Psychosocial Treatment of Depression in Older Adults with Dementia

Abstract

Depression and dementia commonly coexist and are associated with higher rates of behavioral and functional problems. Caregivers of these individuals report higher levels of physical and mental distress, as well. Effective treatment, therefore, has the potential to help both the older adult and their caregiver. This article provides an overview of the current literature on treatment of depression in demented older adults, with particular emphasis on providing guidelines for evidence-based clinical care. Eleven randomized controlled clinical trials were identified following an extensive review of the literature. These studies are reviewed with particular attention to the methodological issues of most relevance to clinicians attempting to use the findings from these studies to guide their practice. Issues of particular relevance when working with this population are also addressed, including (a) for assessment—differential and coexistent diagnosis of depression in dementia, use of collateral informants, self-report and interviewer-obtained information; and b) for treatment—the need for caregiver involvement, individualizing of goals, and planning for future deterioration of cognitive function.

Full text

Psychosocial Treatment of Depression in Older Adults
with Dementia
Linda Teri, Glenise McKenzie, and David LaFazia, University of Washington
Depression and dementia commonly coexist and are
associated with higher rates of behavioral and functional
problems. Caregivers of these individuals report higher
levels of physical and mental distress, as well. Effective
treatment, therefore, has the potential to help both the
older adult and their caregiver. This article provides
an overview of the current literature on treatment of
depression in demented older adults, with particular
emphasis on providing guidelines for evidence-based
clinical care. Eleven randomized controlled clinical trials
were identified following an extensive review of the
literature. These studies are reviewed with particular
attention to the methodological issues of most relevance
to clinicians attempting to use the findings from these
studies to guide their practice. Issues of particular
relevance when working with this population are also
addressed, including (a) for assessment—differential and
coexistent diagnosis of depression in dementia, use
of collateral informants, self-report and interviewer-
obtained information; and b) for treatment—the need
for caregiver involvement, individualizing of goals, and
planning for future deterioration of cognitive function.
Key words:
geropsychology, dementia, depression,
psychosocial intervention, empirically supported treat-
ments.
[Clin Psychol Sci Prac 12: 303–316, 2005]
INTRODUCTION
This article will provide an overview of the current
literature on treatment of depression in demented older
adults, with particular emphasis on providing guide-
lines for evidence-based clinical care. We will focus
our discussion on randomized controlled clinical trials
that have investigated the efficacy of psychosocial
approaches to reducing depression in dementia. While
these are few in number, they provide a clear starting
point for practitioners to understand the current state
of the science and apply this science to their ongo-
ing care of older adults with depression and dementia.
To place this discussion in context, we will also ad-
dress issues of particular relevance to working with
this population, including those influencing proper
assessment, such as differential and coexistent diagnosis
of depression in dementia; use of collateral infor-
mants; self-report and interviewer-obtained informa-
tion; and issues influencing treatment, such as the
need for caregiver involvement, individualizing goals,
and planning for future deterioration of cognitive
function.
The empirical investigation of psychosocial treat-
ments for depression in older adults with dementia is
a relatively new but clearly growing area of study. In
1992, a review of this area identified only one non-
pharmacological controlled trial aimed at treating
depression in persons with dementia (Teri & Wagner,
1992). Our review of the last decade of literature (1994–
2004) located 11 randomized controlled clinical trials
of nonpharmacological treatment of demented older
adults where depression-related outcomes were re-
ported. Interestingly, although pharmacological treat-
ment of depression in older adults remains the dominant
Address correspondence to Linda Teri, Department of Psycho-
social and Community Health, University of Washington,
Box 358733, Seattle, WA 98195–8733. E-mail: lteri@
u.washington.edu.
doi:10.1093/clipsy/bpi032
ÓThe Author 2005. Published by Oxford University Press on behalf of the American Psychological Association D12.
All rights reserved. For permissions, please e-mail: journals.permissions@oupjournals.org. 303

approach to care, a recent review of randomized
controlled trials on the use of antidepressant medication
for the treatment of depression in dementia revealed
only eight published placebo controlled trials, and five
of the eight failed to demonstrate efficacy (Olin, Katz,
Meyers, Schneider, & Lebowitz, 2002). Thus, there
is a clear need for more effective interventions for
depressed demented older adults, and psychosocial
approaches may offer alternatives to pharmacotherapy
as well as ways to augment their treatment effects.
The assessment and treatment of depression in
demented older adults requires an understanding of
each of the issues addressed elsewhere in this volume. It
is further complicated by the cognitive impairment
indicative of dementia. While numerous terms have
been used to classify and clarify the phenomenon of
depression in persons with dementia, including dementia
syndrome of depression and depression syndrome of dementia,
for the purpose of this review, we will use the term
depression in dementia. This is meant to convey the
coexistence of diseases and thereby provide a forum for
articulating the complexity of both aspects of disease
as they affect psychosocial assessment and treatment.
Dementia is characterized by a pervasive short- and
long-term memory impairment accompanied by sig-
nificant disturbances in judgment, higher-order corti-
cal functioning, abstract reasoning, and personality
(American Psychiatric Association, 1994). Alzheimer’s
disease (AD), the most common form of dementia in
older adults, has an insidious onset and progressive
course. Early in the disease, a demented person can fully
participate in assessment and treatment, understanding
and contributing to conversations and plans. Later, as the
disease progresses, persons with dementia will become
increasingly unable to participate: They will have
problems accurately remembering and reporting their
experiences and difficulty communicating with others.
Historically, depression and dementia were consid-
ered mutually exclusive, with an emphasis on meth-
ods for differentiating one from the other. While the
importance of correctly diagnosing depression from
dementia cannot be overstated, over a decade of research
has changed the landscape of our understanding. It is
now well accepted that depression and dementia often
coexist. Furthermore, that coexistence has been strongly
associated with additional morbidity and mortality.
Individuals with coexistent depression and dementia
have been shown to have higher rates of behavioral
and functional problems, and their caregivers report
higher levels of distress, burden, and depression (Pearson,
Teri, Wagner, Truax, & Logsdon, 1993; Teri, 1994;
Schulz, O’Brien, Bookwala, & Fleissner, 1995; Schulz,
Newsom, et al., 1997; Teri, Logsdon, Uomoto, &
McCurry, 1997; Whitlatch, Schur, Noelker, Ejaz, &
Looman, 2001; Tornatore, & Grant 2002). Thus, there is
a critical need for psychological intervention to ease the
disability and distress characteristic of the disease.
UNIQUE ISSUES IN ASSESSMENT
Assessment of depression in older adults with dementia
is characterized by many challenges. Foremost are
questions about a demented person’s ability to self-
report depression and the reliability of informants
reporting for them. All depression measures require
that respondents recall their experiences (often within
a specified timeframe), understand what they are asked,
and be able to articulate their answers. The memory
loss characteristic of dementia makes such reporting
suspect. Persons with dementia often cannot accurately
recall experiences (particularly over the designated
timeframe). They may not know how well they are
eating, if they are experiencing weight loss, the last
time they engaged in an enjoyable activity, and so forth.
They may not be able to communicate their current
mood state. Indeed, all information obtained directly
from persons with dementia may depend more on
their ability to communicate than on their level of
affect. Language problems, characteristic of dementia,
may cause them to experience difficulties understand-
ing questions being asked and articulating their answers.
As the accuracy of self-report becomes more
questionable, caregivers become important sources of
information. Caregivers often have intimate knowledge
of the demented person’s day-to-day activities. They
can report on a number of depression symptoms:
tearfulness, withdrawal, inactivity, and so forth. Care-
givers may not, however, be able to report on subjective
mood states. They can only report what they see and
what they think it means. Their report may also be
influenced by their own level of distress. A study by
Burke and colleagues (Burke, Roccaforte, Wengel,
et al., 1998), found that family caregivers reported more
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V12 N3, FALL 2005 304

