Dementia friendly initiatives: A state of the science review

Person-centered care

PWD frequently interact with healthcare systems, both to address dementia-related symptomatology and for the treatment of comorbid conditions that often occur in older adults (Innes et al., 2016; Parke et al., 2016). Person-centered care (PCC), a holistic approach that involves and empowers PWD and their families as partners in decision-making and care planning, has increasingly been considered best practice in dementia care (Fortinsky & Downs, 2014; Kane & Cutler, 2015; Parke et al., 2016). Also known as person-centered dementia care, PCC is frequently referenced in the DFI literature as a type of DFI undertaken in healthcare settings to include acute, long-term, and community care (Charras, Eynard, & Viatour, 2016; Davis, Byers, Nay, & Koch, 2009; Innes et al., 2016; Parke et al., 2016). Like DFIs overall, PCC approaches strive for care environments and activities that are supportive of personhood and well-being in dementia (Brooker, 2007; Davis et al., 2009; Innes et al., 2016; Parke et al., 2016). PCC approaches diverge from the medical model, and like DFIs, embrace environments and activities centered on the needs and preferences of the individual rather than that of the system (Brooker, 2007; Davis et al., 2009; Downs, 2013; Innes et al., 2016; Parke et al., 2016).

The intersection of PCC and DFIs was demonstrated in a study by Innes et al. (2016), set in acute care, in which measurements of PCC were undertaken to “determine the extent to which wards met dementia friendly principles” (p. 1). Similarly, Palmer et al. (2014) incorporated person-centered care principles into an educational program for hospital staff: “… culture change and person-centered care were purposively woven into all of the curriculum modules and comprise the philosophical underpinning for the DFHI [dementia friendly hospital initiative] program” (p. 418). In an LTC setting, Charras et al. (2016) discussed the use of a framework of person-centered care to design dementia friendly spaces for residents. These studies are described in detail below. While PCC intersects with DFIs in healthcare settings, other DFI approaches reach more broadly into the community, away from the framework of care.

Dementia awareness and education

DFIs aim to create positive conceptualizations about dementia to counteract negative stereotypes (Gilliard, Means, Beattie, & Daker-White, 2005; Innes, 2012). Challenging stigma, defined as unjust negative societal perceptions of dementia, has been identified as a central goal of DFIs to promote inclusion of PWD in society (Davis et al., 2009; Henwood & Downs, 2014). Guidelines from national and international organizations recommend awareness programs to combat stigma (ADI, 2016; Alzheimer’s Society, 2013; WHO, 2012).

Along with reducing stigma, dementia awareness and education efforts have been directed at improvement of clinical and communication skills (Cartwright, Franklin, Forman, & Freegard, 2015; Gitlin & Hodgson, 2016). Two studies sought to improve staff knowledge, attitude, and confidence in caring for dementia patients through education (Galvin et al., 2010; Palmer et al., 2014). A seven-hour interdisciplinary education program entitled Dementia Friendly Hospitals was administered in four U.S. hospitals to 540 staff, and subsequently to 344 staff four years later (Galvin et al., 2010; Palmer et al., 2014). Analysis of pretest and immediate posttest results in both cohorts demonstrated a significant increase in participant knowledge (p = .001), attitude (p = .001), and confidence (p = .001) in caring for PWD. Participant knowledge was tested with seven multiple choice questions about dementia and evidence-based care; attitude and practice were measured by six questions using a five-point Likert scale. An additional posttest was administered after 120 days. The investigator developed the tools after conducting a literature review along with feedback from a national advisory panel with dementia expertise and a focus group of staff from various settings (urban and rural). Participants from three hospitals showed no significant changes in knowledge, attitude, or confidence, while those from the fourth hospital had a significant loss of knowledge (p = .01) and confidence (p = .02) at 120 days. In the second cohort, a measure of internal consistency revealed the knowledge test scored lowest with a Cronbach’s alpha of 0.21, the attitudes test scored 0.39, and only the confidence scale reached an acceptable rating of 0.90. Further refinement of the test items is needed for reliable outcome data. Both educational initiatives were well received by staff (score 4.6/5 and 67%–83% agreement on helpful improvements in care strategies) but neither program evaluated effects on patient outcomes. The majority of participants were nurses (60%–62%), white (83%), and female (90%) in both studies, limiting generalizability. Both programs demonstrated a significant improvement in staff attitude toward dementia care after receiving targeted dementia education. These findings support the correlation of DFIs with a reduction in stigma.

