The role played by various physical and verbal behaviors of professional caregivers in the onset of resistiveness to care (RTC) and collaborative behaviors of nursing home residents with dementia was assessed in a daily hygienic care routine context.

Two hundred and forty hygienic care routines, observed in eight nursing home residents, were analyzed with a video-assisted systematic observation methodology and a sequential statistical analysis strategy.

Caregiver and care recipient behaviors are interdependent in the hygienic care routine context. Physical instrumental behavior, neutral, negative and positive statements, positive and negative instructions, and verbal distraction emitted by caregivers are significantly and moderately associated with the onset of RTC in persons with dementia (PWD), but the strength of relationships observed depends on the care recipient's behavior prior to the caregiver's action. Positive instructions are moderately associated with the onset of collaboration in residents with preserved language abilities. However, for residents with severe language impairment, these same instructions were linked to RTC behaviors.

Although antecedents to RTC can be identified, the risk that caregiver behaviors trigger resistive responses is higher when care recipients are already exhibiting RTC, and is low when no particular behavior or collaboration is shown. Antecedents to collaboration are also identified and discussed. Although different caregiver behaviors may be more or less likely to elicit resistiveness or collaboration, it is the pre-existing state of the care recipient that will determine its reaction to the caregiver's behavior. Clinical implications emerging from these influential findings are elaborated.

Earlier research showed that multi-component dyadic interventions – including a combination of intervention strategies and addressing both the person with dementia and caregiver – have a beneficial impact on the mental and physical health of people with dementia and their family caregivers. A randomized controlled trial (RCT) of a multi-component dyadic intervention, which is a translated and adapted version of an intervention that has been shown to be effective in the US by Teri et al. (2003), was performed. The effects on caregivers’ mood (primary outcome), burden, general health, and salivary cortisol levels (secondary outcomes) were studied.

Community-dwelling people with dementia and their family caregivers (N = 111 dyads) were randomly assigned. The experimental group received eight home visits during three months, combining physical exercise and support (psycho-education, communication skills training, and planning of pleasant activities). Both the physical exercise and support component were directed at both the person with dementia and the caregiver. The comparison group received monthly information bulletins and phone calls. There were three measurements at baseline (prior to the intervention), at three months, and at six months into the intervention. Data were analyzed with Generalized Estimating Equations (GEE) based on an intention-to-treat analysis of all available data.

All analyses showed no benefits of the intervention over time on any of the outcomes.

The negative results might be explained by the translation and adaptation of the intervention that has been shown to be effective in the US: the intervention was shortened and did not include cognitive reframing. However, only the health effects on people with dementia and not on caregivers were studied in the US. Several other factors might also have played a role, which are important for future studies to take into account. These are: the usual health care in the country or region of implementation; the wishes and needs of participants for specific intervention components; the room for improvement regarding these components; the inclusion of positive outcome measures, such as pleasure, and the quality of the relationship.

Mild cognitive impairment (MCI) has been defined as a transitional state between normal aging and dementia. In many cases, MCI represents an early stage of developing cognitive impairment. Patients diagnosed with MCI do not meet the criteria for dementia as their general intellect and everyday activities are preserved, although minor changes in instrumental activities of daily living (ADL) may occur. However, they may exhibit significant behavioral and psychological signs and symptoms (BPS), also frequently observed in patients with Alzheimer's disease (AD). Hence, we wondered to what extent specific BPS are associated with cognitive decline in participants with MCI or AD.

Our sample consisted of 164 participants, including 46 patients with amnestic (single or multi-domain) MCI and 54 patients with AD, as well as 64 control participants without cognitive disorders. Global cognitive performance, BPS, and ADL were assessed using validated clinical methods at baseline and at two-year follow-up.

The BPS variability over the follow-up period was more pronounced in the MCI group than in patients with AD: some BPS improve, others occur newly or worsen, while others still remain unchanged. Moreover, specific changes in BPS were associated with a rapid deterioration of the global cognitive level in MCI patients. In particular, an increase of euphoria, eating disorders, and aberrant motor behavior, as well as worsened sleep quality, predicted a decline in cognitive functioning.

Our findings confirm a higher variability of BPS over time in the MCI group than in AD patients. Moreover, our results provide evidence of associations between specific BPS and cognitive decline in the MCI group that might suggest a risk of conversion of individuals with amnestic MCI to AD.