depression symptoms for the person with dementia
than the person with dementia did for themselves.
However, caregiver report has also been closely
associated to clinician assessment (Teri & Wagner,
1991). So, whether or not caregivers are ‘‘accurate’’
informants is likely a function of what they are
reporting.
The nature of the informant might influence
ratings, as well. Toseland et al. (1997) reported that
nurses observed behavioral differences not noted by
research staff observers. They hypothesized that the
nurses may have more experience with the residents
compared to the prescribed and limited observation
period used by the research staff observers. Accuracy is
likely influenced by not only the informant but also
what is assessed. It has long been argued that disruptive
behaviors may come to the attention of staff whereas
withdrawn behaviors (which may be characterized
by a lack of interest in people or activities, tearfulness,
or sad mood) may be tolerated, as they do not force
staff to take action.
One might consider that clinician-based assessments,
which enable clinicians to interview both the person
with dementia and the caregiver, might be more
accurate than either self-report or informant report
measures. However, even the best clinician interview
must rely upon what the caregiver reports in terms of
the demented person’s activity, affect, and health. There
is no gold standard against which to determine accuracy
of these reports. Furthermore, caregivers may not be
available for some individuals so that the availability of
accurate information is questionable.
UNIQUE ISSUES IN TREATMENT
Many of the issues related to treating depression in the
general older adult population remain relevant for the
person who is also suffering from dementia. We will not
repeat the issues reviewed elsewhere in this volume.
Rather, we will focus our discussion on treatment
considerations particularly for the depressed person with
dementia. We will highlight the nature of cognitive
impairments present in dementia and the unique
environmental and system issues pertaining to the
treatment of depression in dementia.
The pervasive assault on the individuals’ cognitive
processes caused by dementia and the resulting impair-
ments in social and occupational functioning requires
adaptations of traditional psychosocial treatments for
depression. The progressive nature of these limitations
also requires flexible and dynamic approaches to the
treatment of depression (i.e., what ‘‘works’’ will
change). A frequent adaptation that becomes pivotal as
the level of cognitive impairment progresses is the
involvement of caregivers in treatment. Older adults
with dementia may reside in the community or in a
long-term care setting. Therefore, the caregivers that
are involved in treatment vary and can include paid
and unpaid providers, family and friends, and other
interested professionals and nonprofessionals.
Treatment of depression for a person with dementia
is further complicated by environmental and system
issues related to the contexts in which they live.
Institutional variables that may affect the treatment
include staff overload, turnover, and level of supervisor
support (Burgio et al., 2002; Hyer & Ragan, 2002;
Slone, 2002). Community variables impacting treat-
ment would include the relationships within the family,
family background, and issues of maintaining contact
with the community caregiver (Teri, Logsdon, Wagner, &
Uomoto, 1994; Kennedy, 2000). The person with
dementia becomes increasingly dependent on the places,
people, and systems that surround them. Attention to
these elements and their interplay with each other in the
treatment for persons with depression in dementia
cannot be overstated.
TREATMENT OUTCOME STUDIES
The literature about to be reviewed was identi-
fied through several electronic indexes (MEDLINE,
CINAHL, PsychINFO), a general Internet search engine
(Google), reference sections from identified articles,
review articles, and consensus documents. Articles
were included for review if they were (a) randomized
controlled trials, (b) of psychosocial treatments, (c) with
primary or secondary aims of improving depression or
affect, (d) in samples of older adults with dementia,
(e) with specific outcome measures of depression, mood
or affect, (f) published in English, and (g) during the past
10 years (1994–2004). Studies were excluded if they
involved (a) interventions based on physiological
mechanisms (bright light therapy, ECT, acupuncture,
pharmacology), or (b) combined demented and
DEPRESSION IN LONG-TERM CARE TERI ET AL. 305