Community-based dementia awareness and education initiatives are strongly advocated across the globe (DFA, 2017; European Foundations’ Initiative on Dementia [EFID], 2016; Gitlin & Hodgson, 2016; Robinson & Corner, 2014). The Alzheimer’s Society (2013) began a Dementia Friends program now utilized broadly in many countries (ADI, 2016). The 1-hour program provides a basic understanding of brain changes in dementia, a glimpse into living with dementia, and interaction skills (Alzheimer’s Australia, 2013; Alzheimer’s Society, 2013). Outcome studies are not yet available.

In a rigorous qualitative study on DFCs in New Zealand, PWD reported that increased awareness would improve their interactions in the community, increase opportunities for engagement, and improve primary healthcare experiences (Smith, Gee, Sharrock, & Croucher, 2016). In three separate qualitative interview-based studies, stigma was observed in community members with limited exposure to dementia through concerns about excessive cost for accommodating PWD, hesitancy to arrange dementia-specific training for staff, and fear of disruptive behavior (Crampton & Eley, 2013; Page, Innes, & Cutler, 2015; Smith et al., 2016).

Faith communities have been identified as a welcoming site to provide dementia education (Hirst, 2016; Plunkett & Chen, 2016; Smith et al., 2016). Interaction skills gained in awareness training were noted to promote relationships among community members with and without dementia to enhance well-being for all (Robinson & Corner, 2014). Neighborhood relationships have been identified as critical in rural settings where formal social services are often limited (Plunkett & Chen, 2016; Wiersma & Denton, 2016). Community members reported a need for local supportive services information (e.g., meal services or personal care assistance); a lack of support service access may stem from a lack of resource awareness (Crampton & Eley, 2013; Plunkett & Chen, 2016; Wiersma & Denton, 2016). Providing awareness trainings and connection of PWD and families with relevant services has played an important role in DFIs.

Education-based DFIs have demonstrated an improvement in dementia knowledge, attitude, and confidence, yet no significant outcomes related to function, well-being, or health care have been studied.

Environmental design

Environment, physical design, and architectural design were used interchangeably in the dementia literature to indicate any environmental adaptation to enhance the physical, social, and functional ability of PWD. These initiatives comprised 75% (n = 15) of the dementia friendly research literature.

Spatial disorientation and decreased wayfinding were commonly noted with the progression of dementia (Caspi, 2014; Marquardt, 2011). Environmental design changes identified as helpful included easy visual access to frequently used rooms, opportunities for privacy and community engagement, appropriate levels of stimulation, support for movement and engagement in activities, and presence of familiar objects and furniture (Hadjri et al., 2012; Marquardt, 2011; Marquardt & Schmieg, 2009; Parke et al., 2016). These environmental features were proposed, although not validated empirically, to support independence, reinforce personal identity, and enable personhood (Fleming, Bennett, Preece, & Phillipson, 2016). The literature reflected an interdisciplinary collaboration of architecture, engineering, medicine, nursing, psychology, and sociology.

Acute care environmental design. Parke et al. (2016) performed a scoping review to map the knowledge surrounding dementia friendly acute care (DFAC) physical design to identify components that improve the functional ability and independence of hospitalized PWD. The authors found little evidence on DFAC design, with a notable lack of intervention studies. The literature suggested a simplified environment, enhanced lighting, and the use of non-patterned, shock absorbent flooring and grab bars could reduce falls and support function. The authors rated the level of evidence for DFAC design at expert opinion, meaning the evidence is positioned above a book chapter and conference abstract, but below the level of a literature review or research study.

In a broader investigation, four validated tools were employed in a multi-method study of dementia friendly practices to measure environmental facilitators of independent function and provision of PCC in two hospital wards. Researchers employed the environmental audit tool (EAT), dementia care mapping, person-centered care assessment tool (PCAT), and the person-centered climate questionnaire (PCCQ) in two wards both before an educational intervention on dementia friendly principles and PCC and again 12 months later (Innes et al., 2016).

