Effect of Alzheimer's Training on Multicultural Personal Care Aides

This article reports on the first 2 years of an ongoing project that examined the efficacy of a 10-hour dementia training provided to entry-level personal care aide (PCA) trainees from the Hispanic, White, African American, and Asian communities in New York City. Participants were enrolled in a 90-hour PCA training program offered by the New York City Department for the Aging and were either recipients of public assistance, displaced employees from September 11, or recent immigrants to the United States from China. Classes were conducted in Spanish, English, and Mandarin/Cantonese. An 11-item Knowledge of Alzheimer's Disease instrument was developed for the purposes of this project and administered before and after the dementia training and at 3 months following graduation. All groups, regardless of language, showed a significant increase in knowledge of Alzheimer's disease at the conclusion of the training and retention of this knowledge at 3 months follow-up. Age was strongly correlated with an increase in knowledge, while gender and education were not.

Keywords: home care; Alzheimer's disease; multicultural; training

The projected growth in the numbers of older adults in the United States by 2050 will include a significant increase from the current 4.5 million individuals with Alzheimer's disease to an estimated 12 million (Wilmoth & Longino, 2006). The care and management of persons with dementia of the Alzheimer's type requires a specialized knowledge and understanding of home care provision. This project examined the efficacy of efforts by the New York City Department for the Aging (DFTA) to enhance the capabilities of ethnically diverse trainees enrolled in the department's WEP/BEGIN program to train personal care aides (PCAs). It involved a 10-hour dementia training designed to increase trainees' factual and practice knowledge of Alzheimer's disease. The project also examined associations between trainee sociodemographic characteristics and increased knowledge about Alzheimer's disease. A secondary intent of the training was to foster development of a culturally competent direct care workforce by providing trainees with the opportunity to enhance their marketability and subsequent earning power.

The expectancy-value theory of achievement motivation (Atkinson & Raynor, 1978, in Glynn, Aultman, & Owens, 2005) predicts that learning behavior is motivated by the perceived value of a goal and expectation of attaining that goal, contingent on completion of specified activities. Utilizing this framework, it was hypothesized that the PCA trainee would recognize the applied value of increased Alzheimer's knowledge as demonstrated by self-report and improvement in scores from pretest to posttest and by retention of that knowledge at the 3-month follow-up.

LITERATURE REVIEW

The literature on aging is replete with forecasts of an increased population within the next 30 to 40 years (Berkman, Gardiner, Zodikoff, & Harootyan, 2006; Knickman & Snell, 2002; U.S. Census Bureau, 2005). By 2030, the cohort between 65 and 84 years of age and the 85+ cohort are expected to double in number, growing to 72 million and 9.6 million, respectively (U.S. Census Bureau, 2005). The largest percentage of growth will occur in the 85+ age-group (Wang, 2004); by 2050, it is estimated that this oldest cohort will make up 34% of all elderly (Alecxih, 2001). The U.S. Census Bureau also projects that minorities will make up 25% of the elderly population in 2030 (Bonder, Martin, & Miracle, 2001), with notable increases among Hispanics and Asians (Gallagher-Thompson, Solano, Coon, & Are�n, 2003; Herrick & Brown, 1998; Wallace & Lew-Ting, 1992).

A surge in the incidence of Alzheimer's disease is also anticipated (Evans et al., 1989; New York State Department of Health, 2006; Wang, 2004) because the prevalence rate of the disease increases with age. Up to 50% of adults aged 80 and older exhibit some degree of cognitive impairment (Alzheimer's Association, 2004; Anderson, Wendler, & Congdon, 1996). Disproportionate frequency of Alzheimer's disease has been found among Caribbean Hispanics and African Americans (Evans et al., 1989; Tang et al., 2001). Limited information is available on the incidence of Alzheimer's disease in the Chinese population, as stigmatization of the disease in Chinese American communities discourages participation in Alzheimer's research or help-seeking behaviors (Mahoney, Cloutterbuck, Neary, & Zhan, 2005).

