pacify or orientate? Alzheimers...

Specialties Geriatric

Published

So I have worked my third day as a LVN in a LTC facility. Orientated for one day then turned loose...on the alzheimers lock down unit. 21 residents.

A little scary, but I am fairly comfortable, so far. (should I be?)

Mrs. X is driving me crazy. For my three days she has asked to call her daughter to come get her.She is going home, looking for her car, easily agitated,etc.

The aides pacify her: "Mrs. X your daughter is at work, you can call her when she gets home from work" " your going home after lunch" This goes on all day.

I am new with Alzheimers behavior. I am new at being a nurse.

I don't feel good about telling her she can call her daughter to get her

"after she gets off work" , or that she is going home.

Is this not implanting the idea even futher, possibly even creating a cycle?

Any advice/ suggestion?

Validation therapy is the best approach. I am the Dementia Care Coordinator in my facility and am constantly in-servicing staff and family members about the best approach to communicating with individuals with dementia. Sure, "therapuetic lying" is very easy if you're rushed and can get you short term results, but I believe that it is unethical and bases the relationship on deciet. It indicates a lack of respect for others and doesn't address the real issue--the resident who is looking for her mother or wants to go home to make dinner is feeling something; scared, abandoned, worried, lonely. Validation therapy explores this and validates a resident's feelings.

An anecdote: A resident named "Betty" gets anxious and agitated in the late afternoon and attempts to leave the activity group and try to go down the elevator to "get a recipe from her aunt". This behavior is dangerous because she usually falls right around the same time and is difficult to monitor outside of the activity group. I spent five minutes talking to "Betty" about the recipe, the aunt, reminiscing until somehow the conversation got to how "Betty" used to be a phone operator. By using validation techniques on her, "Betty" was left feeling validated, sat back and relaxed and exhibited no further behaviors for the rest of the evening.

I am sure most of you will say, "But I don't have time to talk to her for five minutes!" I will say that that staff don't have time to drag her wheelchair back to the activity every two minutes for 3 hours while she anxiously calls out and cries. The nurse doesn't have time to fill out the incident report when she falls which requires a call to the MD and family. Then I don't have time to fill out the incident investigation and interview everyone involved, update care plans, ect.. It only took five minutes to make the resident feel better and save everyone else a lot of work.

As far as reality orientation, I will just say that it might work for some early stage dementia if the resident asks for it, "what time is it? where am I?" Subtle cues like calendars, clocks on the wall might have meaning for some early stage people.

Great thread!

Thanks Romie! I was beginning to get worried. :)

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There is a lot of debate about whether validation therapy or reality orientation or 'therapeutic lying' are good or appropriate or whatever. I like the validation therapy technique...when it works. When I spend time reminiscing about something with a resident (for example, one who wants to talk to her father) and a few minutes later, she is asking again, sometimes it is less distressing to the resident for someone to simply tell her that he isn't available right now...this works for this particular resident, but not for all. Sometimes validation therapy doesn't work...the resident wants to SEE her father, not just talk about him and gets agitated when you try to redirect..again, sometimes it is less distressing to simply tell her he isn't available right now. The one I am thinking of gets really upset if you remind her that he died years ago and that she is 96, not 26! :)

Reality orientation doesn't always work either...I've seen residents get more upset and confused after looking at a calendar and seeing that it is 2006 than they do believing it is 1948...not always the best answer to let them believe it is 1948, but in the overall scheme of things, does it matter? I would much rather see residents happy in their own world than fearful and agitated when we try to force them into ours.

I think it is best to start with techniques like validation therapy, but to know when it isn't working and to figure out what will work. One of my instructors in paramedic school always told us that education is learning the rules..experience is learning the exceptions. I think he was right...sometimes you just have to punt.

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Specializes in ORTHOPAEDICS-CERTIFIED SINCE 89.

i called my sister from mama's room at the nh. i handed mama the cellphone and she talked w/ sis for about 5 minutes. she handed me the phone back and said what's that?

mama it's a telephone.