There is increasing evidence of a relationship between underweight or obesity and dementia risk. Several studies have investigated the relationship between body weight and brain atrophy, a pathological change preceding dementia, but their results are inconsistent. Therefore, we aimed to evaluate the relationship between body mass index (BMI) and cortical atrophy among cognitively normal participants.

We recruited cognitively normal participants (n = 1,111) who underwent medical checkups and detailed neurologic screening, including magnetic resonance imaging (MRI) in the health screening visits between September 2008 and December 2011. The main outcome was cortical thickness measured using MRI. The number of subjects with five BMI groups in men/women was 9/9, 148/258, 185/128, 149/111, and 64/50 in underweight, normal, overweight, mild obesity, and moderate to severe obesity, respectively. Linear and non-linear relationships between BMI and cortical thickness were examined using multiple linear regression analysis and generalized additive models after adjustment for potential confounders.

Among men, underweight participants showed significant cortical thinning in the frontal and temporal regions compared to normal weight participants, while overweight and mildly obese participants had greater cortical thicknesses in the frontal region and the frontal, temporal, and occipital regions, respectively. However, cortical thickness in each brain region was not significantly different in normal weight and moderate to severe obesity groups. Among women, the association between BMI and cortical thickness was not statistically significant.

Our findings suggested that underweight might be an important risk factor for pathological changes in the brain, while overweight or mild obesity may be inversely associated with cortical atrophy in cognitively normal elderly males.

The objective was to examine whether aspects of social relationships in old age are associated with all-cause dementia and Alzheimer's disease (AD).

We studied 1,715 older adults (≥ 65 years) who were dementia-free at baseline over a period of up to 16 years. Data on living status, contact/visit frequency, satisfaction with contact frequency, and having/not having a close friend were analyzed using Cox proportional hazards regressions with all-cause dementia or AD as the dependent variable. To control for reverse causality and to identify potential long-term effects, we additionally performed analyses with delayed entry.

We identified 373 incident cases of dementia (207 with AD) during follow-up. The variable visiting/visits from friends was associated with reduced risk of all-cause dementia. Further, a higher value on the relationships index (sum of all variables) was associated with reduced risk of all-cause dementia and AD. However, in analyses with delayed entry, restricted to participants with a survival time of three years or more, none of the social relationship variables was associated with all-cause dementia or AD.

The results indicate that certain aspects of social relationships are associated with incident dementia or AD, but also that these associations may reflect reverse causality. Future studies aimed at identifying other factors of a person's social life that may have the potential to postpone dementia should consider the effects of reverse causality.

Phenomenological differences between delirium superimposed on dementia (DsD) versus delirium in the absence of dementia (DaD) remain poorly understood. We aimed to identify phenomenological differences in delirium symptoms (cognitive and non-cognitive) and compare delirium recovery trajectories between DsD and DaD.

We conducted a prospective observational study on individuals admitted to the Geriatric Monitoring Unit (GMU), a five-bed unit specializing in managing older adults with delirium, between December 2010 and August 2012 (n = 234; mean age 84.1 ± 7.4). We collected data on demographics, comorbidities, severity of illness, cognitive and functional scores, and number of precipitants. Cognitive status was assessed using locally validated Chinese Mini-Mental State Examination (CMMSE) and delirium severity assessed using Delirium Rating Scale-Revised-98 (DRS-R98). Delirium disease trajectory was plotted over five days.

DsD patients had a longer duration of delirium with slower recovery in terms of cognition and delirium severity scores compared with DaD patients (0.33 (0.0–1.00) vs. 1.0 (0.36–2.00) increase in CMMSE per day, p < 0.001, and 1.49 ± 1.62 vs. 2.63 ± 2.28 decrease in DRS-R98 severity per day, p < 0.001). When cognitive and non-cognitive sub-scores of DRS-R98 were examined separately, we observed steeper recovery in both sub-scores in DaD patients. These findings remained significant after adjusting for significant baseline differences.

Our findings of slower cognitive symptom recovery in DsD patients suggest cognitive reserve play a role in delirium syndrome development and recovery. This merits further studies to potentially aid in appropriate discharge planning and to identify potential pharmacological and non-pharmacological cognitive interventions for hospitalized older persons with delirium.

