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In: Finnema EJ* (2000) Emotion-oriented care in dementia, a psychosocial approach (pp 57 - 84). Amsterdam: Vrije Universiteit
Also published in: Finnema EJ, Dröes RM, Ribbe MW & Tilburg W van (2000) A review of psychosocial models in psycho-geriatrics; implications for care and research. Alzheimer Disease and Associated Disorders, 14 (2), 68-80

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Keywords: Psychosocial models, psychogeriatric care, emotion-oriented care

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Summary

Purpose: Based on an examination of the relevant literature, a survey of psychosocial models used in the psychogeriatric field is presented. Models with a multidimensional approach to behavior problems in de-mentia, and a focus on the individual, were selected. The utility of these psychosocial models as a theoreti-cal framework for emotion-oriented care for people with dementia, especially Alzheimer’s disease, is ex-amined.
Method: In addition to describing the models, the target group for which these models were developed, the degree to which they have been operationalized for psychogeriatrics and the degree to which they have been subjected to empirical testing are also reported on.
Results: This study shows that all psychosocial models described may be called emotion oriented, al-though they also contain, in varying degrees, elements from the consequences model. It was found that the models are used not only as a theoretical framework for research, but also in the provision of care. Conclu-sions: Despite the fact that most models have been used in the psychogeriatric field, therefore proving their practicability for psychogeriatric practice, only one of the models described has been tested empirically so far. The empirical validity of the models in question is, therefore not yet clear.

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Introduction

Traditionally, the care of residential psychogeriatric patients has had a medical-somatic orientation. The primary goal was the treatment of reversible impairments by means of reactivation therapy (Prins, 1993). A change occurred in the 1970s. The psychologic aspects of dementia became more important, and in addi-tion to a focus on medical and paramedical care, the mental well-being and the social and living environ-ments of the residents gained importance. Therefore, the main emphasis was no longer on illness, but rather on the consequences of illness.
Over the 1970s and 1980s, psychosocial care gained an increasingly important position in the care provi-sion. Psychosocial care may be defined as the treatment and support of mental and behavioral problems that may occur in the process of coping with and adapting to the consequences of dementia (Dröes, 1991). During this period emphasis was placed on the activation and reactivation of cognitive functions and func-tional compensation. The main goal was to maintain, support or compensate those functions that were still intact. Psychosocial care was offered mainly from the so-called consequences or rehabilitation model (Dröes, 1995).
By the end of the 1980s attention shifted from functional thinking to the subjective experiences of people with dementia, and the individual way they cope with the consequences of their illness and experience them subjectively (Miesen, 1990; Cohen, 1991; Dröes, 1991; Kiyak & Borson, 1992; Cotrell & Schulz, 1993; Cotrell & Lein, 1993; Kolanowski & Whall, 1996; Stokes, 1996; Kitwood, 1997; Moore, 1997). When these experiences are taken as the central aspect in the care, we speak of emotion-oriented care (American Psychiatric Association, 1997). Examples are: validation therapy, reminiscence therapy and sensory integration.
This broadening of perspective meant that the existing models, the medical model and the consequences model, no longer sufficed. A need emerged for models that provided insight into the experiences of people with dementia and the way in which they cope with the consequences of the disease. In the course of the 1980s, we see the development of such models, largely based on existing psychologic and sociologic theo-ries. These developments continued into the 1990s.

We present an overview of the psychosocial models currently used in psychogeriatrics. Our study into the effect of emotion-oriented care for people with dementia (Finnema et al. 1998) gave rise to this review.
The objective of the review is to offer information to other researchers who want to set up a study into the effect of emotion-oriented approaches. Furthermore, this review offers professionals in the care for people with dementia the possibility to choose a theoretical framework for the application of emotion-oriented ap-proaches in psychogeriatrics.
We address the theoretical background, contents, and applications of the selected psychosocial models briefly. For more in-depth descriptions, we refer to the original publications of the authors of the various models. Finally, in our conclusion, we discuss the suitability of the models for practice and research. Similarities and differences between the models will be addressed.