It is estimated that caregivers of older persons provide approximately 80% of the assistance needed to maintain them at home (Rosenbaum, Karuza, Katz, & Harazin, 2000). The number of informal caregivers, 2.2 million in 1982 (Anastas, Gibeau, & Larson, 1990), increased to 44.4 million individuals by 2004 (National Alliance for Caregiving & AARP, 2004). The challenges of caring for individuals with Alzheimer's disease have been well documented as caregivers struggle to cope with behavioral changes associated with various stages of the disease (Kuhn, 1990; Souren, Franssen, & Reisberg, 1997). Families frequently draw on their own physical, emotional, and financial resources in an effort to forestall nursing home placement by sustaining the person with dementia in the home (Mittelman et al., 1993; Robinson, Kiesler, & Looney, 2003).

A study of more than 400 caregivers in New York City (Levine et al., 2000) found that more than 58% felt that they were unprepared to care for their family member after a hospital discharge. As the incidence of Alzheimer's increases and as physical and/or cognitive care demands exceed individual and family capacity, the formal caregiving system will play an increasingly important role in providing needed support.

Paraprofessionals are the backbone of the formal care system. They comprise the certified nursing assistants (CNAs), orderlies, home health attendants, and PCAs who provide direct help to individuals with activities of daily living and instrumental activities of daily living. Approximately 600,000 paraprofessionals are employed in nursing homes and assist with bathing, dressing, grooming, feeding, and toileting, while an undetermined number of direct care workers are employed in the home setting (Wilner & Wyatt, 1998). These workers in the home setting are generally employed by a certified home health agency or are independent contractors who additionally shop, cook, and perform light household chores (Paraprofessional Healthcare Institute, 2003).

Close to two-thirds of consumers of paraprofessional services are 75 years of age and older (Alecxih, 2001). The number of elderly needing paraprofessional help is expected to increase exponentially as the population ages and as the model of home- and community-based service provision gathers momentum. In order to meet demand, it is estimated that between 5.7 million and 6.5 million paraprofessionals are needed by 2050 (Department of Health and Human Services & Department of Labor, 2003). Furthermore, given the increasing cultural diversity in the older population and the anticipated increase in Alzheimer's disease as people live longer, this labor force will need to be culturally competent (Alecxih, 2001) and possess some degree of familiarity with Alzheimer's disease and its management.

To develop the workforce to meet this demand, it will be necessary to address factors contributing to an anticipated decrease in the pool of available workers, such as attrition, low wages, lack of incentives, and few opportunities for professional advancement (National Center for Health Workforce Analyses, 2004). It will also be necessary to prepare workers better for the challenges they will encounter in patient care for the elderly.

Very little empirical research has been conducted about direct care workers in the home setting (Stone, 2001), although publications of the Paraprofessional Health Institute have done much to raise awareness about the value of the direct care workforce in general. Evidence-based analyses that address efficacy of dementia training for the home care worker are few. Most studies involving the paraprofessional have been conducted with CNAs in the nursing home or other structured settings.

Two studies described in the literature specifically explored offering dementia training to paraprofessionals in the nursing home environment. Peterson, Berg-Weger, McGillick, and Schwartz (2002) utilized a pretest/posttest/follow-up design to consider the benefits of a dementia course developed by the St. Louis Alzheimer's Association. The 6-hour training for CNAs, nurses, and facility administrators proposed to increase their knowledge of dementia along with their ability to identify nonthreatening approaches to hands-on care and cope with challenging behaviors. Outcome ben-efits were modest, with significance found only for increased knowledge of dementia. Two subscales of a 17-item Dementia Quiz and a Formal Caregiver Stress Index gauged training efficacy.

The second study involved a 6-hour communication skills program aimed at improving the dementia knowledge and caregiv-ing responses of CNAs and at reducing staff turnover (McCallion, Toseland, Lacey, & Banks, 1999). Conducted in three waves (baseline, 3 months, and 9 months), this study additionally looked at improvement in the well-being of nursing home residents as a result of CNA participation in the program. Standardized measures used in this study included a 33-item Knowledge of Alzheimer's Test, the Penn State Mental Health Questionnaire, the Cornell Scale for Depression in Dementia, the Cohen-Mansfield Agitation Inventory, and the Multidimensional Observation Scale for Elderly Subjects. Outcomes were improved caregiving responses and resident well-being as well as reduction in staff turnover. An increased knowledge of dementia was not supported, a finding the authors partially attributed to a training emphasis on behavior management.

