Subject: RFA CA-9l-06 NIH Guide l/25/9l
From: Dot Baker <[email-masked]>
To: [email-masked]
Date: Thu, 24 Jan 91 10:44 EST

Hi Paul,
  The second of five this morning.  Please post to the listserver as:
       RFAAG-91-06.910125
            Thanks.   dottie
 ---------------------------- Text of forwarded message -----------------------
 
REQUESTS FOR COOPERATIVE AGREEMENT APPLICATIONS
 
SPECIAL CARE UNITS FOR ALZHEIMER'S DISEASE
 
RFA AVAILABLE:  AG-91-06
 
P.T. 34; K.W. 0710010, 0715180, 0785035
 
National Institute on Aging
 
Letter of Intent Receipt Date:  February 20, 1991
Application Receipt Date:  April 10, 1991
 
I.  INTRODUCTION
 
The National Institute on Aging (NIA) invites applications for
cooperative agreements (U01) for social and behavioral
research on the impacts of Special Care Units (SCUs).
Special Care Units are defined here as specialized facilities
designed for people with Alzheimer's disease (AD) in long-
term care institutional settings  (e.g., nursing homes, board
and care, assisted living environments, adult day care).  The
impacts of SCUs refer to direct or indirect outcomes of this
form of care on 1) persons with AD and at least one of the
following: 2) family members/caregivers, 3) health care
administrators, 4) staff, and 5) other (non-demented) persons
receiving care in the same institutional settings.
 
This Request for Applications (RFA) supplements, but does not
replace, previous NIA program announcements on related issues
(see NIH Guide for Grants and Contracts Vol. 16, No. 19, June
5, 1987, for Aging and Health Care and Vol. 18, No. 6,
February 24, 1989, for Alzheimer's Disease and Related
Disorders: Issues in Caregiving).  The announcement is
coordinated with relevant programs in the Agency for Health
Care Policy and Research; National Center for Nursing
Research; and National Institute of Mental Health.
 
II.  SCIENTIFIC BACKGROUND
 
It is estimated that Alzheimer's disease and similar
disorders afflict some 4 million American adults (Cross and
Gurland, 1986; Evans et al., 1989) and that 40-60 percent of
nursing home residents suffer from some type of dementia,
primarily Alzheimer's disease (Katzman, 1985; Hu et al.,
1986; Rovner et al., 1990).  As the population ages, this
number may increase dramatically to more than 14 million by
the year 2040.  Because the disease follows a course of
progressive deterioration that often lasts 10-15 years, the
burden of care is extremely heavy and increases as the
afflicted person moves through the several stages of the
disease.  Recent estimates indicate that dementia costs the
American economy nearly $90 billion, with the majority of
costs reflecting the value of the time that relatives spend
caring for patients at home (Hu et al., 1986; Huang et al.,
1988).  Most of the remaining cost of care is associated with
formal care provided by a nursing home.
 
Apart from the costs, institutional care of persons with AD
presents a unique set of problems, including design of the
most appropriate model of care (Buckwalter, 1990). One recent
controversy concerns whether residents with dementia should
be integrated ("mainstreamed") with residents who are not
cognitively impaired, or segregated in a unit designed and
operated specifically for them.  Many nursing home
professionals and researchers agree on the potential benefits
of an SCU  (Johnson, 1989; Kane, 1987; Grossman et al., 1986;
Wolanin and Philips, 1981), although a few writers have argued
the advantages of mainstreaming and questioned the benefits
or need for SCUs (Ohta and Ohta, 1988; Chafetz and West,
1987; Rabins, 1986; Salisbury and Goehner, 1983).  While over
1500 of this country's nursing homes are known to have
established such units over the last decade, this number
represents only about 7.5 percent of all the institutional
facilities for people with AD.  This means that over 90
percent of nursing homes have no such unit at this time (Leon
et al., 1990).
 
Nevertheless, interest in the SCU concept among nursing home
administrators and staff appears high, and new units are
being established so rapidly that the number is expected to
double by 1991 (Leon et al., 1990).  However, few studies
have attempted to determine what patterns of care in SCUs
produce the best results, and results so far identified are
often mixed or disappointing (Chafetz and West, 1987; Mathew
et al., 1988).  Thus, research is needed to specify the
outcomes for persons with AD and the different participants
in their care as a function of the features of SCUs.
 
