Community-based psychoeducational intervention (Garand)

Name of Intervention: Progressively Lowered Stress Threshold (PLST)

Principal Investigator (s): Linda Garand & Kathleen C. Buckwalter

Institutional Affiliation: University of Iowa School of Nursing

Caregiver Intervention Description

1. Summary of Intervention

The Progressively Lowered Stress Threshold (PLST) intervention is an individual educational intervention designed to strengthen the coping skills of family dementia caregivers by teaching methods of understanding and managing behavioral problems exhibited by the person with dementia. The intervention consists of two phases; the first phase is implemented in the caregiver’s home on two separate occasions, each lasting approximately three hours. During the first home visit, the interventionist teaches the underlying principles of the PLST model and instructs family caregivers in the use behavioral logs. The behavioral logs serve as a basis for planning care strategies and focusing discussions on troublesome behaviors during the second phase of the intervention. At the second home visit, the plan of care is reviewed and behavioral management techniques are taught. A plan for home safety is also outlined during this phase of the intervention and supporting literature is left with the caregiver. Referrals for support groups, legal counsel, and case management are provided as indicated.

Phase two of the intervention consists of telephone contacts (by the same interventionist), approximately every other week, for six months. During follow-up telephone discussions, behavioral logs are reviewed and principles underlying the PLST intervention are reinforced while providing concrete suggestions for managing difficult behaviors exhibited by the person with dementia. Throughout both phases of the intervention, caregivers are encouraged to discuss feelings associated with the caregiving experience (as well as general life stressors) and to be actively involved in the care planning process.

The comparison intervention is identical to the PLST intervention, with the exception of education based on the PLST model. During the first phase of the intervention, routine information on dementia is provided, behavioral logs are discussed, a plan for home safety is outlined, and referrals are made for community-based services. Family caregivers in the comparison intervention group also receive follow-up telephone contacts every other week to offer routine information and support. At the study conclusion, family caregivers who receive the comparison intervention are offered the opportunity to learn the experimental intervention.

Family caregivers who receive the PLST intervention show improved mood states and immune function (T-cell function) over time.

Key search terms:



Community based intervention

Immune outcomes

Mood outcomes

Progressively Lowered Stress Threshold

2. Intervention Materials

The following informational handouts were placed in a notebook and given to the family caregiver:

  • Overall Aims of the Caregiver Project
  • Symptoms of Dementia Syndrome
  • Common Behavioral Problems Associated with Dementia
  • The Plan of Care
  • Stress Response in Normal Aging
  • Progressively Lowered Stress Threshold (PLST)
  • Patterns of Dysfunctional Behavior in Dementia
  • Care Plan Compensating for PLST
  • Interventions: Management and Care Planning
  • Interventions: Principles of Validation
  • Interventions: Reality vs. Validation
  • Interventions: Managing Delusions and Hallucinations
  • Interventions: Bathing the Dementia Patient
  • Interventions: Improving Communications
  • Financial Planning for Incapacity
  • The 36 Hour Day
  • Caregiving at a Glance
  • Caring for Memory Impaired Elders: Family Readings
  • Activities for ADRD Patients
  • Caregiver Corner
  • Selected List of Resources
  • How to Hire Helpers
  • Home Safety Checklist
  • Behavioral Logs
  • “The 36 Hour Day” can be obtained at
  • “Caregiving at a Glance” can be obtained at
  • All other materials in the intervention notebook were either designed specifically for the study or were publications obtained from the local Alzheimer’s Association or Area Agency on Aging.

Contact information for further information, materials, and training:

Linda Garand

415 Victoria Building

3500 Victoria Street

Pittsburgh, PA 15261

412-383-7946 (phone)

412-383-7293 (fax)

3. Implementing the Intervention

Training qualifications and guidelines for those delivering the intervention.

Interventionists have a Bachelor’s degree (or higher) and receive face-to-face training before teaching the PLST intervention. A formal training program does not exist for PLST training.

Estimated costs:

Implementing the PLST intervention in family dementia caregiver homes cost approximately $1000 per caregiver.

Caveats/ limitations on the implementation of this intervention:

The PLST intervention is not appropriate for caregiver’s with cognitive impairment or family caregivers who cannot read, write, or understand the English language.

4. For more information

Garand, L., Buckwalter, K.C., Lubaroff, D.M., Tripp-Reimer, T., Frantz, R.A., & Ansely, T.N. (2002). A pilot study of immune and mood outcomes of a community-based intervention for dementia caregivers: The PLST Intervention. Archives of Psychiatric Nursing, 16(4), 156-167 (PMID:12143075).

Hall, G. R. & Buckwalter, K.C. (1987). Progressively lowered stress threshold: A conceptual model for care of adults with Alzheimer's disease. Archives of Psychiatric Nursing, 1, 399-406.

Buckwalter, K. C., Gerdner, L. A., Hall, G. R., Kelly, A., Kohout, F., Richards, B., & Sime, M. (1999a). Effects of family caregiver home training based on the progressively lowered stress threshold model. In S. H.

Gueldner & L. W. Poon (Eds.), Gerontological nursing issues for the 21st century: A multidisciplinary dialogue commemorating the International Year of Older Persons (pp. 81-98). Washington, DC: Sigma Theta Tau International.

Buckwalter, K.C., Gerdner, L., Kohout, F., Hall, G.R., Kelly, A., Richards, B., & Sime, M. (1999b). A nursing intervention to decrease depression in family caregivers of persons with dementia. Archives of Psychiatric Nursing, 13(2), 80-8.

Hall, G.R., Buckwalter, K.C., Stolley, J.M., Gerdner, L.A., Garand, L., Ridgeway, S., & Crump, S. (1995). Standardized care plan: Managing Alzheimer's patients at home. Journal of Gerontological Nursing, 21(1), 37-49 (PMID:7852717).

Kiecolt-Glaser, J. K., Dura, J.R., Speicher, C.E., Trask, O.J., & Glaser, R. (1991). Spousal caregivers of dementia victims: Longitudinal changes in immunity and health. Psychosomatic Medicine, 53, 345-362.

Garand, L., Dew, M.A., Eazor, L.R., DeKosky, S.T., & Reynolds III, C.F. (2005). Caregiving burden and psychiatric morbidity in spouses of persons with mild cognitive impairment. International Journal of Geriatric Psychiatry, 20 (6), 1-11 (PMID:15920711).

Note: This work was funded by the National Institute of Health (NIH), Office of Research in Women’s Health (ORWH) as an administrative supplement to a four-year, multi-site study evaluating the effects of the PLST intervention on caregiver emotional responses (NINR RO1 NR03234). Additional support was provided through research training grants from NIMH (T32 MH19986), NIA (T32 AG 00214), and NINR (F31 NR07114-01A2 and T32 NR7058).