A third report examined training intended to increase the home care worker's fundamental knowledge of aging. Researchers in Hawaii recognized the importance of a learning curriculum that validated and empowered the direct care worker new to the field of aging (Braun, Cheang, & Shigeta, 2005). Utilizing adult learning strategies, the curriculum included role playing, use of multimedia, field experience, and group discussion. The study's pretest/posttest design measured increased knowledge of aging, assessment and reporting skills, ability to manage stress, and empathic understanding of the older direct care client. A 20-item What's Your Aging IQ, a 7-point semantic differential attitude scale, and a 20-item five-module posttest supported an increase in overall aging knowledge and improved attitude toward older adults. Participants also affirmed a greater sense of self-esteem and appreciation for the role of the direct care worker by participants. However, since the curriculum touched only marginally on Alzheimer's disease and included nothing about clinical skills, no findings on these dimensions were reported.

Two chapters of the Alzheimer's Association across the country have reported conducting Alzheimer's-specific trainings for the home care worker for many years. In 1989, the New York City Chapter developed a 15- to 20-hour dementia specialist curriculum for home care workers that provided classroom and field experience (Thomas, 1990). This program has since expanded to a 40-hour training, with graduates receiving a certificate of attendance on course completion. In 1998, the Eastern North Carolina Chapter also began offering dementia training to home care workers. While anecdotal feedback has been largely positive, empirical studies have not been conducted to document the efficacy of this project.

In 1991, the George G. Glenner School of Dementia Care in San Diego, California, began providing basic skills training for paraprofessionals with an optional 9-hour dementia care specialist component. The program targeted individuals who were low income, unemployed, or on public assistance. Program success was measured by subjective reports from local nursing homes and home care agencies that hired graduates, with a reported 80% employment rate 6 months postgraduation.

Although there are similarities between the training efforts described in the literature, particularly the Glenner School's, and the subject of this paper, DFTA's conduct of dementia training in the native language of the PCA trainee is unique. There is a void in the literature regarding language-competent dementia trainings. Given the urgency of understanding Alzheimer's disease and its management within the context of a rapidly expanding minority older population, culturally and linguistically competent dementia training of a multiethnic direct care paraprofessional workforce is important.

METHODS

The target population for this project consisted of PCAs working with older adults with Alzheimer's disease-participants in the English, Spanish, and Chinese PCA training classes of the New York City DFTA and New York City Human Resource Administration's BEGIN program. The sampling frame was the roster of participants accepted into the PCA training class from October 2004 through October 2006; inclusion criterion was acceptance into an English, Spanish, or Chinese PCA training class.

A total of 21 classes received training. Seven PCA classes participated in the first year of the study: two English speaking, two Spanish speaking, and three Chinese speaking. In year 2 of the study, a total of 14 PCA classes were conducted: five English speaking, five Spanish speaking, and four Chinese speaking. Participants were assigned to classes by stated language preference.

Procedures

English- and Spanish-speaking individuals were recruited to the WEP PCA training program from the New York City Human Resource Administration's BEGIN Adult Basic Education and ESL Work Experience Program. As recipients of public assistance, these individuals self-selected to participate in PCA training. The Chinese trainees were workers displaced from the garment industry as a result of the September 11 terrorist attacks or recent immigrants to the United States who learned about this training by word of mouth.

Participants were introduced to the purpose of the 10-hour dementia training at a general orientation to the PCA classes and were provided with greater detail on the requirements of participation prior to the start of the dementia training. In the classroom setting and speaking the respective language of members of each class, research staff explained informed consent, participant confidentiality, the three waves of data collection, and instructions for questionnaire completion. Staff also informed participants that they would receive a nominal stipend on return of the 3-month follow-up questionnaire. Participants were reassured that they would still receive the PCA training should they decide not to participate in the study. All PCAs elected to participate.

The dementia training was conducted by a nurse and a social worker contracted through the Alzheimer's Association, New York City Chapter, and nursing staff from the BEGIN program. Classes were conducted in English, Spanish, and Mandarin/Cantonese, which accommodated the dialects of Chinese students. The initial design of the training was 3 days for all classes with concurrent field placement. In year 2, English and Spanish classes completed the dementia training within 2 days, while the Chinese class completed training within 3 days. Instruction involved an experiential mixed-methods use of lecture, video, role play, group exercises, and case discussion. At designated intervals during the field experience, trainees returned to the classroom to discuss questions or concerns with instructors. Each PCA trainee received a certificate of attendance for this aspect of his or her training. Trainees were guaranteed job placement with a home care agency on graduation.

