Skip to main content Accessibility help

The Functional Transitions Model: Maximizing Ability in the Context of Progressive Disability Associated with Alzheimer's Disease*

  • Susan Slaughter and Jane Bankes


The Functional Transitions Model (FTM) integrates the theoretical notions of progressive functional decline associated with Alzheimer's disease (AD), excess disability, and transitions occurring intermittently along the trajectory of functional decline. Application of the Functional Transitions Model to clinical practice encompasses the paradox of attempting to minimize excess disability while anticipating the progressive functional decline associated with AD. It is suggested that times of functional transition are times of decision making and opportunities for interdisciplinary collaboration to identify and minimize excess disability, for revision of goals and expectations, and for provision of support to patients and caregivers. The model also is applicable as a conceptual framework for education and research.

Le modèle de transition fonctionnelle est conçu selon les principes théoriques du déclin fonctionnel progressif survenant dans la maladie d'Alzheimer (MA), de l'incapacité découlant de la maladie et des phases de transition intermittentes tout au long du déclin fonctionnel. L'application du modèle dans la pratique clinique s'inscrit dans la volonté double de réduire au minimum l'incapacité tout en prévoyant le déclin fonctionnel progressif dans la MA. L'hypothèse étudiée ici veut que les périodes de transition fonctionnelle soient des moments opportuns de prise de décision et de collaboration multidisciplinaire en vue de cerner et de limiter l'incapacité, de revoir les objectifs et les attentes thérapeutiques et d'offrir du soutien aux malades, aux dispensateurs de soins et aux aidants naturels. Le modèle peut également être utile en éducation et en recherche en tant que cadre conceptuel.


Corresponding author

Requests for offprints should be sent to: / Les demandes de tirés-à-part doivent être adressées à: Susan Slaughter, R.N., M.Sc(A), Ph.D(c)., Senior Research Associate, Primary Care Research and Development Group, Department of Family Medicine, University of Calgary, 1635, 1632–14 Ave NW, Calgary, AB T2N 1M7. (


Hide All

This work is funded in part by a Ph.D. studentship held by the first author from the Alberta Heritage Foundation for Medical Research. We acknowledge and appreciate the review and comments made on earlier drafts of the paper by Marlene Reimer, R.N., Ph.D., Neil Drummond, Ph.D., and the anonymous reviewers; however, the views expressed in this paper are those of the authors and not necessarily those of our reviewers.



