•No conflicts of interest
•Opinions are not that of
VAMC or UA
EVIDENCE-BASED
INTERVENTIONS IN
PERSON-CENTERED CARE
A. LYNN SNOW, PHD
ASSOCIATE PROFESSOR,
UNIVERSITY OF ALABAMA
CENTER FOR MENTAL HEALTH AND AGING
& DEPT. OF PSYCHOLOGY;
CLINICAL RESEARCH PSYCHOLOGIST,
TUSCALOOSA VA MEDICAL CENTER
What is Person-Centered Care?
 “Person-centered care is an approach to care
that respects and values the uniqueness of
the individual, and seeks to maintain, even
restore, the personhood of individuals. We do
this by creating an environment that promotes
personal worth and uniqueness, social
confidence, respect, truthfulness,
independence, engagement and hope.”
--Luther Manor Adult Day Center, Wauwatosa, WI
Barsness, S. Person-centered Care and Aging in Place. Retrieved from
http://www.slideshare.net/wef/personcentered-care.
Empowers the
Individual
Fosters
Optimal
Living for
Each
Individual
Person-Centered Care….
Honors the
Uniqueness
of Each
Individual
Supports
Each
Individual in
Functioning
at their
Highest
Possible
Level of
Ability
Core Values Are:
Choice
Dignity
Respect
Purposeful Living
Is Centered Around the Person
and their Needs
and Preferences
Rather than the System
Providing the Care
What is Culture Change?
 Term used to refer to an International
Movement to Transform the Culture of Care for
Older Adults
 Based on Person-Centered Values and
Practices
 “Culture” refers to the organizational or
workplace culture, not one’s ethnicity, race, or
heritage
 (although understanding and respecting each
person’s heritage and background is an important
part of knowing and honoring them as individuals)
•Barsness, S. Person-centered Care and Aging in Place: http://www.slideshare.net/wef/personcentered-care
•Pioneer Network FAQs: http://www.pioneernetwork.net/Consumers/InformTransformInspire/
 “The shift from the old culture to the new is not
about just adding on a few items that were
missing but of seeing almost every feature in a
different way.”
--Thomas Kitwood, Dementia Reconsidered
Barsness, S. Person-centered Care and Aging in Place. Retrieved from
http://www.slideshare.net/wef/personcentered-care.
Vision of the Pioneer Network
 A Culture of Aging that is Life Affirming,
Satisfying, Humane, and Meaningful
Pioneer Network: http://www.pioneernetwork.net/AboutUs/Values/
Ageism
“In our society the only good person is one who
looks and acts like a young person”
--Bill Thomas, Founder of Eden Alternative
Ageism… and Dementia-ism
 “ism”…Defined as Bias or Prejudice Toward
Individuals Because of Their…
 Age
 Diagnosis
 Rooted in Fears of Vulnerability and Mortality
 Fear of Dependency
 Us vs. Them Perception
 Denial: Turning Away Due to Wish to Make
Feared Concept Go Away
Values of the Pioneer Network
 Know Each Person
 Each Person Can and Does Make a Difference
 Relationship is the Fundamental Building
Block of a Transformed Culture
 Respond to the Spirit as well as the Mind and
Body
 Community is the Antidote to
Institutionalization
 Promote the Growth and Development of All
Pioneer Network: http://www.pioneernetwork.net/AboutUs/Values/
Values of the Pioneer Network
 All Elders are Entitled to Self-Determination




Wherever They Live
Risk Taking is a Normal Part of Life
Put Person Before Task
Do Unto Others as You Would Have Them Do
Unto You
Shape and Use the Potential of the
Environment in All its Aspects: Physical,
Organizational, Psycho/social/spiritual
Pioneer Network: http://www.pioneernetwork.net/AboutUs/Values/
Values of the Pioneer Network
 Practice Self-Examination, Searching for New
Creativity, and Opportunities to Do Better
 Recognize that Culture Change and
Transformation are not Destinations but a
Journey, Always a Work in Progress
Pioneer Network: http://www.pioneernetwork.net/AboutUs/Values/
The Battle for Person-Centered Care:
In the Trenches with
Noncognitive Behavioral and
Neuropsychiatric Disturbances
(NBND)
NBND ARE ALMOST UBIQUITOUS TO
DEMENTIA
 High prevalence of NBND in persons with
dementia1
 25-40% mild dementia
 25-80% severe dementia
 90% prevalence over lifetime of person with dementia
1Rabins
PV, Lyketsos CG, Steele CD. Practical Dementia Care, 2nd Edition.
NY, NY: Oxford University Press; 2006:6-7.
NBND HAVE SIGNIFICANT
CONSEQUENCES2,3,4




