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. Author manuscript; available in PMC: 2011 Nov 1.
Published in final edited form as: Geriatr Nurs. 2010 Aug 6;31(6):402–411. doi: 10.1016/j.gerinurse.2010.06.001

An Internet-Based Multimedia Education Prototype to Enhance Late-Stage Dementia Care: Formative Research Results*

John V Hobday 1, Kay Savik 2, Joseph E Gaugler 2
PMCID: PMC3057102  NIHMSID: NIHMS272466  PMID: 20691503

Abstract

The goal of this project was to develop a portable, Internet-based multimedia education program (IBME) to provide a more efficient training resource for direct care workers (DCWs) who care for nursing home residents suffering from late-stage dementia. Thirty-four DCWs from eight nursing homes in eight states completed five post-test open-ended questions and 20 Likert items on the feasibility, strengths, and weaknesses of the IBME prototype. Pre- and post-test surveys also examined whether late-stage dementia care knowledge changed significantly. Over 90% of DCWs “agreed” or “strongly agreed” that the IBME prototype improved DCWs’ feelings of competency and everyday care delivery. Open-ended comments offered several suggestions for improvement, including group-based discussion of the modules. Results also found that DCWs’ late-stage dementia care knowledge significantly increased (p < .001) following completion of the IBME modules. The IBME prototype offers an online, ansychronous training strategy to enhance dementia-pertinent knowledge and skills related to everyday care delivery in nursing homes.

Introduction

The progression of dementia (of which Alzheimer’s disease is the most common form) is ominous in that it not only foreshadows progressive loss of independence in the person with dementia, but also represents complex care challenges for caregivers (both family and professional).1,2 In particular, nursing homes (NHs) have seen an increasing prevalence of residents suffering from Alzheimer’s disease (estimated at 47%).3,4 Due to the insidious, long-term decline of dementia, NHs often provide complex care to residents who are in the “late stages” of dementia (or those who require extensive assistance with basic activities of daily living, have difficulty with verbal communication, and suffer from considerable cognitive impairment). The objective of this project was to produce an Internet-based multimedia education (IBME) training resource targeted to direct care workers (DCWs) of persons with late-stage dementia in NHs. This pilot project focused on online content development of best care practices for those in the very latest stages of dementia and preliminary data collection to inform the feasibility of this approach.

The Complexity of Late-Stage Dementia Care

As the prevalence of dementia in residential care settings remains high, so do the expectations placed upon DCWs to provide high quality care and services to those with dementia.5 Even though DCWs deliver the bulk of hands-on care to residents with late-stage dementia, a number of barriers exist when training these professional caregivers including extensive turnover (in some cases as high as 400%), the costs of face-to-face DCW training, and the content of this training (which often focuses on basic dementia education and not advanced topics like late-stage care).4,6

Ideally, appropriate late-stage care for persons with dementia is based on effective psychosocial approaches where the cognitively impaired resident is recognized as a person (i.e., person-centered care).7 Elements of personhood in late-stage dementia are maintained with various techniques, such as communicating by name.8 While person-centered care is the ideal, there exist a number of systemic challenges that prevent the delivery of this psychosocially appropriate form of assistance to persons with late-stage dementia in NHs.9 One barrier includes inadequate staffing and inflexible care routines; declines in quality of NH care over the past 30 years are linked to poor staffing levels.10 Another significant barrier is the lack of educational preparation of DCWs. Direct care workers frequently lack knowledge about dementia and are generally unaware of effective responses to behavioral symptoms, appropriate use of medications, and meeting basic needs such as pain relief.11 Inappropriate caregiving behaviors and care attitudes also impact the delivery of effective late-stage dementia care in NHs. Due in part to lack of training in appropriate psychosocial skills, DCWs are at-risk for engaging in activities that are potentially demeaning or depersonalized. In addition, the belief that a dementia diagnosis strips the resident of their personhood may attenuate DCWs’ views of their professional roles as meaningful.7,8

The goal of this project was to develop an IBME program as a more efficient training option for DCWs who care for NH residents suffering from late-stage dementia. As noted above, challenges of providing quality late-stage dementia care training in NHs include the costs of in-person training and staff turnover. Such concerns may make the provision of intensive late-stage dementia care strategies for DCWs difficult to achieve. It was anticipated that this project would have a fundamental influence on DCWs’ perceptions of the quality of care they deliver to late-stage dementia residents following participation. This pilot project had three specific aims:

  1. To develop the text, video, audio, and photographic components for three prototype late-stage care modules for DCWs, including specific, real-life video examples of how to provide late-stage dementia care in which actual residents and DCWs are filmed;

  2. To examine the feasibility of applying the prototype in NH settings and its potential influence on care delivery; and

  3. To gather preliminary data about the potential influence of the IBME prototype on DCWs’ late-stage dementia care knowledge.