nondemented subjects for analyses. Using this approach,
we identified 11 treatment outcome studies meeting
our criteria.
There is tremendous diversity in the nature of
treatments included under the rubric ‘‘psychosocial.’’
This diversity is evident in the 11 articles we reviewed.
The studies include interventions based on behavioral
approaches focused on training formal and informal
caregivers in problem solving and communication
strategies (Teri et al., 1997; Proctor et al., 1999; C. K.
Beck et al. 2002; Teri et al. 2003, McCallion, Toseland,
Lacey, & Banks, 1999); interventions based on structured
programs aimed at increasing social engagement for the
person with dementia (Toseland et al., 1997; Camberg
et al., 1999; Buettner & Fitzsimmons, 2002); and inter-
ventions aimed at modifying sensory or environmental
stimulation of the person with dementia (Lawton et al.,
1998; Baker et al., 2003; Berger et al., 2004).
Interventions investigated are often multimodal and
multilevel, with several utilizing similar components
and strategies. To organize this diversity, we will first
address the primary focus of the interventions and then
provide an overview of the full study, including
treatment procedures, control conditions, the duration
of study, and site and sample characteristics. We then
address the overarching methodological issues across
these studies that are relevant to the interpretation of
their findings and extension to clinical practice. To
facilitate this discussion an overview of each study,
including a summary of the intervention, duration, site,
sample and control-group specifics appears in Table 1. It
should be noted that this is based upon our interpretation
of information provided in the published articles. We
were unable to confirm these assignments with each
study author. Some studies provided insufficient detail
for us to feel confident that all aspects of treatment are
represented here. Consequently, information in the
tables is presented as a guide for discussion, not
a definitive statement of the study’s intent.
Behavioral Approaches
Behavior therapy is based on a social-learning model
in which depression is viewed as a series of behaviors
that are learned and maintained through positive
and negative contingencies (Lewinsohn, Sullivan, &
Grosscup, 1980). Behavioral treatment approaches are
therefore focused on increasing pleasant interactions,
decreasing unpleasant interaction, and developing
skills necessary to alter the environment to obtain
positive outcomes (Teri & Logsdon, 1990). The person
with dementia has limited ability to initiate pleasant
interactions or to implement environmental changes.
Behavioral therapy approaches for treating depression
in dementia are therefore often modified, in that
the caregiver, as the person in most control of the
environment, is targeted for training in the use of
behavioral strategies. (The reader interested in learn-
ing more about this framework is referred to Teri,
1997).
Teri et al. (1997) evaluated a behavioral problem-
solving approach to reduce depression in older adults
with dementia. Community-residing family caregivers
were taught behavioral strategies; environmental mod-
ification, distraction, communication, and increasing
pleasant events were key training elements. A signifi-
cant difference in improved depression scores and the
percentage of subjects meeting criteria for clinical
depression was found between treatment and control
groups at posttest and maintained at 6 months.
Proctor et al. (1999) evaluated long-term care staff
to deliver depression treatment. Staff training focused
on establishing individualized, realistic goals for be-
havioral improvement and implementing behavioral
strategies. The goals of treatment were to decrease
behavioral disturbance and to decrease depression. The
intervention also included ongoing supervision and
support for behavioral plan development by members
of a hospital outreach team. The intervention group
showed significant change on depression at 6 months,
and significant differences on depression when compared
to the control group.
C. K. Beck et al. (2002) also trained staff caregivers
(hired for the study) to deliver two behavioral
interventions in a nursing home. There were three
treatment groups. The goals of treatment were to reduce
disruptive behaviors and improve affect. The analysis of
videotaped interventions, using an observational mea-
sure of negative affect, showed a significant decrease in
sad behaviors during treatment for the intervention
groups but not for the control groups.
Teri et al. (2003) extended the prior community-
based behavioral intervention by including a caregiver
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V12 N3, FALL 2005 306

supervised exercise program. Caregivers were trained
to implement the exercise program with the demented
older adult family member; caregivers also received
training in behavioral strategies that were meant to
encourage exercise and decrease problem behaviors
that might arise with increased activity. Depression
scores for subjects in the active condition showed
significant improvement at posttest as compared to
those in control. At 24-month follow up, improved
posttest scores were maintained for subjects who had
entered the study with higher levels of depression.
Improving effective verbal and nonverbal com-
munication between nursing assistants and nursing
home residents with dementia was tested in another
behavioral based training intervention (McCallion et al.,
1999). Communication skills, specific to the person’s
level of dementia, environmental modification, and
approaches to problem behaviors were taught to and
delivered by nursing assistants. Depression scores all
significantly decreased for the treatment group when
compared to the wait-list control. Additionally, with-
drawal behaviors significantly decreased in the treatment
group when compared to the control group at baseline
and 6-month follow up.
Social Engagement Approaches
Social engagement approaches propose to improve
mood in persons with depression in dementia by
providing an increased sense of control over their
environment by distracting attention from negative
thoughts and by decreasing social isolation (Kasl-
Godley, & Gatz, 2000; Buettner & Fitzsimmons, 2002).
Three studies employed this approach.
Toseland et al. (1997) evaluated the efficacy of group
validation therapy, a communication-based approach
that aims to recognize, respect, and validate the
emotions of the person with dementia (Finnema, Droes,
Ribbe, & Van Tilburg, 2000), to decrease problem
behaviors, and improve psychosocial well-being. Verbal
and nonverbal validation included strategies of social
engagement, sensory stimulation, and structured activ-
ities. No significant improvement in either depression
scores or positive social interaction was obtained.
Buettner and Fitzsimmons (2002) tested whether an
activity (therapeutic biking) would improve depressed
demented subjects through improving socialization,
increasing sensory stimulation, and increasing positive
events. Their intervention utilized a special bicycle with
a wheel chair attached on the front end. The bike was
designed to encourage conversation during the ride, and
additionally participants met in structured groups to talk
about the experience. At posttest and follow up,
depression scores decreased significantly in the thera-
peutic biking group as compared to the control group.
Camberg et al. (1999) investigated simulated pres-
ence, designed to utilize selected favorite memories of
the person with dementia to increase a person’s well-
being by providing a calming set of memories, in-
creasing mental stimulation, and engaging the person in
a pleasant (simulated) interaction, on persons with
depression in dementia in nine nursing homes. Taped
conversation, using the voice of a family member or
other well-known caregiver, was used when specific
behaviors (such as withdrawal or restlessness) occurred.
The outcome of withdrawn behaviors (which was
defined as a lack of interest in people, activities, or
things in the environment combined with sad mood), as
measured by direct observation and staff observation
logs, showed significant improvement for the interven-
tion group as compared to the control groups.
Sensory/Environment Approaches
Sensory and environmental stimulation (too little and/or
excessive amounts) are hypothesized to impact behavior
and mood. Baker et al. (2003) used a multisensory
stimulation approach aimed at changing behavior,
mood, and cognition through decreasing sensory
deprivation. Treatment was described as activity sessions
that used visual, auditory, olfactory, and tactile stimu-
lation delivered in a nondirective manner with no
intellectual or physical demands placed on the partic-
ipants. This was compared to the ‘‘usual’’ activity group,
which was described as being directive and having
a purposive group structure. There was no difference
between the groups on mood as measured by direct
observation at the time of intervention or by behavior
scales completed by staff at follow-up.
Lawton et al. (1998) developed and tested a model of
care that had the goal of improving negative behaviors
and observed affect by identifying individual needs for
increased or decreased environmental stimulation.
Additional components included staff training on
DEPRESSION IN LONG-TERM CARE TERI ET AL. 307