The EAT assessed the presence of dementia friendly environmental principles with 72 yes/no questions totaling a possible score of 112. The EAT categories were based on 10 principles that assess for appropriate levels of stimulation, simplicity, social interactions, and engagement in the ordinary tasks of daily living (Fleming, 2011, p. 109). The EAT has been used in acute care, LTC, and the community (Fleming, 2011; Fleming & Bennett, 2015; Fleming et al., 2016; Smith et al., 2012) and has demonstrated adequate psychometric properties in LTC but not yet in acute care settings (Fleming, 2011; Fleming & Bennett, 2015).

The wards scored low on the EAT at both time intervals, with Ward 1 at 22 pre/30 post, and Ward 2 at 28 pre/40 post (Innes et al., 2016). Researchers noted that despite the modest increase in EAT scores after 12 months, several environmental improvements were enacted with the use of local pictures, improved orientation signs for wayfinding, and an increase in comfortable central seating was installed. Notable deficiencies were too many beds (n > 10), and lack of access to personal items, noise control, domestic activities, and intimate space (Fleming & Bennett, 2015; Innes et al., 2016).

PCC was measured from the perspective of the staff (47% response rate) through PCAT (13 Likert-type questions), and the PCCQ (14 Likert-type questions). Psychometric results from previous studies reported the PCAT to have achieved a Cronbach’s alpha of 0.84 and the PCCQ 0.89 in an Australian hospital setting (Edvardsson, Fetherstonhaugh, Nay, & Gibson, 2010; Edvardsson, Koch, & Nay, 2010). The results of PCC assessment suggested staff awareness of PCC principles of dignity and respect, yet this was not consistent with researcher observations of behaviors not reflective of PCC (minimal interaction and rushing through personal care) during dementia care mapping. The results of the posttest staff questionnaires reflected a more negative view of the environment of care than did the pretest results, potentially due to an increased staff awareness of the dementia friendly principles, and subsequent more critical analysis of the environment. This review demonstrated a lack of compelling empirical research for acute care dementia friendly physical environmental design. These findings underscore the interconnectedness of different aspects of DFIs; that is, a multimodal approach to DFIs combining awareness raising with environmental changes may be necessary to fully impact outcomes.

LTC environmental design. Studies that examined the therapeutic impact of physical design in LTC settings were more plentiful and robust than in other settings (Day, Carreon, & Stump, 2000; Parke et al., 2016). Five research studies were uncovered with a dementia friendly design focus in LTC (Charras, Eynard, Viatour, & Fremontier, 2011; Charras et al., 2016; Hadjri et al., 2012; Marquardt, 2011; Marquardt & Schmieg, 2009).

Residents with mild dementia typically demonstrated little difficulty navigating in LTC, but the deterioration of orientation skills as dementia progressed required increasing amounts of environmental support (Charras et al., 2016; Marquardt, 2011; Marquardt & Schmieg, 2009; O’Malley, Innes, & Wiener, 2017). In a literature review of wayfinding for PWD, Marquardt (2011) found settings that facilitated wayfinding with provision of environmental cues and reduction of environmental clutter appeared to facilitate independence. Four overriding principles of wayfinding in a dementia friendly LTC environment were identified as helpful: (a) use geometrically simple rooms and simple layouts which do not require the use of new skills or complex interpretation, (b) allow visual access and overview so that PWD do not have to think abstractly, (c) reduce decision-making by limiting crossroad decision points and making environmental anchors obvious, and (d) increase architectural legibility, that is, create spaces and paths with intuitive or obvious use (Marquardt, 2011).

Marquardt and Schmieg (2009) collected data from 30 nursing homes (n = 450 residents with dementia) to determine the effect of the architectural environment on wayfinding. Nurses rated the level of independence residents demonstrated in their ability to reach five destinations on a three-point scale. This was analyzed against the architectural structure of each facility using a Mann–Whitney U test. Design features to facilitate wayfinding in LTC were found to include straight circulation system with no changes in direction (p = 0.05 in moderate dementia and p = 0.001 in severe dementia), one live-in kitchen rather than several (p = 0.01 in moderate dementia and p = 0.001 in severe dementia), and access to the outdoors through the living area (p = 0.041 in severe dementia; Marquardt & Schmieg, 2009).

