As the 21st century approaches, ever-increasing life expectancy and longevity bring into awareness the concerns of an aging population. One of these concerns pertains to the care of patients with Alzheimer's disease (AD). The cause of AD continues to baffle science in spite of its high research priority in recent years. However, while we wait for science to discover both causative and curative factors, the illness continues to take its toll, placing the burden of care on the families of those stricken. The increased responsibility for care of dementia patients by families in the community calls for interventions that reduce family stress and provide support for caregivers who manage the behavioral manifestations of the dementia.

This article addresses some of the scientific, conceptual, and technical impediments to the timely progress of research on the topics discussed in the workshop. This is a young field of scientific exploration. Most of what has been accomplished thus far is a series of efforts at descriptive research; little truly experimental research has been published. There is, however, abundant information on the methodologic difficulties and other dilemmas encountered in these research efforts in a recent special issue of Alzheimer's Disease and Associated Disorders (Holmes et al., 1994).

Behavioral symptoms are those that diminish the quality of life for either the individual with the symptoms or for that individual's care provider. These symptoms may be very obvious, as in hitting oneself and others, or less obvious, as in emotions that appear to be fear or anguish. Behavioral symptoms need to be understood in a cultural and ethical context that examines terms and approaches from multiple perspectives. For example: To whom is behavior disruptive? Is there any positive value in disruption?

Behavioral and environmental approaches to the treatment and management of Alzheimer's disease (AD) have received increasing attention by both researchers and clinicians over the previous 10 years. Although the impact of the behavioral consequences of the disease on both the victim and the caregiver has been recognized, effective approaches for managing these behavioral consequences have only just begun to be studied and applied in practice. Current knowledge regarding treatment and management of the behavioral symptoms of AD has developed primarily as a result of trial and error on the part of caregivers and the application of effective interventions from other areas of clinical practice (e.g., behavioral symptoms of mental illness and other neurological disorders).

There is a need for more rigorous evaluation research on existing services for Alzheimer's disease (AD; e.g., specialized day care, respite care, etc.). The needs, resources, and responses of rural caregivers, and the development, implementation, and evaluation of innovative services where they do not exist are of particular interest.

Institutionalized persons with Alzheimer's disease (AD) often demonstrate nonfunctional behaviors such as resistance to dressing and washing, disturbed sleep, restlessness, homesickness, and wandering. If behavior is regarded as emanating from the person with impaired cognition interacting with his or her environment, the environment is found to have a very significant impact on retaining functional capacity. For example, studies have demonstrated how behaviors described as wandering and homesickness strongly relate to events and objects in the environment (Zingmark et al., 1993). The context or environment contributes to the success or failure of behavioral strategies. The goal in dementia care must be to have a positive impact on functional behavior. One consequence of this is that functional behavior can be altered, within limits, through environmental strategies.

The relationship between a demented patient and his or her caregiver is an important aspect of the patient's environment. The interaction between the parties is the basis of their relationship. It stems from their ability to communicate—a very complex process with many different aspects from perception to practice.

The proportion of institutionalized and noninstitutionalized demented people differs among countries. In the Kungsholmen study in Sweden, in the total population 75 years and older, around 50% of the demented people lived in their own homes and 50% lived in various types of institutions. In the future, it may not be possible, for ideological and financial reasons, to build new institutions to take care of the increasing number of dependent and ill elderly. Home care with support for relatives, day care, and collective living are better alternatives for some demented people.

The general aims for the care of the elderly in Sweden are to ensure financial security, good housing, service, and care for the elderly. In this regard, two pieces of recent legislation apply: the Social Service Act of 1982 and the Health and Medical Services Act of 1983. The 1982 act emphasizes the right of the individual to receive public service and help at all stages of life; the 1983 act is intended to maintain a good standard of health and to provide care on equal terms for all. In summary, both laws emphasize that help is to be given to everyone who needs help to support himself or herself in everyday needs. Further, this help should be given in as normal a setting as possible. This means that society should help the elderly to remain in their homes for as long as possible, and that the integrity and autonomy of the elderly should be preserved in the home-care environment.

Dementing disorders such as Alzheimer's disease have an enormous impact on the everyday life of the person affected, on his or her family members, and on the staff involved in providing daily care (Borell, 1992). Cognitive dysfunction resulting from dementing diseases, such as memory problems, interferes greatly with the performance of most activities of daily living. The field of occupational therapy has developed a variety of intervention programs addressing everyday activities for persons with dementia. A review of the relevant literature shows, however, that even if the need for such interventions is acknowledged (Porszt-Miron et al., 1988) and an outline for the intervention is described (Bryant, 1991; Rogers et al., 1987), there are few studies evaluating the efficacy and functional relevance of such interventions. Consequently, one urgent task for research is to identify and evaluate intervention strategies addressing occupational functioning among persons with dementia disorders.