Table 1. Overview of Study Characteristics
Study
Intervention Subjects
Measures*Treatment Control Duration Location N Mean Age
Baker, R., et al.
(2003)
Facility staff conducted
Multi-Sensory Stimulation—
eight 30 min sessions
Usual activity (i.e.,
playing cards,
photos)
4 weeks Day hospital & psychogeriatric
ward (UK, Netherlands,
Sweden)
136 82 Caregiver
Informant:
BMD, BRS
Beck, C.K., et al.
(2002)
Nursing assistants, hired and
trained as project nurse assis-
tants, conducted three inter-
ventions: 1) Activities of daily
living (ADL)—individual and
standard strategies for 45–60
min per day, 2) Psychosocial
activity (PSA)—25 total mod-
ules to meet psychosocial
needs implemented for 30 min
perday,3)bothADLandPSA
1) Placebo—1:1 with
nurse (30 min/day); or
2) Usual care
12 weeks Nursing homes (US) 127 84 Observation:
AARS, ODAS
Berger, G., et al.
(2004)
Psychologists and a music
therapist conducted a combi-
nation of caregiver support
group and memory training/
music therapy -conducted
once per week for 1 h
Usual care 2 years memory clinic of a
psychiatric university
hospital (Germany)
36 69 Clinician Interveiw:
Behave-AD;
Observation:
NOSGER
Buettner, L., et al.
(2002)
Research staff used a wheelchair
bicycle with residents in
skilled nursing and assisted
living for one h, five times
a week for two weeks; facility
staff, family, or volunteer,
then used the wheelchair bi-
cycle with residents two times
a week for 10 weeks
Usual care 12 weeks Nursing home and
assisted living (US)
70 Not reported Self-Report: GDS
Camberg, L., et al.
(1999)
Nursing staff played over the
telephone a family member’s
recording of the resident’s best
loved memories at least twice
aday
1) Placebo- tape of
person reading
newspaper; or
1 week Nursing homes (US) 54 83 Observation:
AARS, FACE
2) Usual care
Lawton, M. P., et al. (1998) Research staff conducted twice-
monthly administrative
planning sessions, a human-
relations training with nurses,
and 7 h of training with direct
care staff on the stimulation-
retreat approach; enhanced
interdisciplinary care planning
and activity programming
were developed; family
received support through
phone calls, discussion
groups, and social gatherings
Usual care 12 months 2 nursing homes—special
care units (US)
97 Not reported Observation: AARS,
MOSES; Caregiver
Informant: MDS
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V12 N3, FALL 2005 308

Table 1. Continued
Study
Intervention Subjects
Measures*Treatment Control Duration Location N Mean Age
McCallion, P., et al. (1999) A masters-level social worker
conducted a communication
skills program with nursing
assistants for five 45-min
group sessions and four 30-min
individual conferences
Wait List Control: Normal
facility in-services
Not reported Nursing homes (US) 105 85 Clinician Interview:
CSDD;
Observation:
MOSES
Proctor, R., et al. (1999) Members of the hospital
outreach team provided
nursing and residential homes
care staff training, education,
and psychosocial manage-
ment of behavioral problems
in seven 1 h trainings and
weekly follow-up support by
a psychiatric nurse
Usual care 6 months Nursing and residential
homes (UK)
105 83 Caregiver Informant:
AGE-CAT
Teri, L., et al. (1997) Therapists taught family
caregivers either: 1) Behavior
Training (BT)-Pleasant Events;
2) BT-Problem Solving in nine
60-minute session once per
week
1) Typical care (information,
advice, support); or
9 weeks Community (US) 72 76 Clinician Interview:
CSDD, HDRS;
Caregiver
Informant: BDI
2) Wait list control
Teri, L., et al. (2003) A physical therapist and
masters-level social worker
delivered an exercise and skills
training program with
caregivers and persons with
dementia in 12 one h sessions
conducted in their homes
Routine medical care 3 months Community (US) 153 78Not repor Clinician Interview:
CSDD, HDRS
Toseland, R. W., et al. (1997) Trained therapists conducted
Validation therapy with
residents for four 30-minute
sessions per week
1) Social Contact-group
activities; or
52 weeks 4 Nursing Homes (US) 88 88 Observation:
MOSES
2) Usual care
*Measures.
AARS—Apparent Affect Rating Scale.
AGE-CAT—Automatic Geriatric Examination for Computer Assisted Taxonomy.
BDI—Beck Depression Inventory.
BEHAVE-AD—Behavioral Abnormalities in Alzheimer’s Disease Rating Scale.
BMD—Behavior and Mood Disturbance Scale.
BRS— Behavior Rating Scale.
CSDD—Cornell Scale for Depression in Dementia.
FACE—Facial Diagrams of Mood.
GDS—Geriatric Depression Scale.
HDRS—Hamilton Depression Rating Scale.
MDS—Minimum Data Set.
MOSES—Multidimensional Observation Scale for Elderly Subjects.
NOSGER—Nursing Observation Scale for Geriatric Patients.
ODAS—Observable Display of Affect Scale.
DEPRESSION IN LONG-TERM CARE TERI ET AL. 309