Well-being and various forms of agitation in people with dementia can be improved in a person-centered long-term care setting. Data obtained during the Person-Centered Dementia Care and Environment (PerCEN) randomized controlled trial shed light on the factors that influenced the adoption and outcomes of person-centered interventions in long-term care from the perspective of study participants.

Data were obtained from PerCEN participants: individual semi-structured interviews with care managers (29), nurses and care staff (70); telephone surveys with family members (73); staff reports of care approaches; and 131 field note entries recorded by the person-centered care and environment facilitators. Data were interpreted inductively using content analysis, code building, theme development, and synthesis of findings.

All data sources confirmed that, when adopted, the person-centered model increased the number and variety of opportunities for resident interaction, improved flexibility in care regimens, enhanced staff's attention to resident needs, reduced resident agitation, and improved their well-being. Barriers and enablers for the person-centered model related to leadership, manager, staff and family appreciation of the model, staff's capacity, effective communication and team work among direct care staff, care service flexibility, and staff education on how to focus care on the person's well-being.

Successful knowledge translation of the person-centered model starts with managerial leadership and support; it is sustained when staff are educated and assisted to apply the model, and, along with families, come to appreciate the benefits of flexible care services and teamwork in achieving resident well-being. The Australian New Zealand Clinical Trials Registry number is ACTRN 12608000095369.

To date, few studies have investigated age differences in posttraumatic stress disorder (PTSD) symptoms and none has examined age differences across symptom clusters: avoidance, re-experiencing, and hyperarousal. The first objective of this study was to investigate age differences in PTSD and its three symptom clusters. The second objective was to examine age and indices of health as predictors of PTSD symptom severity.

Participants were 104 male veterans, aged 22 to 87 years, receiving specialized mental health outpatient services. Assessments included measures of health-related quality of life, pain severity, number of chronic health conditions, and symptoms of PTSD, both in total and on the symptom clusters.

There were significant age differences across age groups, with older veterans consistently reporting lower PTSD symptom severity, both in total and on each of the symptom clusters. Hierarchical regression analyses indicated that the inclusion of health indices accounted for significantly more variance in PTSD symptoms over and above that accounted for by age alone. Pain severity was a significant predictor of PTSD total and the three symptom clusters.

Conclusions: This is the first study to report lower levels of PTSD severity among older veterans across symptom clusters. These findings are discussed in relation to age differences in the experiencing and processing of emotion, autobiographical memory, and combat experiences. This study also emphasizes the importance of assessing pain in those with symptoms of PTSD, particularly older veterans who are less likely to receive specialized mental healthcare.

Recommendations for the treatment of elderly schizophrenia patients are largely based on data extrapolated from studies of antipsychotic medications in younger patient populations. We aimed to evaluate the effectiveness and safety of clozapine monotherapy in a diagnostically homogeneous group of elderly patients suffering from schizophrenia (DSM-IV-TR criteria).

A retrospective analysis of computerized medical charts of elderly inpatients suffering from schizophrenia treated at our center during the period January 2007–December 2012 was undertaken. Inclusion criteria were: (1) 60 years and older, (2) unsuccessful treatment with at least three different antipsychotic compounds during the last five years prior to the study period. Mortality and re-hospitalization over a five-year period were the pre-defined outcome measures.

Of 527 elderly patients suffering from schizophrenia 43 patients, mean age 69.4 ± 8.7 years, were treated with clozapine. There were 19 women and 24 men, mean disease duration was 38.8 years. All had been exposed to at least three first- and second-generation antipsychotics prior to clozapine treatment. Clozapine was very well tolerated by the patients and mortality rate (8/43 (18.6% vs. 87/484 (18%)) was equal to that of other first- and second-generation antipsychotics (p < 0.18). Re-hospitalization rates with clozapine were significantly lower than rates for the five-year period prior to exposure to clozapine (0.41 vs. 3.8; p < 0.001).

The present study demonstrates that clozapine is efficacious and safe for the treatment of elderly schizophrenia patients. Prospective studies are needed to support these findings.

Falls in long-term care residents with dementia represent a costly but unresolved safety issue. The aim of the present study was to (1) determine the incidence of falls, fall-related injuries and fall circumstances, and (2) identify the relationship between patient characteristics and fall rate in long-term care residents with dementia.

