Geri Richards Hall

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.

Preclinical cognitive decline in late middle-aged asymptomatic apolipoprotein E-e4/4 homozygotes: a replication study.

In a previous cross-sectional study of 100 asymptomatic individuals aged 49-69, we reported age-related decline in immediate and delayed memory that was steeper in apolipoprotein E (apoE)-e4/4 homozygotes than in members of other genetic subgroups. These findings were preliminarily based upon the statistical problem of multiple comparisons. We therefore sought to replicate these findings in a new cohort. From 1998 to 2000, 80 asymptomatic residents of Maricopa County, AZ were recruited through newspaper ads. 20 apoE-e4/4 homozygotes, 20 e3/4 heterozygotes, and 40 e4 noncarriers were matched (1:1:2) by age, gender, and years of education. All had normal neurologic and psychiatric examinations, including Folstein minimental status exam (MMSE) and Hamilton depression scale, and underwent a battery of neuropsychological tests identical to those in our previous study. The groups were well-matched for age (55.9+/-5.9 years), gender (60% women), and education (15.9+/-2.2 years), and were demographically similar to our previous cohort. Complex figure test recall was lower in e3/4 heterozygotes than noncarriers, but there was no significant difference between e4/4 homozygotes and noncarriers. There were no other significant differences in mean test scores between groups, but Wechsler adult intelligence scale-revised (WAIS-R) digit span showed a significant negative correlation with age in the e4/4 homozygote group relative to e4 noncarriers (p=0.008) as we had found in our previous study. In conclusion, we found a significant negative correlation of WAIS-R digit span with age in apoE-e4/4 homozygotes relative to e4 noncarriers in two separate cohorts, possibly reflecting an age-related effect on frontal lobe function in this genetic subgroup.

STANDARDIZED CARE PLAN: Managing Alzheimer's Patients at Home

1. Family-provided care of members with Alzheimers 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.

CHRONIC DEMENTIA Challenges in Feeding a Patient

1. For the SDAT/MID patient, the nurse must determine food preferences and ability to eat, meet nutritional needs, and have a basic understanding of what techniques might assist professional and family caregivers with appropriate feeding techniques. 2. Ensuring adequate nutrition requires a multidisciplinary approach. Nurses must collaborate with dietitians and other health care professionals regarding food selection, feeding techniques, and environmental management that maximize nutritional outcomes. 3. There is a need for continuing research into nutritional needs and dietary interventions for dementia patients in all stages of illness and in all settings.

Shining through: the humor and individuality of persons with Alzheimer's disease

1. Elders with diminished levels of cognitive functioning are capable of providing meaningful, consistent responses that illustrate individual expressions of self. 2. The demented elders history and experiences may provide important clues to understanding his or her current behaviors, verbalizations, and perceptions. 3. Humor may be used as a therapeutic intervention for persons with dementia and as a coping strategy for caregivers.

From almshouse to dedicated unit: care of institutionalized elderly with behavioral problems

This article provides an historical overview of the care of older persons with behavioral problems, from the almshouses of the early 20th century to the dedicated care units of today. The rôle of the psychiatric nurse in relation to the need for more mental health programming and changes in reimbursement mechanisms for the institutionalized elderly is examined.

The biological basis of behavioral symptoms in dementia

This article describes the pathophysiology of dementia and differentiates between cognitive and noncognitive symptoms that characterize this devastating illness. Relationships between brain anatomic and neurochemical systems and behavioral symptoms of dementia are discussed. An overview of the etiologies and neuropathologies of dementia are presented as they relate to impairments in memory and intellectual abilities, personality changes, and behavioral symptoms. Recent genetic and molecular discoveries that have advanced our understanding of this complex spectrum of disorders and their treatment(s) are also highlighted.

The effects of a dementia nurse care manager on improving caregiver outcomes outcomes.

Iowas Administration on Agings Alzheimers Disease Demonstration Grant to the States was a project to implement and evaluate a nurse care management model of service delivery for persons with dementia or care recipient and their family caregiver that was integrated with the case management system. The goal of the nursing service delivery model was to maintain persons with dementia safely in their homes, by connecting them with appropriate services and providing support to the care recipient and caregivers. Outcomes measures were evaluated over time. This article defines the role of dementia nurse care management and shares the results of the outcomes measurements. The evaluation showed that caregivers assisted by nurse care managements were more likely to show improvement in their stress levels, endurance potential, and well-being. This improvement was consistent over time.

Apolipoprotein E and intellectual achievement

OBJECTIVES To determine whether apolipoprotein E (apo E) genotype influences intellectual achievement in cognitively normal individuals. DESIGN Between 1994 and 1999 we performed apo E testing on 1,000 self-described cognitively normal residents of Maricopa County and detailed neuropsychological testing on a subset of 250. SETTING Tertiary care academic medical center. PARTICIPANTS Cognitively normal adults genotyped for apo E. MEASUREMENTS Measures of intellectual background included years of education and a demographically based estimate of intellectual capacity (demographic intellectual quotient (DIQ)). Measures of intellectual achievement, which included Wechsler Adult Intelligence Scale revised (WAIS-R), information (WAISI), and vocabulary (WAISV) scores, occupational intellectual requirements (OIR), and census-derived estimates of household income, were compared between apo E genetic subgroups while adjusting for intellectual background and demographic variables. RESULTS WAISI, WAISV, OIR, and income correlated with age, sex, education, and DIQ, but after controlling for these variables there were no clinically significant differences between apo E-e4 homozygotes and noncarriers on any measure. CONCLUSIONS No clinically significant differences between genotypes were observed for the effects of education and DIQ on WAISI, WAISV, OIR, or income, although a larger sample size would be required to exclude smaller, clinically insignificant differences.

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.