identifying sensory needs, augmented care planning
teams, and increased activities and family support.
Specific sets of care strategies and environmental
modifications were then implemented to meet the
identified stimulation needs of the specific residents.
Positive affect and negative affect, as measured by direct
observation, were reported to have marginal and
selective differences. Positive affect showed less decline,
and external engagement improved in the treatment
group when compared to the control group.
Berger et al. (2004) evaluated the efficacy of
a combined intervention, which included memory
training and music therapy strategies for the person
with dementia, as well as a support group for their
family caregivers. The goal was to decrease behavioral
and psychological symptoms of the person with demen-
tia and to decrease caregiver burden. No difference was
obtained between the treatment and control groups.
Summary
The majority of studies reported here demonstrate the
efficacy of psychosocial approaches to treatment of
depression in older adults with dementia (7 out of 11
showed significant improvement in the treatment group
as compared to control). They represent a diversity of
theoretical and clinical approaches and yet share clear
commonalities. The behavioral-based studies focused on
training caregivers in the use of problem-solving
techniques to individualize care. They typically included
increasing pleasant events for the person with dementia
and improving communication skills for the caregivers.
The social engagement and sensory/environmental
approaches typically focused on increasing opportunities
for social interaction by increasing pleasant interactions
and structuring individualized activity.
METHODOLOGICAL ISSUES
We now review some of the methodological issues
that impact our ability to generalize from these studies
to clinical practice. While there are many aspects that
can be addressed, we will limit our discussion here to
(a) design elements, (b) subjects and settings, (c) treatment
and control conditions, and (c) measures.
Design
While this review is limited to randomized controlled
trials, there is variance in the nature of randomization
and in the type of controls used. Studies either ran-
domized nursing units (Lawton et al., 1998; McCallion
et al., 1999; Proctor et al., 1999), caregiver dyads (Teri
et al., 1997; Teri et al., 2003; Berger et al., 2004), or
individuals (Toseland et al., 1997; Camberg et al., 1999;
C. K. Beck et al., 2002; Buettner & Fitzsimmons, 2002;
Baker et al., 2003). Controls included no-treatment control
groups (Teri et al., 1997; Toseland et al., 1997; Lawton
et al., 1998; Camberg et al., 1999; Proctor et al., 1999;
C. K. Beck et al., 2002; Buettner & Fitzsimmons 2002),
nonspecific (placebo) comparison groups (Toseland et al.,
1997; Camberg et al., 1999; C. K. Beck et al., 2002;
Baker et al., 2003), component control conditions (Teri
et al., 1997; C. K. Beck et al., 2002), and routine medical
care (Teri et al., 2003). While randomization and
controls are essential to determine the ability of active
treatments to impact change, the variability across
studies impacts our ability to compare findings. (See
Table 1 for additional details on control conditions.)
Subjects and Settings
Some of the studies were conducted in different
countries (see Table 1). This international representation
is exciting but also brings with it variance in psychiatric
terminology, treatments, and setting descriptions. These
differences complicate comparisons of treatment com-
ponents and therefore add to the difficulty of general-
izing across studies and populations.
Studies varied in the nature of subjects enrolled and
the settings from which they were selected and treated.
Participants varied in their level and severity of
depression: only 2 of the 11 studies had depression as
an inclusion criterion (Teri et al., 1997; Buettner &
Fitzsimmons 2002), although all assessed depression as
a primary or secondary outcome. The remaining studies
used selection criteria that resulted in a general array of
problem behaviors, with depression levels and percent-
ages varying widely on the baseline measurements. It is
worth noting that the two studies that selected subjects
with clear levels of depression at enrollment showed the
strongest treatment effects.
Participants varied in their degree of cognitive
impairment and whether or not they resided in
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V12 N3, FALL 2005 310

community or long-term care settings. Of the 11 studies
reviewed, only 3 were conducted in a community
setting (Teri et al., 1997; Teri et al., 2003; Berger et al.,
2004), 7 were conducted in long-term care settings
(Toseland et al., 1997; Lawton et al., 1998; Camberg
et al., 1999; McCallion et al., 1999; Proctor et al., 1999;
C. K. Beck et al., 2002; Buettner & Fitzsimmons, 2002),
and the remaining study included participants from the
community and from a long-term care unit (Baker et al.,
2003). Interventions were delivered in participant homes
(Teri et al., 1997; Teri et al., 2003), in a day hospital
(Baker et al., 2003), at an outpatient memory clinic
(Berger et al., 2004), in nursing homes (Toseland et al.,
1997; Lawton et al., 1998; Camberg et al., 1999;
McCallion et al., 1999; Proctor et al., 1999; C. K. Beck
et al., 2002; Buettner & Fitzsimmons 2002), and in
assisted living residences (Proctor et al., 1999; Buettner &
Fitzsimmons 2002).
In addition, because of these different settings, both
direct care staff (in long-term care; McCallion et al., 1999;
Proctor et al., 1999; C. K. Beck et al., 2002) and family
caregivers (in community settings; Teri et al., 1997; Teri
et al., 2003) were trained. Despite this variability of
participants and caregivers, positive outcomes were re-
ported in both community and long-term care settings.
Intervention
Broad ranges of behavioral, psychological, and social
components were included in these studies. Most
interventions were multifaceted, thereby addressing
the complexity of the disease but making it problematic
to determine the treatment’s active ingredients. Table 2
provides a matrix depicting the extent of overlap in
strategies utilized, as well as differences in the targeted
level of intervention (i.e., caregiver or care recipient),
and mode of delivery.
The duration and dose of the treatments also varied
(see Table 1). The majority of the approaches showing
positive results had interventions in place for 3 months
or more with caregivers delivering interventions on
a daily basis or treatment goals (such as increased activity
or socialization) that were addressed at least daily. In
addition, recall that most programs trained family and
staff caregivers to ‘deliver’ treatment directly to the
person with dementia. This delivery strategy allowed
caregivers to ‘deliver’ the intervention over the course
of a day, and for longer periods of time, most often one
to one. For example, the communication strategies
taught to nursing home staff are not used in a 1-hour
‘session’ but are ongoing through the course of daily
interactions with residents (Lawton et al., 1998;
McCallion et al., 1999; Proctor et al., 1999; C. K. Beck
et al., 2002). Similarly, family caregivers learned and
‘delivered’ behavioral interventions throughout the
day, as needed (Teri et al., 1997; Teri et al., 2003).
Consequently, persons with dementia were getting
intensive treatments that would not be available to
them otherwise.
Measurements
Measurement of change within treatment groups, and of
difference between treatment and control groups, was
addressed in different ways. Four of these studies
specifically used depression scales (Teri et al., 1997;
McCallion et al., 1999; Buettner & Fitzsimmons 2002;
Teri et al., 2003), others looked at depression within the
context of other behavioral problems (Camberg et al.,
1999; Proctor et al., 1999; Baker et al., 2003; Berger
et al., 2004), and still others looked at depression as one
aspect of the broader observation of positive and
negative affect (Toseland et al., 1997; Lawton et al.,
1998; C. K. Beck et al., 2002). Table 1 provides an
overview of the diversity of measures used. Commonly
used measures were the Hamilton Depression Rating
Scale (HDRS; Hamilton, 1967), and the Cornell
Depression in Dementia Scale (CSDD; Alexopoulos,
Abrams, Young, & Shamoian, 1988)). Both instruments
involve a trained interviewer observing the person with
dementia and asking questions of the person with
dementia and their caregiver. Questions are detailed
with probes and potential answer ratings clearly de-
lineated. Both have extensive psychometric data avail-
able and have been used successfully with cognitively
impaired older adults. (Gottlieb, Gur, & Gur, 1988;
Gilley, Wilson, Bienias, Bennett, & Evans, 2004;
Mulsant et al., 1994; Kurlowicz, Evans, Strumpf, &
Maislin, 2002; Alexopoulos et al., 1988; Teri & Wagner,
1991; Maixner, Burke, Roccaforte, Wengel, & Potter,
1995). The HDRS and CSDD scales are quite
comparable, with Katz (1998) reporting that 17 of the
19 items of the CSDD can be mapped against the
HDRS.
DEPRESSION IN LONG-TERM CARE TERI ET AL. 311

