Middle Range Theories of Dementia Care In Nursing

Middle Range Theories of Dementia Introduction

The field of dementia care has witnessed significant advancements over the past decade, particularly through the development and application of middle-range theories. Middle-range theories in nursing provide practical frameworks that guide both research and practice in caring for individuals with dementia. These theories are built on propositions from within and outside of nursing, refined through experiential observation, and adapted to the specific needs of people with dementia.

Middle-range theories of dementia care focus on understanding the cognitive decline associated with dementia and providing appropriate care strategies that cater to individual needs. The theories discussed in this article include the Cognitive Developmental (CD) Model, the Individualized Care for Frail Elders (ICFE) Model, the Need-Driven Dementia-Compromised Behavior (NDB) Model, and the Progressively Lowered Stress Threshold (PLST) Model. Each of these theories offers a unique perspective on dementia care and contributes to a holistic approach to supporting people with dementia.

Middle-Range Theories of Dementia Care

Middle-range theories in dementia care are designed to bridge the gap between high-level conceptual frameworks and the practical needs of patients and caregivers. These theories provide guidance for managing the complex behaviors and symptoms associated with dementia, improving quality of life for patients, and reducing the burden on caregivers. The following sections discuss some of the most prominent middle-range theories developed to address the unique challenges of dementia care.

Cognitive Ability and the Cognitive Developmental (CD) Model

The Cognitive Developmental (CD) Model, proposed by Matteson, Linton, and Barnes (1996), posits that the loss of cognitive abilities in dementia follows a reverse order from their acquisition. This model draws on Piagetian theory, which outlines the stages of cognitive development, suggesting that dementia-related decline occurs in a manner that is opposite to the original learning sequence.

According to Piagetian theory, the loss of cognitive skills begins with the most complex, such as formal operational skills, followed by concrete operational skills, and finally, sensorimotor abilities, which include basic functions like speech and motor coordination. The CD Model suggests that by assessing the specific cognitive level of a person with dementia, healthcare providers can tailor interventions to manage problem behaviors effectively.

Interventions guided by this model focus on behavioral management, environmental modifications, and caregiver interactions that are appropriate for the individual’s developmental stage. Preliminary results of testing the CD Model have shown that it is possible to manage dementia-related behaviors while reducing the use of psychotropic medications (Matteson, Linton, Barnes, Cleary, & Lichtenstein, 1995). This model’s approach has led to the development of instruments that assess earlier periods of cognitive function, and it has been suggested that combining it with other staging and assessment models could enhance its effectiveness.

Individualized Care for Frail Elders (ICFE) Model

The Individualized Care for Frail Elders (ICFE) Model, developed by Happ, Williams, Strumpf, and Burger (1996), emphasizes an interdisciplinary approach to dementia care that focuses on four key components:

1. Knowing the Person: Understanding the individual’s life story, personal history, and patterns of response.
2. The Relationship: Ensuring staff continuity and fostering reciprocal relationships between staff and patients.
3. Choice: Promoting decision-making and risk-taking based on the preferences and capabilities of the individual.
4. Resident Participation: Involving the patient in daily planning and activities to the extent possible.

The ICFE Model is based on cross-cultural observations, including Evan’s studies in four European countries, which supported three factors contributing to individualized care: congruent societal and healthcare values, commonalities of patient needs across settings, and the primacy of caring through knowing the person. Research has also shown that family involvement in decision-making helps to individualize care and maintain a connection to the patient’s personal history and preferences (Rowles & Dallas, 1996).

Studies have demonstrated the cost-effectiveness of this model, linking it to reduced medication costs and lower staff turnover. Ongoing research aims to further refine the model’s definitions, goals, and critical attributes to enhance its applicability and effectiveness in various care settings.

Need-Driven Dementia-Compromised Behavior (NDB) Model

The Need-Driven Dementia-Compromised Behavior (NDB) Model, introduced by Algase et al. (1996), views the behaviors exhibited by people with dementia as manifestations of unmet needs or goals. These behaviors, which can include aggression, wandering, problematic vocalizations, and passive behaviors, reflect the interaction between the individual’s background and proximal factors.

Background factors encompass neurological, cognitive, health status, and psychosocial elements, while proximal factors include physiological and psychosocial needs as well as the physical and social environment. The NDB Model evaluates behaviors based on their frequency and duration, helping to identify at-risk individuals and determine appropriate interventions.

