Just the facts? No way. Managing agitation and behaviors in dementia
Jean Wendland Porter
Anyone who has worked in long-term care knows our dementia patients can sometimes be sweet, sometimes cooperative, sometimes challenging and sometimes aggressive.
In order to understand where the behaviors are coming from, sometimes we need to change our mindset and approach from other perspectives.
Remember the years and decades we spent doing Reality Orientation Therapy (ROT)? I do. We would try to calm our agitated 90-year-old who was sure she had to leave to pick up the kids from school by telling her that the kids are grown. They can drive. They're not in school anymore. They'll be by to visit this weekend.
Did that work? Did she calm down? Never.
The episode that changed my mind about reality orientation as we were practicing it was when my 88-year-old patient began to cry because his father was supposed to come and hadn't. A well-meaning staff member asked him how old he was, and he said he was 85 (pretty close). He asked him what age his father would be? After some thought, the resident began to cry, saying “Are you saying my father is dead? My father is gone?” He mourned his father all over again as if he had just died. He mourned that he had forgotten such a significant event. And it didn't stop him from waiting at the door for his father.
In the early stages of dementia, ROT can be valuable. (Reality Orientation and the reality of the nursing home resident, Tijdschr Gerontol Geriatr. 1989 Oct;20(5):197-201.) As dementia progresses, it becomes more difficult and increasingly useless to try to reorient a dementia patient when his or her reality is not ours.
Validation therapy goes into the world that the dementia patient lives in, and by entering their reality, we can calm their agitation (sometimes only temporarily) and diminish aggressive behaviors.
How does Validation Therapy (VT) work? Validation de-emphasizes the relevance of orientation and facts and explores the respective meaning and motivation for the patient's confusion. Developed by Naomi Feil over two decades ago, VT was never meant to help the demented decrease their confusion. It is meant to restore the patient's dignity and well-being, and calm their agitation. It decreases the emphasis on facts and redirects our efforts toward the resident's feelings.
Using VT on the two examples shown above, I regrouped and started a discussion with the lady who was worried about the children:
How many children do you have?
How old are they?
Are they good kids? What do they like to do in school?
I'm going to call your husband and see if he can pick them up.
And the behaviors reduced. Not forever, and we had to do it repeatedly, but she showed interest in the discussion and liked to talk about the kids.
I tried VT on the man who was waiting for his father:
Is he a good dad?
What do you like to do with your dad?
How long have your parents been married?
Again, as the discussion progressed, the behaviors temporarily subsided, and we had to do it all again the next day.
As our population ages we expect to see more dementia patients in our facilities. Currently, 1 in 10 people over 65 have Alzheimer's, with 10 million new cases each year.
My first Alzheimer's patient in 1978 was only 45 years old. We need to understand how to enter their world to make them comfortable, maintain their dignity and improve the quality of their lives.
Jean Wendland Porter, PT, CCI, WCC, CKTP, CDP, TWD is the Regional Director of Therapy Operations at Diversified Health Partners in Ohio.