Table 2. Summary of Treatment Characteristics
Components Involving the Person with Dementia Components Involving the Caregivers (Community or Staff) Mode of Delivery
Environment
Modification
Memory
Training
Pleasant
Events
Structured
activity
Social
Engagement
Sensory
Stimulation
Behavioral
Problem
Solving
Techniques
Communication
Skills
Community (C)
or Staff (S)
Caregiver
Training
Caregiver
Support 1 to 1 Group
Behavioral Approaches
Beck et al.
2002
XX X X X X(S) X
McCallion
et al. 1999
XX XX(S) X
Proctor et al.
1999
X X (S) X X
Teri et al.
1997
XX XXX(C)XX
Teri et al.
2003
X X X X X X (C) X X
Social Engagement Approaches
Buettner
et al. 2002
XX X XX
Camberg
et al. 1999
XX X X
Toseland
et al. 1997
XX X X
Sensory/Environment Approaches
Baker et al.
2003
XXX XX
Berger et al.
2004
XX X X X
Lawton et al.
1998
X X X X (S) X X
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V12 N3, FALL 2005 312

Only one study used a self-report measure of
depression (Buettner & Fitzsimmons 2002); however,
since the practicing clinician may have need of a simpler
method of assessment than the HDRS or CSDD, we
will briefly discuss this here. The GDS has good
psychometric data with cognitively intact persons
(Yesavage et al., 1983); its psychometric properties
in demented older adults is more controversial—studies
both support (Feher, Larrabee, & Crook, 1992;
Lichtenberg, Steiner, Marcopulos, & Tabscott, 1992;
Ward, Wadsworth, & Peterson, 1994; Isella, Villa, &
Appollonio, 2001) and question (Kafonek et al., 1989;
Burke, Roccaforte, & Wengel, 1991) its validity and
reliability in persons with dementia. Most likely, this
differing experience with the GDS is a function of the
respondent’s level of cognitive impairment. Not sur-
prisingly, GDS sensitivity, specificity, and reliability
become compromised with increasing cognitive impair-
ment (McGivney, Mulvihill, & Taylor, 1994; Bedard
et al., 2003). A modified GDS that allows for caregiver
input may address this problem. Teri and colleagues
(Teri et al., 1997) modified another self-report measure,
the Beck Depression Inventory (A. T. Beck, Ward,
Mendelson, Mock, & Erbaugh, 1961), to enable care-
givers to use it to report symptoms of a demented older
adult; it correlated well with clinician report and was
sensitive to treatment effects.
Two observational scales have been used in more
than one study: the Apparent Affect Rating Scale
(AARS; Lawton, VanHaitsma, & Klapper 1996) and the
Multidiminsional Observation Scale for Elderly Subjects
(MOSES; Helmes, Csapo, & Short, 1987). Both require
trained observers, were developed for research purposes,
and have good psychometric data (Helmes et al., 1987;
Lawton et al., 1996; Lawton, VanHaitsma, Perkinson, &
Ruckdeschel, 1999; Sturmey, Tsiouris, & Patti, 2003).
A number of generalized behavioral disturbance
measures were also used in these trials, although none were
used in more than one study (Table 1 lists these measures).
SUMMARY AND SUGGESTIONS FOR CLINICAL
PRACTICE
Eleven randomized controlled clinical trials investigated
the efficacy of psychosocial treatments to reduce de-
pression in older adults with dementia. Using multiple
techniques, including behavioral skill training, commu-
nication, social engagement, and sensory and environ-
mental stimulation in a variety of settings, including
long-term care and private homes, 7 of the 11 treatments
demonstrated clear improvements in depression. In 6
studies, these improvements were maintained beyond
the active treatment period.
Commonalities across these programs included
assessment strategies, individualization of strategies,
providing treatment in a one-on-one format, using
multiple treatment components in a coordinated pro-
grammatic approach, and focusing on teaching care-
givers to deliver treatments to the persons with
dementia. Much of what caregivers were taught
involved problem-solving disease difficulties and facil-
itating increased pleasant social interaction. Together,
these studies demonstrate the utility of working closely
with caregivers—whether family or staff—to reduce
depression in persons with dementia. When caregivers
are not available, the situation is more problematic and
no studies have yet addressed this.
What is the take-home message for practicing
clinicians? First, a multimodal method of assessment is
critical. This takes into account the demented person’s
subjective report of his or her own mood, the caregiver’s
report of the more objective information (e.g., sleep,
eating, activity) when a caregiver is available, and the
clinician’s overall assessment of the integrity of both of
these sources of information coupled with his or her
own observations. Second, psychosocial treatments of
depression in persons with dementia work. They should
be implemented. Third, depression in persons with
dementia does not remit over time. Five studies showed
no change in wait-list or no-contact controls. If persons
with depression in dementia are not treated it is unlikely
they will get better. Fourth, treatments should focus on
helping caregivers understand and deal with the disease
in a skill-oriented manner. They should be flexible in
their approach to address the progressive deterioration
of function and multifaceted to provide help with the
diversity of problems besetting these older adults and
their caregivers.
Four studies indicated treatment manuals were avail-
able (Teri et al., 1997; McCallion et al., 1999; Buettner &
Fitzsimmons 2002; Teri et al., 2003). Practitioners may
be able to use these manuals as beginning guidelines with
which to treat their patients with depression in
DEPRESSION IN LONG-TERM CARE TERI ET AL. 313

