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In the various roles he has undertaken through the years, Val J. Halamandaris has been a singular driving force behind the policy and program initiatives resulting in the recognition of home health care as a viable alternative to institutionalization. His dedication to consumer advocacy, which enhances the quality of life and dignity of those receiving home health care, merits VNA HealthCare Group’s highest recognition and deepest respect. 

VNA HealthCare Group

I have the highest respect for them, especially for the nurses, aides and therapists, who devote their lives to caring for people with disabilities, the infirm and dying Americans.  There are few more noble professions.

President Barack Obama

Home health care agencies do such a wonderful job in this country helping people to be able to remain at home and allowing them to receive services

U.S. Senator Debbie Stabenow (D-MI) Chair, Democratic Steering and Outreach Committee

Home care is a combination of compassion and efficiency.  It is less expensive than institutional care...but at the same time it is a more caring, human, intimate experience, and therefore it has a greater human’s a big mistake not to try to maximize it and find ways to give people the home care option over either nursing homes, hospitals or other institutions

Former Speaker of the U.S. House of Representatives Newt Gingrich (R-GA)

Medicaid covers long-term care, but only for low-income families.  And Medicare only pays for care that is connected to a hospital discharge....our health care system must cover these vital services...[and] we should promote home-based care, which most people prefer, instead of the institutional care that we emphasize now.

Former U.S. Senator Majority Leader Tom Daschle (D-CD)

We need incentives to...keep people in home health care settings...It’s dramatically less expensive than long term care.

U.S. Senator John McCain (R-AZ)


Home care is clearly the wave of the future. It’s clearly where patients want to be cared for. I come from an ethnic family and when a member of our family is severely ill, we would never consider taking them to get institutional care. That’s true of many families for both cultural and financial reasons. If patients have a choice of where they want to be cared for, where it’s done the right way, they choose home.

Donna Shalala, former Secretary of Health and Human Services

A couple of years ago, I spent a little bit of time with the National Association for Home Care & Hospice and its president, Val J. Halamandaris, and I was just blown away. What impressed me so much was that they talked about what they do as opposed to just the strategies of how to deal with Washington or Sacramento or Albany or whatever the case may be. Val is a fanatic about care, and it comes through in every way known to mankind. It comes through in the speakers he invites to their events; it comes through in all the stuff he shares.

Tom Peters, author of In Search of Excellence

Val’s home care organization brings thousands of caregivers together into a dynamic organization that provides them with valuable resources and tools to be even better in their important work. He helps them build self-esteem, which leads to self-motivation.

Mike Vance, former Dean of Disney and author of Think Out of the Box

Val is one of the greatest advocates for seniors in America. He goes beyond the call of duty every time.

Arthur S. Flemming, former Secretary of Health, Education, and Welfare

Val has brought the problems, the challenges, and the opportunities out in the open for everyone to look at. He is a visionary pointing the direction for us. 

Margaret (Peg) Cushman, Professor of Nursing and former President of the Visiting Nurses Association

Although Val has chosen to stay in the background, he deserves much of the credit for what was accomplished both at the U.S. Senate Special Committee on Aging, where he was closely associated with me and at the House Select Committee on Aging, where he was Congressman Claude Pepper’s senior counsel and closest advisor. He put together more hearings on the subject of aging, wrote more reports, drafted more bills, and had more influence on the direction of events than anyone before him or since.

Frank E. Moss, former U.S. Senator

Val’s most important contribution is pulling together all elements of home health care and being able to organize and energize the people involved in the industry.

Frank E. Moss, former U.S. Senator

Anyone working on health care issues in Congress knows the name Val J. Halamandaris.

Kathleen Gardner Cravedi, former Staff Director of the House Select Committee on Aging

Without your untiring support and active participation, the voices of people advocating meaningful and compassionate health care reform may not have been heard by national leaders.

Michael Sullivan, Former Executive Director, Indiana Association for Home Care

All of us have been members of many organizations and NAHC is simply the best there is. NAHC aspires to excellence in every respect; its staff has been repeatedly honored as the best in Washington; the organization lives by the highest values and has demonstrated a passionate interest in the well-being of patients and providers.

Elaine Stephens, Director of Home Care of Steward Home Care/Steward Health Systems and former NAHC C

Home care increasingly is one of the basic building blocks in the developing system of long-term care.  On both economic and recuperative bases, home health care will continue to grow as an essential service for individuals, for families and for the community as a whole.

Former U.S. Senator Olympia Snowe (R-ME)

NCOA is excited to be part of this great event and honored to have such influential award winners in the field of aging.

National Council of Aging

Health care at home…is something we need more of, not less of.  Let us make a commitment to preventive and long-term care.  Let us encourage home care as an alternative to nursing homes and give folks a little help to have their parents there.

Former President Bill Clinton


Revisiting the Theory of Retrogenesis

By Verna Benner Carson

About three years ago when I began contributing to CARING, I wrote about the program I had developed for responding to patients and/or loved ones who have Alzheimer’s disease. My approach for Becoming an Alzheimer’s Whisperer is based on the theory of Retrogenesis, developed by Dr. Barry Reisberg.1 It has been several years since that initial article was published, so it seems appropriate to review the theory and explain how it can be applied to manage challenging behaviors in a loving, kind, and gentle manner.

