There are certainly challenges associated with working in residential memory care facilities. Even with a good staff-to-resident ratio, access to dementia-specific training and a supportive management structure, the challenges of caring for someone living with dementia or other cognitive impairments can be taxing.
This article outlines specific elements of communication that may smooth the difficult situations that can occur in the line of duty in memory care services, with expert insight from Dementia expert, Rachael Wonderlin of Dementia by Day.
Specialized care is often sought to provide the level of care that can contribute positively to an older adult’s quality of life when home care becomes too stressful for their family, or the person's cognitive abilities suddenly decline. In this instance, families look to find nursing home care with specialized long-term care units specifically for people with dementia. Commonly referred to as memory care communities, units, neighborhoods or facilities, one of the main benefits is the peace of mind of knowing that the healthcare professionals working there are specifically trained to assist those with cognitive impairments.
Still, working in these memory care units presents no shortage of challenges for these caregivers in terms of caring for those experiencing cognitive decline. Memory care residents can experience confusion due to memory loss, which can lead to challenging behaviors, including aggression, angry outbursts and severe distress. These intense and unpredictable behaviors can be challenging for caregivers to manage especially alongside any other medical or personal care that person may need.
Rachael Wonderlin's signature approach to connecting with people living with dementia is called "Embracing Their Reality".1 This has been demonstrably effective at helping caregivers to communicate with memory care residents because it involves meeting that person where they are, in their version of reality as it currently stands in their memory and stage of dementia.
Here are some of Rachael's top tips for behavior-solving and management:
"Embracing somebody's reality means that we go into their world, no matter where it is. [...] It's when we create an environment where residents feel heard and understood. We look to solve emotional challenges instead of letting residents feel agitated and anxious."2
Family who care for those with dementia at home often really struggle with this concept of lying to their parents or other family. Lying is wrong, right? It can be a contentious issue for caregivers whether they are family or healthcare professionals.
These "truths" serve our sense of integrity, but do they serve the person who is living with dementia? Often the answer is "no".
According to Rachael Wonderlin, memory care professionals should "take that word "lie" and throw it away. Replace it with this term [Embracing Their RealityTM]. Not "therapeutic lying", not "fiblets", none of that. Doing what's true for them no matter where it is."2
The premise behind the Embracing Their RealityTM model is that you're not lying by meeting them in their truth any more than they are lying to you when they say that they need to get the laundry done or else the kids won't have any clean clothes for school. The resident is speaking the truth so of course they will get agitated when you remind them that their children are all grown up now and can do their own laundry. They will likely have an emotional response to this "truth". How dare you lie to them, right?
Even though it is still occasionally taught, Reorientation is no longer considered best practice, or even good practice by most dementia experts. Reorientation involves correcting the resident in the hopes of reorienting them in your reality. For example, "Don't you remember? Your parents died years ago."
In this situation, what is the likely outcome of this? Best-case scenario may be confusion, and the worst-case could be indignation, agitation and aggression or distress. Hence why this has been ruled out as an effective communication technique for memory care patients.
Three more widely employed techniques, Redirection, Distraction and ValidationTM will also tell you never to lie to someone with dementia. But are they truly effective either?
Racheal Wonderlin explains her take on these techniques. "To me this leaves a huge gap in how we communicate with people living with dementia. It makes it very confusing."
In terms of alternatives, that's where Embracing Their RealityTM comes in. "We want to take a trip. We want to go over to her reality. This means we don't worry about what is true for us. We do what's true for the person living with dementia. [...] Instead of worrying about lying we want to choose what is true for them."
Doing as Rachael suggests and cutting out therapeutic lying, fiblets, white lies, untruths, Validation, Redirecting or Distracting as viable communication techniques, she suggests a better response to a common query from people living with dementia.
Q: "Where is my mom?"
A: "Where do you think she is?" - This gives the resident the chance to tell you about their reality and inform you of what is true for them.