III.  SPECIFIC OBJECTIVES AND METHODOLOGICAL CONSIDERATIONS
 
The goal of the desired research is to provide systematic
data on outcomes of care in SCUs, and on the factors and
processes associated with particular outcomes.  A further
objective is to develop measures that can be standardized
across studies and subjected to comparable analyses.
 
Specific eligibility requirements for this RFA include:
 
o    Proposed research must be conducted in established SCUs
     (e.g, those that have been in operation for at least six
     months).
 
o    Investigative teams must have prior experience in
     conducting health care research in demented populations.
 
o    Consideration of outcomes in persons with AD and at
     least one other participant in care (e.g., family
     members, health care administrators, staff, or other
     non-demented persons receiving care).
 
Scientific Focus.  The focus of the research is on the
outcomes of care in SCUs, and on the factors and processes
producing particular types of outcomes.
 
     Outcomes must refer to persons with Alzheimer's disease
     and also to one or more sets of participants in care
     (e.g, the administrators or staff of the institution,
     family caregivers, or other non-demented residents).
 
     Factors affecting outcomes may include characteristics
     of the institution (e.g., proprietary/non-proprietary,
     size, physical setting, administrative policies,
     staffing patterns) or characteristics of persons with
     AD as residents of the institution
     (e.g., socio-economic status, personal preferences,
     stage of the disease and presence of behavioral
     disorders, family availability, and support).  The effects
     of the unique characteristics of AD and changes in the
     progress of the disease are especially important
     factors.
 
     Processes concern how the outcomes are produced,
     including the effects of experimental or "natural"
     interventions in the care setting (e.g., changes in
     activity or family programs, in environmental design, or
     in staff training); or including the complex
     interactions among different participants in care (e.g.,
     how administrative policies, by controlling family
     visiting, in turn affect the person with AD).
 
Research Methods.  The research should make use of the most
up-to-date theories, knowledge, and empirical procedures and
may draw from the areas of aging, dementia, health services
research, and behavioral and social sciences generally (e.g.,
sociology, psychology, economics, anthropology).
 
     A range of research designs is acceptable, depending on
     the study objective, including:  in-depth ethnographic
     studies of single institutions; analyses of large
     samples of institutions; or experimental manipulation to
     test the effects of varying specific aspects of care.
 
     The level of analysis requires special attention.  Some
     studies will be based on the institution as the research
     case but will also require analysis of individual
     characteristics.  Other studies will be based on
     individuals as the research case and will treat
     characteristics of the SCU as contextual variables
     referring to individuals.
 
     In drawing samples or matching them for comparison,
     samples of institutions should take into account such
     characteristics as case-mix or regulatory arrangements;
     whereas samples of individuals with AD
     should take into account such characteristics as the
     level of function, diagnosis and severity of the
     disease, educational level, or history of care.
 
     Measurement instruments to be used on persons with
     AD must be validated on cognitively
     impaired residents of long-term care facilities.  The
     development and testing of new measures may be required
     for particular research questions.
 
Investigator Coordination.  To achieve standardization and
comparability in research design, sampling, data collection,
measurement, and analysis of the research approaches that
each investigator presents, cooperative agreement awardees
will meet periodically with the Program Administrator and
other awardees (see terms and conditions under description of cooperative
agreement mechanism in Section V).
 
IV. EXAMPLES OF SPECIFIC RESEARCH QUESTIONS
 
Possible research questions the applicant may elect to
address are illustrated below.  These are examples only.
Applicants are welcome to pose other research questions.  The
only requirement is that the outcome focus on the person with
AD and on either family caregiver or health
care staff, or on non-demented residents.
 
1.  Persons with AD being cared for in an SCU
compared with a regular unit in the long-term care
institution.
 
o    What differences in health and functional status can be
     observed in the residents' a) physical functioning, b)
     cognitive abilities, c) life satisfaction and emotional
     status, d) social behavior, e) incidence of falls or
     injuries, or f) primary or secondary symptoms of the
     disease (e.g., wandering, agitation, belligerence,
     screaming, inappropriate sexual behavior)?
 
o    What dynamics, processes, interventions influence
     different phenomena and outcomes in areas such as (a) to
     (f) above?
 
o    What aspects of the SCU matter most to persons with
     Alzheimer's diseases?  What matter least?
 
o    How does the impact of the SCU vary with co-existing
     morbidities and stage of AD?  How does this impact
     change over the clinical course of the disease?
 
o    How does movement of the person with AD
     through the health system affect experiences with the
     SCU and, in turn, how do different experiences in the
     SCU affect the person's movement through the health care
     system?
 
