Progressively Lowered Stress Threshold Research Articles

P25: Promote DemenTitude® - Cultural Adaption of Progressively Lowered Stress Threshold Model with Social Work Perspective in Hong Kong

Social work principles integrated with the Progressively Lowered Stress Threshold (PLST) model create new inspiration for understanding distressed behaviour among people with dementia in Hong Kong. Social work emphasizes the individuality and uniqueness of every human, whose experiences, perceptions and feelings should be respected. This research aimed to explore the self-perception of people with dementia and the interpretation of their surroundings to understand the rationale behind the distressed behaviour based on the PLST model. In-depth interviews and participatory observations during interviews in the residential care homes of Hong Kong were conducted. Following the theoretical framework blending interpretivism and the sociocultural perspective on dementia, the interpretation of data did not focus solely on what was expressed explicitly but also upon how the experiences, perceptions and interpretations of people with dementia had affected their self-perception and distressed behaviour.Beyond the six principles of care from the traditional PLST model, the research finding in Hong Kong identified the new principles with the adaption of the local context. The seventh principle, known as DemenTitude ®, got the review and approval by one of the original authors, Prof Kathleen Buckwalter, in understanding more distressed behaviour among people with dementia. The new principle involves four key elements as follows: (i) Understand the self-perception and subjective views of people with dementia to synchronize the feeling and impact of dementia; (ii) Avoid using words that stigmatize the person with dementia; (iii) Avoid excess disability and psychosocial restraint & (iv) Assist the person with dementia to create a comfortable relationship with their surroundings and to experience meaningful engagement. Truly listening to the voice of people with dementia and how to minimize different natures of distress with cultural sensitivity is essential to promote a good quality of dementia care in Hong Kong. With the updated finding from the local context and the voice of people with dementia beyond behavioural and psychological symptoms of dementia (BPSD), the paradigm shift should be advocated from the medical model to person-centred care and even further develop a proper caring attitude with the perspective of social work professions, called as DemenTitude®.

The effect of educational intervention based on the Progressively Lowered Stress Threshold extended model on the process of caregiving for people with dementia.

This study examined the impacts of an educational intervention based on the Progressively Lowered Stress Threshold (PLST) extended model on caregiving for people with dementia (PWD). This study was conducted in Isfahan, Iran, from May 2016 to June 2018, with 38 caregivers of PWD as participants assigned to an intervention group. Data were collected using a multi-sectional, researcher-developed questionnaire that recorded the demographic characteristics, and measured the dementia-related knowledge and caregiving practices of the participants. The questionnaire and an educational program were designed in three parts according to the educational needs of caregivers to enhance their practice, skills, and ability to handle challenging behaviours in PWD. The questionnaire's face validity was confirmed by expert review, and its reliability was assessed with Cronbach's alpha coefficient (knowledge section, 0.838; practice section, 0.802). The sampling method used was convenience sampling, and none of the caregivers refused to receive the educational content. Therefore, the evaluation of the program lacks a randomized controlled group. To tailor the intervention program to the participants' needs, the educational content was based on the PLST extended model. The mean scores for knowledge and practice increased following the intervention (P < 0.05). An educational intervention, using the PLST extended care model, thus produced positive impacts in improving the knowledge and practice of caregivers of PWD. Educating caregivers with the PLST extended model, with a specific focus on the cultural and religious backgrounds of societies, is recommended.

Dynamic structural equation modelling evaluating the progressively lowered stress threshold as an explanation for behavioural symptoms of dementia

AimTo evaluate the progressively lowered stress threshold (PLST) conceptual model as an explanation for behavioural symptoms of dementia and test several of its hypothesized propositions. The PLST model suggests that due to impairments in coping, persons living with dementia have a reduced threshold for stress and respond with more behavioural symptoms of dementia as stress accumulates throughout the day.DesignIntensive longitudinal design.MethodsA sample of N = 165 family caregivers completed brief daily diary surveys for 21 days between the dates of 7/2019 and 8/2020, reporting on a total of 2841 days. Dynamic structural equation modelling was used as the analytic technique to examine the impact of caregiver and care recipient environmental stressors on the diversity of behavioural symptoms of dementia to account for the nested data structure and autoregressive relationships.FindingsResults show direct relationships between environmental stressors and diversity of behavioural symptoms of dementia that same day and the following day.ConclusionFindings provide support for the PLST model propositions. Further, findings suggest an extension to the conceptual model is warranted given evidence of an exposure/recovery trajectory and the lagged effects of stress exposure on behavioural symptoms of dementia presentation.ImpactThis study tested whether a commonly used nursing model does in fact explain the occurrence of behavioural symptoms of dementia. The main findings support using the model as an intervention framework and suggest the model should be adapted to consider recovery trajectories. Since behavioural symptoms of dementia represent complex and dynamic temporal phenomena, traditional longitudinal assessments and analyses are an insufficient measurement modality for testing models. Findings inform the design of environmental‐modification type interventions for behavioural symptoms of dementia management and the methods to evaluate such interventions.