Staff Caregiver Burnout
Staff Caregiver Turnover
Staff Caregiver Morbidity
Nursing Home Placement of Persons with
Dementia
 Cost
2Lyketsos
CG, Baker L, Warren A, et al. Major and minor depression in Alzheimer’s
disease: prevalence and impact. J Neuropsychiatry Clin Neurosci. 1007;9:556-561.
3Stern Y, Tang MX, Albert MS, et al. Predicting time to nursing home care and death
in individuals with Alzheimer’s disease. JAMA. 1997;277:806-812.
4Yaffe K, Fox P, Newcomer R, et al. Patient and caregiver charateristics and nursing
home placement in patients with dementia. JAMA. 2002;287:2090-2097.
Noncognitive Behavioral and
Neuropsychiatric Disturbances
(NBND)
 Neuropsychiatric Symptoms
 Affective Cluster
 Psychotic Cluster
 Challenging Behaviors
 Disturbances in Drives
NBND: Neuropsychiatric
Symptoms
Affective Cluster
Psychotic Cluster
 Anxiety
 Delusions
 Irritability
 Suspiciousness
 Euphoria
 Paranoia
 Labile
 Hallucinations
 Panic
 Illusions
 Apathy
 Anhedonia
 Depression
 Suicidality
NBND: Challenging Behaviors
 Physically aggressive, Verbally aggressive
 Repetitive vocalizations (screaming, crying, moaning, repetitive
questions or statements)
 Pacing and Other Repetitive Movements
 Wandering (into inappropriate areas/getting lost)
 Rummaging
 Hoarding
 Social withdrawal
 Uncooperativeness with care
 Demanding
 Outbursts
 Intrusive
 Catastrophic Reactions
 Urinating in inappropriate areas
NBND: Disturbances in Drives
 Hypersexual
 Sexual aggression
 Poor sleep
 Sleeps a lot
 Out of bed at night
 Poor appetite
 Weight loss
 Excessive appetite
 “Sundowning”
NBND and Cost5
 NBND Incremental cost was $30 per month
per point of a one point increase in
Neuropsychiatric Inventory score (95% CI: $19$41).
 Total cost also associated with increased age,
male gender, increased dementia severity, and
vascular dementia as compared to AD

5Hermann
et al. Int J Geriatr Psychiatry, 2006; 21:972-976.
Nonpharmacologic Approaches
to Preventing and Responding
to NBND are First Line
Treatments
 Practice guidelines recommend always trying
nonpharmacologic interventions before
pharmacologic treatments
 Evidence has accrued regarding adverse
effects of atypical antipsychotic drugs in
older people (FDA black box warning)6-8, and
lack of effectiveness for treating agitation9
References for Previous Slide
6Schneider
LS, Dagerman KS, Insel P. Risk of death with atypical antipsychotic drug
treatment for dementia: meta-analysis of randomized placebo-controlled trials.
JAMA. 2005;294:1934-1943.
7Wang PS, Schneeweiss S, Avorn J, et al. Risk of death in elderly users of
conventional vs. atypical antipsychotic medications. N Engl J Med. 2005;353:23352341.
8US Food and Drug Administration Public Health Advisory. Death with
antipsychotics in elderly patients with behavioral disturbance.
http://www.feda.gov/cder/drug/advisory/antipsychotics.htm. Accessed August 23,
2005.
9Sink KM, Holden KF, Yaffe K. Pharmmacological treatment of neuropsychiatric
symptoms of dementia: a review of the evidence. JAMA. 2005;293:596-608.
NBND: Person-Centered Language?
 NBND, Problem Behaviors, Challenging
Behaviors
 Terms Invites Medicalization of Person
 Challenging to Whom? Problem to Whom?
 Defines Through Caregiver Perspective
 Invites Confusion Regarding Goals of
Treatment/Intervention
 Let’s Start by Making the Goals of
Engagement Explicit, Then Identifying
Language to Fit…
OUR GOALS:
 REDUCE DISTRESS OF PERSON WITH
DEMENTIA
 REDUCE DISTRESS OF CAREGIVERS
New Language:
Distress/Distressing
Behaviors
 Behaviors that are signs of Distress in Persons
with Dementia (unmet needs model)
 Behaviors that are Distressing to Caregivers
ENGAGEMENT:
An Evidence-Based,
Person-Centered Approach
to Distress(ing) Behaviors
Engagement:
Evidence-Based Approaches
 MAP (Montessori Activity Programming)
 Cameron Camp
 TAP (Tailored Activity Programming)
 Laura Gitlin
 BACE (Balancing Arousal Controls Excesses)
 Christine Kovach
 Comprehensive Process Model of
Engagement
 Jiska Cohen-Mansfield
Engagement: Two Components
 Conceptualization
 How do I think about this?
 Content
 How do I actually do this?
CONCEPTUALIZATION:
Number One Question:
WHY IS THIS
HAPPENING?
What is causing the
behavior?
CAUSATION THEORIES:
Unmet Needs Model
 The behavior of persons with dementia
represents efforts of the person with
dementia to get unmet needs addressed
Algase, DL, Beck C, Kolanowski A, Whall A, et al. Need-driven dementia-compromised
behavior: An alternative view of disruptive behavior. Am J Alz Dis. 1996;11:12–19.
Needs of All People With
Dementia
 Physical Needs: Hunger, Thirst, Restroom,