2.  Family caregivers of persons with AD
being cared for in an SCU compared with those in a regular
unit.
 
o    How readily do family caregivers accept placement in an
     SCU?  How satisfied are they with this form of care?
     What particular aspects of care are judged most
     satisfactory? What are least satisfactory?
 
o    How does SCU placement affect the family caregiver's
     quality of life, morale, general functional status,
     relations with staff, and interactions with persons with
     AD?
 
3.   Administrators or managers of the SCU
 
o    What role do SCUs play in the hiring practices and staff
     retention of the long-term care institution?
 
o    How do SCUs influence administrators' ability to track
     and monitor nursing care (with consideration of new
     federal nursing home guidelines)?
 
o    How does the SCU affect the overall efficiency of
     operation?
 
4.   Professional or nonprofessional staff of the SCU
 
o    How do SCUs affect staff morale, work behavior, and
     effectiveness compared with those of similar staff not
     working in the SCU?
 
o    From the point of view of staff, what aspects of the SCU
     are most satisfactory?  What are least satisfactory?  Why?
 
o    What is the impact on the staff outside the SCU
     of having persons with AD treated
     in a specialized unit?
 
5.   Non-demented residents in institutions containing SCUs
     compared with those in institutions without SCUs.
 
o    Do non-demented residents feel relieved of the daily
     aggravation of having to live and interact with peers
     who are not mentally intact?   Are they less anxious
     about possible deterioration of their own mental and
     physical condition?
 
o    To what extent is dementia more or less stigmatized and
     feared when its victims are segregated, even if for
     special care?
 
6.   The dynamic interactions among the different
     participants in care (topics 1 through 5 above).
 
o    How does the SCU affect staff-family relations as these,
     in turn, influence resident outcomes?
 
o    How do patient-family interactions in the SCU affect
     staff morale and functioning?
 
o    How do different patterns of family involvement
     influence program operation and resident outcomes either
     positively or negatively?
 
o    How are the effects of administrative policies on
     residents with AD mediated by staff
     behavior?
 
V. MECHANISMS OF SUPPORT
 
Cooperative Agreement:  The administrative and funding
mechanism to be used to support these awards will be
Cooperative Agreements between each awardee and NIA.
Assistance via a Cooperative Agreement differs from the
traditional research grant in that, in addition to the normal
programmatic and administrative stewardship responsibilities,
the component awarding the Cooperative Agreement anticipates
substantial programmatic involvement during performance of
the project.  However, the applicant institution must define
its objective in accord with its own interests in social and
behavioral research on the impacts of SCUs and must develop
the details of the research design following the guidance
given in this RFA.  It is the primary responsibility of the
Principal Investigator to clearly state research objectives
and approaches, to plan and conduct the research stipulated
in the application, and to ensure that the results obtained
are analyzed and published in a timely manner.  The data
obtained will be the property of the awardee.
 
The impacts of SCUs is a relatively new research area.  The
nature and structure of SCUs, as well as the identification
and measurement of relevant sociodemographic, health and
functioning variables for AD residents, family members,
administrators and staff, and other non-demented care
residents, need to be assessed.  The need for significant
programmatic involvement results from an effort to maximize
the information obtainable from the set of funded projects.
The involvement of the designated Program Administrator will
center on assisting with the: 1) study design and protocol;
2) the elements of care being tested; and 3) the outcomes
being measured.
 
During performance of the award, the NIA Program
Administrator may provide assistance in the design of group
activities, the selection of sources or resources,
replacement of staff, the collection and/or analysis of
data, and the preparation of publications.  However, the role
of NIA will be to facilitate and not to direct the
activities.  It is anticipated that decisions in all
activities outlined below will be reached by consensus of the
group and the NIA Program Administrator will be given the
opportunity to offer input to this process.  The manner of
reaching this consensus and the final decision-making
authority will rest with the Principal Investigators.
 