Investigation of the effects of interventions made according to the Progressively Lowered Stress Threshold Model on the care outcomes of Alzheimer patients and their families: a randomized clinical trial.

One of the non-pharmacological methods used to reduce behavioural problems of Alzheimer's patients and the negative emotions accordingly experienced by caregivers consists of interventions performed according to the Progressively Lowered Stress Threshold (PLST) model. This randomized controlled study aimed to determine the effect of interventions performed according to PLST on the care burden, care satisfaction, and life satisfaction of caregivers of middle and advanced stage Alzheimer's disease patients, and on the neuropsychiatric symptoms and agitation levels of these patients. The research was conducted with a total of 29 caregivers divided into intervention (15) and control (14) groups. Data were collected using an Introductory Information Form, plus the Standardised Mini-Mental State Examination, Neuropsychiatric Inventory, Cohen-Mansfield Agitation Inventory, Carer's Assessment of Satisfaction Index, and Life Satisfaction Scale. Three home visits were made to the caregivers by the researchers in the first, second, and twelfth weeks of the intervention. During the home visits, face-to-face training was given as necessary to the individual caring for problems identified in the nursing care plan according to PLST. As a result of the PLST training, there was a decrease in the behavioural problems of Alzheimer's patients, along with a decrease in the care burden of the caregivers and an increase in their care satisfaction. When the scale total scores of the individuals in the intervention and control groups were compared, it was found that only caregivers' care satisfaction increased at a statistically significant level (P < 0.05). At the end of the training given according to PLST, it was found that behavioural problems of Alzheimer's patients and the care burden of caregivers had decreased, and the care satisfaction of caregivers increased. It is recommended that Alzheimer's patients and their caregivers be given training and interventions according to PLST.

Outcomes of a Two-Component Intervention on Behavioral Symptoms in Persons With Dementia and Symptom Response in Their Caregivers.

This study evaluated the longitudinal influence of an individualized evidence-based psychoeducational intervention for caregivers on frequency of behavioral symptoms in persons with dementia (PWD) and caregiver reaction to these symptoms. The intervention included information about the disease process using Progressively Lowered Stress Threshold (PLST) content and a family meeting based on Mittelman's New York University Intervention. A quasi-experimental study design was implemented. The Revised Memory and Behavior Problems Checklist was administered to N = 127 caregiver/care recipient dyads at baseline, 6, 12, and 18 months follow-up. All caregivers were enrolled in the intervention at baseline and followed over 18 months. Linear mixed models were developed to evaluate effects on frequency of behavioral symptoms in PWD and caregiver response. The most frequently occurring behavior was memory problems, although depressive behaviors produced the most negative caregiver responses. Between baseline and 6-month follow-up, there was a significant decrease in frequency of behavioral symptoms. Overall, there was a significant decrease in caregiver's reaction to behavioral symptoms from baseline to 18-month follow-up.

Application of the Progressively Lowered Stress Threshold Model with Community-Based Caregivers: A Randomized Controlled Trial.

The Progressively Lowered Stress Threshold (PLST) is a conceptual model for reducing behavioral symptoms in individuals with dementia. The aim of the current study was to evaluate the effectiveness of the PLST-based intervention on burden, symptoms of depression, and quality of life (QOL) of caregivers, as well as neuropsychiatric symptoms and QOL of individuals with dementia. A randomized controlled trial was used. Sixty-five participants completed the study. Although variables examined in caregivers in the intervention group showed statistically significant improvement throughout follow up, there was no statistically significant difference between the intervention and comparison groups. In addition, no statistically significant difference was noted between groups for patient variables. Care based on the PLST model was clinically effective in decreasing caregiver burden and depression of family members, and in increasing their QOL, but no more effective than routine care. [Journal of Gerontological Nursing, 42(7), 44-54.].

