Validation Approach to Alzheimer’s Patients

Basics

Validation is a method of interacting with the dementia of people in the late stages of Alzheimer's. People with Alzheimer's, especially on the late stages, frequently exhibit abnormal, sometimes even incomprehensible, behavior. For example, they may think they are living in a different time or place or they may continuously repeat a physical gesture. Many people - including professionals - feel that caregivers should handle this behavior by stopping it, ignoring it or correcting it.

According to validation method developer Naomi Feil, this unconventional behavior, while illogical, is an attempt by the Alzheimer’s sufferer to communicate and express their needs. The aim of the validation method is to understand and empathize with the needs the person is trying to express. So, the theory behind validation is the belief that people with dementia do and say things for a reason, and validating their words and actions is a way of encouraging them to keep communication open with the rest of the world. Another foundational principle of validation states, that older people are to be valued as is, and those with dementia should not be changed.

Principles

Here are the key tenets of the Validation Method:

• Validation is a method of communicating with and helping disoriented very old people. It is a practical approach that helps reduce stress, enhance dignity and increase happiness. Validation is built on an empathetic attitude and a holistic view of individuals. By stepping into the shoes of another human being and seeing the world through their eyes, caregivers can step into their world and better understand the meaning of their sometimes bizarre behavior.
• Validation theory understands that these patients are often in the final stage of life and trying to resolve unfinished issues in order to die in peace. Validation techniques allow patients to have the opportunity to express what they wish to express verbally or non-verbally.
• Validation practitioners are taught to be caring, non-judgmental and open to the feelings that patients expressed, believing that when patients can express the things that have often been suppressed for many years, the intensity of the feelings lessen, they communicate more and are less likely to withdraw into further stages of disorientation.

Effects

The way to validate a person that is suffering from dementia is to figure out why they do and say what they do in details, and to accept this behavior. Using validation methods of interaction is thought to prevent late stage Alzheimer's patients from shutting down further mentally, keeping their cognitive function active as much as possible. Validation encourages Alzheimer's patients to forge a trust with their caregivers as a means to encouraging communication between the two.

By lending an understanding ear to someone with Alzheimer's to verbalize their frustrations, worries and fears, the negative emotions can diminish. This will contribute to better cognitive functioning and behavior.

In her article “Communicating with the Confused Elderly Patient,” Naomi Feil gives practical examples of the how the validation method works to help communication between patient and caregiver. The following material is an excerpt from this article:

The following scenario, based on actual case experience, depicts a less effective way of responding to disorientation.

Mrs. K: “Doctor, I have to go home now to feed my children.”

Physician: “Mrs. K, you can’t go home. Your children are not there. You are 96 years old. Your children are grown and live far away.”

Mrs. K.: “Oh, Doctor I know all that. That’s why I have to get out of here, right now. I have to feed them. They’re coming home for lunch, and the door is locked. Get me out of here!”

The following response may be more appropriate, because it focuses instead on the objective here and now and avoids asking why - a concept that disoriented older people may not wish or be able to deal with.

Mrs. K.: “Doctor, I have to go home now to feed my children.”

Physician: “What will you feed them?”

Mrs. K.: “Oh, Doctor, I am a good mother.” (The patient here confuses present and past time.) “They love tuna. Do you think that’s good for them?”

Physician: “It has a lot of protein. Is that what you fed your children? Do your grandchildren eat tuna?”

Mrs. K.: “They love it. I brought them all up right!” (The patient now moves between past fantasy and present reality. When her need to be a good mother is expressed, she can place herself in present time.)

Express the emotional need of the person aloud, thereby affirming the person’s right to feel and to express feelings. Example:

Mrs. K.: “Doctor, I have to feed my children.”

Physician: “You must have been a good mother. You must miss your children.”

Mrs. K.: “You know it. I always cared for them. Whatever they wanted, I gave them. You guessed it. But I get along all right now without them.”

Dimensions

As a caregiver, you have been introduced to a new and different world - the world of dementia. People who inhabit the world of dementia are in a very different place than those of us who live in "Reality" (whatever that is).

1. Time. The first dimension in the Alzheimer’s Universe is Time. Time in the world of dementia operates completely differently than time does for the rest of us. First, time is not sequential in the dementia universe. Time can be present at one moment, past at another and future at another. Time has absolutely no continuity.