Pain/Discomfort, Rest
Feel Safe and Secure
Meaningful Positive Human Contact
Meaningful Activity
Feel That Are Contributing
Have Success Experiences
Needs of All People
With Dementia
 Physical Needs: Hunger, Thirst, Restroom,





Pain/Discomfort, Rest
Feel Safe and Secure
Meaningful Positive Human Contact
Meaningful Activity
Feel That Are Contributing
Have Success Experiences
CAUSATION THEORIES:
Learning/Behavioral Models
 Problem behaviors have been
inadvertently reinforced in the
environment, or positive behaviors have
not been reinforced.
 ABC Model:
 Antecedent->Behavior->Consequence
CAUSATION THEORIES:
Environmental Vulnerability
/Reduced Stress Threshold Model
 Dementia causes a lowered ability to cope with
stimulation from the environment.a
Behaviors are due to person being
overstressed/overstimulated.
 Corollary: Under-stimulation is also problematic.b
aLawton
MP, Nahemo L. An ecological theory of adaptive behavior and aging. In: Eiserdorfer
C, Lawton MP, eds. The Psychoogy of Adult Development and Aging. Washington, DC:
American Psychological Assocation; 1973:657-667.
bKovach CR, Taneli Y, Dohearty P, et al. Effect of the BACE Intervention on Agitation of People
With Dementia. Gerontologist. 2004;44:797-806.
CAUSATION THEORIES:
Biological Models
 Neuropathology leads to neurotransmitter
imbalances which lead to neuropsychiatric
symptoms or disturbances in drives which
lead to Behaviors.
Cause Models are
Complementary and not
Mutually Exclusive
 Implication: Nonpharmacologic interventions
can be developed to address these causes,
even for behaviors caused in large part by
biological problems
Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia:
a review, summary, and critique. AJGP. 2001;9:361-381.
Empirical Evidence Overview
a
 Individualized approaches to Engagement
are among the best supported nonpharmacologic Interventions for Distress(ing)
Behaviors
Cohen-Mansfield J. Nonpharmacologic interventions for inappropriate behaviors in dementia:
a review, summary, and critique. AJGP. 2001;9:361-381.
Salzman C, Jeste DV, Meyer RE, et al. Elderly patients with dementia-related symptoms of
severe agitation and aggression: consensus statement on treatment options, clinical trials
methodology, and policy. The Journal of clinical psychiatry. 2008;69(6):889-98. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2674239&tool=pmcentrez&renderty
pe=abstract.
Empirical Evidence Overview
a
 MAP (Montessori Activity Programming)
 Higher levels of positive engagement and lower
levels of negative forms of engagement a
 TAP (Tailored Activity Programming)
 Reductions in frequency of behavioral occurrences
esp. shadowing and repetitive questioning b,c
 Evidence for cost-effectiveness d
 BACE (Balancing Arousal Controls Excesses)
 Reductions in agitation e
Citations
a Skrajner
MJ, Camp CJ. Resident-Assisted Montessori Programming (RAMP): use of a small
group reading activity run by persons with dementia in adult day health care and long-term care
settings. American journal of Alzheimer’s disease and other dementias. 22(1):27-36. Available
at: http://www.ncbi.nlm.nih.gov/pubmed/17533999. Accessed March 28, 2012.
b Gitlin
L., Winter L, Earlan TV, et al. The Tailored Activity Program to reduce behavioral
symptoms in individuals with dementia: feasibility, acceptability, and replication potential.
