of self-identity in persons with dementia and the impact of this failure on both the process of care and on overall well-being (Cotrell & Hooker, 2005; Sabat, 2001; Tappen et al., 1999). Other authors have also called for a more personalized supporting approach by staff to promote meaningful social personae for individuals with dementia (Sabat & Collins, 1999; Small et al., 1998), and they have stressed the importance of the "communicative care ethic" through which staff focus on preserving the surviving selves throughout all the minutiae and seemingly mundane tasks of everyday life (Vittoria, 1998).
Feedback from family members regarding the impact of the intervention was not systematically gathered; however, when family members volunteered information, the comments underscored the effectiveness of the interventions. In a few cases, family members observed longer-than-expected effects of the intervention, as some participants talked about the intervention for days, even remembering more of the past identity role than was addressed in the intervention. Several relatives noted that the participant had experienced greater positive effects than they had thought possible. In one case, the researchers considered an intervention to be unsuccessful, as the participant did not appear to show much response. However, feedback from the spouse revealed that, given the participant's current level of functioning, the mere fact that the participant was sitting and participating in the intervention was a meaningful achievement. This prolonged positive outcome prompted some family members to continue with the same interventions after the termination of the study. These examples have implications for clinical practice and research. Identification of the individual's motivation and sense of purpose can be critical for successful implementation of interventions. In this study we did not systematically individualize sense of purpose for the participants unless such information was volunteered to us during interviews (mostly by family members). Such information should be examined in future studies. We also report success based on statistical significance utilizing standardized instruments, although examples given here illustrate that clinical success can sometimes occur despite a lack of change on the standardized assessments. Future evaluation should consider additional global clinical evaluation.
Our interventions are meant to individualize and optimize currently provided services. Based on our experiences, we anticipate that individualized treatments based on awareness of self need not involve greater costs than current treatments, because many of the intervention materials are not very costly and because interventions can be delivered in small groups. Similarly, some interventions required minimal staff involvement (e.g., listening to an audiotape of family members reminiscing about past times), and others (discussing past roles, for example) could take place while staff members interact with residents for other reasons (e.g., turning down the bed sheets or preparing the person for sleep). However, the planning of these treatments, such as gaining knowledge of the past identity roles of residents and the acquisition of any related materials (e.g., a deck of cards for those who liked playing cards) or the planning of matching residents by common interests, language, and function, would take additional staff time, and it has to be recognized for reimbursement. The benefit of individualized activities in reducing problem behaviors has to be acknowledged as a cost savings. Indeed, given that reimbursement is available for alternative methods for decreasing behavior problems (e.g., the administration of pharmaceutical agents), policy makers need to consider reimbursement for individualized activities. Reimbursement could be for a social worker or a psychologist who would obtain the information from persons with dementia and their caregivers and formulate the intervention that could be used; it would also include additional time for either activity staff members or nursing assistants to provide the interventions as well as for the social worker or psychologist to mentor and monitor the staff person who provides the intervention. Other models utilizing volunteers could also be tried. Regardless of the model, there would need to be some staff time to collect the information about social role identities and interests, to translate them into interventions, and to either administer or oversee the administration of interventions. One possible avenue for providing such reimbursement within the current reimbursement structure would be to expand the definition of restorative care services, which could include role-identity-based activities.
The importance of a social structure in which one can express and fulfill one's identity seems to be supported by the findings that adult day center participants demonstrated higher levels of identity awareness than nursing home residents did (Figure 8). Aging in place, as is practiced by participants of adult day centers, seems to be more conducive to living according to one's identity than does living in nursing homes.
The implications of our findings extend beyond providing identity enhancement for persons with dementia. They illustrate how understanding and enhancing a person's identity can improve overall care for persons with dementia, resulting in more individualized care and thereby enhancing the person's well-being and decreasing negative symptoms such as disorientation and inappropriate behavior. Therefore, long-term-care settings must strive to provide avenues for identity expression. Policy makers must understand the benefits of such interventions and provide reimbursement for this aspect of care.
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Acknowledgments |
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Footnotes |
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Received for publication March 16, 2005. Accepted for publication November 11, 2005.
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This article has been cited by other articles:
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  L. Clare, J. Rowlands, E. Bruce, C. Surr, and M. Downs The Experience of Living With Dementia in Residential Care: An Interpretative Phenomenological Analysis Gerontologist, December 1, 2008; 48(6): 711 - 720. [Abstract] [Full Text] [PDF]
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