2. Memory. Memory is very different in the world of dementia. Past may be confused with present. Memory may be there one moment and gone the next. The mind plays hurtful tricks in the world of dementia - making a known and loved child or spouse into a stranger to be feared. Family may no longer be family. As much as we in the "Real" world know that this is our mother or wife or husband, the person in the dementia world does not know these "Realities". S/he only knows what they know at any given moment. It is so hard to accept their dementia world.

It is so different from what we know in the "Real" world. Yet, there is no successful alternative but to accept whatever the dementia person claims as their reality - no matter how untrue it is to us. There is no successful way to "force" a person with dementia to join the "Real" world. Usually, the most frustrated caregivers are the ones who have not accepted this simple fact: the world of dementia is defined by the dementia victim. We in the "Real" world do not define it. We can only hope to live in it somewhat peacefully IF AND ONLY IF we accept this dementia world on the terms of the person with dementia. If they "see" a rabbit on the couch, they see it. If you are not their spouse, you are not. If it is breakfast time, it is breakfast time (even at 6 p.m.).

Telling the dementia person that "I am too your wife" or "No, John, it IS NOT Friday. It is Sunday." Or saying, "Sally, you don't have any little babies. You are 85. Your babies are all grown up" - these kinds of statements from the "Real" world almost always serve only to upset and distress the dementia person. However, if you say something like, "If you say so, but I'd like to be your friend. . ." or "It's your Friday, huh? What do you do on Fridays?" or "Sally, tell me about your babies."

3. Emotions. Emotions are also very different in the dementia universe. First, consider that the dementia person's reasoning abilities are very limited or perhaps gone completely. There are actual changes in the brain that affect a dementia person's ability to think. So, they are somewhat like a pre-schooler in their ability to assess, judge, make decisions, etc. Most dementia folks have some difficulty in understanding the spoken language. However, almost all dementia folks can easily pick up on the FEELINGS being expressed. It is very true that in the dementia universe, it is NOT so much what you say, but HOW you say it. When frustration, anger, and loudness creep into your voice, the dementia person is going to feel that much more strongly than the actual words being said.

Types

There are physical, mental and social aspects of validation. Some Alzheimer's validation techniques include:

• Centering. Centering is necessary in order to feel empathy for someone with dementia. To become centered, one must disregard personal feelings and thoughts in the mind.
• Mirroring. Mirroring is adopting similar actions, tone, and volume of voice of someone. This technique is based on the human behavior theory that people like, trust and feel comfortable with people that are similar to them. Mirroring is not imitating or mocking. For example, if someone is leaning in close to speak to you with a calm and low voice, then you would also lean in close and use a low tone of voice.
• Physical Touch. Physical touch is used to foster a relationship and trust with someone with Alzheimer's. This technique can be used in subtle ways over time to foster communication with someone that tends to withdraw.

Features

Alzheimer's validation is comprised of four parts:

1. The behavior of people with dementia is specific to their age. They are trying to tie up the loose ends of their life's issues before they die.
2. Validation puts the behavior of people with Alzheimer's into four stages:
   
   
1. Malorientation involves minimal forgetfulness and confusion;
2. Time confusion involves losing the ability to distinguish chronological time;
3. Repetitive motion--when Alzheimer's patients can't use their words, they resort to repetitive motion to solve problems;
4. Vegetation, or blocking out the rest of the world and ceasing to try to resolve their life issues.
   
   
3. Validation should employ techniques related to the mental, physical, emotional and social aspects of Alzheimer's.
4. Five to 10 people should make up the validation group with the goal of providing stimulation and communication with the person suffering from Alzheimer's.

Benefits

Employing validation techniques has the following benefits for Alzheimer's patients:

• Fewer incidents of lashing out physically;
• Less of a need to be physically restrained;
• Less of a need to be calmed down with medication or tranquilizers;
• Improved communication;
• The speed of Alzheimer's disease progression is slowed;
• Increased self-esteem and value of self.

History

Naomi Feil, an expert on Alzheimer's disease, is credited with founding validation therapy. She was born in Germany in 1932 and raised in a Cleveland, Ohio, home for the elderly. Her mother worked in social services and her father was the director of the elderly home. She developed validation as an alternative to traditional methods of interaction with elderly people with dementia. The Validation Method is a globally acclaimed protocol for care published in her 1982 book, Validation: The Feil Method. Feil’s philosophy for dementia care is holistic and based in her understanding that unusual behaviors expressed by dementia sufferers are often due to a combination of cognitive, physical and social losses, and represent an attempt to express unresolved feelings and emotions.

