Nursing Care and Theories of Dementia

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.