dementia. There is no reason not to do so and every
reason to believe that such treatment will benefit the
person with dementia and his or her caregivers.
ACKNOWLEDGMENT
This study was supported in part by a Pioneer Award from the
Alzheimer’s Association (PIO-1999–1800) and the National
Institute on Aging (R21 MH06951). Appreciation is extended
to ‘‘Buzzy’’ Elizabeth Mounce for her invaluable clerical skills.
REFERENCES
Alexopoulos, G. S., Abrams, R. C., Young, R. C., &
Shamoian, C. A. (1988). Cornell scale for depression in
dementia.
Biological Psychiatry, 23,
271–284.
American Psychiatric Association. (1994).
Diagnostic and
statistical manual of mental disorders
(4th ed.). Washington,
DC: American Psychiatric Association.
Baker, R., Holloway, J., Holtkamp, C., Larsson, A., Hartman,
L. C., Pearce, R., et al. (2003). Effects of multi-sensory
stimulation for people with dementia.
Journal of Advanced
Nursing, 43
(5), 465–477.
Beck, A. T., Ward, C., Mendelson, M., Mock, J., & Erbaugh, J.
(1961). An inventory for measuring depression.
Archives of
General Psychiatry, 4,
561–571.
Beck, C. K., Vogelpohl, T. S., Rasin, J. H., Uriri, J. T.,
O’Sullivan, P., Walls, R., et al. (2002). Effects of behavioral
interventions on disruptive behavior and affect in demented
nursing home residents.
Nursing Research, 51
(4), 219–228.
Bedard, M., Molloy, D. W., Squire, L., Minthorn-Biggs,
M. B., Sobois, S., Lever, J. A., et al. (2003). Validity of self-
reports in dementia research: The geriatric depression scale.
Clinical Gerontologist, 26
(3/4), 155–163.
Berger, G., Bernhardt, T., Schramm, U., Muller, R.,
Landsiedel-Anders, S., Peters, J., et al. (2004). No effects
of a combination of caregivers support group and memory
training/music therapy in dementia patients from a memory
clinic population.
International Journal of Geriatric Psychiatry,
19,
233–231.
Buettner, L. L., & Fitzsimmons, S. (2002). Adventure
program: Therapeutic biking for the treatment of de-
pression in long-term care residents with dementia.
American Journal of Alzheimer’s Disease and Other Dementias,
17
(2), 121–127.
Burgio, L. D., Stevens, A., Burgio, K. L., Roth, D. L.,
Paul, P., & Gerstle, J. (2002). Teaching and maintaining
behavior management skills in the nursing home.
The
Gerontologist, 42
(4), 487–496.
Burke, W. J., Roccaforte, W. H., & Wengel, S. P. (1991). The
short form of the geriatric depression scale: A comparison
with the 30-item form.
Journal of Geriatric Psychiatry and
Neurology, 4
(3), 173–178.
Burke, W. J., Roccaforte, W. H., Wengel, S. P., McArthur-
Miller, D., Folks, D. G., & Potter, J. F. (1998).
Disagreement in the reporting of depressive symptoms
between patients with dementia of the Alzheimer’s type
and their collateral sources.
American Journal of Geriatric
Psychiatry, 6,
308–319.
Camberg, L., Woods, P., Ooi, W. L., Hurley, A. C., Volicer, L.,
Ashley, J., et al. (1999). Evaluation of simulated presence:
A personalized approach to enhance well-being in persons
with Alzheimer’s disease.
Journal of the American Geriatrics
Society, 47
(4), 446–452.
Feher, E. P., Larrabee, G. J., & Crook, T. H. (1992). Factors
attenuating the validity of the geriatric depression scale in
a dementia population.
Journal of the American Geriatrics
Society, 40
(9), 906–909.
Finnema, E., Droes, R. M., Ribbe, M., & Van Tilburg, W.
(2000). The effects of emotion-oriented approaches in the
care for persons suffering from dementia: A review of the
literature.
International Journal of Geriatric Psychiatry, 15,
141–161.
Gilley, D. W., Wilson, R. S., Bienias, J. L., Bennett, D. A., &
Evans, D. A. (2004). Predictors of depressive symptoms in
persons with Alzheimer’s disease.
Journal of Gerontology,
59B
(2), P75–P83.
Gottlieb, G. L., Gur, R. E., & Gur, R. C. (1988). Reliability of
psychiatric scales in patients with dementia of the Alzheimer’s
type.
American Journal of Psychiatry, 145
(7), 857–860.
Hamilton, M. (1967). Development of a rating scale for
primary depressive illness.
British Journal of Social and
Clinical Psychology, 6,
278–296.
Helmes, E., Csapo, K. G., & Short, J. A. (1987). Standardi-
zation and validation of the Multidimensional Observation
Scale for Elderly Subjects (MOSES).
Journals of Gerontol-
ogy, 42,
395–405.
Hyer, L. A., & Ragan, A. M. (2002). Training in long-term
care facilities: Critical issues. In M. P. Norris, V. Molinari, &
S. Ogland-Hand (Eds.),
Emerging trends in psychological
practice in long-term care
(pp. 197–237). New York: Haworth
Press.
Isella, V., Villa, M. L., & Appollonio, I. M. (2001). Screening
and quantification of depression in mild-to-moderate
dementia through the GDS short forms.
Clinical Gerontol-
ogist, 24
(3/4), 115–125.
Kafonek,S.,Ettinger,W.H.,Roca,R.,Kittner,S.,Taylor,N.,&
German, B. S. (1989). Instruments for screening for
depression and dementia in a long term care.
Journal of the
American Geriatrics Society, 37,
29–34.
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V12 N3, FALL 2005 314

