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The following article describes the need to meet people where they are at when they are not living in the same year we are.  Those with dementia will often “find” themselves living at an earlier time, almost as if they are time travelers.  The goal of a good health care provider is to travel into the person’s reality, whatever time period they might be living in.  As an aside, I have often wondered about the status of a Dementia patient if the person was a convert.  There could a point when the person no longer recalls conversion.  Does that nullify a conversion or does cognitive decline not count when considering the person regressing back to former beliefs and actions? 

“Do you see it?” Mrs. Jacobs looked at me and her gray eyes dulled by the ninth decade of life glowed as she pointed to the window.

“I am sorry, Mrs. Jacobs,” I replied as I pulled my chair closer to her to check her pulse before her medications, “I don’t know what I am to see. Can you tell me please?” 

I put her heart medications in the small white medication cup and gently checked her arm band. “Mrs. Jacobs?” I inquired, “What do you see?”

She smiled and proceeded to describe to me heaven outside her nursing home window in Endicott, New York. The beauty of Heaven could not meet the reality of her description – I was stunned. I sat there a moment and stared at her, then out the window. I thought to myself, “I want her drugs.” Only kidding, but I was amazed at her detailed description of the indigo, violet, blue,and red colors in the rainbows and the waterfalls. I nodded gently. “Mrs. Jacobs, I don’t see what you are seeing, but I sure wish I did. It sounds beautiful. I am happy for you.”        

Mrs. Jacobs was pleased. I handed her the little cup of paper that held her digoxin and lasix pills and gently patted her hand. I fluffed her pillow, adjusted her blankets and checked that her pills were swallowed and said, “I will be back dear to check on you later, enjoy your view.”       

“I will dear,” she said and returned to gaze out her nursing home window into what I saw was a neighborhood, filled with back yards and swing sets and middle class family houses. I shook my head.         

Mrs. Jacobs saw heaven. Do I tell her heaven is not outside her window? Do I tell her the reality ? Do I attempt to change her from fantasy to reality and with great faith change her mood? No! I decided not to. I just validated what she was seeing. I just validated that she was safe and content with what she was experiencing. Mrs. Jacob will be the better for it.

(Case study from Ideal Senior Living Center, Endicott, N.Y. Mrs. Jacob’s name has been changed to protect her identity by P.Andrews RN BSN MSCEd.)

Allow me to introduce you to Validation therapy made famous by Naomi Fell LSW. It is defined as an acceptance of another’s reality, an acceptance of the truth of another’s experience, a bridging into the other’s world of confusion and it includes the following concepts: communication, emotion, time and memory.

Validation is helping those “Who Inhabit the World of Dementia”. (Allen 2000)

To understand the confused, one needs to understand their concept of time. Time to the confused is not sequential, it is not in the present, it has not continuum. With some patients/clients, there is no concept of time left.

Case in point: 

“Mrs. Johnson, you have to wait, dinner is almost to be served. Look, it is not 5:00 o’clock yet. You know the dining room opens at 5:00 o’clock. Now let’s sit here and read this magazine ’till it is time to eat, dear.” The nurse speaks gently, places a magazine in her lap and turns to return to her desk to prepare the necessary charts.

She sits down, opens up a chart.

“Excuse me dear, I am hungry. I need to eat. I missed dinner. I need to eat.” Mrs. Johnson stands at the window staring down at the nurse. Her eyes are filling with tears. “Do I pay for it? I cannot find my money?”

The nurse lets out a slow, deep sigh.

No time can be understood. No concept of waiting if there is not concept of time.

Validation therapy tells us to validate Mrs. Johnson’s current hunger. It teaches us to act in their present, not the caregiver’s. Give her a small healthy snack and a cup of tea and lead her to the dining room as soon as it is opened. Refrain from telling her the dining room is closed or that it is opened, she cannot comprehend the sequence of this time sequential. The caregiver may tell her, “You sound like you are hungry dear. I have some crackers here for you. I will see to it you get your dinner.”

The past is confused with the present. A memory is there one moment then gone the next. Memory plays tricks on the confused. It makes it known and loved ones appear as those to be feared. Family is no longer a secure piece of their minds. The family roles are no longer their realities; these roles have left their ability to retrieve.