The Dementia Services Design Centre (DSDC, 2013) criteria were used to assess the dementia friendliness of the physical design of nursing and care homes in Northern Ireland through completed questionnaires by facility staff (Hadjri et al., 2012). With a 45% response rate from facilities (n = 53), the study found that nursing homes (68%) aligned better with DSDC design criteria than did residential care homes (32%). This may be due to the heightened regulations present in the nursing home industry, which can be a facilitator (i.e., ensure evidence-based practices) or barrier (e.g., inflexible requirements for signage) for dementia friendly design. The main deficits in design features were (a) safe, accessible enclosed outside space, (b) signage, (c) toilet and bathroom design, (d) removable mirrors, and (e) discreet storage space.

In an ethnographic evaluation of the dementia friendly physical design of three dementia care units, the following concepts were uncovered with qualitative content analysis: (a) organization of space, (b) space induced social cohesion, (c) residential ambiance, (d) privacy, (e) display of care, and (f) control and attention provided to residents (Charras et al., 2016). Previous to this study, a randomized controlled trial found simultaneous changes in both the physical and social environment in eight dementia care units (n = 63 PWD) were more effective in improving quality of life scores than adapting only the physical or social situation (Charras et al., 2011). The statistical outcomes including the p value were not reported, and therefore, the validity is not verifiable. These results again suggest that awareness and environmental components of DFIs are interconnected, as previously noted.

Hogewey, a dementia care village, serves as a case study for dementia friendly design in LTC (Jenkins & Smythe, 2013). Located in the Netherlands, the physical design of Hogewey resembles a typical village with shopping and activities to allow PWD to experience independence, involvement, and choices in everyday life. PWD have repeatedly expressed distress from the gradual loss of ability to participate in everyday life, such as shopping and getting out, and about the resultant isolation this brings (Crampton & Eley, 2013; Henwood & Downs, 2014; Swaffer, 2014); therefore, this physical design has potential for enhancing quality of life (Jenkins & Smythe, 2013).

While the research base of dementia friendly design in LTC is more robust than that of acute care, dementia friendly specific studies require a more consistent use of evidence-based evaluation tools, with full reporting of psychometric properties.

Community environmental design. Dementia design principles have expanded to the built environment of cities and neighborhoods, along with community wayfinding to promote aging in place (Keady et al., 2012; Milton, 2012; Mitchell, 2012; Mitchell & Burton, 2010). Design principles identified for neighborhood-based solutions to improve independence included signage with photos, safe and easy to use transportation, areas supporting intergenerational relationships, appropriate use of colors and contrast, and noise reduction (Crampton & Eley, 2013; Mitchell & Burton, 2010). The consistent use of familiar landmarks as cues has been shown to assist with outdoor navigation (Mitchell, Burton, & Raman, 2004).

The EAT has recently been adapted for community use as the Dementia Friendly Communities Environment Assessment Tool (DFC EAT, Fleming et al., 2016). The 37-item tool was developed based on a literature search, an iterative item development with expert review, and testing by PWD in Australia in a sample of commercial and public buildings. Preliminary results demonstrate an interrater reliability of 0.57 to 0.90 and an internal consistency of 0.59 to 0.82 (p < 0.030). The six building types evaluated followed by their total mean EAT scores included banks (66%), council buildings (44%), shopping malls (64%), medical clinics (65%), small shops (64%), and supermarkets (52%). Although small sample sizes do not allow for generalizations, this tool has the potential to enable comparisons of various building types for dementia friendliness.

In qualitative studies, PWD reported valuing the ability to access outdoor spaces for physical and mental health (Crampton & Eley, 2013; Mitchell & Burton, 2010; Smith et al., 2016). Open spaces with clear visual access to toilets and other common sites supported wayfinding (Mitchell & Burton, 2010). Familiar and recognizable buildings with distinct architecture were preferred over non-descript buildings without design variation (Crampton & Eley, 2013; Mitchell & Burton, 2010).

A dementia friendly building design was found to be functional for both PWD and people without dementia, as investigated in a qualitative study by McCabe and Sim (2006). The dementia services program moved to a new facility constructed with dementia friendly design principles. The staff members interviewed were initially wary about a dementia friendly open floor plan but adapted successfully. An identified theme was the pride expressed by staff in having a dementia friendly building to serve their community. Similar results of pride were found by Crampton and Eley (2013) in interviews of the people of the York (England). The framework of people (aware and supportive), places (clarity and familiarity), networks (professional and non-professionals working together to support PWD), and resources (health, social care and businesses) summarized their findings on investigating a DFC, resounding with “what is good for dementia is good for everyone” (p. 57).