The theory of Retrogenesissuggests that the brains of people with Alzheimer’s deteriorate functionally and cognitively in the reverse order of how their brains developed from birth. Building on that theory, my approach is reminiscent of the “horse whisperer” or “dog whisperer” as they explore and enter the world of others without making any demands. This strategy provides a framework to minimize resistance and aggression while approaching challenging behaviors.

A common criticism and misconception about this theory is that we treat adults with Alzheimer’s like they are children, even using “baby talk” in our conversations. This conclusion is absolutely incorrect! We never talk down to anyone — but we consciously choose inclusive language that the listener can understand! The theory does not imply that the caregiver should treat an adult with Alzheimer’s like a child, or talk to that person in a way that would make them feel insignificant or small! This would be wrong. So the theory suggests that caregivers examine how they are responding to those with Alzheimer’s and consider whether their own behavior is a major reason for the aggression and resistance they encounter while providing care.  If the answer is yes, they might consider changing their behavior and the theory of Retrogenesis provides a roadmap for a variety of different approaches.

Earlier this year I wrote about the death of my youngest sister who was born with Down’s syndrome and developed Alzheimer’s disease in her forties. Applying the theory of Retrogenesis aided us tremendously as we lovingly dealt with Mary Lynn’s deterioration. Even though our family needed to simplify how we communicated with Mary Lynn, we never talked down to her or used “baby talk!” We communicated on her level — which was the most loving approach to use! Even at the end of her life, she never had any difficulty understanding us and we never had any trouble understanding her wants and needs.

Let’s examine resistance to bathing, one of the most common challenging behaviors. Sometimes the resistance is so unwavering that the caregiver gets hurt in some way — kicked, slapped, bitten — certainly not the response that would make a caregiver want to continue care and one that frequently hastens a decision for placement. What can be done? Let’s examine the usual bathing process. Generally caregivers shower individuals with Alzheimer’s. Showering is probably the most common way that adults bathe themselves so it is not surprising that caregivers choose this approach. Showering seems to be the easiest approach. It is also what the caregiver “knows,” and most of us tend to gravitate to what we are already comfortable doing. So showering may seem like the most logical and efficient approach to bathing. Yet it frequently results in anger, hostility, and violence between the care recipient and caregiver.

How does the theory of Retrogenesis help to explain this resistance? Very simply! By the time someone with Alzheimer’s requires the assistance of another to do basic activities such as bathing, the person is functioning at Stage 6 which is the moderately severe level on the FAST (Functional Assessment Staging Tool). This stage equates to the cognitive and functional level of a toddler, and we generally do not shower toddlers. The water from the shower hitting the toddler in the face would be very frightening to the child! We generally bathe toddlers in a tub. We sing to them while we bathe them; we put toys into the bath water with the child; we try to make the bathing experience pleasant — we certainly don’t choose a method of bathing that frightens or in any way upsets the child.

Finding approaches that are not frightening and do accomplish the care goal should also be our mantra when dealing with those with Alzheimer’s disease! There are so many alternatives to a shower — when I am asked about this the writing of Dr. Seuss always comes to mind — I can bathe you here, I can bathe you there, I can bathe you just about anywhere … anywhere but the shower!  What are the options for bathing? We can bathe someone wrapped in a warmed towel and standing in front of a sink; we can bathe the person sitting on a shower chair using a hose to rinse them; we can bathe the individual sitting on a toilet, in bed, in a tub — so many choices have the possibility of working without the possibility of the caregiver getting hurt! We can add pleasure to the bathing experience by pairing it with a “tootsie roll pop” or something else that is sweet thus “sweetening” the experience and making it that much more pleasant for the recipient of our care!

Let’s look at one more application of the theory of Retrogenesis to understanding how to manage challenging behaviors. A number of them stem from unrecognized pain, another major problem in the care of those with Alzheimer’s disease. It is a problem in private homes, in assisted living, and in long-term care facilities. Again the problem with recognizing pain begins in stage 6 of the FAST scale. At this point, the person with Alzheimer’s cannot verbally express the presence of pain — just like a toddler would not be able to express pain in words — but would express discomfort in distressed behaviors.

Without an understanding of the theory of Retrogenesis, both family and professional caregivers interpret crying, screaming, resistance to care, and refusal to eat as agitated and aggressive behaviors that require medication to manage. Unfortunately the medication of choice is not an analgesic but it will most likely be an anti-anxiety or antipsychotic medication — neither of which do anything to decrease pain! Once the caregiver is aware that these challenging behaviors could be due to pain, the next step is to assess the degree of pain using a tool like the FACES Pain scale — which works wonderfully for individuals with Alzheimer’s disease.

The FAST scale can be easily found on the Internet but the following provides a review of the scale.

The Stages of Alzheimer's Disease

At the New York University Medical Center's Aging and Dementia Research Center, Barry Reisberg, MD, and colleagues have developed the Functional Assessment Staging (FAST) scale, which allows professionals and caregivers to chart the decline of people with Alzheimer's disease. The FAST scale has 16 stages and sub-stages:

FAST Scale Stage


1... normal adult

No functional decline.