Conceptual framework for cognitive function enhancement in people with dementia

This aim of this study is to propose a conceptual framework for guiding interventions to enhance the cognitive function of people with dementia. Few studies have been published on non-pharmacological approaches with a conceptual framework for an intervention to enhance cognitive function. The Progressive Lowered Stress Threshold model is one of the useful theoretical models for predicting the occurrence of dysfunctional behaviour in people with dementia. Based on the theoretical assertion of the Progressive Lowered Stress Threshold model and empirical findings on the relationship of anxiety and depression with cognitive function, an expanded model is proposed. Discursive paper. Literature regarding stress and anxiety in people with dementia was reviewed and critically analysed, and then integrated into the Progressive Lowered Stress Threshold Model. With careful considerations about the relationships between the variables indicated in the Model and the evidences and limitations suggested in the literature reviewed, an expanded model has been proposed, which may guide the development of non-pharmacological intervention for promoting cognitive functions of people with dementia. Recommendations or implications for practice have been given. There are three commonly used models in dementia care, including the biomedical, behavioural and Progressively Lowered Stress Threshold model. Their uses and weaknesses are given. An expanded model is suggested, and explanations are provided with regard to its merits in guiding the development of interventions for people with dementia. Further testing on this model is suggested. Cognitive function and dysfunctional behaviour are the major concerns of caregivers of dementia patients. Interventions that can alleviate the symptoms and enhance cognition are likely to improve the well-being of patients and their caregivers. This proposed model can guide the development of interventions.

Temporal Patterning of Agitation and Stressors Associated With Agitation: Case Profiles to Illustrate the Progressively Lowered Stress Threshold Model

BACKGROUND: Stressors in persons with dementia (PWD) are often unrecognized until serving to trigger challenging behaviors, such as agitation. OBJECTIVE: The purpose of this study was to examine temporal patterning of stressors associated with agitation in PWD as postulated in the progressively lowered stress threshold (PLST) model. STUDY DESIGN: Baseline data of agitation from an intervention study of 39 cognitively impaired elders residing in a long-term care facility were analyzed. A modified Cohen-Mansfield Agitation Inventory was used during a 3-week period to document the frequency of agitation twice weekly for an hour during estimated “peak levels of agitation.” Anecdotal notes documented stressors. RESULTS: Case profiles were developed to illustrate factors identified in the PLST model that may contribute to stress and cause agitation. CONCLUSIONS: Findings suggest that temporal patterning of agitated behaviors in PWD may be predictable based on the PLST model. Recognizing early signs of agitation and its underlying meaning can facilitate timely and appropriate intervention by psychiatric nurses.

Predictors of Use of Services Among Dementia Caregivers

Caregivers of persons with dementia do not use community resources until late in the disease process, despite the fact that judicious use of community resources can delay nursing home admission. Data from the National Caregiver Training Project, based on Hall and Buckwalter's (1987) progressively lowered stress threshold (PLST) model, were used to examine variables related to use of community resources. Spouse and adult child caregivers were divided into two groups based on amount of community resources used per week. Within this geographically diverse sample of caregivers, 64% did not use professional services, 79% did not use respite services, and 65% did not use other services. Being a spouse decreased the odds that the caregiver would use community resources. Resource use was also related to the care recipient's problems with activities of daily living and the increase in frequency of memory and behavioral problems.

Development and Analysis of the Effects of Caregiver Training Program on Aggressive Behavior in Elders with Cognitive Impairment