The designated Program Administrator will meet with the
Principal Investigators and key staff three times in the
first year and every six months thereafter to assist in protocol
development, standardization of key measurements, and
appropriate analysis techniques.  Applicants should request
support for such travel in their proposals.  It is our
experience that four to six months of time at the beginning
of the study will be needed to assist with standardizing
definitions and measurements across sites.  This should be
indicated in the individual project's timelines.
 
Additionally, each applicant should nominate and budget funds
for one outside expert to serve on an Advisory Panel for this
set of projects.  The Advisory Panel, consisting of expertise
in aging, AD, behavioral and social
sciences, health services research, biostatistics, and ethics
will be nominated at the first meeting of the Principal
Investigators.  The composition and selection of this
Advisory Panel will be discussed and voted on by the
Principal Investigators.
The Program Administrator will seek scientific expertise from the
Advisory Panel as needed.
 
Budgetary Considerations
 
o    This initiative seeks to fund 4-6 research projects.
 
o    Total costs for each project should not exceed $250,000
     in the first year.
 
o    Depending on scientific merit, we anticipate spending up
     to $1,000,000 on these projects.
 
o    This RFA is a one-time solicitation.  In addition to FY
     1991 awards, other proposals responding to this RFA may
     be funded in Fiscal Year 1992, depending on quality of
     proposals and availability of funds.  Issuance of awards
     pursuant to this RFA is contingent on the availability
     of funds for this purpose.
There is not intention to change the mechanism after award.
 
Cooperative Agreements are subject to the same administrative
requirements as grants.  Projects will be supported by the
Research Project (Cooperative Agreement) (UO1) mechanism.
The regulations (Code of Federal Regulations, Title 42, Part
52 and Title 45, Part 74) and policies that govern the
research grant programs of the PHS will prevail.  The
awarding of funds pursuant to this RFA is contingent on
availability of funds.  All pertinent DHHS, PHS, and NIH grant
regulations, policies and procedures are applicable.
Business management aspects of these awards will be
administered by the NIH in accordance with DHHS and PHS grant
administration requirements.
 
VI. REVIEW PROCEDURES AND CRITERIA
 
Applications will be received by the NIH Division of Research
Grants and will be assigned to the NIA.  Responsive
applications will be assigned to a special Institute review
group for review.  Proposals judged by the NIA to be non-
responsive (those not directed at the goals of this RFA) will
be administratively withdrawn and returned to the applicant
without review.  Proposals may first receive a preliminary
review by a subcommittee of the review panel to establish
those applications deemed to be competitive.  Those proposals
judged non-competitive will be so designated, and an
abbreviated summary statement noting the major areas of
concern will be sent to the Principal Investigator.
Applications judged to be competitive will be given full
review.  Following review by the initial review group, the
applications will be considered by the National Advisory
Council on Aging.
 
Listed below are the major review criteria to be used in the
evaluation of the applications received in response to this
RFA:
 
o    scientific merit of the research proposed.
 
o    significance of the research project to the goals
     of the RFA.
 
o    appropriateness and adequacy of the experimental
     approach and methodology proposed to carry out the
     research
 
o    qualifications, experience, and commitment of the
     investigators and their ability to devote the
     required time and effort to the project.
 
o    appropriateness of the total budget and budgetary
     requests.
 
o    institutional commitment to the requirements of the
     project.
 
o    adequacy of inclusion of women and minorities
 
VII.  SPECIAL INSTRUCTIONS TO APPLICANTS REGARDING IMPLEMENTATION OF
NIH POLICIES CONCERNING INCLUSION OF WOMEN AND MINORITIES IN
CLINICAL RESEARCH STUDY POPULATIONS
 
NIH and ADAMHA policy is that applicants for NIH/ADMHA
clinical research grants and cooperative agreements will be
required to include minorities and women in study populations
so that research findings can be of benefit to all persons at
risk of the disease, disorder or condition under study;
special emphasis should be placed on the need for inclusion
of minorities and women in studies of diseases, disorders and
conditions which disproportionately affect them.  This policy
is intended to apply to males and females of all ages.  If
women or minorities are excluded or inadequately represented
in clinical research, particularly in proposed population-
based studies, a clear compelling rationale should be
provided.
 
The composition of the proposed study population must be
described in terms of gender and racial/ethnic group,
together with a rationale for its choice.  In addition,
gender and racial/ethnic issues should be addressed in
developing a research design and sample size appropriate for
the scientific objectives of the study.  This information
should be included in the form PHS 398 in Section 2, A-D of
the Research Plan and summarized in Section 2, E, Human
Subjects.
 