Methods

Content Development

The program content was conceived and developed by the primary author <name blinded,>, <name blinded>’s instructional designer <name blinded>, and a multidisciplinary expert team of consultants (including experts from the Alzheimer’s Association, academia, and geriatric clinical settings) who guided the content-development process. A total of 10 modules were planned, three of which were fully written, reviewed, and approved by key team members and the expert team during this formative research effort. Completion of the remaining seven modules will occur as part of pending larger-scale evaluation of the IBME program. A member of the national office of the Alzheimer’s Association reviewed completed content to provide comments and suggestions.

The IBME prototype was developed as a browser-based computer program using the Adobe® Flash® programming environment. The program is accessible from any Internet-connected computer on either Macintosh® or PC platforms. The program requires a Web browser (such as Internet Explorer® or Netscape®) and a Flash Player® plug-in. If a user does not have the plug-in, the program prompts the user to download it for free. The topics (which were developed in collaboration with expert consultants from academia, the Alzheimer’s Association, and clinical settings) include: 1) Introduction to Dementia; 2) Rethinking Activities; 3) Bathing; 4) Dressing; 5) Food as Comfort; 6) Grooming; 7) Mobility: Transferring and Positioning; 8) Mouth Care; 9) Recognizing and Managing Pain; and 10) Toileting. A three-module prototype including the Introduction to Dementia, Rethinking Activities, and Toileting modules was initially developed and pilot-tested. The three prototype modules contained approximately three hours of content and are accessible at the following Web address: <blinded for review>. The formative research project took place during a 10-month timeframe (June, 2007–April, 2008) in eight facilities in eight states (Minnesota, New York, Massachusetts, Illinois, Arizona, Georgia, Michigan, and Colorado). Pre-test mail surveys were administered prior to viewing the IBME prototype, and DCWs were asked to complete the post-test survey immediately after viewing the IBME program. Direct care workers were asked to view the IBME program on any Internet-connected computer. On average, DCWs spent 2.2 hours completing the IBME modules.

Sample

To recruit research subjects, the first author disseminated an informational email to all project consultants and asked them to circulate to any NHs or professional colleagues, who then promoted the study within their respective facilities. Once subjects were identified at the facility level, they filled out and mailed/faxed a paper informed consent form, which was approved by the University of Minnesota Institutional Review Board (IRB# 504E68756). Sixty-three DCWs were originally approached to participate. Due in part to a five-month delay in prototype development and administrator turnover in three facilities, 29 of these 63 DCWs did not complete post-test surveys. This resulted in a formative evaluation sample of 34 participants, which exceeded the original pilot evaluation sample target (n = 30) and allowed for subsequent pilot analyses. Descriptive sample data are presented in Table 1.

Table 1.

Descriptive Information of Direct Care Worker Sample (N = 34)

Characteristic
Female 85.3%
Race/Ethnicity
 African-American 38.2%
 Caucasian 32.4%
 Latino/Hispanic 2.9%
 Asian 5.9%
 Other 20.5%
Education: Completed High School 88.2%
Education: Attended College 58.8%
Education: Attended Technical School 29.4%
Education: Completed College 32.4%
Age M = 42.7 years
SD = 10.6
Range = 21.0 to 63/0
Length of Employment as a DCW M = 6.3 years
SD = 3.1
Range = .08 to 33.7
Used a Computer Before 85.3%
Took a Previous Training Course Via Computer 47.1%
Have Digital Subscriber Line Internet Access 26.5%
Have Telephone-Based Internet Access 41.2%
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NOTE: M = mean; SD = standard deviation

Of the 29 DCWs who did not complete post-test surveys, 21 completed a pre-test survey allowing for a comparison of attrition. There were no differences in any sociodemographic or background characteristics except completion of high school education; those DCWs who did not complete post-test surveys were less likely to have completed high school (86%) than those who participated in the full evaluation (100%).