The purposes of this study were to 1) describe the type and frequency of aggressive behavior of cognitively impaired nursing home resident, 2) develop a caregiver training program on prevention and management of aggressive behavior, 3) examine the effects of caregiver training program on the incidence of aggressive behavior of cognitively impaired nursing home resident, and 4) examine the effects of caregiver training program on nursing staff's aggressive behavior management skills. One-group, time series, quasi-experimental design with a pre-test and two post-tests was used. Data were collected from cognitively impaired home residents (N=32) and nursing staff (N=36) in a proprietary nursing home using Ryden Aggression Scale I, II, and Aggressive Behavior Management Scale. Data were entered and analyzed by descriptive statistics and repeated measures ANOVA. Incidence of aggressive behavior was high with a mean score of 3.09 (SD=3.11) at baseline. Caregiver training program was developed based on Progressively Lowered Stress Threshold (PLST) model and gerontological and psychiatric literature. The mean scores of aggressive behavior at baseline, Post I, and II did not differ significantly although the difference approached to the significant level (F=2.925, p=.066). Nursing staff's aggressive behavior management skills increased at Post I, and at Post II when compared to baseline, and the difference was significant (F=12.736, p=<.001). Caregiver training program showed potential impact on reduction of aggressive behavior in elders with cognitive impairment and was effective in increasing nursing staff's aggressive behavior management skills.

Touch-Stress Model and Alzheimer's Disease

This article presents a theoretical model for future nursing research and practice on the use of touch intervention in patients with Alzheimer's disease. A theory synthesis was conducted that built on a base of previous research findings pertaining to the phenomenon of interest identified by two conceptual models: the Progressively Lowered Stress Threshold (PLST) model and the Touch model. The literature review was restricted to published articles in nursing and health services journals from 1970 through 2000. The Touch-Stress model formulated through theory synthesis can contribute to theory development, serve to improve care of patients with Alzheimer's disease suffering from emotional and behavioral disturbances, and increase the quality of life for the caregivers and families of patients with Alzheimer's disease.

History, development, and future of the progressively lowered stress threshold: a conceptual model for dementia care.

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.

A nursing intervention to decrease depression in family caregivers of persons with dementia

The goal of this study was to evaluate a community-based psychoeducational-nursing intervention designed to teach home caregivers to manage behavioral problems of persons with Alzheimer's disease and related dementias (ADRD) using the Progressively Lowered Stress Threshold (PLST) model, and to compare this intervention with routine information and referrals for case management, community-based services, and support groups. Previous caregiver studies have overwhelmingly pointed to the adverse effects of caregiving on the caregivers' physical and mental health, and high prevalence rates of depression among caregivers of persons with ADRD have consistently been reported. Therefore, a primary aim was to evaluate the impact of the intervention on caregivers' affective responses, especially depression. Data from both the Profile of Moods States and the Geriatric Depression Rating Scale support the effectiveness of this intervention in decreasing depression among caregivers who received the experimental training. Additional analysis of factors associated with caregiver depression are also reported. The pivotal role of psychiatric nurses in the assessment and treatment of depression among caregivers of persons with ADRD is discussed.

Pastoral Care for the Person with Dementia

SUMMARY We discuss the various stages of Alzheimer's disease and related disorders (ADRD) and present a psychosocial model which spiritual caregivers can use in their ministry, the Progressively Lowered Stress Threshold (PLST) model. We argue that religious activities are very important to these patients and that spiritual caregivers can make an important contribution.

Standardized care plan. Managing Alzheimer's patients at home.

1. Family-provided care of members with Alzheimer's disease and related disorders (ADRD) is complicated by the presence of secondary behavioral symptoms, such as agitation, that lead to caregiver depression, burden, and breakdown. 2. Caregiver education to manage secondary symptoms in ADRD can be simplified by using a theoretical framework of person-environment fit, providing a selection of interventions to modify the environment to reduce demand on the dwindling resources of the demented person. 3. The Progressively Lowered Stress Threshold (PLST) model identifies six areas of stress for persons with ADRD fatigue, change of caregiver, environment or routine, demands to achieve beyond capability, multiple and competing stimuli, affective response to perceived losses, and physical stressors.

CARING FOR PEOPLE WITH ALZHEIMER’S DISEASE USING THE CONCEPTUAL MODEL OF PROGRESSIVELY LOWERED STRESS THRESHOLD IN THE CLINICAL SETTING

Care of the people with Alzheimer's disease and related disorders (ADRD) has been fraught with controversy, often resulting in competing philosophies about what constitutes the "correct" approach. Whether developing an individualized plan of care or specialized programming, it is helpful to use a conceptual framework. The Progressively Lowered Stress Threshold (PLST) conceptual model has been used extensively for planning individualized care for patients with ADRD, developing specialized environments and programming, evaluating outcomes of interventions, and serving as the theoretical framework for nursing research. This article describes use of the PLST model in a clinical setting.