Method


Search procedure

The search strategy we used consisted of searching for references in various bibliographic databases (i.e. Medline, PsycLit and Sociofile). We coupled the terms dementia and Alzheimer’s disease separately with the following terms: model (conceptual/psychological/psychosocial/nursing), approach (psychologi-cal/psychosocial/nursing), theory (psychological/psychosocial/nursing), coping (behavio(u)r/strategies) and adaptation/adaptive behavio(u)r. Furthermore, we used the snowball effect by retrieving other publications based on the references in the publications found initially.


Selection criteria

Our selection of psychosocial models was based on Taft’s (1997) description of psychosocial models for people with dementia, which we can summarize as follows:

“psychosocial models are characterized by a focus on the individual, validation of the person with the disease and linking up with the need of the person and with what the person is (still) able to do well, instead of emphasizing that which the person is no longer capable of doing well. In addition, psychosocial models view behavior problems multidimensionally, as symptoms that can be ex-pressed both emotionally and somatically, and which can be the result of external factors in the en-vironment, or internal person-related factors.”

We did not include all psychosocial models that are used in the psycho-geriatric field. We excluded models that focus exclusively on development (Zinder, 1984; Matteson et al. 1996), learning theory (Rabins, 1994), or on the functional consequences of the disease (Levy, 1987a; 1987b) and models with a unidimen-sional approach to the problems of people who have dementia (Jones & Burns, 1992). We also excluded models that focus exclusively on dealing with and caring for people with dementia and that offer no expla-nation for the behavior of people with dementia, as for example the application of Sullivanian theory (Whall, 1989), the Jones communication model (1992) and the nursing model for caring for the elderly (Jones & Burns, 1992). The same applies to a few general nursing conceptual models that, as far as we know, have not yet been used in the care of people with dementia, or that have been described only inci-dentally, such as the Johnson behavioral model which was used in the group support of caregivers of eld-erly people with dementia (Fruehwirth, 1989) and the Roy adaptation model (Thornbury & King, 1992).


Sample

The study concentrated on publications from 1960 through April 1999. We examined volume 1966 through April 1999 of the bibliographic database Medline, PsycLit volumes 1974 through March 1999 and So-ciofile volumes 1974 through April 1999. We made no distinction between types of articles and, in princi-ple, collected all publications that yielded substantial information, including theoretical opinions and inter-vention studies.


Analysis

The following questions served as starting points for the analysis:
1. What psychosocial models are used in the treatment and support of people with dementia?
2. What is the theoretical framework of these models?
3. What core aspects for care are derived from these models?
4. Have the models been applied before in research and in care situations?


Results

We traced eight models that fit the established criteria, ranging from develop-ment-oriented to system-theory-oriented models. We describe these models in chronological order. They are: the Erikson develop-mental stage model (1963), the progressively lowered stress threshold model (PLST model) (Hall & Buckwalter, 1987), dialectical framework (Kitwood, 1989), attachment theory (Bowlby, 1983; Miesen, 1990), the adaptation-coping model (Dröes, 1991), dynamic system analysis (DSA) (Bakker, 1992), the stages approach of Souren and Franssen (1993), and the Hagberg psychodynamic perspective (1997).


Erikson developmental stage model

The Erikson developmental stage model (1963) is based on eight psychosocial development stages in the lifetime of every individual. Erikson was influenced to some degree by Freud. However, Erikson’s starting point is that development is a continuous life-span process in which the individual must constantly find a balance. Crises dating from an earlier phase of life may return later if they are not dealt with adequately. Furthermore, Erikson attaches importance to cultural influences on development, whereas Freud empha-sized instinctual needs (Hetherington & Parke, 1993).
Erikson speaks of psychosocial stages because he starts from the premise that the psychologic development of people is dependent on the social relations they have at various points in their life. At every stage people are confronted with specific problems (see Figure 3.2). Depending on the way these problems are handled, either ‘strong’ or ‘weak’ characteristics develop.

