Helping the Disoriented Elderly
Kenneth at 48 seemed a most fortunate man. He was a successful insurance executive, doted on his wife and children and enjoyed his friends. Then he started to change. At first, subtly, then markedly, he began to withdraw from his family and friends. He grew apathetic; his memory deteriorated; he ignored his work. His wife, Bobbie, had to hold him by the hand when they went out or he would wander away and get lost. At times, he became violent. Now, 12 years later, Kenneth is bedridden in a hospital, a mental and physical vegetable. He speaks to no one, recognizes no one, stares vacantly into space. Says his wife, “It’s like a funeral that never ends.”
Kenneth is one of more than one million elderly persons in the United States who suffer from severe dementia to the extent that they are unable to perform the normal tasks of daily living. Another 3 million are moderately affected. By the year 2005, this number could increase by 50 percent, if the current trend continues.
These illnesses have major impact on families and caregivers who need some idea of what is going to happen to the disoriented person. They need a chance to psychologically adjust to this source of stress and consternation. They need to learn about the management and care that will be needed. Who are the disoriented? How does the family or caregiver help them? Are there well-developed approaches or methods for relating to the disoriented? This publication addresses these concerns.
Who are the disoriented?
Persons who have lost some of their ability to think and remember become forgetful, although they can be very skillful at concealing this. Their ability to understand, reason and use good judgment may be impaired. They gradually may become unable to recall what day it is, or where they are. They may be unable to do simple tasks such as dressing, and may no longer be able to put words together coherently.
They may also experience changes in personality. Some may become passive, dependent and apathetic. Others may become fearful and restless, or become irritable and demanding or depressed. Tasks that were previously simple may become too difficult. It is typical for them to become enormously upset by small things. This is known as a “catastrophic reaction.”
These persons may wake at night and wander about or rearrange things in the house. They may also hear or see people who are not there and become very suspicious and fearful that these people are stealing things or are going to harm them. These experiences are real to them.
The course of the disease and the prognosis varies with the specific disorder and with the individual. In the past, many names have been given to the diseases and symptoms of adults with memory loss and the loss of thinking capacity. Older medical books refer to organic brain syndrome, chronic brain syndrome, senility, or hardening of the arteries to describe conditions that result in mental confusion, memory loss, disorientation, intellectual impairment or similar symptoms. For years, elderly people with signs of mental deterioration were routinely dismissed as senile, and therefore, incurable.
Today, attitudes of physicians and researchers reflect a revolution in thinking about the reversibility of dementia. They know that severe memory loss is never the natural result of getting older. Dementia is no longer seen as hopeless. Though it is claimed that slightly more than one-half of all dementias are caused by the irreversible Alzheimer’s Disease (Kenneth’s affliction), increasingly more and more cases are reversible.
In fact, a quarter of all dementia cases are thought to be reversible. Reversible cases of dementia are those in which underlying physical and psychological causes (brain tumors, abnormal functioning of the thyroid, adverse drug effects, neglect and depression) result in chronic confusion and forgetfulness. Often, when the underlying problem is treated, the level of alertness and intellectual function returns to normal. Initiating a treatment plan depends on the first step, diagnosis.
A complete diagnosis or evaluation tells the exact nature of the person’s illness, whether the condition is reversible, the nature and extent of the disability, the patient’s other health problems which need treatment and which might be making the dementia worse, and the social and psychological needs and resources of the person. This is usually done by a neurologist or a psychiatrist who has additional training in neurology.
Much is unknown about these illnesses, but new information is being gathered each day. No one person can keep up with all the advances in medicine, and some busy doctors may not know about specialized care for the person with dementia. You may need to talk with more than one doctor before finding one suited to the needs of the family. Discuss needs and expectations thoroughly and honestly.
Helping the Disoriented Person
In the beginning, disoriented persons bear the emotional brunt of the disease. Especially at the outset, they are aware of changes and need support. They may be frightened, embarrassed and suffer lowered self-esteem. The problems are compounded when relatives who are unaware of the problem misinterpret inappropriate behavior as stubbornness, hostility, inattentiveness or attention-getting measures.
Family and other care givers are often at a loss for methods of dealing with the condition of the confused. Several approaches have been developed for helping the disoriented person. Three major ones are described here.
The goal of reality orientation is to help persons with memory loss reestablish and maintain contact with reality, reducing their disordered behavior. With this technique, care givers actively and repetitively present information needed to relocate oneself in time and place. Reality orientation is built on the premise that to function adequately in the environment one must have clues such as date, time and place which help form a basic framework necessary for developing behavior and daily routines. When people no longer have these clues, they may forget where they are, who the people around them are, and what they are expected to do or say in any given situation.
There are a number of techniques for interacting to bring persons into contact with reality. Generally, the proponents of this method recommend reducing stress by providing an unhurried and familiar environment. They suggest providing stimulation to the five senses and privacy. More specifically, correction of confused individuals who ramble in speech and action is considered a key in reality orientation.
This correction program is based on repetition. Any time persons are confused, they should be told where they are and why, who they are with and the time of day. They are told this information the first thing in the morning and repeatedly throughout the day. This procedure is not boring to the confused. In the following examples the words in bold type are the clues that orient the person to the surroundings.
Good morning, Mother. How are you today? (Wait for a reply.) It is a beautiful fall day. It must be 40 degrees today, and it is such a pleasant morning. Are you ready for your breakfast? (Wait for the person’s reply.) Here is your breakfast tray. It is 8 o’clock in the morning and your breakfast is here. The eggs look delicious. Mother, would you like some orange juice with your breakfast? (Wait for the person’s reply.)