Gerontologist. 2009;49:428-439.
c Gitlin
LN, Winter L, Burkey J, et al. Tailored activities to manage neuropsychiatric behaviors in
persons with dementia and reduce caregiver burden: a randomized pilot study. Am J Geriatr
Psychiatry. 2008;16:229-239.
d Gitlin
LN, Hodgson N, Jutkowitz E, Pizzi L. The cost-effectiveness of a nonpharmacologic
intervention for individuals with dementia and family caregivers: the tailored activity program.
The American journal of geriatric psychiatry : official journal of the American Association for
Geriatric Psychiatry. 2010;18(6):510-9. Available at:
http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2938079&tool=pmcentrez&rendertyp
e=abstract. Accessed March 28, 2012.
e Kovach
CR, Taneli Y, Dohearty P, et al. Effect of the BACE intervention on agitation of people
with dementia. The Gerontologist. 2004;44(6):797-806. Available at:
http://www.ncbi.nlm.nih.gov/pubmed/15611216. Accessed March 28, 2012.
Engagement: Individualized,
Strengths-Based Approaches
 Using the right APPROACH to working with
people with dementia is fundamental
 The SPECIFIC ACTIVITIES that are best to
provide will be easier to identify once the
right APPROACH is understood
Engagement: Individualized,
Strengths-Based Approaches
 Understanding
 (a) cognitive strengths and challenges
 (b) physical strengths and challenges
 (c) individual values and preferences
 Allows
 (d) targeting Engagement efforts to build on
the person’s strengths rather than
emphasizing their weaknesses
Individualized Approaches to
Engagement Principles
 Engagement in meaningful, pleasant, and
spontaneous activities is foundational to
Health and Quality of Life
 “Doing”, to most people, is synonymous with being
alive
– Jitka Zgola
 Meaningful Engagement should be an
integral part of life
 Yet, most caregivers have limited knowledge
and skill in how to create, initiate, and
maintain activities that are pleasant and
meaningful
Individualized Approaches to
Engagement Principles
 Provide methods for CONCEPTUALIZING,
CREATING, and PRESENTING activities
based upon models of learning and
rehabilitation
Individualized Approaches to
Engagement Principles
 Modify activities so that all can have a role
based on their strengths, with supports for
their areas of difficulties
 Providing continuous opportunities for
pleasant and meaningful activity is
everyone’s job
 Involve residents in all stages of activities
 Planning
 Developing materials
 Implementing
Typical* Impairments
*These are general “rules of thumb” and will not all be
present for any particular person with dementia. Type of
dementia, dementia stage, and many other variables will
affect what skills are impaired and preserved for any
particular individual.
Mr. PALMER has Dementia:*
 Perception
 Ability to Tolerate Frustration and Tiredness
 Language
 Memory
 Emotional Control
 Reasoning/Judgment
Preserved Skills*
*These are general “rules of thumb” and will not all be
present for any particular person with dementia. Type of
dementia, dementia stage, and many other variables will
affect what skills are impaired and preserved for any
particular individual.
Preserved Skills: Overlearned Info

 Rule
of Thumb #1:
 FIRST IN = LAST OUT

The last information learned will be the first information lost.