Dementia friendly environmental design has been studied in multiple settings. A notable 73% of environmentally focused dementia friendly studies have been published within the past five years. The instruments appear promising yet require psychometric testing in diverse settings. The recommended interventions must be more rigorously evaluated for effectiveness in improving function and well-being.

Dementia friendly communities

When used in the context of community, dementia friendly reflected a broader and more integrated approach than more targeted DFI interventions discussed above, such as environmental changes or dementia awareness sessions (Henwood & Downs, 2014; Lin & Lewis, 2015). The literature described DFCs as characterized by an underlying tightly connected network of support and resources for PWD and their families (Crampton & Eley, 2013; Heward et al., 2017; Smith et al., 2016). Eight of the 20 DFI research studies centered on the topic of DFCs, with all but one DFC study (Fleming et al., 2016) based in qualitative methodology, demonstrating the exploratory and contextual nature of current DFC research. Not all documents specifically defined a DFC, but the concepts of autonomy, awareness, dignity, empowerment, enablement, engagement, inclusion, independence, safety, support, and understanding for PWD and their caregivers consistently surface in DFC literature in varying amounts of emphasis depending on the setting (Table 2) (British Standards Institute [BSI], 2015; Charras et al., 2011; Crampton & Eley, 2013; Davis et al., 2009; Milton, 2012; Smith et al., 2016; Wiersma & Denton, 2016).

DFCs are emerging throughout the world, each corresponding to the needs and strengths of their culture (ADI, 2016; Innes, 2012). While DFCs first appeared in Japan in the late 20th century, the United Kingdom has also been a prolific leader, having included DFC goals in their National Dementia Strategy beginning in 2009 (ADI, 2016; Department of Health, 2009, 2012). In July 2015, Dementia Friendly America (2017) was created to support, “communities where all people can live, age, and thrive.” Reports generated from organizations with dementia expertise reveal a proliferation of DFCs across the world (Alzheimer Europe, 2015; EFID, 2016).

Kane and Cutler (2015) identified DFCs as an important consideration for government program administrators in the greatly needed overhaul of disconnected and outdated social services for older adults in the United States. Community development efforts to organize stakeholders around incorporating and supporting PWD have laid the foundation for DFCs (ADI, 2016). Key stakeholders vary depending on the local context of each DFC but have often included PWD, caregivers, health and social service providers, aging and dementia advocacy organizations, and local businesses (Crampton & Eley, 2013). In the first study to specifically address the realities of stakeholder involvement and sustainability of DFCs, Heward et al. (2017) identified challenges and opportunities through directed content analysis of dementia friendly project worker interviews and documents over 12 months. Triangulation of evidence from individual and focus group interviews supported the rigor of this qualitative study. Challenges to achieving stakeholder involvement included (a) establishing networks and ensuring adequate representation from the local community, (b) involving people affected by dementia, and (c) gaining commitment from organizations (Heward et al., 2017, p. 5). Strategies identified to solidify stakeholder involvement included (a) a sustainable approach (creating a steering team with specific action plans), (b) spreading the word (awareness sessions, local media, and social media), and (c) sharing ideas and success stories (among project workers; Heward et al., 2017, p. 6).

PWD and their families identified the presence of services such as meal provision, personal care assistance, and resource connection as crucial components of DFCs, often to serve as a safety net for aging in place (Wiersma & Denton, 2016). Residents in rural communities were noted to be significantly (p < 0.005) more likely than those in urban communities to refer someone with suspected dementia to friends or family rather than to healthcare or social services (Wiersma & Denton, 2016). Fewer resources in rural areas created a greater dependency on friends and families, underscoring the importance of a well-established network of social support in DFCs. Transportation options, whether public or private, were noted as necessary as driving is one of the first activities a PWD must forego (Crampton & Eley, 2013; Smith et al., 2016; Wiersma & Denton, 2016). The importance of awareness/education surfaced in DFCs, as it did in the acute and LTC settings, as simply providing social services is not sufficient when residents are unaware of their presence or access point.