Nursing’s role within the NDB framework is to identify individuals at risk and intervene with tailored strategies suited to various environmental circumstances. Research on the model has been extensive, with a special issue of the Journal of Gerontological Nursing (1999) providing an overview of the NDB Model and its applications. Subsequent publications have focused on deriving practice interventions and measurement strategies from the model (NDB Intervention, 2002; Behavioral Symptoms, 2004). Current research is examining the commonalities and differences among various behaviors and applying linear modeling techniques to further develop the theory.

Progressively Lowered Stress Threshold (PLST) Model

The Progressively Lowered Stress Threshold (PLST) Model, developed by Hall and Buckwalter (1987), is based on the premise that individuals with dementia experience baseline anxiety and dysfunctional states throughout the disease’s course. According to this model, anxious behaviors occur in response to stress, and prolonged stress can lead to more severe dysfunctional states, such as panic.

The PLST Model outlines six principles to guide nursing care:

1. Maximize Safe Function: Support all areas of loss in a prosthetic manner to maintain the highest possible level of safe function.
2. Provide Unconditional Positive Regard: Show consistent respect and empathy to reduce anxiety and stress.
3. Use Behavior as a Guide: Observe behaviors to determine limits of stimuli and activity.
4. Teach Caregivers: Train caregivers to interpret and evaluate both verbal and nonverbal responses.
5. Modify the Environment: Adapt the physical environment to support losses and enhance safety.
6. Provide Education and Support: Offer continuous education, support, and problem-solving assistance to caregivers.

The PLST Model has been used to investigate the effects of caregiver education on caregiving outcomes, demonstrating positive impacts such as reduced caregiver burden and improved mood (Garand et al., 2002; Buckwalter et al., 1999). The model has also been tested in various interventions, including those centered on music, touch, pain management, nonnutritive sucking, and sleep. Ongoing research is focused on testing the model’s core assumptions and further refining its application in diverse settings.

Other Theoretical Approaches in Dementia Care

In addition to the above models, several other theoretical approaches have emerged in the past decade, providing additional perspectives on dementia care. These include:

• Sensor Stasis Model (Kovach, 2000): Focuses on maintaining sensory equilibrium in dementia patients.
• Cognition Sensitive Approach (Barnes & Adair, 2002): Emphasizes the importance of cognitive functioning in care planning.
• Implicit Memory and Familiarity Framework (Son, Therrien, & Whall, 2002): Utilizes implicit memory to foster a sense of familiarity and comfort.
• Comprehensive Model of Psychiatric Symptoms of Progressive Degenerative Dementias (Volicer & Hurley, 2003): Addresses psychiatric symptoms associated with degenerative dementias.

Algorithmic frameworks (Beck, Heacock, Rapp, & Mercer, 1993) and decision trees (Richie, 1996) have also been developed to guide the determination of appropriate levels of assistance and nursing interventions.

Measurement Tools and Instruments for Dementia Care

Numerous instruments have been created to assess variables relevant to middle-range theories in dementia care. These include:

• Cohen Mansfield Agitation Inventory (modified by Whall, Chrisman, Tabar, & Booth, 1991): Used to observe agitation in dementia patients.
• Ryden Aggression Scale (Ryden, Bossenmaier, & McLachlen, 1991): Measures aggression in individuals with dementia.
• Hurley’s Discomfort Scale (Hurley, Volicer, Hanrahan, Houde, & Volicer, 1992): Assesses discomfort levels in dementia patients.
• Modified Interaction Behavior Measure (Burgener, Jirovec, Murrell, & Barton, 1992): Evaluates the quality of interactions between dementia patients and caregivers.
• Dementia Mood Picture Test (Tappen & Barry, 1995): Assesses mood in people with dementia.
• Algase Wandering Scale (Algase, Beattie, Bogue, & Yao, 2001): Measures wandering behaviors in dementia patients.

These tools contribute to the practical application of middle-range theories by providing standardized methods for evaluating patient behaviors, needs, and responses to care.

Conclusion

The development and testing of middle-range theories in dementia care have accelerated over the past decade, driven by a growing recognition of the need for evidence-based frameworks to guide practice. As these theories continue to evolve through rigorous research and application, they hold great promise for improving the quality of care provided to individuals with dementia and supporting caregivers in their roles. By advancing our understanding of the complex needs and behaviors associated with dementia, these theories will help shape more effective and compassionate care strategies in the years to come.