“IF WE DON’T GO TO THEIR REALITY, WE MAKE THEM PRISONERS OF OURS”

Not opposing realities, their reality

This true story was selected for the purpose of emphasizing the value and importance of working within the loved one’s sense of reality rather than struggling in the midst of opposing realities.

At the time I worked in a locked dementia facility.  Heading to my office, I made my way up to the second floor only to find that once the elevator doors open, I’m greeted by Michael, an award-winning retired architect.  I see he’s not wearing shoes and socks but instead is wearing a pair of black leather gloves on his feet.  His footsteps mimic those of a swimmer wearing flippers making their way to the water from the shore. 

Assess the Need in the angst of opposing realities

“Good morning Michael,” I exclaim.  “How are you?” “7.5, 7.6, 7.7…,” he numerically responds in unison with every step he takes.  Michael remains 100% oblivious to the fact he speaks in numbers and while most people turn to Word Salad as they begin to lose their verbiage, Michael’s brain resolved his communication issue by using his beloved numbers, which is highly unusual.   

“Get me a cup of cocoa from the kitchen,” I requested a caregiver as she walked up to me.  “Okay.  He won’t let us put shoes on him,” she explained.  “I’m gonna do that now.  Meet me in the activity room,” I replied.

Michael and I “hobbled” down the long hallway to the activity room.  With zero recall as to who I am, Michael’s reality indicated my caring friendliness as that of a longtime friend and took upon himself a gentleman’s courtesy, offering his arm to guide me onward.  

My reality indicated I was stabilizing each stride he took until he was safely seated.  This act of love clearly showed how two opposite realities can very easily coexist.

Addressing Michael’s Psychosocial Needs

“Look!  Your favorite seat is available!  Do you have time to talk to me?  It’s important.  I need your expertise to guide me.” I share.  “4.7, 4.8, 4.9…,” Michael responds.  I see a “toolbox” sitting on the counter filled with high end toy screwdrivers, drills, wrenches, and more.  Some make realistic motor sounds, giving one the illusion it is real while remaining safe for anyone to use.  

I open it up, “Michael, I don’t know which tool I’m supposed to use.  Can you show me?”  Michael breaks into a mesmerized smile and starts fondling each tool, making numeric responses about each one.  Respectfully I respond with vague but acknowledging statements, “Well I tried that one but it’s the wrong size,” or “I don’t know what I am supposed to do with that one…”  

An aromatic cup of cocoa arrives.  “Get Michael’s shoes and socks please,” I request.  “Michael!  Take a sip for me.  I KNOW you will like it.  He nods and does so.  

“Mmmm 7.2, 7.3, 7.4….,” Michael delightfully expresses while looking back and forth from the cocoa to the tool box.  I say, “Michael, this young lady and I are going to put different shoes and socks on you.  It’s pretty cold outside today.  I want you to stay warm.  Are you okay with that?”

Respect Their Sense of Autonomy

Agreeing, I ask, “Can I put this shoe on you?”  as I hand it to him for inspection and approval.  “What do you think about wearing these socks, look like they’ll be okay?”  He studies them briefly before nodding in agreement, returning his attention to the tools and cocoa.  Within a matter of seconds the task became a success.  

Michael was not willing to take his glove-shoes off because they were attempting to correct the situation within their reality, not his.  Now I know Michael is safe, content and ready to inhale the rest of his day with great gusto.

The Breakdown of “Reality Orientation” for a Person With Dementia 

Join me now as we relive this scenario using non-dementia-wise interaction along with reality orientation:  The caregiver explains they have tried all morning to get Michael to wear shoes but the resident was “unwilling and resistive.”  

“Michael,” we say, “We need you to sit down here.  You need shoes and socks on you.  You’re wearing gloves on your feet and that might make you fall” (this is reality orientation).  

Have you have ever watched a Peanuts cartoon?  Then you know whenever an adult speaks it is not heard as verbiage but instead it’s the “wah wah” sound from a trombone.  That’s how reality orientation sounds to Michael; to anyone with dementia.  

If we’re lucky enough to even get him to sit, we will still need two more caregivers to help.  Caregiver number one quickly pulls off the left glove thinking fast actions will confuse Michael, making him less resistive to the changes that are about to come, but instead Michael reacts with panic.  

Caregiver number two tries to put the sock on the left foot which is now frantically jerking about in resistance.  Michael further reacts negatively as he tries to pull away shouting and contorting his body in hopes of escape.

We Did it Our Way, But….

“Maybe aversion will work,” a caregiver suggests between huffs and puffs during this “now-almost-at-the-level-of-a-wrestling-match” event.  “Hey Michael, look at this cool measuring tape I just bought.  Do you like it?  Go ahead, take it, check it out, see what you think,” I suggest.  Michael’s response?  Not his usual fascination with tape measures as he ignores my invitation altogether.

Michael’s senses have gone into overload.  His body is beginning to shut down as the adrenalin begins rushing to vital organs.   We have now introduced Michael to “fight or flight” syndrome.  He is fearing for his life. In his reality we are his enemies.  Caregiver number two says, “We need to get the nurse to help; he’s just too resistive.”  The nurse comes up and tells Michael, “You need your shoes and socks on, Michael.”  Michael scowls and says, “3.2, 3.3, 3.4!”  In other words, an argument ensues.  The nurse makes a failed attempt at giving Michael a benzodiazepine med to calm him down and decides to give him something topical instead.  Michael continues to resist before the meds calming effect hits.   

No Autonomy, No Quality of Life

Staff no longer includes Michael in their plans.  Instead they are instructing and kibitzing with each other to get the task accomplished…… “Get the sock ready while I grab his leg……”  Finally, by simply being outnumbered, Michael is wearing shoes and socks (according to our reality).  According to his reality someone has just robbed him, leaving him with “this stuff.”   

Frightened, upset, and thoroughly confused Michael isolates himself in a closet where a med-induced nap takes effect.  There he stays until someone finds him for mealtime.  It will take a fair amount of urging and cajoling, even after hours of self confinement, just to get him to come back out again.  Michael is no longer able to recall the incident but all the high-stress emotions evoked during this drama, all the “not-feel-so-good chemicals” his brain released are still working their way through his system, leaving the trauma very much alive inside of him.

For a complete picture of what took place for Michael, please read “Opposing Realities – Part 2.”

Psychosocial Encouragement

• Remind them they are loved by others.  “Your granddaughter Atira sends her love.  She says she misses you and hopes to see you soon.”
• Continually strengthen their sense of value and self-worth.  “I love you,”  “Please hand me the spoon.  Thank you.”
• Expressing jobs well done supports their need to be successful in achieving goals.