Principles of Behavior Management and Reality Orientation with Dementia – Principle 8

The information in this blog series is intended to help paid and unpaid caregivers manage problem behaviors caused by dementia. The slow insidious decline that we see in dementia is characterized by losses in mental, emotional, behavioral, and self-care capacities. The recommended interventions offered are considered milieu-based, or environmentally-based because they help to create an environment that is structured and anxiety-reducing, settings that reinforce appropriate behaviors while avoiding interactions that trigger unwanted behaviors.

This blog describes the need for extraordinary structure, explanation, and cues to make up for what is missing due to the loss of general awareness and information that accompanies dementia. This loss is manifested in little or no awareness of everyday events, like holidays, important facts, seasons, local or world events, anything that you and I may take for granted. Because the person with dementia is unaware of these facts, it is essential to communicate these to the patient, and repeating as often as necessary. This is referred to as reality orientation, and should take place whenever interacting with the person. We want to communicate what’s happening to the individual: explain what is going to happen, what just happened, what the daily schedule is, what the day and date and seasons and upcoming holidays are, when the next meal is, even what we’re having for the next meal or had for the last meal, and so on. We see this on the activity boards in the nursing home, though the verbal interaction between caregiver and patient is much more effective.

We take this information all around us for granted, but for the confused, disoriented person, it is necessary to replace this missing information. And, the need for this information sharing is not short term or temporary, but permanent. The term “prosthetic environment” is used to describe the permanent, extraordinary atmosphere that we want to create: multiple cues and reminders, continually offering explanations, facts, everyday information, in short, anything and everything that helps to orient the person, and helps her feel safe and secure. This is called a prosthetic environment for good reason: a prosthesis is a device used to replace a missing part of the body, such as a leg. And, just as a prosthetic leg is needed permanently, a prosthetic environment is also needed permanently for those with brain impairment to minimize confusion, disorientation, anxiety, and distress. Whatever structure, communication, and reality orientation we can provide, the better. In the absence of this, the person gets more anxious because she cannot tolerate uncertainty, ambiguity, or the unknown. The more the anxiety level escalates, the more likely she is to engage in problem behaviors.

As we learn the many ways that dementia impairs a person’s functioning, we can be better prepared to anticipate, make up for, or replace some of the losses that the patient experiences. This means better management of potential behavior problems, and helping the person function at her highest possible level.

Many of these concepts can be found in the caregiver educational programs on our website, http://www.cohealth.org/. Some of the titles include behavior management, understanding Alzheimer’s disease, nursing home placement, and end of life decision making.