2... normal older adult

Personal awareness of some functional decline.

3... early Alzheimer's disease

Noticeable deficits in demanding job situations.

4... mild Alzheimer's

Requires assistance in complicated tasks such as handling finances, planning parties, etc.

5... moderate Alzheimer's

Requires assistance in choosing proper attire.

6... moderately severe Alzheimer's

Requires assistance dressing, bathing, and toileting. Experiences urinary and fecal incontinence.

7... severe Alzheimer's

Speech ability declines to about a half-dozen intelligible words. Progressive loss of ability to walk, sit up, smile, and hold head up.

Detailed Description of Each of the 7 Stages

Stage 1(No Cognitive Decline) No subjective complaints of memory deficit. No memory deficit evident on clinical interviews.

Stage 2 (Forgetfulness)Very mild cognitive decline.

Subjective complaints of memory deficit, most frequently in the following areas:

  1. forgetting where one has placed familiar objects;
  2. forgetting names one formerly knew well.

No objective evidence of memory deficit on clinical interview. No objective deficits in employment or social situations. Appropriate concern regarding symptoms.

Stage 3 (Early Confusional)Mild cognitive decline. Earliest clear-cut deficits.

Manifestations in more than one of the following areas:

  1. patient may have gotten lost when traveling to an unfamiliar location;
  2. co-workers become aware of patient's relatively low performance;
  3. word and name finding deficit becomes evident to intimates;
  4. patient may read a passage of a book and retain relatively little material;
  5. patient may demonstrate decreased facility in remembering names upon introduction to new people;
  6. patient may have lost or misplaced an object of value;
  7. concentration deficit may be evident on clinical testing.

Objective evidence of memory deficit obtained only with an intensive interview. Denial begins to become manifest in patient. Mild to moderate anxiety accompanies symptoms.

Stage 4 (Late Confusional)Moderate cognitive decline. Clear-cut deficit on careful clinical interview.

Deficit manifest in following areas:

  1. decreased knowledge of current and recent events;
  2. may exhibit some deficit in memory of one's personal history;
  3. concentration deficit elicited on serial subtractions;
  4. decreased ability to travel, handle finances, etc.

Frequently no deficit in the following areas:

  1. orientation to time and place;
  2. recognition of familiar persons and faces;
  3. ability to travel to familiar locations.

Inability to perform complex tasks. Denial is dominant defense mechanism. Flattening of affect and withdrawal from challenging situations occur.

Stage 5 (Early Dementia)Moderately severe cognitive decline.

Patient can no longer survive without some assistance. Patient is unable during interview to recall a major relevant aspect of their current lives, e.g., an address or telephone number of many years, the names of close family members (such as grandchildren), the name of the high school or college from which they graduated. Frequently some disorientation to time (date, day of week, season, etc.) or to place. An educated person may have difficulty counting back from 40 by 4s or from 20 by 2s. Persons at this stage retain knowledge of many major facts regarding themselves and others. They invariably know their own names and generally know their spouse's and children's names. They require no assistance with toileting and eating, but may have some difficulty choosing the proper clothing to wear.

Stage 6 (Middle Dementia)Severe cognitive decline. May occasionally forget the name of the spouse upon whom they are entirely dependent for survival. Will be largely unaware of all recent events and experiences in their lives. Retain some knowledge of their past lives but this is very sketchy. Generally unaware of their surroundings, the year, the season, etc. May have difficulty counting from 10, both backward and sometimes forward. Will require some assistance with activities of daily living, e.g., may become incontinent, will require travel assistance but occasionally will display ability to recognize familiar locations. Diurnal rhythm frequently disturbed. Almost always recall their name. Frequently continue to be able to distinguish familiar from unfamiliar persons in their environment.

Personality and emotional changes occur. These are quite variable and include:

  1. delusional behavior, e.g., patients may accuse their spouse of being an impostor, may talk to imaginary figures in the environment, or to their own reflection in the mirror;
  2. obsessive symptoms, e.g., person may continually repeat simple cleaning activities;
  3. anxiety, agitation, and even previously nonexistent violent behavior may occur;
  4. cognitive abulia, i.e., loss of willpower because an individual cannot carry a thought long enough to determine a purposeful course of action.

Stage 7 (Late Dementia)Very severe cognitive decline. All verbal abilities are lost.

Frequently there is no speech at all, only grunting. Incontinent of urine, requires assistance toileting and feeding. Lose basic psychomotor skills, e.g., ability to walk, sit and control their head. The brain appears to no longer be able to tell the body what to do. Generalized and cortical neurologic signs and symptoms are frequently present.



1Reisberg, B. (1984). Alzheimer’s disease: Stages of cognitive decline. American Journal of Nursing, 84: 225.


Verna Benner Carson, Ph.D., CNS/PMH-BC, is president of C&V Senior Care Specialists and Associate Professor of Nursing at Towson University in Baltimore, MD. Dr. Carson can be reached at

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