Figure 3.2 Erikson’s stages of psychosocial development (Atkinson et al. 1990)

Stages	Psychosocial crises	Favorable outcome
1. 1th year	Trust versus mistrust	Trust and optimism
2. 1-2 years	Autonomy versus doubt	Sense of self-control and adequacy
3. 3-5 years	Initiative versus guilt	Initiative versus guilt
4. 6-puberty	Industry versus inferiority	Competence in intellectual, social and physical skills
5. Adolescence	Identity versus confusion	An integrated image of oneself as a unique person
6. Early adulthood	Intimacy versus isolation	Ability to form close and lasting relationships; to make career commitments
7. Middle adult-hood	Generativity versus self-absorption	Concern for family, society and future generations
8. The aging years	Integrity versus despair	A sense of fulfillment and satisfaction with one’s life; willingness to face death

In the final development stage of the Erikson developmental stage model ‘integrity versus despair’, people evaluate their lives by reminiscing. Butler describes the importance of looking back on life (life review) for the psychologic well-being of people. He indicates that this becomes increasingly important as people be-come older. It is a natural, spontaneous process, during which one becomes conscious again of past events.
In the psychogeriatric field, Feil (1967, 1984, 1989) and Kihlgren et al. (1996) have applied the Erikson developmental stage model. Feil (1967, 1984, 1989) based her validation approach on elements from the Erikson developmental stage model. Validation is based on the idea that behavior of the elderly is deter-mined not only by the condition of the brain, but also by a number of other physical and psychosocial fac-tors. One of those factors is the degree to which a person has gone through the different stages of develop-ment successfully (Feil, 1992). Feil criticizes Erikson for not taking into account the serious physical losses that occur at an advanced age during the final stage of life (integrity versus despair). Feil and De Klerk-Rubin (1991) indicate that inner harmony (integrity) can only be reached if a person still has the cognitive ability to cope with problems. Therefore, she added a ninth stage to the Erikson developmental stage model. In this ninth stage, ‘resolution versus vegetation’ is the central issue. Adding this stage makes it possible to give more specific attention to disoriented elderly people, who experience relief when validated in their feelings. This is a central aspect of the validation approach.
Kihlgren et al. (1996) used the Erikson developmental stage model as the theoretical framework for the in-tervention and data analyses in research among nursing home residents with severe dementia (N=5). After the staff took part in a training course, aimed at encouraging the inner harmony (integrity) of the residents, interaction between residents and staff increased, and the residents started exhibiting more ‘strong’ char-acteristics, such as: expres-sing hope, their own wills, goals, competence, and trust. The vague description and observability of the ‘weak’ characteristics proved problematic in the application of the Erikson devel-opmental stage model (Kihlgren et al. 1996).


Progressively lowered stress threshold model

Hall and Buckwalter (1987) developed the progressively lowered stress threshold model (PLST model) starting from a balanced interaction between individual and environment. Their model is based on the coping theories of Lazarus (1966) and Selye (1980) and the results from learning theoretical and physiol-ogic research on people with Alzheimer’s disease (Hall, 1994).
The PLST model focuses on the influence of the care environment. The star-ting point is that the environ-ment must be adjusted to fit people with dementia and their deteriorating cognitive and functional abilities (Gerdner et al. 1996).
The model’s target group consists of people with Alzheimer’s disease and related disorders. The model aims to provide a theoretical framework for the individual care of these people, both in the home situation and the institutional setting (Hall et al. 1995b).
The PLST model distinguishes four stages in Alzheimer’s disease: (forgetfulness, confusion, ambulatory dementia, and end stage). The accompanying symptoms consist of: cognitive or intellectual losses; affec-tive or personality changes, conative (concerning the will) losses, planning capability losses and a progres-sively lowered ‘stress threshold’, which may generate dysfunctional behavior (i.e., agitation, repetitive be-havior, wandering, night-time unrest, aggression).
As the disease progresses, the stress threshold is lowered during the course of the day, depending on the stress factors. The stress factors are divided into six categories: (1) fatigue, (2) changes regarding the care-giver, environment or routine, (3) demands that exceed a person’s capabilities, (4) overwhelming and con-flicting stimuli, (5) affective reactions to experienced losses, and (6) physical stressors, such as acute ill-ness or pain. This categorization of stress factors can be used to gather diagnostic data and to plan and evaluate care.
The PLST model has been used extensively in the provision of care for people with Alzheimer’s disease to design individual care programs, modify the environment and, design special treatment programs, and evaluate interventions (Hall, 1988, 1994; Hall & Buckwalter, 1991; Hall et al. 1995a). The model is fur-thermore used as a context for nursing research (Hall, 1994; Collins et al. 1995).