The more often a piece of information was used (rehearsed, repeated) over a lifetime, the
longer it will be preserved after the progressive dementing process begins
 Examples: FIRST IN/LAST OUT:
 Speaking English (learned and practiced since age 2)
 Reading (learned and practiced since age 6)
 Stripping wire for an electrician (learned and practiced almost daily
from age 22-65)
 Examples: LAST IN/FIRST OUT:
 A second language learned at age 30
 Names of grandchildren
 Names of nursing home staff
Preserved Skills:
Recognition & Implicit Memory
  RULE OF THUMB #2 :

MEMORY SKILLS THAT TAKE LESS EFFORT ARE LESS IMPAIRED

The types of memory that require more effort and conscious control will be more impaired earlier in
the dementing process

Recognition is More Preserved (Recall is impaired first)

Recall memory (list learning; i.e., fill in the blank) is more impaired earlier than
Recognition Memory (remembering with cues; i.e., multiple choice)

Example: Remembering what to get at the store vs. Recognizing your doctor’s
name on a list of doctors.

Implicit [Procedural] is More Preserved (Explicit is impaired first)

Explicit memory (facts that are purposely learned, i.e., studying) is more impaired
earlier than Implicit memory (learning by doing or experiencing , things that are
“accidentally” or “unconsciously” learned, i.e., priming, procedural learning)

Explicit Example: Learning the names of your new neighbors is Explicit. Implicit
Examples: Learning that you don’t like “that mean nurse” because she is the one
who always gives you your bath…or Learning which chair in the dining room is yours
because you always sit there.
Preserved Skills:
Semantic Categories & Memories
  RULE OF THUMB #3 : Use Meaningful Categories As Cues
 The ability to access information by semantic category is relatively
preserved.
 Semantic (definition): of or relating to meaning, especially meaning in
language
 Semantic Categories: broad categories for information
 Example: Army vs. Navy; things good to eat/not good to eat
 Semantic Memories: semantic memory (the facts we study and
learn throughout our lives) is relatively preserved. In contrast
recent episodic memory (memory for recent events) is more
impaired.
 Example: Who you saw at church this morning vs. where the sun
rises.
Preserved Skills: Activities
 Rule #1: FIRST IN LAST OUT
 Reading
 Emotional communication
 even after words are gone)
 Social Skills (small talk)
 Singing/music
 Rules #2 & #3: MEMORY SKILLS THAT TAKE LESS EFFORT ARE
LESS IMPAIRED & USE MEANINGFUL CATEGORIES AS CUES
 Activities using Overlearned Facts & Cues
 Category Sorts (word or picture sorts), Fill in the Blanks
 Things I Like to Drink/Things I Don’t Like to Drink
 The sun rises in the _____ (east)
 “Let me call you”_______ (sweetheart)
 Reminiscence/Life Review
 Facts about the person’s past personal life (Job, Family
Life, Childhood, Military Life)
Supporting Areas of Impairment
 Reduced Memory & Conceptualization Abilities
 External cues and templates
 Reduced Language & Visual Spatial Abilities
 Use Multiple Modalities (written & picture)
 Place Yourself Directly in Person’s Line of Sight
 Reduced Ability for Concentration
 One Thing at a Time
 Use Manipulatives (“hands on”)
 Use Aesthetically Pleasing and Interesting Items
 Use effective seating arrangements
 Tight circles
 Sit close together
Supporting Areas of Impairment
 Reduced Ability to Handle Stimulation
 Remove distractions in environment
 Remove unrelated objects from table
 Remove distractions in activity materials
 No extraneous words, pictures, directions
 Demonstrate silently first (watch me, now you)
 Or Demonstrate and speak with few words (2-5)
 Limit steps
 Match your speed to person’s speed
Engagement Means Meaningful
as well as Do-able
 Activities should have a clear objective that is
meaningful to the person with dementia
 Provide opportunities for choice
 Invite participation (choice)
 Offer a choice of 2-3 activities/topics
 Workstations, Reading nooks
 Remember there is no such thing as a “right
way” for the person to complete the activity
 Don’t repeatedly correct
 Make it a success experience by changing the focus
Putting it Together: Example
 Invite persons to be on planning committee
 The committee members develop an idea for a
special dinner event
 There are special committees for
 Decorations
 Invitations
 These goals guide development of activities such as
category sorts, lead to reminiscence and
conversation opportunities as everyone works
 Jobs for greeters, providing menus, taking orders,
bringing out food…
 Everyone has a role matched to their abilities/values
Needs of All People With
Dementia
 Meaningful Positive Human Contact
 Meaningful Activity
 Feel That Are Contributing
 Have Success Experiences
 Feel Safe and Secure
 Have Physical Needs Met: Hunger, Thirst,
Restroom, Pain/Discomfort, Rest
Needs of All People
With Dementia
 Physical Needs: Hunger, Thirst, Restroom,