"oh really i never saw anything like that...."

and that folks is alzheimer's. she can remember her phone number from 1925, she can recall a monkey my granddaddy had in 1947, but now every 2-3 minutes is a whole new day.

orienting someone who can't hold on to the orientation is just going to frustrate both of you. i don't like the lying term, or pacifying, but re-socializing seems to work for mama.

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So how many years have you worked in LTC? I'll bet almost none?

The lazy and innappropriate/ illegal way to do it is to restrain and medicate. Fortunatly for my pts this is not an option. I can go on and on about why you are wrong on so many levels, but I'll just let you see how far you get with telling "the truth" to your demented patients.

Go right ahead... I'm very interested to see what you say in regard to me being 'wrong on so many levels.'

I want to know how you try to justify lying to your patients.

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Specializes in LTC,Hospice/palliative care,acute care.
I use this kind of redirecting all the time. I learned this with my grand mother.

My great aunt and I went to see her one day and granny said she had just gotten home from a wonderful time in Galveston. She was bedridden in a ltc at the time. My Aunt began to correct her and attempted to reorient her I was a nurse at the time and stopped her. and then asked Granny How is the weather there and was it too windy. and she began to tell me stories of when she was a girl in galveston.

My aunt was furious and raled at me for an hour. I didnt care My Granny and I had a great day at the beach.

Oh I LOVE your post.! Sadly that kind of communication is not the norm.Too many family members are like your aunt...I'm glad that you and your g-mom got to enjoy the beach again....
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Specializes in LTC,Hospice/palliative care,acute care.
Go right ahead... I'm very interested to see what you say in regard to me being 'wrong on so many levels.'

I want to know how you try to justify lying to your patients.

You sound a little bitter and angry-are you dealing with dementia in a loved one?

We are talking about pts with diagnosed dementias.Not the kind of patient you see daily in your ICU...That's the difference .Your patients need to be re-oriented and hopefully will return to their baselines(mental and physical)...Ours are NEVER going to get better-all we can do is help their loved ones accept that and keep them as comfortable as we can for as long as we can.We want to maintain their highest level of functioning as long as possible and maintain their dignity...."Re -orienting" the demented was how it was done years ago-all the studies show that is not effective and is in fact damned cruel....Telling a 96 yr old demented resident that her mother has been dead for 45 yrs is in-appropriate.Not every method works for every pt. every time.We have to be creative....We also have to learn the normally abnormal behaviors for our pts so we can recognize a change that may signal something like a UTI.Your example of the 12 yr old kid going to the park is flawed.The dementia resident won't remember they have been lied to....Every pt has be addressed in an appropriate manner -you have to take into consideration the stages of dementia and where that pt. is at the time....I don't LIE-I validate..

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If my pt insists its time to get up and go to work or she must go make dinner....telling her he doesn't work or she doesn't make dinner anymore isn't going to work. Fighting with them and insisting that they understand that they are in a nursing home, its 2006, their mom is dead...etc ain't gonna work. They will become more frustrated and upset and that could last all day long.

As a previous poster stated...validation doesn't always work. Telling that person...hey...its your day off or I made dinner...etc will. Is it a lie....yes.

We use very little psych meds, hardly any restraint (maybe a few side raiils or geri chairs) and I've worked in LTC wth very difficult alz pts for the last 10 yrs. Rarely do we have a problem when we treat res with dignity and respect using validation and the theraputic lies.

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When I was a brand new EMT, we picked up a lady who had fallen and was very confused. She was combative, crying, yelling, spitting, etc until I walked in the door. Somehow she thought I was her friend Margaret. The EMT in charge started trying to convince her I wasn't Margaret, but I just sort of jumped in and played the role. I talked to her about her grandchildren, asked her what she was growing in her garden, asked her if she wanted me to lock the door when we left, and told her I would get a hold of her family and tell then what happened...and we managed to safely get her immobilized, get her into the ambulance, and get her to the hospital. When we got to the hospital, I waited with her until her daughter got there and she was fine. The EMT in charge was not happy because you should NEVER lie to your patients...I wonder how much harder it would have been to get her to the hospital safely if "Margaret" hadn't shown up.