Sources and Additional Reading:

http://www.ehow.com/about_4598311_alzheimers-validation.html

http://www.parentgiving.com/elder-care/alzheimers-caregiving-with-the-validation-method/

http://www.alzwell.com/validation.html

http://www.ec-online.net/community/Activists/difficultbehaviors.htm

http://www.alzheimersreadingroom.com/2007/07/alzheimers-validation-therapy-and.html

How to Manage hallucinations and suspicion in Alzheimer’s Patients?

Alzheimer’s and Hallucinations

People with Alzheimer's disease may see, hear, smell, taste, or feel things that are not really there. The most common hallucinations are those that involve sight or hearing. Some people with Alzheimer's disease develop strange ideas about what is actually happening and may come to believe that other people want to harm them. This kind of belief is called a delusion.

These symptoms are usually thought of as being caused by mental illness, but they are actually fairly common in Alzheimer's disease, especially in the middle stage, although they can occur at other stages. There may be many causes mostly having to do with the parts of the brain affected by the disease. In any case, it is important not to be frightened by what are irrational thoughts and experiences and to know how to respond to them. Maintaining sameness and calmness in the environment can help reduce hallucinations. Also, violent movies or television can contribute to paranoia, so avoid letting the patient watch disturbing programs.

A number of symptoms of Alzheimer’s disease are labeled as "psychotic," hallucinations being one of them. Around 18 percent of people with Alzheimer’s disease experience hallucinations, and they are more often reported in people with a later disease onset. For the majority these are visual, for others they are auditory, with some having both. Experiencing hallucinations normally lasts from one to two years and occurs in line with declining cognitive functions.

Some hallucinations are temporary, do not cause long-term difficulties, and are unrelated to mental illnesses. Sometimes, though, they can represent a major problem and specific treatment is needed. In addition to the dementia itself, there could be other causes for hallucinations including physical illness, fever and medications. In fact, many healthy people experience brief hallucinations at some time in their lives. But since they can 'test reality' or solve problems accurately, they are aware that these are not real, and as such, not worrying.  People with dementia may not be able to do this accurately.

Monitor and analyze any factors which may contribute in changes to the patient’s behaviors, such as:

• Sensory defects such as poor eyesight or poor hearing.
• Side effects of some medications.
• Psychiatric illness as part of multiple diagnoses.
• Recently changed and unfamiliar environment.
• Inadequate lighting, making visual clues less clear.
• Physical conditions such as infections, fever, pain, constipation, anaemia, respiratory disease, malnutrition, dehydration.
• New and unfamiliar caregivers.
• Disruption of familiar routines.
• Misinterpretation of environmental cues often a result of forgetting to use a hearing aid or glasses.
• Sensory overload because of too many things going on at once.

Possible Reasons for Hallucinations?

Lewy Bodies

Alzheimer’s disease brains show disc-shaped plaques outside brain cells called neurons, and neurofibrillary tangles inside them. However, there is debate about whether these are the cause of hallucinations. There is better linkage between hallucinations and "Lewy Bodies," round masses inside neurons. Debbie Tsuang, in the American Journal of Geriatric Psychiatry's April 2009 edition, found these in nearly 2/3 of patients with visual hallucinations. A review by Antony Harding in the February 2002 edition of Brain, detailed how Lewy Bodies were shown in brain areas affected by Alzheimer’s disease, such as the hippocampus and amygdala, which are involved in emotional interpretation. Lewy Bodies are more often seen in Parkinson’s disease and dementia with Lewy Bodies--where hallucinations are one symptom. Harding suggests people with Alzheimer’s disease with hallucinations may also have one of these disorders.

The Occipital Lobe

The occurrence of visual hallucinations is not related to defects in the eyes or retinal connections to the brain, although visual problems may exacerbate hallucinations. Shu-Han Lin discusses in the November-December 2006 edition of Clinical Imaging how instead hallucinations are associated with a decreased occipital lobe, which is involved in visual interpretation. This has led some, including Suzanne Holroyd in the Journal of Neuropsychiatry and Clinical Neurosciences Winter 2000 edition to propose that hallucinations are due to damage to brain regions involved in vision and those that interpret visual signals, including the occipital lobe, the amygdala and the hippocampus.

Genes

APOE4 is one form of the gene for the protein apolipoprotein E, normally involved in neuronal functioning. APOE4 is found in around 15 percent of people and causes functional problems with apolipoprotein E, leading to an eight-fold risk for developing Alzheimer’s disease. Study results are mixed regarding whether APOE4 is involved in the development of hallucinations. While the Tsuang study above didn’t find an association, another, by Kristina Zdanys in Neuropsychopharmacology's January 2006 edition, found APOE4 associated with an increased risk of “visual disturbances.”

