Disorientation and Confusion in Dementia
Dementia can be stressful and anxiety-provoking. Symptoms of dementia such as memory loss, confusion, and disorientation are often present. Although the cause of dementia is complicated, being with someone living with it, it does not have to be.
There is no cure for dementia, nor is there a viable treatment to reverse the process. There are great techniques for improving the quality of life for both partners in care. Validation theory is one of the best.
What Is Validation Theory?
Origins of Validation Theory
Naomi Feil developed Validation Theory as a way to convey empathy to people living with dementia. Validation techniques can help to reduce anxiety by increasing connection and decreasing confusion.
Reasoning Behind Validation Theory
Disorientation often stems from confronting or correcting a person’s reality. Confronting a person or correcting what they say is not usually an effective way to address anxiety and agitation and often increases these feelings. I am sure you have experienced this yourself.
Think of a time when you disagreed with someone where their reality differed from your own. Maybe it was while driving. In your reality, a driver cuts you off. For the other driver, they felt they had plenty of room to merge. These reality differences happen in little ways every moment of every day.
Each of us lives in our own personal reality. We all make unspoken agreements to create a consensus reality. For example, we agree on what year and time it is. We agree that paper currency, plastic cards, and numbers in computers have a common value. We agree that we have to cover certain parts of our bodies with clothes. Every day we are usually unaware of these little agreements.
The changes associated with dementia can make these differences in reality more dramatic. This makes it harder for someone with dementia to agree with someone that is not affected by it. Dementia can also make the differences harder to communicate, further compounding the challenge. Combine this with dementiaism, the systemic bias against the value of the perspective of those living with dementia, and you can see where the frustration comes from.
For example, a person living with dementia may believe it is 1947. For them, this feels as real as you knowing it is 2020. Narratives about people living with dementia being ‘already gone’ and ‘shells of themselves’ teach us not to value their perspective. Therefore, we dismiss and correct them. Understandably, this causes frustration for both parties. There is another way to approach this that will not result in as much frustration or anxiety.
Why Validation Theory Works
Validation theory states that whenever there is upset (anxiety, agitation, depression), it points to an underlying unmet need. Thus, the difficult behaviors exhibited by people living with dementia are due to one or more unmet needs. Below are some examples of needs and expressions. These are singular examples for each need. In reality, there are a plethora of ways each need manifests.
Examples of Unmet Needs
- Need to resolve unfinished issues in order to die in peace. Wanting to call a loved one who died some time ago.
- Need to live in peace. “Leave me alone” or having strong opinions about how things should be done.
- Need to restore a sense of equilibrium. When eyesight, hearing, mobility, and memory fail, they may hold onto a wall for support while walking or avoid the dark tiles on a multi-colored floor.
- Need to make sense out of an unbearable reality. To find a place that feels comfortable, where one feels in order or in harmony, and where relationships are familiar. They might call new people by the names of past friends, crafting a story of reality that makes sense to them.
- Need for recognition, status, identity, and self-worth. Repeating who they are or stories of past accomplishments.
- Need to be useful and productive. Finding tasks such as organizing papers left out on a desk, packing a suitcase, folding laundry. These tasks likely will not be done the way you desire.
- Need to be listened to and respected. Raising of voice and making demands and threats to alert figures of authority.
- Need to express feelings and be heard. Crying, laughing, dancing, yelling.
- Need to be loved, to belong, and to have human contact. Reaching out to touch those that walk past.
- Need to be nurtured, feel safe and secure, rather than immobilized and restrained. Removal of restraints. Trying to dismantle locks.
- Need for sensory stimulation. Tactile, visual, auditory, olfactory, gustatory, as well as sexual expression and flirting.
- Need to reduce pain and discomfort. Attempting to wrap painful body parts.
These needs may ring a familiar bell. That is because they are universal. What changes in the context of dementia is what it takes to meet them. By uncovering and meeting the need, you can decrease the upset.
In the example above, the person may have needed it to be 1947 to resolve some unfinished business from that time. By pulling them back to 2020, that need was not met.
How to Use Validation Theory with a Person Living with Dementia
How are these principles applied in real-life situations? It is common for people with dementia to forget that they have lost a spouse or to want to go to a previous home. Seeking a lost spouse or home is an expression of an unmet need. The need will be different for each person. Looking at the above list, you could start with some of the more likely ones such as: need to be loved, belong, have human contact or a nurturing experience, or feel safe.
These expressions of need, such as wanting to go home, will be repeated over and over again until the need is met.