Measures

Measures to assess feasibility and late-stage dementia care knowledge were developed for this formative research project by the <name blinded> team to address the outcomes of interest.

Feasibility assessment

A 20-item measure was utilized to examine DCWs’ perceptions of the internet-based training modules. Items ascertained how completion of the training modules influenced feelings of competency pertaining to late-stage dementia care as well as DCWs’ perceptions of how the training modules affected day-to-day care delivery, satisfaction with the IBME prototype, and other issues pertaining to late-stage care delivery (i.e., called the care competency scale). Item responses were completed on a Likert scale ranging from 1 = “Strongly Disagree” to 5 = “Strongly Agree.” The competency scale showed good internal reliability (α = .85).

Several open-ended items also offered the opportunity for DCWs to provide written reflections of their experience using the internet-based training modules. The five open-ended questions were phrased as follows: “What did you like best about this training program;” “What did you like least about this training program;” “How was this training program useful to you in performing your job;” “What suggestions do you have that would make this training program better;” and “If you were recommending the LATE STAGE training program to someone else, what would you tell them about it?”

Knowledge inventory

A 15-item survey was administered to DCWs prior to and following completion of the internet-based late-stage dementia training program. Items included multiple-choice items (with 4 possible answers) that addressed various facets of late-stage dementia care, appropriate activities for persons with late-stage dementia, effective care strategies, and similar domains that were reviewed in the IBME program. A geriatric expert (blinded) who was part of the primary development team developed item content (see Table 2). The inventory showed moderate internal reliability (α = .61).

Table 2.

Knowledge Inventory With Answer Key

Important: Please do not discuss this pre-test with any of your co-workers.

  1. Dementia can affect:

    1. Perception – what you see and hear

    2. Motor skills – physical abilities

    3. Memory – remembering things from the past

    4. All of the above.

  2. The ability to focus, remember a goal or purpose, sequence steps, perform an action, and recognize an object are necessary for:

    1. Successfully performing everyday tasks.

    2. Being admitted to a care facility.

    3. Overcoming dementia.

    4. None of the above.

  3. Which of the following is not typical of a resident with late-stage dementia?

    1. Losing the ability to walk.

    2. Not being able to communicate with words.

    3. Recognizing all important people in his/her life.

    4. Having trouble controlling emotions.

  4. What do the letters “CARES” stand for in the CARES Approach?

    1. Connect with the Resident

      Assess their Health

      Respond Appropriately

      Evaluate What Works

      Share with the Doctor.

    2. Connect with the Resident

      Answer their Concerns

      Request help from the Supervisor

      Evaluate what works

      Share with the family.

    3. Connect with the Resident

      Assess their Behavior

      Respond Appropriately

      Evaluate What Works

      Share with the Team.

    4. Contact the Resident

      Answer their Concerns

      Respond Appropriately

      Evaluate What Works

      Share with the Team.

  5. Which of the following is not a good way to care for residents in the late-stage of dementia?

    1. Pay attention to their nonverbal communication and anticipate their needs.

    2. Use a gentle, reassuring touch.

    3. Tell the resident step-by-step what will be happening as care is provided.

    4. Give the resident several choices while providing care.

  6. Residents with late-stage dementia respond best to:

    1. Group activities.

    2. Formal activities.

    3. Activities with a goal or purpose.

    4. One-on-one interactions.

  7. Which of the following is not an example of a sensory activity appropriate for a resident with late-stage dementia?

    1. A lotion hand massage.

    2. Listening to big-band music from the 1930s.

    3. Playing bingo.

    4. Watching squirrels out the window.

  8. It is hard to get a smile from Mr. Carson. He does not react to very many things. One day a visitor brings in a puppy and you sit with Mr. Carson so that he can pet it. He smiles and laughs and you know that:

    1. This was a meaningful activity for him.

    2. You have finished your responsibilities for the day.

    3. His thinking skills are improving.

    4. None of the above.

  9. Mrs. Tenorio taught pre-school for 25 years. Which of the following may not be a meaningful activity for this former teacher?