Pain/Discomfort, Rest
Feel Safe and Secure
Meaningful Positive Human Contact
Meaningful Activity
Feel That Are Contributing
Have Success Experiences
How to Frustrate a Person
with Dementia
 Tire Them Out
 Bore Them
 Low Frustration Tolerance
 Need to Alternate Periods of Rest and Periods
of MEANINGFUL ENGAGEMENT (30:30 Rule)
 Make Them Feel Like a Failure
 Talk Too Fast; Correct Them All The Time; Are
they Always Getting Help, Never Getting to
Help
How to Help a Person with
Dementia
 Give Them Success Experiences!
 Find Ways for them to Contribute
 Can They Keep Up??? Slow It Down
 Can They Hear??? Speak Loudly, Clearly, Slowly
 Can They See??? Make Sure You Have High Contrast, No Glare
 Be Enjoyable to Be Around!
 Implicit Learning & Emotional Memory are Preserved
Skills: People with dementia remembering people they
Like (and Don’t Like)...so be Rewarding to be around...)
The Wonder Drug…
 “If there was a pill you could give that
completely took away problem behavior,
would you give it to your patients with
dementia?”23
 If the effects only lasted 30 minutes, how
often would you give it?
 You’d give the pill every 30 minutes, Right??
Positive Attention: The
Wonder Drug!!!
 There is...it’s called Positive Attention.
 Most Unhelpful Statement Ever: “She Just
does that [insert problem behavior here] for
the Attention”
 More Helpful: “Let’s Figure out How to Give
Her More Positive Attention so She Won’t Do
That!!!”
Resources
 Therapeutic Activity Kits (part of the great
Hartford “Try This” Series)
 http://consultgerirn.org/uploads/File/trythis/thera
Act.pdf
 Bathing without a Battle
 http://www.bathingwithoutabattle.unc.edu/
 Montessori-Based Activities for Persons with
Dementia Vol. I & II
 Cameron Camp: see next slide
Resources
A Different Visit: Activities for Caregivers and their Loved Ones with Memory
Impairments. Amazon link: http://www.amazon.com/Different-Visit-ActivitiesCaregivers-Impairments/dp/0967634334/ref=pd_sim_b_5
A Therapy Technique for Improving Memory: SPACED RETRIEVAL. Amazon
link: http://www.amazon.com/Therapy-Technique-Improving-MemoryRETRIEVAL/dp/096763430X/ref=pd_sim_b_2
Montessori-Based Activities for Persons With Dementia. Amazon link:
http://www.amazon.com/Montessori-Based-Activities-Persons-DementiaCameron/dp/187881267X/ref=pd_sim_b_1
Montessori Based Activities for Persons, Vol.II. Amazon link:
http://www.amazon.com/Montessori-Based-Activities-Persons-VolII/dp/1933829001/ref=sr_1_2?ie=UTF8&s=books&qid=1266205783&sr=8-2
Resources
 http://www.health.state.ny.us/diseases/co
nditions/dementia/edge/interventions/ind
ex.htm
 Under Simple Pleasures > Program Structure –
there is a list of 23 activities for moderately
demented individuals.
 Sing Along books from S and S magazine.
Patriotic sing along or dvd sing along, Old time
favorites vol 1 and 2
 Reminiscence Magazine (google it)
 Brainyhistory.com
Resources
 Ambient DVD to create soothing atmospheres
from VAT19.com
 complete the phrase from PASTIMES- Faces and
Places, Discussion Cards,
 Subscription to Activityconnection.com to print
the DAILY CHRONICLES to read everyday in
English and Spanish
Acknowledgements
 Thanks to Cameron Camp, Laura Gitlin,
Christine Kovach, Cornelia Beck, JoAnn
Rader, Nancy Mace, Donna Algase, and Jiska
Cohen-Mansfield whose excellent work and
teachings have directly informed this
workshop
 Thanks to all the wonderful VA staff and CLC
residents whose hard work and experiences
have informed this lecture, and to TVAMC, VA
HSR&D VA RR&D, and University of Alabama
Center for Mental Health and Aging for their
support of this work