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The Art of Re-Direction in Memory Care
Assisted Living Success magazine
October 2003
When working with persons with memory loss issues, dementia or an Alzheimer's diagnosis, it becomes quickly apparent that straight logical thinking and rational problem solving is not always the best approach. Instead, we have to listen in new ways, pause to see more layers of influence in a situation, and bring our compassion to the fore. This creative exchange is part of the reason why, although this is often a degenerating prognosis and a challenging job, that staff say they love working with these residents.
When staff does not have access to some of the innovative thinking about these behaviors, and communication issues, we often see greater turnover and less job satisfaction. In family situations when they have not incorporated some of these approaches into the daily routines, we also see greater frustration and stress. Artful re-direction can make a huge difference in the moment to moment experiences we share, sustaining an up-lift, and capturing that illusive phrase "quality of life."
A little history
In the late 1970s and early 1980s, it was standard practice to correct a confused resident with reality orientation. For example, for a 90-year-old looking for her mother, the typical response might have been: "Your mother is dead. It's Monday and we are now serving lunch." This is a shocking response for someone who does not have short-term memory and may only be able to remember things in the distant past. This person was still alive to them and in their life years ago, and the memory of the death or long absence is not.
This approach also did not take into account the stages of the disease progression. In early stages of Alzheimer's, it is very appropriate to provide reality orientation when residents are still aware of some of these life events and are looking for insight and reassurance.
Many persons in early stages are still using notes, clocks and calendars. This person may have a sense that their mother is no longer living but needs help piecing facts together. Taking the recollection far enough back in time where you feel this person can recall things is helpful. You may ask: "Did your mother live near you or with you when she was older? Was she ill for any time?" Sometimes this jogs the persons own recollection and they realize the answer to their own question: "Oh yes, she was ill for some time, and then she passed away." Instead of shock and grieving at the news, often the resident is calmed by knowing they do not need to "look" for this missing person right now.
Naomi Feil worked as a social worker during this era and realized there had to be a more therapeutic approach for elders with memory loss than trying to jar them out of their world into ours. As a result of her experiences and observations, she wrote a wonderful book called Validation Therapy and a more current edition, Validation Breakthrough. Her work changed how many professionals approached this population in the field and provided great insights for families working with individuals in their homes.
Validation Therapy has grown to a worldwide movement with training programs and an institute continuing to hone this philosophy. The basic tenet of Validation Therapy is that although memory may be impaired, this is an adult with many emotions and life experiences. Some of these issues may remain unresolved as a person is shifting into their elder years and when impaired by dementias this person still has the right to resolve and review these things as they come up.
That approaching one's death and aging needs to be supported and reflected back to the person in a way that they can process them and ultimately have resolution and a sense of peace as they make their final transition. By "validating" the person's feelings and working with their perceptions in an affirming way, caregivers become more skillful at re-directing in an artful way and still help the resident navigate their day.
The next horizon
Through the 1980s and 1990s, the Alzheimer's Association was gaining strength and spreading from its founding chapter in Chicago to a national and international organization. In the early days there was a lot of discussion about the victim with Alzheimer's disease and an emphasis on supporting the caregiver. In those days, we talked about managing behaviors and institutional settings had strong medical models. This meant even though a person might live in the facility for a long time, it still had the feel of a hospital.
During this period, the structure for care was set up around staff convenience and the skill set was much stronger around medical and physical needs. Thankfully, over the years many facilities began designing and building facilities based on a social model of care. To a large degree, this issue was forced into the forefront by persons with dementia. They wanted to go outside, go for walks, and needed to use their energies and enjoy doing the familiar things they had done in the past. They did not recognize these settings as "home" and their area of need was in the environment and the social approaches the staff provided.
The Alzheimer's Association verbiage reflected this shift by talking about the person with Alzheimer's disease, by creating support groups throughout the country that these individuals could attend as well as offering the continued support for caregivers.
Over time, we began seeing alternatives for senior care grow around the country. Assisted living is an option many communities did not have 10 years ago, and assisted living centers that provide support for persons with memory loss is growing. Day care for adults has also expanded and home care organizations have caregivers that can assist family members in the home.
In 1997, Virginia Bell and David Troxel published a book called the Best Friends Approach based on their experiences with very vibrant day care programs for dementia care. They gave very clear examples of what it is to have the "knack" with folks with Alzheimer's. Rather than putting the emphasis on the disease, it was placing the focus on the person, the individual and what their strengths and needs are. The caregiver was encouraged to be a friend and to view the changes as areas that need support rather than problems; eccentricities and uniqueness rather than stigmatizing the person into a box.
The success of Best Friends Approach has lead to two more books, one specifically for staff, The Best Friends Staff, and one for families, A Dignified Life. These books provide wonderful guidance on successful ways to communicate with persons with dementia, activities to do together, ways to adjust to changing needs and helpful considerations for the care of the caregivers as well.
What to do now If you are currently working with someone with memory loss, and the confusion at times causes increased tension, there are some helpful techniques to deal with this. First, look at the rhythm of the day. Does it have a predictable structure? Are there times of rest and passive activity or stimulation and physically activity? Is the environment confusing and loud, or is it calm? These factors can influence a person.
Someone may have too much energy and need to expend it and sometimes a person is not being stimulated enough and is too lethargic and sleepy, even bored. Creating a clear rhythm can be a natural re-direction technique. In addition, observing body language and facial expression, tone of voice — in both the resident and you — is very important. Creating a lilt, or a pause, changing an accent, or using song can change a mood and lift a spirit.
Good communication skills are essential when dealing with a person with memory loss. Typically these individuals are trying to conceal their losses. Your communication should highlight their strengths, not spotlight their weaknesses. If a resident is asking for a knife and they are sitting in front of a bowl of ice cream, don't correct them. Rejoice in their ability to use free association and that they were able to find the right family of words. Bring the utensil and say as you give it to them: "Here is your spoon."
Our goal is to create comfort, so it is important to try to find the right thing to say that brings that feeling. Therapeutic "fibs" are examples of this. For example, a resident may want to leave and walk home. But their "home" is the home of their childhood memories. Or they feel a need to leave to go to work. By responding to the urge rather than the specifics, we may be able to go to their room and look at family photo's and have them tell stories, or leave and go for a walk to get a change of scenery. We may be able to tell them about the work they do here and how helpful they are, or it's a Saturday and they don't need to go to work right now. This is not considered lying in the dementia world. This is trying to create a blend between two ways of perceiving reality, and again, comfort is always the goal.
Working with individuals with Alzheimer's Disease and other forms of memory care loss can be very challenging, but also very rewarding. Learning to redirect energy can help to elevate emotions and keep residents and staff stress at manageable levels. There is obviously much more that can be said about this aspect of memory loss care but hopefully this provides some resources and ideas that will assist you in the art of re-direction.
Megan Carnarius, RN, NHA, is executive director of Balfour Cherrywood Village, a memory care residence in Louisville, Colo. Megan is a frequent speaker on the topic of Alzheimer's Disease and memory care issues.