Twenty long-term care residents with dementia (80 ± 11 years; 60% male) participated. Falls were recorded on a standardized form, concerning fall injuries, time and place of fall and if the fall was witnessed. Patient characteristics (66 variables) were extracted from medical records and classified into the domains: demographics, activities of daily living, mobility, cognition and behavior, vision and hearing, medical conditions and medication use. We used partial least squares (PLS) regression to determine the relationship between patient characteristics and fall rate.

A total of 115 falls (5.1 ± 6.7 falls/person/year) occurred over 19 months, with 85% of the residents experiencing a fall, 29% of falls had serious consequences and 28% was witnessed. A combination of impaired mobility, indicators of disinhibited behavior, diabetes, and use of analgesics, beta blockers and psycholeptics were associated with higher fall rates. In contrast, immobility, heart failure, and the inability to communicate were associated with lower fall rates.

Falls are frequent and mostly unwitnessed events in long-term care residents with dementia, highlighting the need for more effective and individualized fall prevention. Our analytical approach determined the relationship between a high fall rate and cognitive impairment, related to disinhibited behavior, in combination with mobility disability and fall-risk-increasing-drugs (FRIDs).

Depression is a common comorbid disorder of dementia. This study explores the prevalence of and factors associated with depressive symptomatology, and antidepressant prescription rates in severe dementia across eight European countries.

In total, 414 people with severe dementia completed measures of cognition and quality of life (QoL), whilst carers completed proxy measures of activities of daily living (ADLs), depression, neuropsychiatric symptoms, QoL and comorbidity.

Findings indicated that 30% of the sample had depression, whilst the highest and lowest prevalence of depression was reported in Germany and Finland, respectively. Lower QoL, the presence of pain and more frequent neuropsychiatric symptoms were associated with depressive symptomatology, whilst no significant relationship between impairment of ADLs, comorbidity, and depression emerged. Spain and Estonia had the highest and lowest rates of antidepressant prescribing, respectively, whilst Germany had the highest discrepancy between depressive symptomatology and prescription.

The study highlights variations across countries in the prevalence of depressive symptomatology in severe dementia and prescription of antidepressants. Information about factors associated with depressive symptomatology may help to better identify and manage depression.

Little is known about the occurrence of psychotic or quasi-psychotic experiences in older people with anxiety disorders.

We used a cross-sectional national probability sample of community-residing individuals to investigate the prevalence and correlates of delusion-like experiences in older people with DSM-IV anxiety disorders. The 2007 Australian National Survey of Mental Health and Well-being (NSMHWB) included 1,905 persons between the ages of 65 and 85 years. Anxiety disorder diagnoses were established using the Composite International Diagnostic Interview (CIDI v3). Participants were asked about three types of delusion-like experiences: thought control or interference, special meaning, and special powers. We used multivariate logistic regression to examine the relationship between a 12-month history of any anxiety disorder and the presence of these delusion-like experiences, adjusting for several potential confounders.

Eighty-two of 1,905 (4.3%) older people met criteria for an anxiety disorder over the previous 12 months. Of these, six reported delusion-like experiences, whereas the prevalence of these experiences among older people without anxiety disorder was 26/1,822 (7.3% vs. 1.4%; χ2 = 16.5; p = 0.000). In a logistic regression model, male gender (OR 0.38; p = 0.019), separated marital status (OR 4.86; p = 0.017), and the presence of anxiety disorder (OR 5.33; p = 0.001) were independently associated with delusion-like experiences, whereas MMSE (Mini-Mental State Examination) score, general medical conditions and affective disorder were not.

In this cross-sectional study, self-reported delusion-like experiences occurred at increased prevalence among community-residing older persons with anxiety disorder. More work is needed to clarify the nature and significance of these findings.

Upon encountering older adults, individuals display varying degrees of prosocial attitudes and behaviors. While some display compassion and empathy, others draw away and wish to maintain their distance from them. The current study examined if and how ageist attitudes influence the association between the sight of physical incapacity in older age and compassionate reactions toward them. We predicted that ageist attitudes would interfere with the ability to respond to them with compassion.

Young adults (N = 149, ages 19–29) were randomly distributed into two experimental conditions, each viewing a short video portraying different aspects of older adult physicality; one group viewed older adults displaying incapacitated behavior, and the other viewed fit behavior. Participants subsequently filled out scales assessing aging anxieties, and ageist and compassionate attitudes.

