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Honesty with Dementia: Always a Good Policy?

Personal or professional caregivers who work with individuals experiencing dementia often encounter challenges when their care recipients possess an altered sense of reality. An individual may expect to see a deceased relative or friend, insist on driving to the store when he/she is no longer able to safely operate a vehicle, or believe that a personally owned item (such as an article of clothing), isn’t theirs.  What is the best way to handle these and other similar situations?

A caregiver’s first inclination may be to use logic to explain the situation. Unfortunately, the conditions which cause symptoms of dementia result in damage to brain cells which impair their ability to communicate with each other. Individuals lose the capacity to recall previous information and process new information.  However, the thoughts and feelings of individuals with dementia are fixed and real in each particular moment, and using logic to try to change their minds about a particular idea often results in frustration and anxiety for both the caregiver and the care recipient. If an individual wants to see his/her mother, and a caregiver tells the individual that mother died twenty years ago, the individual is most likely to experience disbelief, renewed grief about the loss, and/or anger due to an impression that “Nobody told me!”

Think of the brain as a filing cabinet which is filled with information about everything from childhood memories to how to brush your teeth. As the disease processes which cause dementia progress, individuals gradually become unable to access a “file drawer” and specific “folder” within their brains to store new information or retrieve information which is already there.  In the early stages of dementia, it is common for certain information to be recalled one day but not the next. When there is only minimal damage to the brain cells, they may sometimes be able to communicate with each other and create the appearance that the individual is okay or improving. For observers and caregivers, it doesn’t appear to make sense that an individual may retain the ability to calculate the answer to a math problem but be unable to put on a pair of pants. The location of each “file drawer” and “folder” within the brain and extent of the disease process determine which abilities/memories are retained and which are now locked and inaccessible. The use of logic may be successful during the early stages of dementia, but gradually the ability to reason will decline and other methods must be utilized to obtain the care recipient’s cooperation with the task at hand.

If a logical explanation is not the best way to handle a situation, some individuals may be able to be redirected by changing the focus of their thoughts. The person who wants to drive to the store may forget about driving and the store if the caregiver offers a reasonable alternative to occupy their attention, such as having lunch ‘first’ or ‘waiting until the rain stops’.  Sometimes, asking for details about the person’s life related to an aspect of the situation will lead to conversation which can then flow into other subjects and redirect the attention.  Open ended statements or questions which require the person to stop and think will have the greatest chance of success.  For example, “Please tell me about …” (example: learning to drive or a first car).

When redirection is unsuccessful, another alternative to address a difficult situation is therapeutic fibbing. Some caregivers may feel uncomfortable with telling their loved one something which isn’t true. Instead of viewing this method as lying; this technique can be seen as a way to acknowledge the care recipient’s reality, validate his/her feelings about the situation, and provide another option which will minimize his/her anxiety and frustration about not being able to perform the desired activity. Statements such as “Your coat is at the cleaners so I brought this one for you to wear instead” may help the person understand and accept that whatever coat he/she is thinking about isn’t available. Additional encouragement can be provided by pointing out the benefits of the replacement item or task. In this case the softness of the ‘new’ coat and/or that the ‘new’ coat is a favorite color may be appealing.

For a successful outcome to therapeutic fibbing, validation of the individual’s feelings is an important aspect of the process. Viewing a situation from the individual’s perspective will help a caregiver develop empathy.  Even though individuals with dementia may not be able to identify specific emotions or understand the reasons behind these emotions, they often absorb the emotions of others around them.  A caregiver who is empathetic will promote a sense of trust and security for the individual with dementia, thereby encouraging cooperation with the caregiver’s ideas and plans.

Living and working with individuals who are experiencing dementia often requires quick thinking by caregivers. An understanding of the rationale behind the use of redirection and therapeutic fibbing and practice of these techniques can improve the daily lives of caregivers as well as their care recipients.

Karen Kaslow, RN, BSN