Data were collected through self-administered questionnaires in three waves: prior to the start of the dementia training, on completion of the dementia training, and 3 months after graduation. Research staff remained in the room during completion of pretest and posttest questionnaires and collected completed instruments. The average completion time was 20 minutes. Tests were coded by class, and each participant had a unique identifier known only to one research staff member. The completed questionnaires were secured in a locked file drawer in a different building.

Follow-up questionnaires were mailed to each participant's home with a linguistically appropriate explanatory letter and a stamped, self-addressed envelope in which to return the survey. On receipt of the completed 3-month follow-up questionnaire, participants were mailed a stipend of $5.

Measures

An 11-item Knowledge of Alzheimer's Disease index was created for the purpose of this study and was used at pretest, posttest, and follow-up. The instrument was translated from English into Spanish and Chinese and back translated in order to ensure accuracy of meaning. Index items had face validity and consisted of questions that were developed on the basis of a review of the literature, expert opinion, and consensus. The index was designed to assess overall knowledge of Alzheimer's disease, care provision, communication, and behavior management.

Each item had four answer choices: one correct choice, two incorrect choices, and a choice of "don't know." Each correct choice contributed 1 point toward the total score. The theoretical range of scores was 0 to 11, with 11 indicating a high knowledge of Alzheimer's disease, provision of care, communication, and behavior management. If a respondent selected more than one choice or no choice was indicated, the answer was scored as incorrect and contributed 0 points toward the total score.

At pretest, participants were additionally asked to provide socio-demographic information and to indicate previous experience working with demented persons, prior receipt of formal caregiv-ing training, and length of time since formal caregiving training. Responses were open ended. At posttest, degree of satisfaction with the training was measured by asking if the training was useful to the participants' work as a PCA, if the material was easy to understand, if the participant felt more confident as a PCA because of this training, if the participant would be interested in more dementia training, and if the participant would recommend this training. Responses were agree, not sure, and disagree. Participants were also asked about the perceived helpfulness of the training format of lecture, role plays, video, and handouts; responses ranged from very helpful to not very helpful.

At 3 months, participants were asked if they had cared for anyone with dementia since graduation from the PCA training program, if the participant was currently caring for a person with dementia, if the participant felt the dementia training was helpful in caring for the client, and if the participant had subsequently reviewed any of the material received during training. Response categories were yes, no, and unsure. Space was provided for participants to comment briefly on the perceived value of the training.

RESULTS

Sociodemographics

A total of 144 trainees participated in the project, 37 in the English-speaking classes, 54 in the Spanish-speaking classes, and 53 in the Mandarin/Cantonese classes. All three waves of data collection were completed by 42.5% of participants (61 persons). Close to 32% completed pretest and posttest only. The majority of respondents were female (88.3%), with a mean age of 43.8 years ( SD = 11.3). Slightly more than 10% of participants were between the ages of 60 and 73. More than half the participants were Hispanic (55.8%), and more than one-third, 34.5%, were Asian. Of the remaining participants, 7.1% were Black/African American, and 1.8% were White (1.8%). The majority of respondents had at least some level of high school education (62.3%).

Knowledge of Alzheimer's Disease

The 61 participants who completed all three waves of data collection gained and retained a significant amount of knowledge as a result of the training. The mean index score prior to training was 7.16. This score significantly increased to 9.23 ( p < .001) at posttest and 9.26 ( p < .001) at 3-month follow-up, supporting the hypotheses of improved knowledge of Alzheimer's disease as a result of this training and retention of knowledge from pretest to 3-month follow-up. While posttest and follow-up scores were significant for all classes, Chinese participants scored higher at posttest and at follow-up than did the English- and Spanish-speaking groups.

PCA performance on a question about response to an Alzheimer's client who hits out during bathing illustrates the gain in knowledge. Answer choices were to "Give her a sponge and ask her to help with the bathing" (correct), "Tell her to stop because it's not nice to behave this way," and "Slap her back so she knows how it feels." At pretest, 11.5% answered incorrectly; at posttest and at 3 months, 100% responded correctly.