Hide All
Aguero-Torres, H., Qui, C., Winblad, B., & Fratiglioni, L. (2002). Dementing disorders in the elderly: Evolution of disease severity over 7 years. Alzheimer Disease and Associated Disorders, 16(4), 221227.
Albert, M., & Cohen, C. (1992). The test for severe impairment: an instrument for the assessment of patients with severe cognitive dysfunction. Journal of the American Geriatrics Society, 40, 449453.
Albert, S.M., Jacobs, D.M., Sano, M., Marder, K., Bell, K., Devanand, D., et al. (2000). Longitudinal study of quality of life in people with advanced Alzheimer's Disease. American Journal of Geriatric Psychiatry, 9(2), 160168.
Allen, N.H., Burns, A., Newton, V., Hickson, F., Ramsden, R., Rogers, J., et al. (2003). The effects of improving hearing in dementia. Age and Ageing, 32, 189193.
Ashford, J.W., & Schmitt, F.A. (2001). Modeling the time-course of Alzheimer dementia. Current Psychiatry Reports, 3, 2028.
Baltes, M.M. (1996). The many faces of dependency in old age. Cambridge, UK: Cambridge University Press.
Baltes, M.M., Burgess, R.L., & Stewart, R.B. (1980). Independence and dependence in self-care behaviours in nursing home residents: An operant-observational study. International Journal of Behavioral Development, 3, 489500.
Barberger-Gateau, P., Alioum, A., Peres, K., Regnault, A., Fabrigoule, C., Nikulin, M., et al. (2004). The contribution of dementia to the disablement process and modifying factors. Dementia and Geriatric Cognitive Disorders, 18, 330337.
Barton, E.M., Baltes, M.M., & Orzech, M.J. (1980). Etiology of dependence in older nursing home residents during morning care: The role of staff behaviour. Journal of Personality and Social Psychology, 38(3), 423431.
Berg, L. (1988). Clinical dementia rating (CDR). Psychopharmacology Bulletin, 24, 637639.
Bourgeois, M.S., Dijkstra, K., Burgio, L.D., & Allen, R.S. (2004). Communication skills training for nursing aides of residents with dementia: The impact of measuring performance. Clinical Gerontologist, 27(1/2), 119138.
Bridges, W. (1980). Transitions: Making sense of life's changes. Boston, MA: Addison-Wesley.
Brodaty, H., & Gresham, M. (1989). Effect of a training programme to reduce stress in carers of patients with dementia. British Medical Journal, 299, 13751379.
Brody, E.M., Kleban, M.H., Lawton, M.P., & Silverman, H.A. (1971). Excess disabilities of the mentally impaired aged: Impact of individualized treatment. Gerontologist, 11, 124133.
Cohen-Mansfield, J., Werner, P., Culpepper, W.J., & Barkley, D. (1997). Evaluation of an inservice training program on dementia and wandering. Journal of Gerontological Nursing, 23(10), 4047.
Cohen-Mansfield, J., Werner, P., & Reisberg, B. (1995). Temporal order of cognitive and functional loss in a nursing home population. Journal of the American Geriatrics Society, 43, 974978.
Connell, B.R., & McConnell, E.S. (2000). Treating excess disability among cognitively impaired nursing home residents. Journal of the American Geriatrics Society, 48(4), 454455.
Dawson, P., Kline, K., Crinklaw-Wiancko, D., & Wells, D. (1986). Preventing excess disability in patients with Alzheimer's disease. Geriatric Nursing, 7, 289301.
Dawson, P., Wells, D.L., & Kline, K. (1993). Enhancing the abilities of persons with Alzheimer's and related dementias: A nursing perspective. New York: Springer.
Eisdorfer, C., Cohen, D., Paveza, G.J., Ashford, J.W., Luchins, D.J., Gorelick, P.B., et al. (1992). An empirical evaluation of the Global Deterioration Scale for staging dementia. American Journal of Psychiatry, 149(2), 190194.
Espiritu, D.A.V., Rashid, H., Mast, B.T., Fitzgerald, J., Steinberg, J., & Lichtenberg, P.A. (2001). Depression, cognitive impairment and function in Alzheimer's disease. International Journal of Geriatric Psychiatry, 16, 10981103.
Feldman, H., Sauter, A., Donald, A., Gelinas, I., Gauthier, S., Torfs, K., et al. (2001). The disability assessment for dementia scale: A 12-month study of functional ability in mild to moderate severity Alzheimer disease. Alzheimer Disease and Associated Disorders, 15(2), 8995.