There are no more moms, no more dads, no more daughters or sons – it is hard for the family, but remember that the confused will usually recognize a face and smile at you.

The confused person is limited to one’s abilities to think and to make decisions. They cannot make good judgment decisions. With the cognition process limited, the emotional processes will lift to the surface. They will be more emotional than cognitive in their responses. They will pick up on other’s emotions as well, such as; anger, frustration, anxiety and depression. They may become weepy themselves. They may become agitated and violent and not be able to control their ‘stop’ button. The caregiver needs to stay calm and quiet.

To push a client/patient to make a decision may push them to a point of agitation and violence may occur. Validate their feelings for them to be understood.

Case in point:

“Tricia, will you get Martha to stop coming to our nurse’s station and standing there staring at us – it is creepy. She won’t listen to us. We even put a red tape on the floor board and told her not to cross it, and look, she does anyway,” the nurses told their nursing supervisor with a great amount of frustration. I was the nursing supervisor. I stood back and watched as Martha, our patient on the geropsychiatric unit, came up to the station and did exactly what the nurse told me she would do. Her arms crossed. Her eyes staring down at the nurse’s desk, Martha stood. She was in her eighth decade of life.

I approached her. She stood rigid. She tensed. I pulled back. I spoke softly. “Martha, it looks like you want something. Can you tell me what it is?” I watched her movements. She stared down at the nurses once again. I sighed. this may take a while to solve.

I left the desk, and I left Martha standing in her familiar spot and took her chart off the rack to look through. I spun quickly to the psychosocial section and flipped it open. I stood staring down at the words. Retired from occupation “Nursing.” I had it. I hurried back to Martha.

“Martha, you want to do your charting, so you can go home?” She gave me a toothless smile and nodded. Chills went up and down my spine – I had reached her. I had validated her behaviors, without the ability to put into words, our dear Martha was still a nurse, would always be a nurse and God Bless her, had to do her charting.

I told the nurses. They stared up at me. So simple, yet so missed. The nurses said to her, “Martha, do you want to chart with us?”  She nodded slowly.

“Here dear, here is a chart to write in then.” The nurse gave her a blank chart and a pen and she wrote and wrote and wrote and then closed the chart’s binder, handed it to me and walked off quickly to her bedroom. We smiled at each other. Thank you Tricia, now we know what she wanted.

(Case study from Wilson Medical Center, Johnson City, N.Y. geropsychiatric unit. Martha’s name has been changed to protect her identity)

We validated her behaviors!

Consider the topic of communication. The caregiver needs to play the listener role. He/she is the observer of the behaviors and the detective to figure out what the behaviors are saying to you. He/she needs to focus and not react. Here are some helpful hints: Acknowledge, Respect, Listen, Observe, Redirect, Agree and Steer away.

Some don’ts!

  • Dismiss what they are saying.
  • Confront.
  • Shatter their only reality.
  • Hurt their ego.
  • Hurt their feelings.
  • Embarrass them or let them embarass themselves.

Some do’s !

  • Treat them with genuine respect.
  • Remember it is their mind that is affected, not their feelings.
  • Divert from a stressful event to a more pleasant one.
  • Be creative.
  • Speak in simple terms.

What do you need to do within your own psyche?

  • Have empathy (as if you were them).
  • Be non-judgmental.
  • Be able to control your own feelings of frustration/anger.
  • Be able to CENTER (clear out your own emotions, breathe, de-fuse).
  • Observe the verbal and the NON-VERBAL.
  • Step inside their personal reality.
  • Build trust.
  • Use POLARITY…”What do you miss the most about your house?”
  • Accept the loss of logic, time and socialization.

You don’t want the person to feel alone, to feel forsaken.
They need closeness. They need not to feel embarrassed.   

So what to do?

  • Re-Phrase “You want to go home. What would you be doing if you were home now?”
  • Reminisce, “Did you build your own house?”
  • Acknowledge their need to talk about their home! Their life! Their emotions!

Case in point:

“Tricia, get the leathers. We need them in room 404 – Mr. O”Reilly is out of control again.” I shuttered. I hated putting patients in 4 point leather restraints. I pulled them out of the drawer but hid them on a cart with a sheet draped over them. I went slowly into the room where I saw the nurse holding the gentleman patient down on his bed. He was thrashing and hitting and rolling to get loose. The television rang loud with a football game. I shivered once again.