The Dialectical framework

Kitwood (1989, 1990, 1993a, 1993b, 1996, 1997, 1998) starts from a dialectical framework to explain the dementia process. In his opinion, a constant interaction between neurologic disabilities (situation) and so-ciopsychologic processes (causal factor) cause the dementia process. This interaction is responsible for the emergence of a new situation that in turn interacts with causal factors, which again generates a new situa-tion, and so on (Kitwood, 1996).
The dialectical framework was developed from the idea that the biomedical perspective is inadequate when it comes to explaining the dementia process and the clinical dementia picture. Kitwood does not dismiss the biomedical paradigm, but views the symptomatology of elderly people with dementia as a result of the interaction between various factors (i.e., personality, life history, physical health, neurologic damage, and the sociopsychologic environment).
Personality, life history and progressing neurologic damage are presumed to be ‘facts’ that are difficult to influence. Physical health, social psychology, and the way the person is approached by others then remain as crucial factors that can be influenced. Regarding physical functioning, an improvement in physical functions is frequently accompanied by an improvement in mental health (Kitwood, 1993a).
As the brain increasingly degenerates and inner stability decreases, psychologic functioning becomes in-creasingly susceptible to negative environmental influences. That is why it is important that an environ-ment is created that offers sufficient stability and love to enable the person with dementia to maintain the highest possible level of psychologic functioning.
Within the sociopsychologic environment, behaviors are distinguished that may have a negative impact on the person with dementia, such as: treating the person as a child, taking over activities unnecessarily, and ignoring the dementing person’s feelings (Kitwood, 1990; 1993a). However, there are also approaches that may have a positive effect on the well-being and functioning of the person with dementia, for example: of-fering a safe environment, accepting the way the person experiences the world, enabling the person to do things they would otherwise be unable to do, and stimulating the senses (Kitwood, 1996).
A purely scientific verification of the Kitwood model is difficult, because the subject matter is too complex and the theory is too vague (Kitwood, 1990). It is, however, possible to examine the effect of a positive or negative approach on the person with dementia by means of dementia care mapping (DCM). Dementia care mapping is an observational technique that entails indicating what happens to the elderly person with dementia and the degree of his well-being during a set time in consecutive periods of 5 minutes. One hundred ten aspects are distinguished (i.e., sleeping, walking, receiving physical care); in addition, negative behaviors by people in the environment of the person with dementia have been operationalized into 30 categories.
Kitwood indicates that his starting points apply to both the home situation and to institutional settings. We were not able to determine to what extent the model is being applied in practice and research outside the dementia care mapping studies conducted by Kitwood (Kitwood & Bredin, 1992; 1994) and by Spaull and Leach (1998) who used dementia care mapping in their evaluation of the effects of sensory stimulation on people who have dementia.