Although gender and education were not associated with greater knowledge of Alzheimer's disease, there was a strong positive correlation between age and knowledge posttest and follow-up scores, r = .552 and .501, respectively. The older the participant, the higher the knowledge score.

Satisfaction With Training

Although 15% of respondents indicated that they had previously provided care ranging from 1 month to 5 years for older relatives who were cognitively impaired, almost 62% of participants reported no prior dementia training. A little more than three-fourths (79%) viewed the training as being useful to their work as a PCA. Similarly, 77.8% reported that their self-confidence as a PCA increased as a result of this training.

The degree of difficulty in understanding the information as presented was not a barrier to understanding for three-quarters (75%) of the participants. Over three-quarters of the participants viewed lecture, video, and handouts as the most helpful modalities of learning, with role play the least helpful (68%). More than three-fourths of the participants (77.8%) wanted more dementia training, and 76.4% would recommend this training to others. At 3-month follow-up, slightly more than one-quarter (26.7%) of participants had cared for or were currently caring for persons with dementia. The majority of participants (90.7%) viewed the training to be helpful in preparation for their work with dementia clients.

DISCUSSION

Unique features of this study were the provision of dementia training in three languages to meet participants' linguistic preferences and guaranteed employment as PCAs on completion of the program. It is important to note that the PCA trainees recognized the potential value of learning about Alzheimer's disease, as every trainee chose to participate in the offered dementia component. The success of this project was demonstrated by the overall increase in dementia knowledge and its retention at 3 months.

The 2-point increase in average score for all classes speaks to the receptivity of the students as well as to the educators' ability to convey pertinent information adequately. Nonetheless, the higher scores in the Chinese-speaking classes warrant further discussion. It is possible that the 3-day training for the Chinese classes allowed more in-depth exploration of thoughts, questions, and subsequent discussion than the condensed 2-day training of the English- and Spanish-speaking classes, thus reinforcing learning. It is also likely that the additional day of training encouraged better assimilation of material, particularly where there had been no prior experience with dementia. Participants in the English- and Spanish-speaking classes may have felt more fatigued as a result of shorter dementia class time, which was coupled with field placement and clinical skills training.

Inspired by the "teach a man to fish and he eats for life" philosophy, it was hoped that this dementia training would be a catalyst for participants to expand their marketability beyond home care into potentially more stable and lucrative employment situations such as those found in nursing homes or other long-term-care facilities. Although it was beyond the scope of this study to ascertain whether the training actually produced this result, there are grounds for expecting that at least some participants will use the training to further their careers. Since its inception 17 years ago, an estimated 80% of graduates from the BEGIN program have continued their education to become home health aides, with another 10% becoming CNAs or LPNs. One PCA founded and maintains her own home care agency in Puerto Rico.

Of interest was the range in age of participants. Enrollment of trainees in their 20s, 30s, 40s, and even 50s could have been anticipated. While there were only 10 participants in the 60-73 age-group, the presence of older adults in the training group was nevertheless unexpected because direct care work is physically demanding and to begin a career of this nature later in life is unusual.

These older PCAs bear witness to a change in the aging population with implications for the direct care workforce. Active older adults are seeking postretirement jobs or continuing employment in greater numbers than ever before. At the same time, increasing longevity, coupled with a declining birthrate, makes it apparent that there will be more individuals in need of care than there will be persons available to provide that care into the foreseeable future. The participation of older persons in the PCA dementia training suggests that it may be advantageous to look to the older worker to provide an appreciable amount of the care needed by frail elderly in the coming years. Older workers' sense of responsibility to their community and their personal understanding of the aging process can bring added value to their participation in the direct care workforce.

Limitations

In preparing for this project, the challenges presented by its multilingual focus soon became clear. Identification of linguistically proficient trainers from the non-English-speaking communities with a working knowledge of Alzheimer's disease, the skills to convey that knowledge, and the availability of time to participate was the first hurdle. Ultimately, two nurses employed by the BEGIN program were trained to conduct the training by the local chapter of the Alzheimer's Association.

Locating culturally appropriate and validated measures of dementia knowledge was a challenge that remained unresolved. Investigation highlighted the enormous lack of culturally relevant and language-specific instruments available for replicable research in this area. Despite the precaution of back translating the Knowledge of Dementia index, it became clear from a number of responses in the first year that one particular question in all three languages warranted modification for greater clarity of understanding. This change was made at the beginning of year 2.