Kasl-Godley, J., & Gatz, M. (2000). Psychosocial interventions
for individuals with dementia: An integration of theory,
therapy, and a clinical understanding of dementia.
Clnical
Psychology Review, 6,
755–782.
Katz, I. R. (1998). Diagnosis and treatment of depression in
patients with Alzheimer’s disease and other dementias.
Journal of Clinical Psychiatry, 59
(Suppl. 9), 38–44.
Kennedy, G. J. (2000).
Geriatric mental health care: A treatment
guide for health professionals.
New York: Guilford Press.
Kurlowicz, L. H., Evans, L. K., Strumpf, N. E., & Maislin, G.
(2002). A psychometric evaluation of the Cornell scale
for depression in dementia in a frail, nursing-home
population.
American Journal of Geriatric Psychiatry, 10
(5),
600–608.
Lawton, M. P., Van Haitsma, K., Klapper, J., Kleban, M. H.,
Katz, I. R., & Corn, J. (1998). A stimulation-retreat special
care unit for elders with dementing illness.
International
Psychogeriatrics, 10
(4), 379–395.
Lawton, M. P., VanHaitsma, K., Perkinson, M., &
Ruckdeschel, K. (1999). Observed affect and quality of
life in dementia: Further affirmations and problems.
Journal
of Mental Health and Aging, 5
(1), 69–82.
Lawton, M. P., VanHaitsma, K. S., & Klapper, J. A. (1996).
Observed affect in nursing home residents.
Journal of
Gerontology: Psychological Sciences, 51B,
P3–P14.
Lewinsohn, P. M., Sullivan, J. M., & Grosscup, S. J. (1980).
Changing reinforcing events: An approach to the treatment
of depression.
Psychotherapy: Theory, Research and Practice,
17,
322–334.
Lichtenberg, P. A., Steiner, D. A., Marcopulos, B. A., &
Tabscott, J. A. (1992). Comparison of the Hamilton
Depression Rating Scale and Geriatric Depression Scale:
Detection of depression in dementia patients.
Psychological
Reports, 70,
515–521.
Maixner, S. M., Burke, W. J., Roccaforte, W. H., Wengel,
S. P., & Potter, J. F. (1995). A comparison of two
depression scales in a geriatric assessment clinic.
American
Journal of Geriatric Psychiatry, 3
(1), 60–67.
McCallion, P., Toseland, R. W., Lacey, D., & Banks, S.
(1999). Educating nursing assistants to communicate more
effectively with nursing home residents with dementia.
The Gerontologist, 39
(5), 546–558.
McGivney, S. A., Mulvihill, M., & Taylor, B. (1994).
Validating the GDS depression screen in the nursing
home.
Journal of the American Geriatrics Society, 42,
490–492.
Mulsant, B. H., Sweet, R., Rifai, A. H., Pasternak, R. E.,
McEachran, A., & Zubenko, G. S. (1994). The use of the
Hamilton rating scale for depression in elderly patients with
cognitive impairment and physical illness.
American Journal
of Geriatric Psychiatry, 2
(3), 220–229.
Olin, J. T., Katz, I. R., Meyers, B. S., Schneider, L. S., &
Lebowitz, B. (2002). Provisional diagnostic criteria for
depression of Alzheimer disease: Rational and background.
American Journal of Geriatric Psychiatry, 10,
129–141.
Pearson, J. L., Teri, L., Wagner, A., Truax, P., & Logsdon,
R. G. (1993). The relationship of problem behaviors in
dementia patients to the depression and burden in
caregiving spouses.
American Journal of Alzheimer’s Disease
and Related Disorders, 8,
15–23.
Proctor, R., Burns, A., Powell, H. S., Tarrier, N., Faragher, B.,
Richardson, G., et al. (1999). Behavioral management in
nursing and residential homes: A randomised control trial.
Lancet, 354,
26–29.
Schulz, R., Newsom, J., Mittelmark, M., Burton, L., Hirsch,
C., & Jackson, S. (1997). Health effects of caregiving: The
caregiver health effects study: An ancillary study of the
cardiovascular health study.
Annals of Behavioral Medicine,
19,
110–116.
Schulz, R., O’Brien, A. T., Bookwala, J., & Fleissner, K.
(1995). Psychiatric and physical morbidity effects of
dementia caregiving: Prevalence, correlates, and causes.
The Gerontologist, 35
(6), 771–791.
Slone, D. G. (2002). A team effort for treating depression in
dementia. In M. P. Norris, V. Molinari & S. Ogland-Hand
(Eds.),
Emerging trends in psychological practice in long-term care
(pp. 173–196). New York: Haworth Press.
Sturmey, P., Tsiouris, J. A., & Patti, P. (2003). The
psychometric properties of the Multi-Dimensional Obser-
vation Scale for Elderly Subjects (MOSES) in middle-aged
and older populations of people with mental retardation.
International Journal of Geriatric Psychiatry, 18,
131–134.
Teri, L. (1994). Behavioral treatment of depression in patients
with dementia.
Alzheimer’s Disease and Associated Disorders,
8,
66–74.
Teri, L. (1997). The relation between research on depression
and a treatment program: One model. In R. L. Rubinstein &
M. P. Lawton (Eds.),
Depression in long-term and residential
care: Advances in research and treatment
(pp. 129–153).
New York: Springer.
Teri, L., Gibbons, L. E., McCurry, S. M., Logsdon, R. G.,
Buchner, D. M., Barlow, W. E., et al. (2003). Exercise plus
behavior management in patients with Alzheimer disease:
A randomized controlled trial.
Journal of the American
Medical Association, 290
(15), 2015–2022.
Teri, L., & Logsdon, R. (1990). Assessment and management
of behavioral disturbances in Alzheimer’s disease.
Compre-
hensive Therapy, 16,
36–42.
DEPRESSION IN LONG-TERM CARE TERI ET AL. 315

Teri, L., Logsdon, R. G., Uomoto, J., & McCurry, S. (1997).
Behavioral treatment of depression in dementia patients: A
controlled clinical trial.
Journals of Gerontology B: Psycho-
logical Sciences and Social Sciences, 52B
(4), P159–P166.
Teri, L., Logsdon, R., Wagner, A., & Uomoto, J. (1994). The
caregiver role in behavioral treatment of depression in
dementia patients. In E. Light, B. Lebowtiz, & G. Niederehe
(Eds.),
Stress effects on family caregivers of Alzheimer’s patients
(pp. 185–204). New York: Springer Press.
Teri, L., & Wagner, A. (1991). Assessment of depression in
patients with Alzheimer’s disease: Concordance between
informants.
Psychology and Aging, 6,
280–285.
Teri, L., & Wagner, A. (1992). Alzheimer’s disease and
depression.
Journal of Consulting and Clinical Psychology, 3,
379–391.
Tornatore, J. B., & Grant, L. A. (2002). Burden among family
caregivers of persons with Alzheimer’s disease in nursing
homes.
The Gerontologist, 42
(4), 497–506.
Toseland, R. W., Diehl, M., Freeman, K., Manzanares, T.,
Naleppa, M., & McCallion, P. (1997). The impact of
validation group therapy on nursing home residents with
dementia.
Journal of Applied Gerontology, 16
(1), 31–50.
Ward, L. C., Wadsworth, A. P., & Peterson, L. P. (1994).
Concurrent validity of measures of anxiety, depression, and
somatization in elderly, demented, male patients.
Clinical
Gerontologist, 15
(1), 3–13.
Whitlatch, C. J., Schur, D., Noelker, L. S., Ejaz, F. K., &
Looman, W. J. (2001). The stress process of family
caregiving in institutional settings.
The Gerontologist,
41
(4), 462–473.
Yesavage, J. A., Brink, T. L., Rose, T. L., Lum, O., Huang, V.,
Adey, M. B., et al. (1983). Development and validation of
a geriatric depression screening scale: A preliminary report.
Journal of Psychiatric Research, 17,
37–49.
Received August 12, 2004; accepted March 7, 2005.
CLINICAL PSYCHOLOGY: SCIENCE AND PRACTICE V12 N3, FALL 2005 316