Attachment theory

Miesen (1990, 1992, 1997) used the attachment theory developed by Bowlby (1983) as an explanatory model regarding parent-fixation in elderly people with dementia.
Bowlby (1983) states that attachment behavior consists of all behaviors that focus on the proximity of an ‘attachment figure’, who is another person. Attachment behavior induces the attachment figure to exhibit care behavior. Attachment behavior is present or potentially present throughout life and is manifested espe-cially by children and elderly people in stressful situations. The way in which and the person to whom this behavior is expressed changes over time (Miesen, 1990). Although Bowlby indicates that attachment be-havior is potentially present throughout a person’s lifetime, he has conducted no empirical research of at-tachment behavior during old age or in people with dementia.
Miesen applied attachment theory to elderly people who have dementia (1990, 1992, 1993). Based on clinical experience, Miesen concluded that every elderly person with dementia, at some point, appears to cling to the idea that his or her parents, who have long since died, are still alive (parent-fixation). This be-havior is expressed, among other things, by: the person with dementia expressing the desire to go home or to his or her parents and asking where their parents are (Miesen, 1993).
From the attachment theory perspective, this behavior not so much implies loss of memory, but might be an anxiety reaction because of experiencing the losses that accompany the dementia. In this way parent-fixation can be con-sidered an expression of the need for security (Miesen, 1990). Furthermore, it is possi-ble that the elderly person with dementia experiences the deterioration that accompanies the dementia as a strange and stressful situation, which also evokes attachment behavior.
Miesen tested this theoretical assumption about the attachment of elderly people with dementia in 1987 in a study among the residents of a psychogeriatric nursing home. Parent-fixation was found in two thirds of the residents involved in the study (N=40), and it was also found that the degree and the way in which parent-fixation exists is related to the stage of the dementia. Parent-fixation was exhibited especially by elderly people with dementia who had a low level of cognitive functioning (Miesen, 1993).
Coleman et al. (1997) examined whether a training course based on attachment theory for the staff of resi-dential homes had a positive effect on the staff members’ recognizing the emotional needs of the residents with dementia. In 18 training sessions, based on attachment theory, subjects such as dementia and depres-sion, communication with the person with dementia, and coping with behavior problems were addressed. This training course appeared to result in an increased response from staff members to signals from resi-dents aimed at getting attention, and in a decrease of the intensity of anxiety in the residents.
In The Netherlands, the principles of attachment theory are applied in the so-called ‘warm care’, an ap-proach that is similar to the ‘gentle care’ approach used in the United States and Canada (Jones & Wright, 1991). This approach focuses on offering a homelike, familiar and secure environment to elderly people with dementia (Houweling, 1987).


Adaptation-coping model

Dröes (1991, 1996, 1997b) developed the adaptation-coping model (1991, 1996, 1997b). The model offers a frame for explaining behavior problems in elderly people with dementia. One of the major presumptions of the adaptation-coping model is that people constantly strive for equilibrium. When people are con-fronted with changes in their existence, this will lead to a disruption of the balance. To regain balance, they will try to cope with these changes.
Dröes applied this general interactional principle formulated by Lazarus and Folkman (1984) to elderly people with dementia and added elements from Moos and Tsu’s (1977) crisis model which concentrates specifically on the adjustment of people in the case of serious illness. Moos and Tsu (1977) indicate that a number of general adaptive tasks are important for the restoration of the balance disrupted by serious ill-ness.
Elderly people with dementia can also be confronted with a disrupted balance as a result of the conse-quences of the illness. Dröes (1991) therefore assumes that the adaptive tasks mentioned by Moos and Tsu are also important to people with dementia. She names the following examples of cognitive adaptive tasks: learning to cope with the invalidity that is caused by the dementia and the development of an adequate re-lationship with the professional staff. Examples of emotional adaptive tasks are: preserving an emotional balance, preserving a positive self-image, and preparation for an uncertain future. She distinguishes the following social adaptive tasks: developing and maintaining social relationships and dealing with the nursing home environment and special treatment procedures (Dröes, 1997b).
Theoretically, the different adaptive tasks are distinguishable from each other, but, in reality, the way in which the person with dementia handles the adaptive tasks mentioned is, of course, a complex adaptation process (see Figure 3.3).
The degree to which an adaptive task is experienced as stressful depends on the cognitive appraisal of the situation or the change the elderly person with dementia is going through, either consciously or uncon-sciously. Personal factors, illness-related factors, and material and socioenvironmental factors affect this subjective appraisal. The adaptation-coping model views adjustment as an interactional, dynamic process that develops through an internal and an external cycle. The internal cycle takes place inside the person with dementia and may be viewed as a learning process. The external cycle concerns the interaction be-tween the elderly person with dementia and the environment (Dröes, 1991).

The application of the adaptation-coping model in psychogeriatrics offers possibilities for diagnosis, treat-ment, and evaluation of psychosocial problems in elderly people with dementia.
It is used in several psychogeriatric nursing homes in the Netherlands (Van der Kooy & De Ruiter, 1996), as well as in support programs for people with dementia who live at home and their central caregivers (Dröes & Breebaart, 1994; Dröes, 1996;1997a; Koens, 1997; Ladage, 1997; Projectgroep Gro-ningse Ont-moetingscentra, 1997). The model has been operationalized for application in psychomotor therapy (Dröes,1991; 1997b) and has proved to be a practicable theoretical framework for intervention research among people with dementia (Dröes, 1991; 1996).