Possible difficulty in conceptual understanding, observed in select responses to two other questions on the Knowledge of Alzheimer's Disease index, was noted with several trainees in the English-speaking classes. It is likely that these individuals were linguistically stronger in Spanish, although they chose to participate as English speakers.

Not all PCA trainees completed all three waves of data collection, as some participants arrived in the classroom after testing began or did not return the survey.

It had been anticipated that the majority of participants would provide care for clients with dementia during the course of their employment, but only slightly more than one-quarter of the PCAs were found to have done so between graduation and 3-month f ollow-up. As there was no subsequent contact with participants, it is unknown if this percentage has changed.

Implications

The importance of developing a dementia-trained, culturally competent home care workforce cannot be overstated. Home care providers properly trained to support the efforts of family caregivers are vital. As the trend moves away from long-term services in institutional settings and toward community-based care, it is imperative that home care professionals be prepared to provide optimum care for their current and future clients.

Training about cultural issues must be part of this preparation. Provision of service in a linguistically and culturally competent manner can lead only to improved quality of care (DeSavorgnani & Haring, 1999) and better psychological health of the caregiving family (Janevic & Connell, 2001) since caregivers are more likely to accept help from outside the family system when it comes in the form of a qualified individual who shares the cultural understanding and linguistic nuances of the client. It is equally important that training itself meet the linguistic needs of the trainees who will be providing this care.

Preparation must also include a dementia component. Although continuing education is required for all health care workers, Alzheimer's disease and associated behavior management techniques are generally not among the mandated topics. Training to enhance direct care worker's knowledge of and ability to manage the symptoms of Alzheimer's disease needs to be routinely incorporated into the educational curriculum provided to all health care workers. To sustain the knowledge and employability gained from training, the recommendation offered by McCallion et al. (1999) to conduct booster training sessions for paraprofessionals at regular intervals merits consideration.

Further research is necessary to identify training content and methods best suited to achieving better outcomes for workers and, by extension, clients and family. Replication of multilingual education projects involving PCAs, such as that described by this project, will lead to further refinement of content, format, and evaluation methodology and possible expansion of dementia training to other types of paraprofessionals who provide care in the home. One of the difficulties facing researchers in this regard is the challenge of establishing replicable study conditions for home care workers in particular. Nonetheless, in order to validate the different aspects of training usefulness, viable research designs must be developed.

Additional areas for further research include the creation of valid and reliable linguistic- and culture-specific measures of Alzheimer's disease and associated spheres of knowledge, perception, functioning, and well-being relative to client, worker, and family.

Another important focus is the role of older persons in the direct care workforce. Creating conditions conducive to training and employing this valuable resource makes political and economic sense. Investigation is needed to understand better how to accommodate their needs and make the best use of their contribution.

This project was a win-win for all stakeholders, as individuals received the tools to enable them to rely less on government assistance and move toward becoming independent, self-sufficient members of a valuable workforce. State and local governments reduced the number of individuals on public assistance, persons previously unemployed found employment, and older adults dependent on assistance from others acquired home care workers with enhanced ability to provide high-quality services.

The stories of personal heroism in overcoming numerous social and economic obstacles to participate in this program and the sight of very proud family members on graduation day spoke volumes about the meaning of this training to the graduates and their families. With a 91% retention rate of trainees employed from this project 3 months after graduation, it is clear that there is a humanitarian and economic interest in continuing to prepare an elder-responsive workforce.

[Reference]

REFERENCES

Alecxih, L. (2001, Spring). The impact of sociodemographic change on the future of long-term care. Generations, 7-11.

Alzheimer's Association. (2004). Hispanics/Latinos and Alzheimer's disease. Retrieved February 12, 2007, from http://www.alz.org/national/documents/HispanicReportEnglish.pdf.

Anastas, J., Gibeau, J., & Larson, P. (1990). Working families and elder-care: A national perspective in an aging America. Social Work, 35 (5), 405-411.

Anderson, M., Wendler, M., & Congdon, J. (1996, November). Entering the world of dementia: CNA interventions for nursing home residents. Journal of Gerontological Nursing, 31-37.

Atkinson, J., & Raynor, J. (1978). Personality: Motivation and achievement. Hoboken, NJ: Wiley.