Applicants/offerors are urged to assess carefully the
feasibility of including the broadest possible representation
of minority groups.  However, NIH recognize that it may not
be feasible or appropriate in all research projects to
include representation of the full array of United States
racial/ethnic minority populations (i.e., Native Americans
(including American Indians or Alaskan Natives), Asian
/Pacific Islanders, Blacks, Hispanics).  The rationale for
studies on single minority population groups should be
provided.
 
For the purpose of this policy, clinical research includes
human biomedical and behavioral studies of etiology,
epidemiology, prevention ( and preventive strategies),
diagnosis, or treatment of diseases, disorders or conditions,
including but not limited to clinical trials.
 
The usual NIH policies concerning research on human subjects
also apply.  Basic research or clinical studies in which
human tissues cannot be identified or linked to individuals
are excluded.  However, every effort should be made to
include human tissues from women and racial/ethnic minorities
when it is important to apply the results of the study
broadly, and this should be addressed by applicants.
 
For foreign awards, the policy on inclusion of women applies
fully; since the definition of minority differs in other
countries, the applicant must discuss the relevance of
research involving foreign population groups to the United
States' populations, including minorities.
 
If the required information is not contained within the
application, the application will be returned.
 
Peer reviewers will address specifically whether the research
plan in the application conforms to these policies.  If the
representation of women or minorities in a study design is
inadequate to answer the scientific question(s) addressed AND
the justification for the selected study population is
inadequate, it will be considered a scientific weakness or
deficiency in the study design and will be reflected in
assigning the priority score to the application.
 
All applications for clinical research submitted to NIH are
required to address these policies.  NIH funding components
will not award grants or cooperative agreements that do not
comply with these policies.
 
VIII.  METHOD OF APPLYING
 
Researchers considering an application in response to this
RFA are strongly encouraged to discuss their project with the
program contacts in advance of formal submission.  Applicants
are strongly encouraged, but not required, to send a letter
of intent giving the title of the proposed project, the
name of the
Principal Investigator and, when known, other key
participants.  This letter should be received by the staff
contacts listed below by February 20, 1991.
 
Applications must be submitted on the standard PHS 398
(revised 10/88 reprinted 9/89) application form (available at
most institutional business offices) and from the Division of
Research Grants, NIH, 301-496-7441.  The deadline for receipt
of applications is April 10, 1991.
 
The RFA label contained in the application kit must be
affixed at the bottom of the face page of the application.
Failure to use this label could delay processing of the
application.
 
On item 2 of the face page of the application, applicants
must enter:  NIA RFA AG-91-06--Special Care Units for
Alzheimer's Disease.  The completed application and four
copies must be sent to:
 
Application Receipt Office
Division of Research Grants
National Institutes of Health
Westwood Building, Room 240
Bethesda, MD  20892**
 
At the same time the application is submitted to the Division
of Research Grants, two
copies of the application must be sent to:
 
Chief, Scientific Review Office
National Institute on Aging
Building 31, Room 5C12
9000 Rockville Pike
Bethesda, MD  20892
 
Failure of these copies to be received by the deadline may
prevent the application from being reviewed under this
announcement in time to be considered for an award as in
NIH Manual 4815.
 
IX. STAFF CONTACTS
 
Potential applicants interested in obtaining further
information may write or call:
 
Program Coordinator
Marcia G. Ory, Ph.D., Chief, Social Science Research on Aging
Behavioral and Social Research Program
National Institute on Aging
Building 31, Room 5C32
National Institutes of Health
Bethesda, MD  20892
Telephone:  (301) 496-3136
 
Alternate Program Coordinator
Neil Buckholtz, Ph.D.
Neuroscience and Neuropsychology of Aging
National Institute on Aging
Building 31, Room 5C35
National Institutes of Health
Bethesda, MD  20892
Telephone:  (301) 496-9350
 
Other institutes and agencies are also interested in research
dealing with AD and related disorders.  For
information concerning related research interests, contact:
 
1)  National Center for Nursing Research
Dr. Patricia Moritz
Building 31, Room 5B09
Bethesda, MD  20892
Telephone:  (301) 496-0523
 
