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Dementia and “Entering Their Reality:” Combining Elements of Truth with Preserving Dignity

When I began my nursing career in the mid-80s, we were taught to “present reality” to persons with dementia (PwD). Yeah, that did not go so well. But that was what the “experts” were claiming. I found out the hard way that this approach was terrible while working the 11-7 shift. I had a PwD awaken and immediately attempt to get out of bed because she “had to catch a train to get to work” at 2 am. I went in, tucked her back in, and calmly explained that she was at Saint Joseph’s Nursing Home and it was 1984. It was 2 am and she needed to go back to sleep. Guess what happened? She climbed out of bed again. This futile activity went on for a good eternity (ok, 5 minutes). Another nursing assistant walked into the room and said, “It’s OK. The train doesn’t leave until 8 am. I’ll wake you up at 6 am and make sure you have a good breakfast, and then you can catch the train with the other girls.” The lady rolled over and went to sleep. The nursing assistant looked at me like I was a moron because I was a nursing student and should have known better.

There have been many approaches to handling PwD who are moving backward in time and are wanting to “go back home” or “see Mom” or “catch a train to work” at 2 am. I once belonged to the School of Therapeutic Fibbing, where I made up a plausible story in my desire to “soothe” the PwD. It worked. Temporarily. Because I was not aware of the emotions or message that was underlying the current behavior. I was putting a band-aid on a wound that needed stitches.

Later in my career, I came across the work of Naomi Feil. She developed “Validation Therapy,” where you get to the meanings behind the behavior. Dr. Feil despises “Therapeutic Fibbing,” a term coined by 2 researchers in the late 80’s and a technique I had unfortunately used a great deal in my practice.

Now, I recommend that people “Enter the PwD’s Reality.” This may take several forms. In the case of care refusal, like refusing to take medications, “Entering Their Reality” means coming up with a reason for the medications that MAKES SENSE TO THE PERSON. In order to do this, you have to know the person’s previous occupation(s) and value systems…which many family caregivers know.

Think of “Entering Their Reality” as a gentle and kind approach to delivering truth with dignity. Let’s say I go shopping with my daughter Sara. I select a dress with a tag that proclaims it to be a size 12 but, once on, fits more like a size 6. Sara has a choice. She can say:

  • “Mom, you are way too fat for that dress.”
  • “Mom, that dress is not a good match for your body shape. It hides your best features.”
  • “Mom, I think somebody messed up and put the wrong tag on that dress. I think it may be cut way too small.”

I like #2 or #3. All give the same message, “You do NOT look good in that dress.” All contain ELEMENTS OF THE TRUTH. But the second and third options allow me to accept the situation (the dress does not fit me) but still feel good.

I use “Entering Their Reality” a lot in my practice and my research. I’m curious as to your experience with this strategy!

Want more information? I provide monthly webinars and individual coaching for caregivers who would like to learn more about dementia, and how to successfully deal with frustrating or scary behaviors. Click here!

Categories: Alzheimer's Disease Caregiving Dementia Driving FTD Lewy Body Dementia Refusal Behavior Understanding Behaviors

Dr. Rita Jablonski

Rita Jablonski, PhD, CRNP, FAAN, FGSA is a nurse practitioner, researcher, tenured professor, and former family caregiver. Her research and practice involve all aspects of dementia management; she is best known for non-drug strategies to address dementia-related behaviors.

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