    1. Looking at picture books together.

    2. Watching the children play on the playground across the street.

    3. Looking at a magazine with birds and wildlife.

    4. Singing the alphabet song with her.

  10. Mrs. Hall has a tendency to fall asleep after dinner, and then she is up much of the night. A good activity to stimulate her after dinner would be:

    1. Listening to some soothing music.

    2. Having a lotion hand massage.

    3. Singing a song.

    4. All of the above.

  11. Helping a resident to use the toilet and stay dry is important because:

    1. It can save time by not having to clean up the resident or bedding.

    2. Being able to use the toilet helps maintain the resident’s dignity.

    3. An upright and seated position makes it easier to empty the bladder and have a bowel movement.

    4. All of the above.

    5. B and C above.

  12. If a resident suddenly becomes incontinent, or if there is a change in urine color or smell, you should:

    1. Get him/her to a toilet at once.

    2. Start using disposable briefs with the resident.

    3. Report the change to a nurse.

    4. Change the resident’s diet.

  13. Which of the following is not a common sign that a resident with late-stage dementia needs to use the toilet?

    1. He/she looks anxious or nervous.

    2. He/she is sleepy.

    3. He/she is trying to get up out of a chair.

    4. He/she is wandering.

  14. Learning a late-stage resident’s toileting pattern can make it easier to help him/her stay continent. You can learn this pattern by:

    1. Asking the resident.

    2. Keeping a bladder/bowel diary on the resident for 72 hours.

    3. Talking with family members about the resident’s habits.

    4. All of the above.

    5. B and C above.

  15. Which of the following is not a good way to help a resident to stay continent?

    1. Limit fluids.

    2. Take the resident to the toilet on a regular schedule determined by the team.

    3. Help the resident to stay mobile.

    4. Put a photo of a toilet on the bathroom door.

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NOTE: Answer Key:

1. D

2. A

3. C

4. C

5. D

6. D

7. C

8. A

9. C

10. C

11. D

12. C

13. B

14. E

15. A

Analysis

Item frequencies were analyzed on the 20-item competency scale to determine how the late-stage training modules potentially influenced DCWs’ satisfaction, competency, and late-stage dementia care delivery. Open-ended written comments were also compiled and examined to examine feasibility, areas of strength, and weaknesses of the IBME training modules. Correct responses on the 15-item pre-/post-knowledge survey were summed and analyzed to determine whether late-stage dementia care knowledge changed after completion of the internet-based training modules. A paired T-Test was used to analyze whether mean change in knowledge was significantly different from zero (i.e., p < .05).

Results

Feasibility Analysis

As shown in Table 3, example items of DCWs’ perceptions of the IBME modules included “The videos gave me new ideas on how to care for residents with LATE STAGE dementia;” “I am more confident and comfortable in communicating with residents with LATE STAGE dementia since completing this training program;” and “Since completing the training program, I have learned a ‘common language’ that will make it easier for me to talk to other (DCWs) that I work with about the care of residents with LATE STAGE dementia;” and “It was easy for me to fit the training program into my work schedule.” No participants indicated “strongly disagree” on any of the items. A little over 6% of DCWs were undecided. The overwhelming majority of DCWs (91.4%) “agreed” or “strongly agreed” with the items on the competency scale (47.6% agreed and 43.8% strongly agreed).

Table 3.

Post-Test Late-Stage Dementia Care Competency Results (N = 34)

Competency Item Strongly Disagree Disagree Undecided Agree Strongly Agree
1. The Internet-based LATE STAGE Training Program was an interesting way to learn about dementia compared to learning in a classroom, or by reading 0 0 3.0 48.5 48.5
2. The information presented in this training program was easy to understand and follow. 0 0 0 44 56
3. The graphics, sound, and video in this presentation made the training more interesting than other training programs I have participated in. 0 3 3 44 50
4. The use of only real CNAs, supervisors, residents, and family members for all of the movies made the program more credible and trustworthy 0 0 6 44 50
5. I am more confident about my skills in caring for residents with late-stage dementia, after completing this training program. 0 0 0 50 50
6. Other nursing home staff (Administrators, Physicians, CNAs, food handlers, janitors, etc.) will find this training program helpful. 0 3 6 32 59
7. I would like to use this type of training program to learn about other topics that will help me better care for residents. 0 0 6 27 68
8. The videos gave me new ideas on how to care for residents with LATE STAGE dementia. 0 3 3 52 42
9. It was easy for me to fit the training program into my work schedule. 0 9 9 50 32
10. In order to complete the LATE STAGE Training Program, it was important to be able to go back and review the training program as often as I wanted. 0 6 21 38 35
11. I preferred learning with this Internet- based training program as opposed to sitting in a classroom. 0 3 21 35 41
12. I have a better understanding of the changes in thinking that are associated with LATE STAGE dementia after completing the training program. 0 0 0 55 45
13. I am more confident and comfortable in communicating with residents with LATE STAGE dementia since completing this training program. 0 0 6 49 45
14. I feel more confident and comfortable in caring for residents with LATE STAGE dementia than I did before I completed this program. 0 3 3 58 36
15. I feel more confident and comfortable in helping residents with LATE STAGE dementia got to the bathroom (toilet) than I did before I completed this training program. 0 9 18 50 24
16. I feel more confident and comfortable in helping residents with LATE STAGE dementia participate in activities than I did before I completed this training program. 0 3 3 61 33
17. The information provided in the training program will help me better communicate with a resident’s family members and loved ones. 0 3 0 46 49
18. Since completing the training program, I have learned a “common language” that will make it easier for me to talk to other CNAs that I work with about the care of residents with LATE STAGE dementia. 0 0 6 57 34
19. I will discuss the CARES Approach that I learned in the training program with the CNAs in my workplace. 0 0 11 54 31
20. The LATE STAGE Training Program has helped me to learn new techniques that make caring for residents with LATE STAGE dementia easier to me. 0 3 0 54 40
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NOTE: CNAs = certified nurse assistants; CARES™/CARES Approach™ = Connect with the resident, Assess their behavior, Respond appropriately, Evaluate what works, Share with the team.