Pro Tip: While the request may be specific, such as, “I want to go home”, the solutions to the need “feeling safe and secure” can vary.
It can be tempting to tell a ‘white lie’ such as, “You can go home tomorrow, but isn’t it nice here?” This fib may deter the expression of the need at the moment, meaning that the person may not ask again right away to go home. This tactic, however, does not uncover or address the unmet need. So, the request will come up again and again. Besides not being a lasting solution, telling a fib does not honor the person’s reality and needs. It is like putting a band-aid on a wound that needs stitches!
A Validation Theory Approach:
1. Acknowledge what the person is expressing. A parent may ask over and over where their spouse is when, in reality, the spouse died many years ago. Rather than saying: “Mom, Dad has died!” try a response that opens communication. For example, “Mom, what are your favorite things about Dad?” Use the improv tactics of “yes, and..” instead of fibbing or correcting them.
2. Honor. Ease anxiety by honoring the feeling behind the request. A spouse who is in memory care may state over and over again that they want to go home. It can be tempting in these situations to say, “But you are home now.” Or, “You moved here over a year ago. Your home is gone.” A much better approach gets to the heart of what the person needs. Are they cold, hungry, fearful, or in pain? Agree and validate. Say, “Your home sounds wonderful. Tell me more about it.”
3. Act to meet the need. When someone is telling you about their spouse or home, put on your ‘Sherlock Holmes’ hat and investigate what need they are expressing. Then experiment with ways to meet this need.
For example, I worked in memory care with a man who wanted to go home. When this request was not respected, he would get very, very upset. After listening to him, it became clear that without switching locations such as from work to home, he didn’t know when his day was over. Thus, he could not relax. For him, ‘wanting to go home’ meant wanting to know his workday was over, and he was allowed to be where he was and relax. After reviewing his personal story, I noticed there was a ritual of having a drink before dinner listed in his chart. Somehow the delivery of this had gotten lost in translation. The staff was administering the drink in a medicine cup only after he was upset. In our mainstream medical model, this makes sense but was not psychologically effective. We were able to get an unbreakable but glass feeling snifter and have the drink brought to him each day before dinner. After this, only rarely did he want to ‘go home.’
The next time you notice an unmet need, try acknowledging, honoring, and acting.
Tips to Keep in Mind When Using Validation Theory
1. Avoid confrontation. If you are trying to offer a calming presence to someone living with dementia, avoid confrontation. Confrontation is likely to escalate the situation. Instead, try validation.
2. Avoid reasoning and explanations. Your loved one may not be able to process the information the same way you do. How to communicate with someone living with dementia is quite different than communication with someone without it. If you give reasons and explanations they may become even more insistent and distressed. We can’t know what anyone is feeling inside. In the context of dementia, communicating this can become even more difficult. Anger may be utterly unrelated to the stated subject. Try your best to honor and respect whatever the feeling is. Your parent or spouse may be in pain or some other discomfort. Perhaps they are tired or bored.
3. Never fib. According to Validation Theory, it is never acceptable to lie. Instead, try and get to the heart of the matter. Realize that people living with dementia are trying to retain some sense of control. Be as calm as possible to create a sense of security and comfort. Both of you will benefit.
Benefits of Using Validation Theory
Using Validation Theory may take a little more time at first as you train your brain to notice unmet needs and find ways to meet them. The reward for this little bit of extra effort up front will be returned exponentially for both you and your loved one living with dementia. According to the Validation Training Institute, using Validation can provide marked benefits for people living with dementia and those that love them.
Potential benefits for older adults living with cognitive decline:
- Siting more erect
- Keeping their eyes open more.
- Displaying more social controls.
- Crying, pacing, and pounding less.
- Expressing less anger, fear, and other painful emotions.
- Communicating more verbally and non-verbally.
- Withdrawing less.
- Experiencing an improved sense of self-worth.
- Assuming familiar social roles in groups.
- Developing an enhanced awareness of reality, even though this is not a goal of Validation.
- Finding their sense of humor.
Benefits for care-partners, both at home and in care communities experience:
- Decreased need for chemical and physical restraints
- Increased morale is increased
- Decreased burnout sense of fulfillment at work.
- competence when handling difficult situations.
Benefits in the family’s experience:
- More joy with their loved ones.
- Improved relationships.
- Better communication with their loved one.
- Greater understanding, less anxiety, guilt, or anger.
Start small in a moment that is not very upsetting for you or your loved one. Bring an attitude of playful experimentation. Once you begin practicing validation theory, it will become easier and easier.