Using Reality Orientation in Alzheimer's and Dementia

Strategies and Cautions in Its Use

A Nurse Using Reality Orientation

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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 disease and other dementias.

The tools for reality orientation aim to reinforce the naming of objects and people as well as a timeline of events, past or present. This typically involves:

  • Talking about orientation, including the day, time of day, date, and season
  • Using people's name frequently
  • Discussing current events
  • Referring to clocks and calendars
  • Placing signs and labels on doors, cupboards, and other objects
  • Asking questions about photos or other memorabilia

Effectiveness

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 a study in 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.

A 2013 review published in Dementia and Geriatric Cognitive Disorders concluded that the use of reality orientation helps 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 behaviors that can reduce the quality of life in people with dementia.

Reality Orientation vs. 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 large 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—resulting in heartless responses to questions like, "Where is my mother?"—validation orientation establishes the context by which to frame the response. Instead of providing the facts and just the facts, a person might respond, "Your mother died a long time ago. You're 92, and your mother couldn't possibly be alive today."

Validation therapy aims to acknowledge a person's feelings and to discuss those feelings to help orient when events occurred, what they mean, and how they relate to current behaviors.

Precautions

As a rule, reality orientation must be mixed with compassion and used appropriately to benefit someone living with the confusion of dementia. Applying it without evaluating if it might cause emotional distress to the individual since there are some times when it would not be appropriate.

In many situations such as casual daily conversations, reality orientation can be used to help cue the person as to the setting around them. However, if the person to whom you're talking becomes more upset instead of less so, it's a safe bet that you should back off your attempts to orient and let compassion drive your conversation by joining their reality.

Broadly speaking, reality orientation may be better suited for people with mild to moderate cognitive impairment. In this context, it not only helps delay nursing home placement but also provides an improved sense of control and self-esteem.

A Word from Verywell

Clearly, those who use reality orientation must apply sensitivity and wisdom. In clinical and home settings, 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.

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