Middle Range Theories of Dementia Care In Nursing

Nursing Care and Theories of Dementia

Middle-Range Theories of Dementia Care,Cognitive Ability and Model, Individualized Care for Frail Elders (ICFE) Model,Need-Driven Dementia-Compromised Behavior (NDB) Model,Progressively Lowered Stress Threshold (PLST) Model.

Middle-Range Theories of Dementia Care

    Nursing has developed and synthesized a number of approaches to guide research and practice for the care of people with dementia. Primarily middle-range theory in nature, these approaches drew upon theoretical propositions developed within and outside nursing that were modified via experiential observations. 

    Nursing knowledge concerning dementia care has grown tremendously during the past decade. Utilizing the criteria of publication and dissemination within nursing, the following middlerange theories were selected (listed alphabetically): 

    Cognitive Developmental (CD) Model (Matteson, Linton, & Barnes, 1996), Individualized Care for Frail Elders Model (Happ, Williams, Strumpf, & Burger, 1996), the Need Driven Dementia Compromised Behavior Model (Algase et al., 1996), and the Progressively Lowered Stress Threshold Model (Hall, G. R., & Buckwalter, 1987). 

Cognitive Ability and Model

    The CD Model (Matteson, Linton, & Barnes, 1996) posits in part that loss of cognitive abilities in dementia follows a reverse order from acquisition. 

    Piagetian theory determines the order in which skills are affected, e.g., at first, formal operational skills are lost, followed by concrete operational tasks, and lastly, sensorimotor abilities which include speech and motor dysfunction. 

    Propositions derived from the model are based on an assessment of the appropriate cognitive level and problem behaviors associated with it. Behavioral management, environmental modification, and caregiver interactions are then determined according to the appropriate developmental stage. 

    Preliminary results of model testing indicate that it was possible to manage behaviors while reducing the number of psychotropic medications (Matteson, Lin- ton, Barnes, Cleary, & Lichtenstein, 1995). Instrument development to assess earlier periods of cognitive function and the combination of this approach with other staging and assessment models have been suggested.

Individualized Care for Frail Elders (ICFE) Model

    The ICFE Model (Happ et al., 1996) embodies an interdisciplinary approach to care and emphasizes four points. These are:

(1) knowing the person (life story and patterns of response),

 (2) the relationship (staff continuity and reciprocity),

 (3) choice (decision-making and risk-taking), and

(4) resident participation (daily planning).

    Evan's cross-cultural observations in four European countries sup- ported related propositions and delineated three factors that contributed to individualized care:

 (1) congruent societal and health care values,

 (2) commonalities of patient need in all settings, and

 (3) primacy of caring through knowing the person

    Rowles & Dallas (1996) found that family involvement in nursing home decision making served to individualize care and provided a continuing link to the person's personal history and preferences. Several studies supported cost effectiveness linked to lowered medication costs and staff turnover. Further research on outcomes and refinements in definitions, goals, and critical attributes is ongoing.

Need-Driven Dementia-Compromised Behavior (NDB) Model

    The NDB approach views the person with dementia as experiencing an unmet need or goal that results in need driven behaviors such as aggression, wandering, problematic vocalizations, and a recent addition, passive behaviors. 

    Behaviors reflect the interaction of salient background and proximal factors found either within the person or in the environment or both. Background variables include neurological, cognitive, health status, and psychosocial factors. 

    Proximal factors include physiological and psychosocial need states and the physical and social environment. NDBS are evaluated on dimensions of frequency and duration. 

    Nursing's role is to identify those at risk and to intervene with strategies under various sets of environmental circumstances. Collective programs of re- search on the model were highlighted in a special issue of the Journal of Gerontological Nursing (Overview of NDB Model, 1999). 

    Multiple methods for deriving practice interventions from the model were also published in a subsequent special focus section of this journal (NDB Intervention, 2002). A special section in Aging and Mental Health was devoted to model derived measurement and intervention strategies (Behavioral Symptoms, 2004). 

    Current research efforts are focused on the identification of variables common to and different from each of the behaviors and on the application of linear modeling to further build the theory.

Progressively Lowered Stress Threshold (PLST) Model

    The PLST Model (Hall, G. R., & Buckwalter, 1987) views the person with dementia as experiencing baseline anxieties and dysfunctional states throughout the course of the dis- ease. Anxious behavior occurs during stress, and if stress continues, dysfunctional states such as panic occur. Six principles guide nursing: 

(1) maximize the level of safe function by supporting all areas of loss in a prosthetic manner

(2) provide unconditional positive regard

(3) use behaviors indicating anxiety to determine limits of stimuli and activity

(4) teach caregivers to listen and evaluate verbal and nonverbal responses

(5) modify environ- ment to support losses and enhance safety

(6) provide education, support, care, and problem-solving for caregivers

     The PLST Model has been used to investigate caregiver education effects on caregiving consequences. Training decreased the impact of caregiving (Garand et al., 2002), and improved caregivers' mood (Buckwalter et al., 1999). 

    The model has been tested in regard to interventions centered on music, touch, pain, nonnutritive sucking, and sleep. Continued research will test the main assumptions of the model.

    Examples of other approaches from the last decade (organized chronologically) include: the Sensor stasis Model (Kovach, 2000), the Cognition Sensitive Approach (Barnes & Adair, 2002), the Implicit Memory and Familiarity Framework (Son, Therrien, & Whall, 2002), and the Comprehensive Model of Psychiatric Symptoms of Progressive Degenerative Dementias (Volicer & Hurley, 2003). 

    Algorithmic frameworks (Beck, Heacock, Rapp, & Mercer, 1993) and decision trees (Richie, 1996) have addressed strategies to determine level of assistance and nursing interventions.

    A number of other approaches explicated selected aspects of middle-range theory work for dementia and produced instruments which assess model variables.     

    These include the modification as an observational tool of the Cohen Mansfield Agitation Inventory by Whall (Chrisman, Tabar, Whall, & Booth, 1991), the Ryden Aggression Scale (Ryden, Bossenmaier, & McLachlen, 1991), Hurley's Discomfort Scale (Hurley, Volicer, Hanrahan, Houde, & Volicer, 1992), the Modified Interaction Behavior Measure (Burgener, Jir ovec, Murrell, & Barton, 1992), the Dementia Mood Picture Test (Tappen & Barry, 1995), and the Algase Wandering Scale (Algase, Beattie, Bogue, & Yao, 2001). 

    The past decade has been characterized by a resurgence of interest in the development and testing of middle-range theories of dementia care. As these efforts continue to be supported by programs of research, they hold great promise for more effective care in the years ahead.