“Let him up.” I said. “Step back, but let him up.”

The nurse stared at me, “I said let him up.”

The nurse released his arms, stood back, and ran to the door behind me and said, “Well Tricia, you are the nursing supervisor, he is all yours.” And she left me alone with him.

I stared into wild eyes that focused immediately on the television. He said to me, “Deary, do you have a beer? I need one for this game. I need a beer. Got one back there?”

I was amazed, no memory of what had just occurred. I sat down and observed him a few more minutes. I noticed his large reddened nose and Irish accent. Of course!

He said, “This is a cool place, just need a beer deary. Get us one and watch the game with me, okay?”

Well in this hospital unit, there was not beer available, and so I did the next best thing. Come on Mr. O’Reilly, come with me.

He put his arm around my shoulders and started to sing the most pleasant Irish melody that I ever heard. We walked arm in arm to the nurse’s break room. The nurse’s station was filled with young nurses staring at me and wondering just what this nursing supervisor was up to. I was up to simulating his reality to have him think we were going for a beer. We opened the refrigeration together and I pulled out two sodas that I had brought for refreshments for me, and we pulled the small metal tab up together and swish!!!

Mr. O’Reilly cheered and sang some more. “Good going girly,” he said.

We swayed and sang our way back to his room and I sat him down in front of his television, with his Sprite, (oh, I mean beer, ha!) and he was happy. “Stay with me deary and have a drink and watch the game.” I knew he had no idea where he was or who I was. I knew he was in some other place with his beer and his game. I knew I had validated his behavior as frustration and that where he needed to be; now he was.

The nurses had no other problems with him the rest of the evening, as long as he got his second “beer” or Sprite when he asked for it. We were all cool.

(Case study from Lourdes Hospital, Binghamton, N.Y. Mr. O’Reilly’s name was change to protect his identity).

Delve deeper

  • What is the intent of the behavior?
  • What motivated them to do or say what they did?
  • What was the trigger?
  • What was the concern?
  • What started the anxiety?
  • Are they sorting through past issues and confusing them with present. Are they trying to restore a balance in their feelings state? Do they feel out of control?
  • Why are they hoarding?
  • Could it be a fear of losing, so give them a safe box to store their treasures in?
  • Always allow a graceful exit from a scene!
  • I’m so confused?

 Now let us add a psychiatric illness. How do you handle this?

  • Unlocking the mind isn’t easily done.
  • Hallucinations/Delusions confuse the dementia even more.
  • Any of the 5 senses can be involved
  • Some know their brain is playing tricks on them, so do not, they have no clue.
  • Oftentimes these disturbances appear REAL and are VIVID.
  • Ask if you can help them? Validate that you would be upset too if you were having these experiences, if they state they are frightened or scared.

Things you can say.

  • “I’d be upset too, if that happened to me.”
  • “I understand why you feel that way.”
  • “Come let’s have a cup of tea and talk about your mother.”
  • “Dinner is being served now. After dinner we can talk about it if you like.”
  • “Tell me about your mother.”
  • “Tell me of your children.”
  • “What was the color of your hair?”
  • Utilize questions, low soft spoken tones to distract!

 Let’s review the concepts behind to validate. It is to accept the values of the person. It is to accept their beliefs. It is to accept their reality and realize it is not yours. The caregiver will receive more cooperation if they agree and steer away and do not confront. Do not challenge their reality; work with their current state of mind.

“My mother was here today,” Mrs.Smithwick told me. “My mother brought me these flowers. Aren’t they pretty?”

I said “yes, they are lovely. How was your visit with your mother today, Mrs. Smithwick?”

“Oh lovely dear, just lovely.” She said.

“That is good dear; you must love your mother very much.” I said.

Mrs. Southwick is 94 years old.

(Case study from Wilson Medical Center, Johnson City, N.Y. geropsychiatric unit. Mrs. Smithwick’s name has been changed to protect her identity.]

References

By Patricia Andrews, RN, BSN, MSCED

http://spiralenterprises.health.officelive.com/default.aspx