Reality orientation: it’s still necessary, sometimes.

Generally speaking, reality orientation is ill-advised in dementia caregiving. Gone are the days when trying to get a person with dementia to know/remember what day of the week it is, or what is going to be served for lunch, is considered good dementia care. Reality orientation is usually fruitless.

For example, trying to convince Winnie that her sister isn’t coming to visit today because she has been deceased for several years is fruitless. Winnie has lost the ability to separate the layers of time and past, present, and future co-mix and mingle in a fluid manner that caregivers have difficulty keeping up with. And so many feel compelled to set the record straight by pointing out the sad facts in Winnie’s family history.

Why reality orientation is usually not the best approach

Yet pointing out the facts will only cause Winnie sorrow, agitation, and/or anxiety as she relives her initial grief over her sister’s passing. Hearing this information from a caregiver will have the same effect on Winnie, or nearly so, as if she was learning it for the first time. Because Winnie’s present has blurred with her past.

Correcting Winnie will do nothing to console her. When caregivers identify the root cause of statements like, “When is my sister coming to visit? She hasn’t been here to see me and I miss her.” they can discover the clues to resolve Winnie’s unmet needs and the negative emotions associated with them.

A common unmet need for people with dementia is the need to belong. When dementia damages people’s ability to interpret and respond to the world around them in the ways they once did, it creates a sense of isolation. Winnie’s statement “she hasn’t been here to see me” may signal a clue that Winnie feels lonely, isolated, or abandoned. These are all emotions that result when one no longer feels they belong.

Correcting Winnie may create an unhealthy divide between her and her caregiver. Caregivers must cultivate trust from their family member or client constantly, for several reasons. People with dementia lean on caregivers for everything, and if a sense of trust in caregivers is not strong, it will create unnecessary anxiety that can trigger escalations. The primary way dementia caregivers can establish trust is to validate their family members or clients with dementia.

Correction is antithetical to validation. This is why reality orientation is usually the wrong approach.

But sometimes, we must engage in reality orientation. When the stove is empty but still hot from cooking, but a person with dementia believes the surface is safe to touch (today’s glass top stoves can be confused with a number of surfaces unrelated to cooking like card tables, pianos, or desks), caregivers must intervene, and quickly.

When is it necessary to use reality orientation?

Reality orientation is still advised when a person with dementia is in danger of hurting themselves or another person. The stove top example is clear and imminent danger, but other situations may not be so clear cut.

I was advising a client yesterday who felt challenged by a situation that was not as imminent. His widower stepfather, who now lived alone and was several states away, wanted to go on a cruise, now that pandemic levels seem to be mostly under control. Yet it was not feasible for my client to accompany him. Should he tell his stepfather that he could no longer travel alone because of his cognitive decline? This was the question he asked me.

I asked him to identify the unmet need behind his stepfather’s desire to travel. Could it be under-stimulation? A lack of belonging from not being around others? A lack of purpose from not engaging in an activity that was once very common and rewarding?

My client had already tried ways to help his stepfather experience mental stimulation around travel that didn’t involve leaving his apartment. His examples included reminiscing about old trips, or mailing picture books on destinations his stepfather had explored in the past. Nothing was diverting this stepfather or addressing the unmet need.

My client was convinced it was no longer for his stepfather to travel alone, yet there were no companions who could accompany him on a cruise. My client worried that telling his stepfather straight out that he could not travel would erode the trust between them, cause their conversation to feel unsafe to the stepfather, and create a scenario wherein his stepfather would no longer confide in him. As an out-of-state dementia caregiver, this last concern was paramount.

Working together, we reasoned that reality orientation was necessary. AND, we found a scapegoat. My client would focus on the fact that it was still too risky to travel due to the pandemic, particularly with the emergence of the delta variant. In effect, he could take a position wherein travel was not out of the question, but just not yet. And, he could allow COVID to be “the bad guy” rather than himself kyboshing the plan.

In summary, reality orientation is usually not recommended, unless danger threatens the person with dementia or those around him or her. And, whenever possible, scapegoats can help dementia caregivers remain trusted by their family members or clients living with dementia.

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