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Specializes in FNP, Peds, Epilepsy, Mgt., Occ. Ed.

Could someone direct me to a source of information about validation therapy? I don't work LTC so I'm not familiar with that.

"Back in the day" when I was a student and new nurse, orienting patients to reality was what we were taught. It only took me a short time as a nurse to figure out that it might not work real well.

We had a patient with MID. She looked exactly like my conception of Mrs. Santa- round pink cheeks, twinkling blue eyes, curly white hair, pleasantly plump. She was also a real Houdini and could get out of a Posey or wrist restraints several times faster than you could put them on. (This was more than 20 years ago when restraints were common). She was very sweet and quite confused, trying to get someone to take her to visit her sister. We reoriented her repeatedly, many times a shift. Then one day it hit me.

I was telling "Mrs. Claus"

yet one more time where she was, what day it was, and so forth. She was smiling at me and patting me gently on the arm. She was humoring me!! I could almost read the thoughts in her head: "Poor dear, she's so confused! She thinks this is a hospital and she's a nurse..."

I've seen plenty of patients get agitated with reorientation, but never another one who made it so clear that I was the one with the problem!

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When I was a brand new EMT, we picked up a lady who had fallen and was very confused. She was combative, crying, yelling, spitting, etc until I walked in the door. Somehow she thought I was her friend Margaret. The EMT in charge started trying to convince her I wasn't Margaret, but I just sort of jumped in and played the role. I talked to her about her grandchildren, asked her what she was growing in her garden, asked her if she wanted me to lock the door when we left, and told her I would get a hold of her family and tell then what happened...and we managed to safely get her immobilized, get her into the ambulance, and get her to the hospital. When we got to the hospital, I waited with her until her daughter got there and she was fine. The EMT in charge was not happy because you should NEVER lie to your patients...I wonder how much harder it would have been to get her to the hospital safely if "Margaret" hadn't shown up.

Yes...that is what I'm trying to describ. A lot of times you are thier mom, sister, friend etc. I worked with one aid who reminded a res of her dghter. The dghter was abusive toward the mother and this aid was unable to care for this pt.

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You sound a little bitter and angry-are you dealing with dementia in a loved one?

We are talking about pts with diagnosed dementias.Not the kind of patient you see daily in your ICU...That's the difference .Your patients need to be re-oriented and hopefully will return to their baselines(mental and physical)...Ours are NEVER going to get better-all we can do is help their loved ones accept that and keep them as comfortable as we can for as long as we can.We want to maintain their highest level of functioning as long as possible and maintain their dignity...."Re -orienting" the demented was how it was done years ago-all the studies show that is not effective and is in fact damned cruel....Telling a 96 yr old demented resident that her mother has been dead for 45 yrs is in-appropriate.Not every method works for every pt. every time.We have to be creative....We also have to learn the normally abnormal behaviors for our pts so we can recognize a change that may signal something like a UTI.Your example of the 12 yr old kid going to the park is flawed.The dementia resident won't remember they have been lied to....Every pt has be addressed in an appropriate manner -you have to take into consideration the stages of dementia and where that pt. is at the time....I don't LIE-I validate..

No, I fortunately do not have any family members or close people dealing with this disease. I just happen to take mental health seriously and as a healthcare professional, I am bothered when other Nurses think it's acceptable to lie to patients. I only wish other Nurses had a great psych instructor like I had in school.

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No, I fortunately do not have any family members or close people dealing with this disease. I just happen to take mental health seriously and as a healthcare professional, I am bothered when other Nurses think it's acceptable to lie to patients. I only wish other Nurses had a great psych instructor like I had in school.

So...what do you suggest? I'm not trying to be rude here, but a lot of your posts do come off as a bit uppity and condescending. You seem to do a lot of correcting and instructing...tell us how we should do it.

Apologies in advance for sounding like I am flaming...just getting frustrating with people who are have no experience in our world telling us how it should be.

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