The Dynamic system analysis model (DSA)

Bakker (1992, 1994, 1997) has applied a number of principles from the system-theory perspective (Von Bertanlanffy, 1974; Sipsma, 1988; Milders & Van Tilburg, 1988) to the situation of elderly people with dementia. He pre-sents a model that attempts dynamically to integrate psychosocial and somatic factors, as well as their continuous mutual interaction, and that involves psychologic, somatic, sociologic and life history factors (Bakker, 1992).
According to the dynamic system analysis (DSA) mental disorders in psychogeriatric patients are the result of an imbalance within the person, the environment, and the interaction between the two (Bakker, 1992; 1997). This imbalance results in a reduction or loss of autonomy and loss of the ability to realize a suitable environment. The relationship between cause and effect is not immediately obvious, there is a whole group of interrelated factors (the system). The important positive and negative factors that cause the psycho-geriatric disorder can vary per individual. That is why the significance of those factors in their mutual in-teractions (analysis) is examined on an indivi-dual basis. The analysis starts as much as possible from the way the person with dementia experiences and gives meaning to his or her environment. Intervening in specific factors in these cyclical processes can influence mental problems.

Figure 3.4 Model dynamic system analysis (Bakker, 1994)

Figure 3.5 Illness stages and stages of support for people with Alzheimer’s disease
(Souren en Franssen, 1993a)

Illness stage	Stages of support
I. Loss of planning and initiative	Encouragement stage
II. Loss of insight, judgement and motivation	Intervention stage
III. Loss of learned everyday, more or less routine activities and speech	Stage of partial taking over of activities
IV. Complete loss of spontaneous motor movement activity	Stage of complete taking over of activities

Figure 3.6 Coping in a life-span perspective (Hagberg, 1997)

The model attempts to represent the relationship between the different varia-bles. It is based on the as-sumption that the person with dementia adjusts to the changes brought on initially by the dementia through an adaptive psychodynamic process, which is based primarily on earlier experiences and personal factors, such as personality and ego functions (see also Dröes, 1991).
The most important symptom of dementia is cognitive change. This has a far-reaching impact on general functioning. The person with dementia not only reacts to changes in cognitive functioning, but is also in-fluenced by them, for example in the capacity to process new experiences. Quickness of response, concen-tration, abstract thinking, and planning ability decrease, as do the available defense mechanisms.
Hagberg (1977) views the degree of cognitive deterioration based on three dimensions: cognitive powers, ego functions, and social relationships. He distinguishes five stages of cognitive deterioration, varying from: no cognitive disabilities to general deterioration accompanied by aphasia, apraxia, and agnosis. The various stages of cognitive deterioration are generally accompanied by certain dominant behaviors. Based on this, several approaches are suggested, such as: training, supporting, explaining, empathizing, and acti-vating. The care must focus on optimizing the adaptation.
The principles of the Hagberg psychodynamic approach are partly theoretical and partly based on the re-sults of the Lund Longitudinal Dementia Study (Hagberg, 1997). Hagberg advocates a practical application of this approach in the psychogeriatric field. We do not know if the Hagberg psychodynamic perspective is currently being used as a theoretical principle to care for elderly people with dementia.