Following the same logic, other situational responses could be:
Q: "I'm going to be late for work"
A: "Oh really, what do you do for work?" - Now you know what it is they want and what the source of their potential anxiety is.
Q: "I'm going to call the police."
A: "Well I can call the police, but I need to know what to say to them. Can you sit and write out what the problem is or explain it to me slowly so I can write it down?" - Getting them to sit and focus on something like this will not only make them feel heard and understood but will stop them from moving about in an agitated manner which can cause accidents.
Q: "How do I get out of here?"
A: "Where are you trying to get to?" - Whatever they answer, now you at least know more about where they think they are and where they think they should be.
These are some of the things you might find yourself saying ten times a day in a memory care unit as a caregiver and how Rachael Wonderlin advises you reorient (see what we did there?) your words to get better results.2
Swap: "Do you want to have a snack?"
With: "Do you want a banana or a cookie?" - Give a choice, without giving an explicit opportunity to refuse food altogether. Too many choices = drama though so keep it simple.
Swap: "Do you want a drink?"
With: "Here, take a sip." - Gives them direction without an explicit opportunity to refuse.
Swap: "Do you want to join this activity?"
With: "Can you help me with this?" - Giving them a sense of purpose and achievement.
Swap: "Do you want to play with the baby(doll)?"
With: "What do you think about this?" - Gives them the opportunity to look at the doll and tell you where their reality is right now so you can embrace what's true for them.
According to Rachael Wonderlin, "When people are feeling calm and situated, guess what they're not doing? They're not walking down the hallway stressed as anything, looking for their loved one, looking for the exit."2
A key question to ask when engaging with people with dementia who are anxious or panicked is "Can you help me with this?". This invites the resident to an activity that feels like it has purpose and meaning. "Do you want to help me with this?" could be a little less effective as it leaves the playing field for "no" wide open. But "Can you help me with this?" is more likely to result in a "yes" and help someone who might otherwise be up, moving down the hallway looking for something or someone, to calmly situate themselves here.
This recent article outlines some of Rachael's activity and life station ideas that are purposeful, age-appropriate and engaging for dementia care settings.3
Finding useful resources that are appropriate for every level of education and seniority of caregiver can be challenging to source, but we can help. With a view to helping long-term care professionals equip themselves and their teams with the knowledge and training they need to deliver quality care to their residents, Accora executes a continuous program of training events and resources and it's completely free.
You can access webinars such as 5 tangible ways to prevent falls in dementia care with Rachael Wonderlin on demand via this link or access our ever-growing bank of articles on topics relevant to senior caregivers here. Suitable for clinical caregivers from Directors of Nursing through to Certified Nursing Assistants and everyone in between. We are confident there is something for everyone.
If you want to teach these communication techniques outlined in this article to the interdisciplinary team then we advise you direct them to the on-demand webinar with Rachael, particularly the first 10 minutes in which she focuses on her Embracing Their RealityTM model and the limitations of other communication methods.
While every day in memory care communities can present unique challenges, effective communication between nurses and residents is a common source of potential aggravation. Using dementia expert Rachael Wonderlin's communication model for engaging with those experiencing cognitive decline is advisable. If for no other reason than considering the answer to the question "how would I like to be cared for and communicated with as a person with dementia?"
Would you wish to be corrected or distracted like a child or would you like to be given the freedom to exist in your truth, in your unique reality without feeling shamed, confused or lied to by those around you? Or even now, how would you react to being told with certainty in the midst of casual conversation that your loved one is dead when you know they aren't - you saw them just this morning. Your reality now appears to be just as true as that of the people in your nursing home living with dementia.
1 - https://rachaelwonderlin.com/2019/04/23/embracingtheirrealitytm/
2 - https://us.accora.care/webinars
3 - https://us.accora.care/blog/activities-for-dementia-patients---8-creativity-box-and-5-life-station-ideas