Berkman, B., Gardiner, D., Zodikoff, B., & Harootyan, L. (2006). Social work and aging in the emerging health care world. Journal of Geron-tological Social Work, 48 (1/2), 203-217.

Bonder, B., Martin, L., & Miracle, A. (2001, Spring). Achieving cultural competence: The challenge for clients and healthcare workers in a multicultural society. Generations, 35-42.

Braun, K., Cheang, M., & Shigeta, D. (2005, February). Increasing knowledge, skills, and empathy among direct care workers in elder care: A preliminary study of an active-learning model. The Gerontologist, 45 (1), 118-124.

Department of Health and Human Services & Department of Labor. (2003, May 14). The future supply of long-term care workers in relation to the aging baby boom generation. Retrieved September 2, 2006, from http://www.directcareclearinghouse.org/l_art_det.jsp?res_ id=59410

DeSavorgnani, A., & Haring, R. (1999, April). The impact of cultural issues on home care personnel and patients. Caring, 22-27.

Evans, D., Funkenstein, H., Albert, M., Scherr, P., Cook, N., Chown, M., et al. (1989). Prevalence of Alzheimer's disease in a community population of older persons: Higher than previously reported. Journal of the American Medical Association, 262 (18), 2551-2556.

Gallagher-Thompson, D., Solano, N., Coon, D., & Are�n, P. (2003). Recruitment and retention of Latino dementia family caregivers in intervention research: Issues to face, lessons to learn. The Gerontologist, 43 (1), 45-51.

Glynn, S., Aultman, L., & Owens, A. (2005). Motivation to learn in general education programs. Journal of General Education, 54 (2), 150-170.

Herrick, C., & Brown, H. (1998). Underutilization of mental health services by Asian-Americans residing in the United States. Issues in Mental Health Nursing, 19, 225-240.

Janevic, M., & Connell, C. (2001). Racial, ethnic, and cultural differences in the dementia caregiving experience: Recent findings. The Gerontologist, 41 (3), 334-347.

Knickman, J., & Snell, E. (2002, August). The 2030 problem: Caring for aging baby boomers. Health Services Research, 37 (4), 849-884.

Kuhn, D. (1990). The normative crises of families confronting dementia. Families in Society: The Journal of Contemporary Human Services, 71 (7), 451-459.

Levine, C., Kuerbis, A., Gould, D., Waliser, M., Feldman, P., & Donelan, K. (2000). A survey of family caregivers in New York City: Findings and implications for the health care system. A United Hospital Fund Special Report, in partnership with the Visiting Nurse Service of New York. New York: United Hospital Fund.

Mahoney, D., Cloutterbuck, J., Neary, S., & Zhan, L. (2005). African American, Chinese, and Latino family caregivers' impressions of the onset and diagnosis of dementia: Cross-cultural similarities and differences. The Gerontologist, 45 (6), 783-792.

McCallion, P., Toseland, R., Lacey, D., & Banks, S. (1999). Educating nursing assistants to communicate more effectively with nursing home residents with dementia. The Gerontologist, 39 (5), 546-558.

Mittelman, M., Ferris, S., Steinberg, G., Shulman, E., Mackell, J., Ambinder, A., et al. (1993). An intervention that delays institutionalization of Alzheimer's disease patients: Treatment of spouse-caregivers. The Gerontologist, 33 (6), 730-740.

National Alliance for Caregiving & AARP. (2004, April). Caregiving in the U.S. Report funded by Metlife Foundation. Washington, DC: AARP; Bethesda, MD: NAC.

National Center for Health Workforce Analyses. (2004). Nursing aides, home health aides and related health care occupations: National and local workforce shortages and associated data needs. Rockville, MD: Health Resources Service Administration.

New York State Department of Health. (2006, January). Alzheimer's disease: Frequently asked questions. Electronic dementia guide for excellence (EDGE) project. Retrieved February 9, 2007, from http://192.135.176.25/diseases/conditions/dementia/alzheimer/alzheimer_qaa.htm

Paraprofessional Healthcare Institute. (2003). Training quality home care workers. A PHI Technical Series Publication. Bronx, NY: National Clearinghouse on the Direct Care Workforce.

