History, Development, and Future of the Progressively Lowered Stress Threshold: A Conceptual Model for Dementia Care

Abstract

Behavioral symptoms associated with dementia are a major concern for the person who experiences them and for caregivers who supervise, support, and assist them. The knowledge and skill of formal and informal caregivers affects the quality of care they can provide and their ability to cope with the challenges of caregiving. Nurses are in an excellent position to provide training to empower caregivers with the knowledge and skills necessary to reduce and better manage behaviors. This article reviews advances in geriatric nursing theory, practice, and research based on the Progressively Lowered Stress Threshold (PLST) model that are designed to promote more adaptive and functional behavior in older adults with advancing dementia. For more than 17 years, the model has been used to train caregivers in homes, adult day programs, nursing homes, and acute care hospitals and has served as the theoretical basis for in-home and institutional studies. Care planning principles and key elements of interventions that flow from the model are set forth, and outcomes from numerous research projects using the PLST model are presented.

The Repeated Appeal to Return Home in Older Adults with Dementia: Developing a Model for Practice

“…Once care workers discover how "here and now" situations are experienced by older persons with dementia, the care workers can identify the needs which arose from the conflicts between the expectations of the older person and the strict environmental regulations of community life, such as rules the nursing facilities set (Cohen-Mansfield and Mintzer 2005;Morgan and Stewart 1999;Smith et al 2004). For example, although cooking may be an important role for some older clients, they may not be allowed to enter the kitchen in the nursing facility.…”

“…These behaviors are included in Behavioral and Psychological Signs and Symptoms of Dementia (BPSD), defined as "signs and symptoms of disturbed perception, thought content, mood, or behavior that frequently occur in patients with dementia" (Finkel et al 1996, p. 498). BPSD both cause and result from conflicts between the frail older adult with dementia and his/her environment, due to impaired ability to adapt to environmental change (Cohen-Mansfield 2001;Cohen-Mansfield and Mintzer 2005;Smith et al 2004;Werezak and Morgan 2003). BPSD are often problematic for caregivers, creating difficulties with home care.…”

“…Unfortunately, their experiential learning is often concealed below the level of consciousness: it has not been accumulated as usable knowledge, nor has it been articulated in a way that can be shared with other workers. The approach to BPSD among care workers has been trapped in a "trial and error" type of practice (Barton et al 2005;Clavel 1999;Hutchinson et al 1996;Smith et al 2004) which seldom benefits from the expertise of long-time formal caregivers.…”

Multilevel Models for Examining Individual Differences in Within-Person Variation and Covariation Over Time

“…The first goal of the analysis was to examine stability of self-reported mood across days and individual differences in that stability. It was expected that positive and negative mood will be less stable (i.e., show greater within-person variation) in persons with lower mental functioning, given that external or contextual factors are thought to have a greater influence on mood in such persons (Smith, Gerdner, Hall, & Buckwalter, 2004).…”

Towards defining restlessness in individuals with dementia

“…We have identified four theoretical models that may have applicability to restlessness and which have been used previously to understand other behavioral symptoms and inform intervention development: (1) neurobiological/genetic framework (e.g., Cohen-Mansfield, 2000; Garand & Hall, 2000; Raskind & Peskind, 1994), (2) behavioral model (e.g., Teri, 1997), (3) reduced stress threshold model (Hall & Buckwalter, 1987; Smith, Gerdner, Hall, & Buckwalter, 2004), and (4) unmet needs model (e.g., Algase et al, 1996). …”