Ageism was associated with reduced compassion toward the figures. Moreover, viewing incapacitated older adults led to increased concern toward them and perceived efficacy in helping them. However, significant interactions proved that higher scores of ageism in response to the videos led to increased need for distance and reduced efficacy toward incapacitated adults, an effect not observed among subjects with lower ageism scores.

Ageism seems to be a factor which disengages individuals from older adults displaying fragility, leading them to disregard social norms which dictate compassion. The results are discussed from the framework of terror management theory, as increased mortality salience and death-related thoughts could have led to the activation of negative attitudes which, in turn, reduce compassion.

This study identified possible risk factors for newly diagnosed mood disorders, including depressive and bipolar disorders, in prostate cancer patients.

From 2000 to 2006, two cohorts were evaluated on the occurrence of mood disorder diagnosis and treatment. For the first cohort, data of patients diagnosed with prostate cancer was obtained from the Taiwan National Health Insurance (NHI) Research Database. As the second cohort, a cancer-free comparison group was matched for age, comorbidities, geographic region, and socioeconomic status.

Final analyses involved 12,872 men with prostate cancer and 12,872 matched patients. Increased incidence of both depressive (IRR 1.52, 95% CI 1.30–1.79, P <0.001) and bipolar disorder (IRR 1.84, 95% CI 1.25–2.74, P = 0.001) was observed among patients diagnosed with prostate cancer. Multivariate matched regression models show that cerebrovascular disease (CVD) and radiotherapy treatment could be independent risk factors for developing subsequent depressive and bipolar disorders.

We observed that the risk of developing newly diagnosed depressive and bipolar disorders is higher among Taiwanese prostate cancer patients. Clinicians should be aware of the possibility of increased depressive and bipolar disorders among prostate cancer patients in Taiwan. A prospective study is necessary to confirm these findings.

Person-centered care (PCC) is a widely recognized concept in dementia research and care. Dementia Care Mapping (DCM) is a method for implementing PCC. Prior studies have yielded heterogeneous results regarding the effectiveness of DCM for people with dementia (PwD). We aimed to investigate the effectiveness of DCM with regard to quality of life (QoL) and challenging behavior in PwD in nursing homes (NHs).

Leben-QD II is an 18-month, three-armed, pragmatic quasi-experimental trial. The sample of PwD was divided into three groups with three living units per group: (A) DCM applied since 2009, (B) DCM newly introduced during the study, and (C) a control intervention based on a regular and standardized QoL rating. The primary outcome was QoL measured with the Quality of Life-Alzheimer's Disease (QoL-AD) proxy, and the secondary outcomes were QoL (measured with QUALIDEM) and challenging behavior (measured with the Neuropsychiatric Inventory Nursing Home version, NPI-NH).

There were no significant differences either between the DCM intervention groups and the control group or between the two DCM intervention groups regarding changes in the primary or secondary outcomes. At baseline, the estimated least square means of the QoL-AD proxy for groups A, B, and C were 32.54 (confidence interval, hereafter CI: 29.36–35.72), 33.62 (CI: 30.55–36.68), and 30.50 (CI: 27.47–33.52), respectively. The DCM groups A (31.32; CI: 28.15–34.48) and B (27.60; CI: 24.51–30.69) exhibited a reduction in QoL values, whereas group C exhibited an increase (32.54; CI: 29.44–35.64) after T2.

DCM exhibited no statistically significant effect in terms of QoL and challenging behavior of PwD in NHs. To increase the likelihood of a positive effect for PwD, it is necessary to ensure successful implementation of the intervention.

Despite its increasing personal and societal impact, assessment of late-life anxiety has received relatively little attention in psychiatric research. Differential symptom presentation and physical comorbidities among the elderly, relative to younger cohorts creates a need for anxiety measures that are psychometrically validated in the elderly.

The present study examined the factor structure and discriminant validity of the state-trait inventory for cognitive and somatic anxiety (STICSA) in a sample of Italian middle-aged and older adults. Participants were 396 community-dwelling middle-aged (50–64 years) and older (≥65 years) adults. In addition to the STICSA, participants completed two depression measures and a general well-being survey with physical and mental health subscales.