2)  National Institute of Mental Health
Dr. Enid Light
Parklawn Building, Room 11C03
5600 Fishers Lane
Rockville, MD  20857
Telephone:  (301) 443-1185
 
3)  Agency for Health Care Policy and Research
Ms. Linda Siegenthaler
Maxima Building, Room 634
Rockville, MD  20852
Telephone:  (301) 443-6990
 
This program is described in the Catalog of Federal Domestic
Assistance No. 93.866, Aging Research.  Awards will be made
under the authority of the Public Health Service Act, Title
III, Section 301 (Public Law 78-410, as amended; 42 USC 241)
and administered under PHS grant policies and Federal
Regulations 42 CFR Part 52 and 45 CFR Part 74.  This program
is not subject to the intergovernmental review requirements of
Executive Order 12372 or Health Systems Agency review.
 
REFERENCES
 
Advisory Panel on Alzheimer's Disease, Report of the Advisory
Panel on Alzheimer's Disease.  Washington, DC:  Office of
Technology Assessment, 1989.
 
K.C. Buckwalter, Segregating the cognitively impaired: Are
dementia units successful? In Katz, Kane, and Meze (eds.)
Advances in Long-term Care New York: Springer Publishing,
1990, pp. 43-60.
 
P. K. Chafetz and H. L. West, Longitudinal control group
evaluation of a special care unit for dementia patients:
Initial findings.  Presented at the Annual Meeting of the
Gerontological Society of America, Washington, DC, 1987.
 
P. S. Cross and B. J. Gurland, The epidemiology of dementing
disorders.  Contract report prepared for the Office of
Technology Assessment, U. S. Congress, 1986.
 
D. A. Evans, P. A. Scherr, N. R. Cook, M. S. Albert, H. H.
Funkenstein, L. A. Smith, L. E. Hebert, T. T. Wetle, L. G.
Branch, M. Chown, C. H. Hennekens, and J. O. Taylor, Impact
of Alzheimer's disease in the United States population.  In
R. Suzman and D. P. Willis (eds.), The Oldest Old.  London:
Oxford University Press, 1989.
 
H. Grossman, A. S. Weiner, M. J. Salamon, and L. Burros, The
milieu standard for care of dementia in a nursing home.
Journal of Gerontological Social Work, 1986, vol. 9, 73-89.
 
L.F. Huang, W.S. Cartwright, and T.H. Hu, The economic cost
of senile dementia in the United States, Public Health
Reports 1988, vol. 103 (Jan-Feb): 3-7.
 
T. Hu, L. Huang, and W. Cartwright, Evaluation of the costs
of caring for the senile demented elderly:  A pilot study.
The Gerontologist, 1986, vol. 26, 158-163.
 
C. J. Johnson, Sociological intervention through developing
low stimulus Alzheimer's wings in nursing homes.  The
American Journal of Alzheimer's Care and Related Disorders
and Research, 1989, vol. 4, 33-41.
 
R. Kane, Considerations before developing a special care unit
for Alzheimer's patients.  Beyond Folklore III:  Standards of
Care in Managing Alzheimer's Patients.  Symposium conducted
by the University of Minnesota and the Veteran's
Administration, Minneapolis, Minnesota, 1987.
 
R. Katzman, Aging and age-dependent disease:  Cognition and
dementia.  In America's Aging:  Health in an Older Society.
Washington, DC:  National Academy Press, 1985.
 
L. Mathew, P. Sloane, M. Kilby, and R. Flood, What's
different about a special care unit for dementia patients?  A
comparative study.  The American Journal of Alzheimer's Care
and Related Disorders & Research, 1988, 16-23.
 
R. J. Ohta and B. M. Ohta, Special units for Alzheimer's
disease patients.  The Gerontologist, 1988, vol. 28, 803-808.
 
P. V. Rabins, Establishing Alzheimer's disease units in
nursing homes:  Pros & cons.  Hospital and Community
Psychiatry, 1986, vol. 37, 120-121.
 
B. Rovner, et al., The prevalence and management of dementia
and other psychiatric disorders in nursing homes.
International Psychogeriatrics, 1990, vol. 2, 13-24.
 
S. Salisbury and P. Goehner, Separation of the confused or
integration with the lucid?  Geriatric Nurse, 1983, vol. 6,
157-159.
 
M. Wolanin and L. Phillips, Confusion:  Prevention and Care.
St. Louis:  Mosby, 1981.