Would you be surprised that individuals diagnosed with moderate to severe dementia require redirection during approximately 78% of staff interactions? Perhaps the only surprise is that the 78% is so low.
When you get a chance, review a random sample of your d ementia careplans. I’m betting you’ll see the word “redirection” in nearly every care plan.
Redirection is an absolute foundation level skill for all dementia caregivers. The technique is straightforward, and it works.
My all-time favorite example of redirection is a mother and daughter conversation captured on YouTube under the title “Dementia Can Be Beautiful.”
All descriptions of redirection have the same basic components. This summary is from Nancy Kriesman, LCSW.
• Assess the environment
• Don’t try to explain or reason
• Go outside
• Introduce a meaningful activity
• Keep it simple
• Use bridge phrases to put the focus back on the person
• Use touch to calm and focus
Great information if you have adequate set-up time. But what do you do in a crisis situation when you don’t really have time to reason and explain? When going outside would be dangerous? When the only meaningful activity is protecting residents and yourself? Does redirection still work?
Here’s an example of using redirection during a crisis from my case files.
A little background … I was asked to provide behavior management training for staff working in a very rural facility in Alabama that was preparing to admit geropsychiatric patients for the first time.
I like to work with staff on all shifts, so I decided to start this training on a Sunday morning at 3 a.m.
The setting is an important antecedent for this case study. The center is way out in the country. The driveway is about a mile from the closest state route. There is a small parking lot just steps from the center’s front door. Dense woods surround the center, and a small lake is situated just past the woods in the general direction of the front door.
When I arrived at the center, I saw two guys in the parking lot trying to jump-start a pickup truck. Both were center employees (one was a nurse and the other was the maintenance guy). I introduced myself and offered to help. As luck would have it, I had a set of jumper cables that was substantially longer than the set the guys were using and dug them out. In exchange, the maintenance guy gave me the door code and let me know that fixing the door’s auto-closing mechanism was on his work list for later today. I would need to pull the door shut until I heard a distinct click to make sure the door was closed.
As soon as I got inside the facility and started to pull the door shut, with my back to the interior hallway, I heard an adult male screaming, “Those guys are stealing my truck, I’m going to kill them, kill them all!”
I turned around to see a 5-foot-6-inch, 165-pound guy about 50 feet away, running directly at me. Turning around required letting the door go, which caused it to fly all the way open. Now, with my back to the door, I’m frantically attempting to grab the door to pull it shut.
Meanwhile … 40 feet away I hear, “Get out of my way, mister, unless you want some, too.” I, in fact, did not want any.
I realized that I didn’t have a lot of choices. I could try to tackle the guy who’s very angry, but that would result in two ambulance rides, or I could simply get out of the way and let this man run into the parking lot, assault the guys trying to jump start the truck, and/or head for the woods/lake/state route, but that would result in several ambulance rides, calling the sheriff’s department, helicopters, and the press.
I didn’t want any of that, either.
Twenty feet away, two very important things happened, in this order: first, thanks to the nurse who knew the patient, I heard the door click shut. Second, I noticed the patient was wearing a baseball cap with a highly stylized letter “A” embroidered on the front.
Ten feet away, the patient screams at me, “I got a shotgun and I’m going to shoot you, you (insert derogatory comments about my questionable parentage here)!”
My response? I yelled, “ROLL TIDE!” as loudly and as Southernly as possible. Loud, I can do, but Southern? Not so much — I was born in Northwest Indiana.
Five feet away from an imminent collision, the patient stops and says, “Are you a ‘Bama fan”?
I responded, “Hell, yeah!” and I can see the patient physically relax.
For all non-sports fans, the ‘A’ on the baseball cap is a symbol for the University of Alabama and yelling “ROLL TIDE!” is a fan right-of-passage. For the record, those were the only things I knew about the University of Alabama, having just read the novel, Forrest Gump.
If you review the seven concepts of redirection, you’ll see that I’ve barely done one and a half steps: I assessed the situation, and sort of used a bridge phrase. There was certainly nothing calm about this situation, and touching the patient at this point would have been a really bad idea.
Telling the patient that I was a ‘Bama fan was enough a positive Consequence that I could ask other questions. Here’s the good, the bad, and the ugly rest of this story.
The patient (I’ll call him Steve) says at a loud, but not shouting level, “Help me get those guys away from my truck.”
I (I’ll call me Mark) say, “What kind of truck do you have?” This is a most excellent redirection question to ask at this time. If Steve says a different make of truck than the one that is in the parking lot, I can point that out to him and the situation would quickly decelerate from there. Also, with each subsequent question I ask, I am modulating my voice to be a bit quieter.
At the same time, I’m making ridiculous windmilling arm motions to get the guys away from the truck to reduce some of the anger-producing stimulus. Luckily the guys outside have interpreted my actions correctly, and have moved away from the truck and out of our sight.
Steve: “Ford F-150.” Said in a just-barely-louder-than-conversational-level, which didn’t work because the truck was a Ford.
Mark <sigh> “What color?” This gives me better odds.
Steve: “Black.” Of course his truck is black, like the one in the parking lot.
Mark: <heavy sigh> “What year?” This question has to work. I’m betting that Steve will give me a year of a truck he remembers, and the truck in the parking lot is clearly only a few years old.
Mark: “Ah, it looks like that’s a 2000 or 2001.” I really don’t have a clue, but 2000 sounds way different than 1968 — a year that seems comfortable for this gentleman …
Steve: “I think that might be a 2002. Look at the wheels, Ford didn’t put them on the 2001.” Said in a conversational tone, with normal calm breathing.
Mark: “Dude, you’re right ’bout that. When did Ford stop chroming their bumpers? I’m moving the conversation well away from guys stealing his truck.
Steve: “Had to be late ’70s. I had a ’77 and it didn’t have a lick of chrome anywhere. Too bad. That was a good look.”
Mark: “Yup, sure was.”
And with that, the redirection was complete. The patient was calm and no ambulances, sheriffs, helicopters or press were called.
Total time from the time I entered the center to complete calm? Three minutes.
Redirection is a powerful technique as long as you are comfortable with calling an audible from time to time.
Regier, N. G., Hodgson, N. A., & Gitlin, L. N. (2017). Characteristics of Activities for Persons With Dementia at the Mild, Moderate, and Severe Stages. The Gerontologist, 57(5), 987–997. https://doi.org/10.1093/geront/gnw133
Mark Pavlovich is the president of Yardstik Behavioral Analytics and a veteran senior care professional.