Five open-ended general survey questions were asked of participants. Sample responses to the “What did you like best about this training program?” were as follows

  • “It show (sic) me how to work with patient and their family;”

  • “The personal experiences that are shared by real residents, nurses, [DCWs], family and not by actors;”

  • “That is was internet based, so that we could do it when we had time;”

  • “The patient views and the read along (sic) also that we were able to receive certificates at the end of program;”

  • “The videos that pictured people repeatedly & that were given background information of them. You felt connected to them;”

  • “I saw real interaction with residents and [DCWs]/nurses in the videos;”

  • “… to be able to understand the dementia’s late stage “CLEARLY.” This training program was very informative. I really enjoyed the commentary of people who actually work with the elderly patients.”

Some DCWs offered several ideas to enhance the training modules via their answers to the question “What did you like least about this training program?” Participants mentioned that:

  • “There was no hand-out/written material with which to refer back to when questions arise;”

  • “It needs more questions for the person taking the program;”

  • “Not enough details about toileting and personal hygiene” (Authors note: this is addressed in the full IBME program).

Similarly, when answering “What suggestions do you have that would make this training program better,” sample responses included:

  • “Share with the group;”

  • “More information about dementia;”

  • “Provide guide/handout that could be downloaded and printed fro (sic) future reference;”

  • “Just more programs like this one because it is so enlightening and interesting;”

DCWs also indicated that the training program was useful in delivering everyday care. Sample responses to “How was this training program useful to you in performing your job?” included:

  • “I liked what others shared and new ideas and approaches;”

  • “Gave me additional confidence and hope;”

  • “…every resident is unique, in personality, and in needs. It gave me a better understanding of the thought process of someone with late stage dementia and how to care for and serve them better (i.e.: strategies, activities, etc.);”

  • “I have a much better outlook on life of people with dementia. I feel I will be able to do more with my residents now.”

Similarly, DCWs were positive in recommending the internet-based training program to others. Sample responses included:

  • “The approach for a patient can make a big difference in providing care for the patient and the patients (sic) family;”

  • “That they would really benefit from the training program and understand what really happens with late stage dementia;”

  • “1 - You can read/learn at your own pace. 2 - It was fun and fast. 3 - You can go back if you missed something;” “

  • Yes I would. You will find out that there are so many residents alike. Different faces but the same…You will have a flashback about the training program.”

Comments of interest included the degree of efficacy related to use of technology. Direct care workers were almost uniformly positive about the ease of use of the IBME prototype. Specific comments included:

  • “You can stop and Start. Easy to catch up.”

  • The easy click/point/go.”

  • “That it was available on the internet with access to it at home or at work.”

  • “Being able to click onto the different activities that were on the right hand side.”

  • “…and I could stop the computer and answer a light etc. then return to where I left off.”