Factor analysis supported the validity of both state–trait and cognitive–somatic distinctions underlying the STICSA, all dimensions exhibited excellent internal consistency (Cronbach's α coefficients ≥ 0.86), and correlations with depression measures provided limited evidence for differentiation of anxious and depressive symptoms. The STICSA also showed evidence of discriminating anxious symptoms from physical health symptoms, a particularly relevant feature of a valid anxiety measure in elderly samples.

The STICSA appears to be a valid measure of cognitive and somatic anxiety in the elderly.

Impaired spatial navigation is an early sign of Alzheimer's disease (AD), but this can be difficult to assess in clinical practice. We examined how the performance on the Floor Maze Test (FMT), which combines navigation with walking, differed between patients with subjective cognitive impairment (SCI), mild cognitive impairment (MCI), and mild AD. We also explored if there was a significant relationship between the FMT and the cognitive tests or sociodemographic factors.

The study included 128 patients from a memory clinic classified as having SCI (n = 19), MCI (n = 20), and mild AD (n = 89). Spatial navigation was assessed by having the patients walk through the FMT, a two-dimensional maze. Both timed measures and number of errors were recorded. Cognitive function was assessed by the Word List Memory test, the Clock Drawing test, the Trail Making tests (TMT) A and B, and the Mini Mental Status Examination (MMSE).

The patients with MCI were slower than those with SCI, while the patients with mild AD more frequently completed the FMT with errors or gave up than the patients with MCI. Performance on the FMT was significantly associated with executive function (measured by TMT-B).

The performances on the FMT worsened with increasing severity of cognitive impairment, and the FMT was primarily associated with executive function. The explained variance was relatively low, which may indicate that the standard cognitive test battery does not capture impairments of spatial navigation.

The evaluation of quality of life (QoL) among older adults has become increasingly important, and living arrangements play a pivotal role in determining the QoL of people with cognitive impairment (PWCI). Although informal care (home-based) is favored, transition to formal care (residential care) often becomes necessary, especially in the later stages of cognitive impairment. The primary objective was to compare the QoL of PWCI in the community and nursing homes. Additionally, factors differentiate the QoL of PWCI in these two settings were identified.

This is a quasi-experimental study design involving 219 older adults with cognitive impairment, aged 60–89 years old from both nursing home and home care. Participants completed the EUROPE Health Interview Survey-QoL (WHO-8), the Short Mini-Mental State Examination (SMMSE), the Barthel Index (BI), the Geriatric Depression Scale (GDS-15), and the Friendship Scale (FS).

There were significant differences in QoL, depression, social connectedness (p < 0.01) and cognitive functions (p = 0.01) between home care recipients and nursing home participants. No significant differences were observed with regards to health condition, co morbidities and physical functions between study cohorts.

Older adults with cognitive impairment living at home experienced higher QoL, had better cognitive function, were less depressed and reported higher social connectedness compared to those living in institutional care. Therefore, support should be provided in enabling home care and empowering caregivers to provide better care for PWCI.

There are many recommended language-based strategies for effective communication with persons with dementia. What is unknown is whether effective language-based strategies are also person centered. Accordingly, the objective of this study was to examine whether language-based strategies for effective communication with persons with dementia overlapped with the following indicators of person-centered communication: recognition, negotiation, facilitation, and validation.

Conversations (N = 46) between staff-resident dyads were audio-recorded during routine care tasks over 12 weeks. Staff utterances were coded twice, using language-based and person-centered categories. There were 21 language-based categories and 4 person-centered categories.

There were 5,800 utterances transcribed: 2,409 without indicators, 1,699 coded as language or person centered, and 1,692 overlapping utterances. For recognition, 26% of utterances were greetings, 21% were affirmations, 13% were questions (yes/no and open-ended), and 15% involved rephrasing. Questions (yes/no, choice, and open-ended) comprised 74% of utterances that were coded as negotiation. A similar pattern was observed for utterances coded as facilitation where 51% of utterances coded as facilitation were yes/no questions, open-ended questions, and choice questions. However, 21% of facilitative utterances were affirmations and 13% involved rephrasing. Finally, 89% of utterances coded as validation were affirmations.

The findings identify specific language-based strategies that support person-centered communication. However, between 1 and 4, out of a possible 21 language-based strategies, overlapped with at least 10% of utterances coded as each person-centered indicator. This finding suggests that staff need training to use more diverse language strategies that support personhood of residents with dementia.