Peterson, D., Berg-Weger, M., McGillick, J., & Schwartz, L. (2002). Basic care I: The effect of dementia-specific training on certified nursing assistants and other staff. American Journal of Alzheimer's Disease and Other Dementias, 17 (3), 154-164.

Robinson, K., Kiesler, K., & Looney, S. (2003, November/December). Effect of respite care training on the knowledge, attitude, and self-esteem of volunteer providers. American Journal of Alzheimer's Disease and Other Dementias, 18 (6), 375-382.

Rosenbaum, J., Karuza, J., Katz, P., & Harazin, M. (2000). Long term care. In The future of aging in New York State: Project 2015 (pp. 59-67). Albany: New York State Office for the Aging.

Souren, L., Franssen, E., & Reisberg, B. (1997). Neuromotor changes in Alzheimer's disease: Implications for patient care. Journal of Geriatric Psychiatry and Neurology, 10 (3), 93-98.

Stone, R. (2001, Spring). Research on frontline workers in long term care. Generations, 49-57.

Tang, M., Cross, P., Andrews, H., Jacobs, D., Small, S., Bell, K., et al. (2001). Incidence of AD in African-Americans, Caribbean Hispanics, and Caucasians in Northern Manhattan. Neurology, 56 (1), 49-56.

Thomas, A. (1990). The Alzheimer's Association dementia specialist training program. Pride Institute Journal, 9 (4), 10-15.

U.S. Census Bureau. (2005). 65+ in the United States. Washington, DC: Author.

Wallace, S., & Lew-Ting, C. (1992, September). Cross-cultural medicine a decade later. Getting by at home. Community-based long-term care of Latino elders. Western Journal of Medicine, 157 (3), 337-344.

Wang, D. (2004). Service delivery and research considerations for the 85+ population. Journal of Gerontological Social Work, 43 (1), 5-17.

Wilmoth, J., & Longino, C. (2006). Demographic trends that will shape U.S. policy in the twenty-first century. Research on Aging, 28 (3), 269-288.

Wilner, M., & Wyatt, A. (1998, September 10 &11). Paraprofessionals on the front lines: Improving their jobs, improving the quality of long-term care. Unpublished manuscript.

[Author Affiliation]

Robin C. Fenley, MSW

Sarah J. Bober, MS, MA

Mebane E. Powell, MSW

Jacquelin Berman, PhD

Barbara N. Altman, MSW

[Author Affiliation]

Robin C. Fenley, MSW, is director, Alzheimer's and Caregiver Resource Center, New York City Department for the Aging. Sarah J. Bober, MS, MA, is director, Alzheimer's Grants, Aging in New York Fund. Mebane E. Powell, MSW, is research associate, New York City Department for the Aging. Jacquelin Berman, PhD, is director, Research, New York City Department for the Aging. Barbara N. Altman, MSW, is special assistant, Aging in New York Fund.

Acknowledgments. The authors gratefully thank Edwin M�ndez Santiago, commissioner, New York City Department for the Aging, for his encouragement, support, and leadership in addressing aging issues in a diverse society and the Aging in New York Fund, the Department's not-for-profit arm, for their administrative support. Thanks also to Rebecca Rodriguez, director; Michael Giannadeo, assistant director; and staff of the Work Experience Program, New York City Department for the Aging: Nancy Aponte, Beatriz Fab-regas, Miuhing E. Yuen, and Polly Woodard. Staff of the Alzheimer's and Caregiver Resource Center, New York City Department for the Aging, contributed their translation skills to this project. Gail Evans, senior issues writer for the Department's Public Affairs Office, provided editorial assistance. Finally, ongoing collaboration with the Alzheimer's Association, New York City Chapter, in particular Jed Levine, Della Frazier-Rios, and Paulette Michaud, continues to make this project possible. This project was supported, in part, by grant number 90AZ2791 from the Administration on Aging, Department of Health and Human Services, Washington, DC 20201. Grantees undertaking projects under government sponsorship are encouraged to express freely their findings and conclusions. Points of view or opinions do not, therefore, necessarily represent official Administration on Aging policy.

Correspondence regarding this article should be directed to Robin C. Fenley, MSW, Alzheimer's and Caregiver Resource Center, New York City Department for the Aging, 2 Lafayette Street, 15th Floor, New York, NY 10007. E-mail: rfenley@aging.nyc.gov