Table 3.7 Psychosocial models in psychogeriatrics

Model	Theoretical perspective	Starting point	Focus of care	Application	Research Care
Developmental stage model (Erikson, 1963)	Developmental theory	Eight developmental stages with specific problems. Depending on how people cope they develop “strong” and “weak” characteristics	Foster positive results from psychosocial crises by offering environment that uses capacities of person with dementia optimally	Study among nursing home residents with dementia	Feil (1991) adds stage nine ‘resolution vs. vegetation’. ‘Integrity promoting care’ in nursing home residents with dementia
PLST model (Hall & Buckwalter, 1987)	Coping theories Lazarus (1966) and Selye (1980), learning theory and physiological research	Phased course of DAT with lowering of stress tolerance threshold which increases changes of dysfunctional behavior	Modify environment to person’s stress tolerance threshold, f.e. by reduction of stimuli	Theoretical framework in nursing research	Basis for treatment programs and care plans for elderly with dementia at home and in institutions
Dialectical framework (Kitwood, 1989)	Biologic and psychologic principles; observational research, interviews with family	Dementia is a combination of neurologic and sociopsychologic factors. Psychologic environment is important to well-being	Approach person with dementia respectfully to limit deterioration in functions	Studies of the effect of psychologic environment on people with dementia	Unknown if model is used anywhere outside DCM studies conducted by Kitwood
Attachment theory (Miesen, 1990)	Attachment theory (Bowlby, 1983)	Parent-fixation, possibly anxiety response to losses accompanying dementia	Offer familiar environment to reduce anxiety in person with dementia	Research of parent-fixation in dementia	Elements from attachment theory basis for ‘warm care’
Adaptation-coping model (Dröes, 1991)	Coping model Lazarus and Folkman (1984) and adaptive tasks Moos and Tsu (1977)	Behavior pro-blems result from adaptation problems. Adaptation affected by environmental, illness, and personality factors	Support adaptation based on cyclical model for psychosocial care	Framework for research among people with dementia at home and in residential care	Principle in model for psychosocial care in intramural and extramural setting
Dynamic system Analysis (Bakker, 1992)	System theory	Mental disorders result from imbalance within person, environment and interaction between the two	Analyze indivi-dual as a system. Offer emotional support, modify environment and medication	Framework for retrospective study among people in the early stages of dementia	Theoretical framework for multidisciplinairy care in intramural setting
Stages approach (Souren & Franssen, 1993)	Biological approach; FAST (Reisberg et al. 1993)	Phased course of DAT and increasing loss of skills	Maintain activity of people with Alzheimer’s disease and support them through illness by offering affection	Applied in longitudinal study of people with Alzheimer’s disease	Not used in the care, apart from the study mentioned (as fas as could be determined)
Psychodynamic model (Hagberg, 1997)	Psychodynamic theories, Lund longitudinal dementia study (Hagberg, 1997)	Cognitive change affects all aspects of being. Coping behavior related to diagnosis, social relations, person and experience	Optimize adaptation, based on diagnosis and personality of person	Model not yet applied in research, as far as could be determined	Not yet used in care as far as could be determined

Conclusion and discussion

Based on an examination of the literature, the contents, background, and application of psychosocial mod-els used in the psychogeriatric field were addressed (see Table 3.7). Eight models were traced, all charac-terized by a focus on the individual and a multidimensional view of the behavior of people with dementia.
Although all of the described models may be called psychosocial and emotion- oriented, they also contain, in varying degrees, elements from the consequences model (see introduction). In other words: they also pay attention to compensating and limiting the functional consequences of dementia.
The theoretical background of the models (f.e., system theory, developmental theory, or psychodynamic theory), determines whether emphasis is placed on the consequences of the disease or on coping with the consequences of the disease. Examples are: attachment theory, the progressively lowered stress threshold model, the Kitwood dialectical framework and the LIMIT scheme. These models attach great importance to the modification of the psychosocial and/or material environment of the person with dementia, to compensate for his deteriorating mental functions.
The majority of the models consider the dementia and the accompanying changes in cognitive functioning as the main determinants and, unfortunately, as unalterable factors in the behavior of the person with de-mentia. None of the described models start from a medical perspective, in the sense that they focus on tracing the cause of the disease to cure it. Integration of the perspectives of the medical model, the conse-quences model, and the psychosocial model is expressed most explicitly in the dynamic system analysis model.
We wonder to what extent the models described here may serve as a starting point for emotion-oriented care for people with dementia syndromes, more specifically Alzheimer’s disease, and to what extent may serve as a theoretical framework for research into this type of care. To answer this question we use the fol-lowing criteria: the degree to which the model has been operationalized and offers points of departure for psychogeriatric care, the degree to which the model has been subjected to empirical testing and the target group for which the model was developed.