Fick, D.M., Agostini, J.V., & Inouye, S.K. (2002). Delirium superimposed on dementia: A systematic review. Journal of the American Geriatrics Society, 50, 17231732.
Fougeyrollas, P., Noreau, L., Bergeron, H., Cloutier, R., Dion, S.A., & St-Michel, G. (1998). Social consequences of long-term impairments and disabilities: Conceptual approach and assessment of handicap. International Journal of Rehabilitation Research, 21, 127141.
Glass, T.A. (1998). Conjugating the “tenses” of function: Discordance among hypothetical, experimental, and enacted function in older adults. Gerontologist, 38(1), 101112.
Green, C.R., Mohs, R.C., Schmeidler, J., Aryan, M., & Davis, K.L. (1993). Functional decline in Alzheimer's disease: A longitudinal study. Journal of the American Geriatrics Society, 41, 654661.
Haupt, A., Karger, A., & Janner, M. (2000). Improvement of agitation and anxiety in demented patients after psychoeducative group intervention with their caregivers. International Journal of Geriatric Psychiatry, 15, 11251129.
Hébert, R., Lévesque, L., Vézina, J., Lavoie, J.P., Ducharme, F., Gendron, C., et al. (2003). Efficacy of a psychoeducative group program for caregivers of demented persons living at home: A randomized controlled trial. Journal of Gerontology: Social Sciences, 58B(1), S58S67.
Hogan, D.B. (1994). Progression and outcome of patients in a Canadian dementia clinic. Canadian Journal of Neurological Sciences, 21, 331338.
Holtzer, R., Scarmeas, N., Wegesin, D.J., Albert, M., Brandt, J., Bubois, B., et al. (2005). Depressive symptoms in Alzheimer's disease: Natural course and temporal relation to function and cognitive status. Journal of the American Geriatrics Society, 53(12), 20832089.
Hughes, C.P., Berg, L., Danziger, W.L., Coben, L.A., & Martin, R.L. (1982). A new clinical scale for the staging of dementia. British Journal of Psychiatry, 140, 566572.
Katz, S. (1983). Assessing self-maintenance: Activities of daily living, mobility, and instrumental activities of daily living. Journal of the American Geriatrics Society, 31, 721727.
Katz, S., Ford, A.B., Moskowitz, R.W., Jackson, B.A., & Jaffe, M.W. (1963). Studies of illness in the aged: The index of ADL—A standardized measure of biological and psychological function. Journal of the American Medical Association, 185, 914919.
Larson, E.B. (1997). Minimizing excess disability: A common strategy for chronic disease management. Journal of Geriatric Psychiatry and Neurology, 10, 4950.
Lawton, M.P., & Brody, E.M. (1969). Assessment of older people: Self-maintaining and instrumental activities of daily living. Gerontologist, 9, 179186.
Liken, M.A. (2001). Managing transitions and placement of caring for a relative with Alzheimer's Disease. Home Health Care Management and Practice, 14(1), 3139.
Malloy, D.C., & Hadjistavropoulos, T. (2004). The problem of pain management among persons with dementia, personhood, and the ontology of relationships. Nursing Philosophy, 5, 147159.
McKeith, I.G., Galasko, D., Kosaka, K., Perry, E.K., Dickson, D.W., Hansen, L.A., et al. (1996). Consensus guidelines for the clinical and pathologic diagnosis of dementia with Lewy Bodies (DLB): Report of the consortium on DLB international workshop. American Academy of Neurology, 47, 11131124.
Neary, D., Snowden, J.S., Gustafson, L., Passant, U., Stuss, D., Black, S., et al. (1998). Frontotemporal lobar degeneration: A consensus on clinical diagnostic criteria. American Academy of Neurology, 51, 15461554.
Neumann, P.J., Araki, S.S., Arcelus, A., Longo, A., Papadopoulos, G., Kosik, K.S., et al. (2001). Measuring Alzheimer's disease progression with transition probabilities. Neurology, 57, 957964.
Njegovan, V., Man-Son-Hing, M., Mitchell, S.L., & Molnar, F.J. (2001). The hierarchy of functional loss associated with cognitive decline in older persons. Journal of Gerontology: Medical Sciences, 56A(10), M638M643.
Nygard, L. (2004). Responses of persons with dementia to challenges in daily activities: A synthesis of findings from empirical studies. American Journal of Occupational Therapy, 58(4), 435445.