Another gene possibly involved in hallucinations is for the protein brain-derived neurotrophic factor, or BDNF, which is involved in dynamic neuronal changes. There are decreased amounts of BDNF in Alzheimer’s disease, in line with disease severity. One form of the BDNF gene was reported by Kristina Zdanys in the Journal of Alzheimers Disease July 2009 edition to be significantly linked to increased occurrences of hallucination.

A third gene is for one of the neuronal receptors for the brain neurochemical serotonin, called 5HT2A. Stimulation of this receptor can cause hallucinations, and a study by Antonia Pritchard in Neurobiology of Aging's March 2008 edition found a small association between hallucinations and one form of the 5HT2A receptor.

How to Manage Hallucinations in Alzheimer’s Patients?

When hallucinations or illusions do occur:

• It is essential that you do not tell the person who is seeing or hearing things that you know what he sees is not real because the things are real to the person.
• Discuss the patient’s feelings relative to what they imagine they see. 
• Respond to the emotional content of what the person is saying, rather than to the factual/fictional content. 
• Reassure the person that you will keep him safe and try to understand the emotion behind the hallucination or delusion.
• Physical contact may be reassuring as well, but be sure that the person is willing to accept this.
• Hallucinations or false ideas may be harmless, and they are sometimes best ignored or accepted. If they don’t upset the person experiencing them, there may be no need for intervention. But be sure to report delusions and hallucinations to the person’s doctor to rule out physical or psychiatric illness.

This may be enough to enable the person to let go of these concerns, at least for the moment. If the hallucination is pleasant and the person is planning a birthday party, try to connect to her by joining in the fantasy. You do not need to say that you see or hear the same things but you can accept that the person does. Seek professional advice if you are concerned about this problem, and you feel it goes out of proportions. Medications can sometimes help to reduce hallucinations, and managing the prescriptions my easy the problem or even make it go away. 

Alzheimer’s and Suspicion

People with Alzheimer's disease may also become suspicious and may accuse someone of stealing from them when they cannot find something. When the person with dementia does not remember where he put something, the idea that it has been taken by someone may appear to be a reasonable explanation for its being missing. Tell him you will help him look for it, and try not to mention the fact that he is the one who misplaced it. He may feel relieved when the object is found.

Paranoia in people with Alzheimer's disease appears as unrealistic beliefs, usually of someone seeking to do them harm. They may hoard or hide things because they believe someone is trying to take their possessions. These symptoms can be very distressing both for the person with AD and for you. Remember, what the person is experiencing is very real to him. It is best not to argue or disagree.

• Try not to take unjust accusations personally. In this situation it is best to offer to help the person to find the missing item. It will not be helpful to try to convince him that his explanation is wrong or based on his poor memory.

• Offer a simple answer to any accusations, but don’t argue or try to convince them their suspicions are unfounded.
• Distract the patient with another activity. Distractions which may help include music, exercise, activities, conversations with friends and looking at old photos.
• If suspicions of theft are focused on a particular object that is frequently mislaid, such as a wallet for example, try keeping a duplicate item on hand to quickly allay the patient’s fears.
• Keeping a diary may help to establish whether these behaviors occur at particular times of the day or with particular people. Identifying such causes may help you to be able to make changes to overcome the difficulties.

When these behaviors do not respond to supportive caregiving techniques it may be necessary to consider medication, especially if the person is very upset or puts himself or others in danger because of his symptoms. These symptoms are sometimes caused by depression, which often accompanies Alzheimer's disease. Consult with your physician, who may recommend an antidepressant medication. Other medications, called anti-psychotics, are frequently prescribed. They should be used with caution and sensitivity.

Sources and Additional Information:

http://helpguide.org/elder/alzheimers_behavior_problems.htm#hallucinations

http://www.caring.com/articles/alzheimers-disease-paranoia

http://203.89.197.244/services/hallucinations--false-ideas.aspx

http://www.dementiamanagementstrategy.com/Pages/ABC_of_behaviour_management/Management_strategies/Hallucinations__delusions_and_paranoia.aspx

http://alzheimers.org.uk/site/scripts/documents_info.php?documentID=172

http://www.livestrong.com/article/161568-what-causes-hallucinations-in-alzheimers-patients/