These sentences remind the confused person of the time of day, her role, the season, the weather and what she is supposed to do. The three questions give the person a sense of responsibility. The pauses for the replies reassure her. Conversations like this, no matter how repetitive they may seem, must be repeated throughout each day.
This method always directs persons back to reality. If they start to ramble, help them put their thoughts in order. Remind them to speak slowly and clearly. Reply clearly and concisely to their questions.
Help the confused person know what you want him to do. Don’t assume he knows how. Demonstrate the task. For example, when asking him to wash his face or comb his hair, guide his hands through the motions. You may have to do this many times until he relearns the task.
Be consistent in all dealings with the confused person. This means constantly reminding him in conversational tone of basic facts even during baths, meals, activities and visits with friends and families. Maintain a calm environment because tension increases disorientation.
In group situations, classes in reality orientation for the elderly disoriented may be held. Emphasis is on building a bridge to reality by asking each person in the circle to read a reality orientation board. The reality board lists the place, the day of the week, the day of the month and year, the weather, the next holiday, the next mail and the next day, and so forth. This board stimulates conversation. The older persons are encouraged to chat about themselves or anything of interest springing from the information on the board. The climate is one of acceptance, warmth and appreciation.
The reality orientation method is probably overused. Proponents use this method regardless of the causes or severity of confusion. They believe it is the responsibility of those working or living with confused individuals to bring them back to reality.
While the aim of reality orientation is to help ANY confused person adjust to his surroundings, the focus of remotivation therapy is to recreate interest in life. It is directed only toward those with the potential for healthy interest outside themselves. The extent to which this method will succeed depends on the severity of withdrawal and disorientation.
People in institutions become passive and dependent. Remotivation therapy is for individuals who need stimulation to enable them to participate in their environment. Remotivation therapy stimulates the person’s mind and brings him out of the shell into which he has retreated. It relies heavily in the beginning on reminiscence stimulated by presentation of objects for discussion. The patient interacts with others in an atmosphere of acceptance and friendship.
The technique involves a leader bringing up a selected topic for discussion. After the elderly are warmed up and participating, objects and props open up another topic for discussion. Questions about the prop are posed based on “Who? What? How? Where? When?” The objective is to encourage people to talk and share their ideas and experiences. Any conversation offered is accepted unless it is abusive or off track. The group leader steers conversation to topics relating to something less subjective, challenging them to think of things outside the room. For example, describe a typical day in the life of a relative or community worker. What jobs do they do? Who do these jobs help? How do they carry out their work?
The Feil Method is a newer approach for relating to the disoriented elderly. It is called validation/fantasy therapy and recognizes that there is logic behind all behavior. The goals are improved functioning and contentment of the disoriented elderly. Understanding and exploring the fantasy of the disoriented person and tuning into feelings rather than intellect are primary techniques used. Validating feelings and establishing a sense of trust are also important in this approach. Proponents of this method believe that validation therapy helps older people reminisce and resolve life’s unfinished business. As they regain identity and sense of self-worth, the progression of disorientation stops and reality can more readily be faced.
Validation/fantasy therapy was developed by Naomi Feil at a home for aged. Her early experiences of growing up in this home where her parents lived as administrators no doubt contributed to her insights of the elderly. These insights drew her back to the home after completing her education. Then, through experiences of tuning into feelings rather than intellect, she discovered there was reason behind all behavior, no matter how bizarre. Through research she found that empathetic relationships and other techniques giving attention to the end-of-life goals brought peace to the elderly.
Validation/fantasy therapy is especially appropriate for the disoriented old. Disorientation progresses through several stages, according to Feil:
- Stage One – Mild Confusion. Mildly confused people are aware of their confusion and resist change because they are threatened by loss of control. They want to be reminded of present reality; for example, time of day, what is to happen next, and so forth.
- Stage Two – Time Confusion. These people lose track of time and move back and forth between past and present. Feil believes an excellent memory has emotional meaning. As those in this stage lose some adult controls, they become less aware of the need to conform. This is the beginning of their retreat inward and the time when fantasy begins.
- Stage Three – Perpetual Motion. The use of fantasy is now full blown. Being so confused, people are unaware of their present identity. For example, they may act out being a young mother or lover. To stimulate self-recognition, they rock, bang, tap and use other constant and repetitive body movements and sounds. They may also use symbols to represent other people or memories. Feelings are still keen, so these people have a capacity for a genuine trusting relationship even though reasoning has declined. They respond more readily to the person they sense as caring.
- Stage Four – Vegetation. People in this stage are extremely withdrawn; there is no eye contact or desire to relate to anyone. They may close their eyes or sleep to ward off despair. They no longer talk to those around them. Though they turn their back to the world, they still need touch, recognition and nurturing from another human being.
Proponents of the Feil approach believe reality orientation can help those in mild confusion. Validation/fantasy therapy, however, helps in all stages and prevents progression to succeeding stages. Validation/fantasy therapy techniques are most helpful to those in stages two and three, time confusion and perpetual motion.
The principles and techniques of validation/fantasy therapy have evolved through years of experimentation and practical application. Positive changes have been demonstrated and recorded.
Adapted with permission from materials originally prepared by Lou Isbell, State Specialist, Child and Family Development, and Edith Lush, Area Specialist, Child and Family Development, University of Missouri-Columbia, and published by the University of Missouri-Columbia, Extension Division, College of Home Economics.
Prepared by: Extension Gerontology Specialist, Texas A&M AgriLife Extension Service, Texas A&M System.
Last updated: 21 November, 2013
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