Ostwald, S.K., Hepburn, K.W., & Burns, T. (2003). Training family caregivers of patients with dementia. Journal of Gerontological Nursing, 29(1), 3744.
Phinney, A. (2002). Fluctuating awareness and the breakdown of the illness narrative in dementia. Dementia, 1(3), 329344.
Proctor, R., Burns, A., Powell, H.S., Tarrier, N., Faragher, B., Richardson, G., et al. (1999). Behavioural management in nursing and residential homes: A randomized controlled trial. Lancet, 354, 2629.
Reifler, B.V., Larson, E.B., & Teri, L. (1987). An outpatient geriatric psychiatry assessment and treatment service. Clinics in Geriatric Medicine, 3(1), 203209.
Reimer, M.A., Slaughter, S., Donaldson, C., Currie, G., & Eliasziw, M. (2004). Special care facility compared with traditional environments for dementia care: A longitudinal study on quality of life. Journal of the American Geriatrics Society, 52, 10851092.
Reisberg, B. (1986). Dementia: A systematic approach to identifying reversible causes. Geriatrics, 41(4), 3046.
Reisberg, B. (1988). Functional assessment staging (FAST). Psychopharmacology Bulletin, 24(4), 653659.
Reisberg, B., & Ferris, S.H. (1988). Brief cognitive rating scale (BCRS). Psychopharmacology Bulletin, 24(4), 629636.
Reisberg, B., Ferris, S.H., De Leon, M.J., & Crook, T. (1982). The global deterioration scale for assessment of primary degenerative dementia. American Journal of Psychiatry, 139(9), 11361139.
Rogers, J.C., Holm, M.B., Burgio, L.D., Hsu, C., Hardin, J.M., & McDowell, B.J. (2000). Excess disability during morning care in nursing home residents with dementia. International Psychogeriatrics, 12(2), 267282.
Román, G.C., Tatemichi, T.K., Erkinjuntti, T., Cummings, J.L., Masdeu, J.C., Garcia, J.H., et al. (1993). Vascular dementia: Diagnostic criteria for research studies. Neurology, 43, 250260.
Ryden, M.B. (1998). A theory of caring and dementia. American Journal of Alzheimer's Disease, 13(4), 203207.
Schumacher, K.L., Jones, P.S., Meleis, A.I. (1999). Helping elderly persons in transition: A framework for research and practice. In Swanson, E.A., & Tripp-Reimer, T. (Eds.), Life transitions in the older adult: Issues for nurses and other health professionals (pp. 126). New York: Springer.
Silva-Smith, A.L., & Kovach, C.R. (2006). Positive gain: Rethinking the outcomes of dependency. Journal of Gerontological Nursing, 32(5), 3641.
Slaughter, S. (2000). Dementia education: Staff, families and volunteers report the benefits. Health and Healing (Autumn), 11.
Smith, M., Gerdner, L.A., Hall, G.R., & Buckwalter, K.C. (2004). History, development, and future of the progressively lowered stress threshold: A conceptual model for dementia care. Journal of the American Geriatrics Society, 52, 17551760.
Tanguay, A. (2003). The progressive course of Alzheimer disease: A training tool for caregivers. Geriatrics and Aging, 6(5), 5658.
Volicer, L., Hurley, A.C., Lathi, D.C., & Kowall, N.W. (1994). Measurement of severity in advanced Alzheimer's disease. Journal of Gerontology: Medical Sciences, 49(5), M223M226.
Wald, C., Fahy, M., Walker, Z., & Livingston, G. (2003). What to tell dementia caregivers: The rule of threes. International Journal of Geriatric Psychiatry, 18, 313317.
Walstra, G.J., Teunisse, S., van Gool, W.A., & van Crevel, H. (1997). Symptomatic treatment of elderly patients with early Alzheimer's disease at a memory clinic. Journal of Geriatric Psychiatry and Neurology, 10(1), 3338.
Webster's New Collegiate Dictionary. 1973 Toronto: Thomas Allen.
Wells, D.L., Dawson, P., Sidani, S., Craig, D., & Pringle, D. (2000). Effects of an abilities-focused program of morning care on residents who have dementia and on caregivers. Journal of the American Geriatrics Society, 48(4), 442449.
World Health Organization (2001). International Classification of Functioning, Disability and Health. Retrieved 19 July 2006 from



Full text views

Total number of HTML views: 0
Total number of PDF views: 0 *
Loading metrics...

Abstract views

Total abstract views: 0 *
Loading metrics...

* Views captured on Cambridge Core between <date>. This data will be updated every 24 hours.

Usage data cannot currently be displayed