The development of peer relationships with meaningful engagement in the greater community has been reported to promote well-being (Henwood & Downs, 2014; Hirst, 2016; Rahman, 2014; Woods, 2012): “Ongoing family involvement and community connections are essential for the creation and sustainability of a dementia friendly environment” (Davis et al., 2009, p. 193). Examples of such engagement have included art programs, exercise programs, and memory cafes (ADI, 2016; Dementia Friendly America, 2017). PWD and their care partners frequently identified tailored activities for the PWD as their desired outcomes of community care (Low et al., 2013). Faith communities have served as an important site for inclusive programming (Hirst, 2016; Smith et al., 2016). DFC development reflects a comprehensive approach to dementia beyond the healthcare setting into everyday life, with the involvement of multiple stakeholders and sectors, including PWD.

In summary, this review of the literature indicates a growing body of qualitative evidence on dementia friendly initiatives, along with quantitative evidence on dementia friendly physical design in particular. A multimodal approach, that is, simultaneous implementation of more than one DFI, has appeared to influence positive outcomes. The next section examines the theoretical bases of DFIs, to further support the development of a strong research trajectory (Handley, Bunn, & Goodman, 2015; McEwen, 2011).

The theoretical base of dementia friendly initiatives

Seven of the 22 research studies explicitly identified an underlying theoretical framework (Table 1). The principles of the theory of personhood had a strong presence, but authors rarely specifically acknowledged personhood by name. Other identified theoretical frameworks include human rights and citizenship, the social theory of disability, and the environmental press model (EPM).

While the biomedical approach to dementia has improved diagnosis and treatment, this singular lens has left the social experience and viewpoints of PWD sorely ignored (Innes, 2012; Sabat, Johnson, Swarbrick, & Keady, 2011; Vernooij-Dassen, & Jeon, 2016). The theory of personhood developed by Kitwood (1997) provided a groundbreaking shift toward the psychosocial perspective of dementia care, with the view of PWD as social beings deserving of recognition as unique individuals worthy of respect and trust (Sabat, 2001). Personhood provides a framework to see beyond the diagnosis of dementia to the whole person in relation to their social surroundings (Kitwood, 1997). Kitwood acknowledged the importance of considering the perspective of PWD, and capturing opportunities to understand their attempts at expression. Inclusion of PWD and their lived experience is increasingly considered an essential element in the development of DFIs, with 26 of the 32 empirical, conceptual, and theoretical DFI sources acknowledging this perspective. Over half (55%) of the empirical studies included the perspective of PWD although authors reported difficulty with population access, resulting in low numbers of participants (Crampton & Eley, 2013; Wiersma & Denton, 2016).

Three articles explicitly identified human rights and citizenship theory as an underpinning to dementia friendly inquiry (Bartlett, 2016; Charras et al., 2016; Downs & Bowers, 2014). Downs and Bowers (2014) explained that without human rights and citizenship, and the consideration of PWD as equal citizens, living well with dementia is not achievable. Bartlett and O’Connor (2007, 2010) have long advocated for the active inclusion of PWD not only in their own lives but also in social and political decisions, to promote their agency as valuable contributors to the community rather than only as recipients of services. Bartlett (2016) identified DFCs as supportive of moving the concept of citizenship for PWD forward due to the inclusive climate prevalent in DFCs in which PWD are expected to be heard and involved.

Henwood and Downs (2014) aligned DFCs with the social model of disability. In this model, society is labeled as a contributor to disability by not providing adequate supports or compensation to fully accommodate physical or mental impairments (Gilliard et al., 2005). Just as people with physical impairments have been provided with wheelchair ramps and automatic doors, PWD should likewise have access to accommodations for their cognitive impairments.

The EPM recognizes external forces as supportive or inhibitive of well-being and provides a framework to evaluate the interaction of PWD within their environment (Lawton, 1985). A mismatch between environmental demands and abilities of an individual, whether physical or cognitive can lead to maladaptation (Charras et al., 2011). Only one study specifically referred to EPM (Charras et al., 2011), although several others implicitly drew on the theoretical principles of assessing an individual’s competencies for their ability to adapt with the level of complexity in the environment (Charras et al., 2016; Crampton & Eley, 2013; Fleming et al., 2016; Marquardt, 2011; Marquardt & Schmieg, 2009; Mitchell & Burton, 2010; Mitchell et al., 2004; Parke et al., 2016).

While much of the reviewed literature did not explicitly delineate a theoretical stance, DFIs have impelled the theoretical base of dementia away from a narrow medical model toward an inclusive, holistic, and socially based model.