Using Reality Orientation in Alzheimer's and Dementia

A Nurse Using Reality Orientation
Cultura RM Exclusive/Tim MacPherson Cultura Exclusive 145083639/ Getty Images

What Is Reality Orientation?

Reality orientation has its roots in a technique used with disabled veterans to help them engage in, and connect with, their surroundings. It's an approach where the environment, including dates, locations, and current surroundings, is frequently pointed out and woven into the conversations with the person. Reality orientation, when used appropriately and with compassion, can also benefit those living with Alzheimer's and other dementias.

Is Reality Orientation Helpful in Dementia?

Multiple studies have demonstrated that the use of reality orientation has improved cognitive functioning for people living with dementia when compared to control groups who did not receive it.

Reality orientation also has been shown to improve cognition when accompanied by medication. According to the British Journal of Psychiatry, the use of reality orientation by trained family members when coupled with the medication Aricept (donepezil) demonstrated an improvement in cognitive functioning, although it did not affect mood or behavior.

One study found that the use of reality orientation may delay nursing home placement by slowing cognitive decline.

Furthermore, after reviewing six randomized controlled trials, a study in the Cochrane Library concluded that there may be some benefit for not only cognition, but also in the challenging behavior of some people with dementia.

Challenging behaviors in dementia often reduce quality of life and may precipitate nursing home placement.

Strategies for Reality Orientation

  • Talk about orientation, including the time of day, the date, and the season
  • Use the person's name frequently
  • Discuss current events
  • Refer to clocks and calendars
  • Place signs and labels on doors and cupboards
  • Ask questions about photos or other decorations

How Does Reality Orientation Contrast with Validation Therapy?

Reality orientation has, until more recently, experienced a decline in popularity over the years, especially in comparison to validation therapy. This is due, in part, to a concern of people applying the reality orientation broadly without taking into account the person's emotions and mental health.

In contrast to reality orientation, validation therapy emphasizes the feelings behind the behaviors or statements. It encourages the person to talk about the reality they're in (rather than the one we know to be true), and believes that by processing some perhaps unresolved issues, they'll eventually be able to be more at peace.

Strict reality orientation could result in a harsh imposition of the "real" reality and a heartless response to the question, "Where is my mother?" Pure reality orientation would respond, "She died a long time ago. You're 92 and your mother couldn't possibly be alive today." Validation therapy, meanwhile, would acknowledge the person's feelings, ask questions about the person's mother, and ask what you missed most about her.

Clearly, those who use reality orientation must apply sensitivity and wisdom. In my clinical experience, an understanding of both validation therapy and reality orientation is beneficial. Depending on the person's emotional state, personality and situation, the response that is most beneficial to the individual can then be used.

Sources:

The British Journal of Psychiatry (2005) 187: 450-455. Reality orientation therapy combined with cholinesterase inhibitors in Alzheimer’s disease: randomised controlled trial. http://bjp.rcpsych.org/content/187/5/450.full

Camargo C, Justus F, Retzlaff G. Effectiveness of reality orientation in the treatment of Alzheimer’s disease (P6.181). Neurology. 2015;84(14 Supplement):181–6. http://www.neurology.org/content/84/14_Supplement/P6.181. 

Carrion C, Aymerich M, Baillés E, López-Bermejo A. Cognitive psychosocial intervention in dementia: A systematic review. Dementia and geriatric cognitive disorders. 2013;36:363–75. https://www.ncbi.nlm.nih.gov/pubmed/24022505.

Cochrane Database Systematic Review. 2012 Feb 15;2. Cognitive stimulation to improve cognitive functioning in people with dementia. http://www.ncbi.nlm.nih.gov/pubmed/22336813

Dementia SOS. Colorado's Dementia News and Resource Center. Reorientation Strategies. http://coloradodementia.org/2012/02/03/reorientation-strategies/

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