Problems with the technology interface of the IBME specifically revolved around length:

  • “The narrator read too slowly”

  • “I read faster than it was spoken”

  • “To slow-could have moved on a little faster”

  • “It was a little long”

Change in Knowledge

Of the 34 DCWs who completed the pre-test and post-test knowledge inventory, 82.8% showed a gain in knowledge of between 1 and 6 points on the 15-point inventory. Three participants (8.6%) showed a loss of knowledge between 1 and 2 points. Three participants showed no change from pre-test to post-test on knowledge. The paired T-test showed a strong and statistically significant increase (t = −5.5, df = 34, p < .001) from pre-test (M = 10.6; SD = 2.1) to post-test (M = 12.6; SD = 1.2).

Discussion

The findings from this formative research project suggest the potential of the IBME prototype to enhance DCW training in NHs. As demonstrated in the competency items of Table 3 and the open-ended responses, DCWs indicated that the information provided in the late-stage dementia training modules were pertinent to their everyday care situations. The portable and asynchronous nature of the IBME training modules greatly enhanced feasibility of delivery for DCWs, as such a training approach provided a degree of flexibility that is not usually available in most traditional face-to-face DCW training protocols. Responses to this formative study also suggest the pertinence of the material covered. The topics reviewed and the care strategies suggested in the three online modules (Introduction to Dementia, Rethinking Activities, and Toileting) appeared relevant and useful to participating DCWs. Over 90% of DCWs either agreed or strongly agreed (close to half in the latter instance) that the IBME modules would influence and improve everyday late-stage dementia care. From communication to care delivery, DCWs largely agreed or were enthusiastic that the IBME training protocol positively influenced late-state dementia care in the NH setting.

Key results, in addition to the apparent feasibility and relevance of the IBME prototype, were the statistically significant changes in knowledge. Nearly 83% of DCWs indicated some gain in knowledge after participating in the IBME. Overall, mean change in knowledge was statistically significant as well (at the p < .001 level). Although the results presented here are preliminary, the findings suggest the potentially important effects of the IBME prototype on late-stage dementia care knowledge.

There are several limitations that are important to note. While the feasibility and knowledge measures were developed to more specifically address the objectives of the IBME, they were not subjected to formal psychometric testing prior to this pilot study. The place and time of IBME completion were not tracked; for this reason, it was not clear whether DCWs completed the training at work or another time. As the open-ended comments imply, several improvements could enhance the design, content, and delivery of the IBME prototype. One area of need is to provide a hardcopy or downloadable version of a “study guide” to help direct DCWs through the computer-based video, text, and oral content; this may also facilitate note-taking and further retention of the late-stage dementia concepts provided to DCWs. In addition, DCWs suggested a group session to discuss the modules. Evaluations of prior interventions to enhance dementia care training for NH staff emphasize that establishing some kind of group-based information exchange option can facilitate the long-term maintenance of program benefits.12 More information on dementia was also requested from DCWs who participated in the IBME prototype. As indicated above, <blinded> has expanded the original three modules to include additional key training topics (e.g., bathing, dressing, toileting, etc.) in the full online late-stage dementia training program. As this is a formative research project, the smaller sample size as well as the lack of a control group limits conclusions of efficacy.

In the context of a larger-scale evaluation of efficacy, more formal assessments of DCWs’ level of skill change as it pertains to dementia care, intrapsychic benefits for DCWs (i.e., feelings of empowerment), and even facility-level measures such as retention and cost benefits are important outcomes to consider as the development and implementation of the IBME moves forward. Nonetheless, this preliminary research implies that the IBME prototype has potential benefits for late-stage dementia care training in NHs. In contrast to other evidence-based protocols,12,13 the IBME prototype offered on online, ansychronous training strategy that not only has the potential to positively influence everyday care delivery as indicated in the post-test competency findings and open-ended comments, but also enhance dementia-pertinent knowledge (as demonstrated in the statistically significant increase in late-stage dementia knowledge results). In this regard, the portable IBME approach may offer a cost-efficient and flexible alternative to more intensive in-person training strategies.

Footnotes

*

This research was supported by a grant from the National Institute on Aging (1R43AG026210-01; John Hobday, Principal Investigator). Mr. Hobday is the Chief Executive Officer of HealthCare Interactive Incorporated, the company that has developed and is selling the internet-based multimedia education prototype version of this program. Ms. Savik is Co-Investigator and biostatistician of the National Institute on Aging grant that supported the results presented in this paper. Dr. Gaugler is a scientific consultant with HealthCare Interactive, Incorporated. The authors would like to thank Stan Smith, MD, for his clinical contributions.

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