Operationalization of the model for psychogeriatrics

The degree to which the models have been operationalized and offer concrete starting points for the provi-sion of care varies. The Erikson developmental stage model and attachment theory do not offer concrete leads for the care provision, but they have been operationalized for psychogeriatrics. Feil (1967, 1984, 1989) has added a ninth stage to the Erikson developmental stage model to accommodate people with de-mentia. Kihlgren et al. (1996) examined the suitability of the theory for application as a theoretical frame-work in ‘integrity promoting care’ for nursing home residents with dementia. The limited operationaliza-tion of especially the ‘weak’ characteristics has proved to be an important shortcoming of the develop-mental stage model.
Miesen (1990) tested the attachment theory on people with dementia. However, attachment theory explains only one aspect of the behavior of elderly people with dementia, i.e. parent-fixation. In our opinion, this renders the attachment theory unsuitable as a general theoretical frame for the total psychosocial care in dementia. The other models consider the behavior of the person with dementia in a more general way and are, therefore, more suitable as starting points for the care provision. The LIMIT scheme of Souren and Franssen and the Kitwood dialectical framework offer the most detailed suggestions of how to approach and support people with dementia and provide care to them. Three of the other models, i.e. the adaptation-coping model, the dynamic system analysis and the progressively lowered stress threshold model, have furthermore been elaborated into concrete instructions for the entire cyclical care process from diagnosis, when establishing the request for help is the central issue, through evaluation. These models have been op-erationalized at the behavioral level, and have also been used in research. For now, we recommend that practitioners or researchers use one of these three models.


Empirical verification

As far as we know, the validity of only the attachment theory (Miesen, 1990) has been tested empirically. With the adaptation-coping model, only the different adaptive tasks have been tested so far (Dröes, 1991). Currently, the model as such is being tested in a group of psychogeriatric nursing home residents. There-fore, in general, we must conclude that the degree of validity of the models previously described is not clear.
Empirical verification of a model is of importance in a research setting, but from the caregiver’s perspec-tive, this may be less important than its practicability. This practicability is naturally linked to the degree to which the model can be operationalized for the care setting. As we observed earlier, opera-tionalization and application proved possible for the majority of the models described. Only with regard to the Hagberg (1997) psychodynamic perspective does it remain unclear whether this perspective has already been ap-plied to the care practice and to the study of people with dementia.


Target group

The target groups for which the models were developed also vary. The progressively lowered stress thresh-old model, the adaptation-coping model, and the LIMIT scheme were originally developed for people with a probable diagnosis of Alzheimer’s disease or a related disorder. Hagberg and Kitwood developed their model for a broader group, i.e. persons with different types of dementia (including frontal lobe dementia, vascular dementia, and Alzheimer’s disease). The other models were developed for psychogeriatric patients in the broad sense of the term, not for a specific diagnostic group.
It is obvious that a fitting theoretical framework is essential for providing emotion-oriented care to people with dementia. Because most models are quite recent and have not yet been subjected to empirical testing, it is too early to judge their theoretical validity. Practitioners will prefer those models that are operational-ized for home care or institutional care, and have already been found suitable for the target group.
The progressively lowered stress threshold model, the adaptation-coping model, and the dynamic system analysis model meet the requirement of clear operationalization, the first two being for both home care and institutional care, and the dynamic system model being only for institutional care. They offer concrete in-structions for the entire cyclical care process. That is why, for now, the use of one of these models is rec-ommended as a basis for emotion-oriented care.
The challenge for future research is the empirical testing of the models to advance the development of knowledge in the care of people with dementia. So far, only the attachment theory has been tested. Fur-thermore, a start has been made with the empirical testing of the adaptation-coping model.
For a model to be tested, it needs to be operationalized clearly. For most of the psychosocial models de-scribed this seems to be the case. An exception is the Erikson developmental model, which lacks clear definitions of especially the ‘weak’ characteristics. Finally, evaluation research can be fruitful to test the ef-fect of interventions resulting from the psychosocial models on people with dementia with regard to main-taining an optimal quality of life.
If the models withstand empirical scrutiny, they can truly provide a systematic structure for thinking, for observations, and for interpreting what is seen. Furthermore, they can give a rationale for activities and point out solutions to practical problems (Fawcett, 1989).


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