When a Parent Has Dementia, Arguments Can Be Counterproductive

"Thank you for helping an old man’s fantasies,” Dad said, in one of his increasingly rare moments of clarity. He looked at me through clear, intelligent eyes to thank me for producing the degrees and awards he’d asked for; for taking dictation and "mailing" letters to local and national leaders; and for supplying him with business cards and a title. The moment was brief. His pupils soon returned to mere pinpoints, his gaze unfocused. Dad, once again, was swallowed up by his dementia.
 
My father didn’t have Alzheimer’s disease. He’d suffered a closed head injury during World War II but had recovered enough to lead a fairly normal life. However, the body never forgets traumatic assault. The shadow of his injury began to overtake him in his 70s. He underwent surgery meant to prevent impending dementia, but it backfired and, overnight, Dad as we knew him disappeared.

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At that time, almost 20 years ago, many psychiatrists believed that people with dementia should, when delusional or confused, be redirected to what most of us understand as reality. I knew nothing about this theory. But I did know my dad, and he didn’t respond well to this type of redirection. He felt diminished and humiliated. He became defensive, angry and argumentative, which was the reverse of his normal personality.

The Importance of Validation

I could have argued with Dad when he told me he needed to have his medical degree hung on the wall of his room in his nursing home. In reality, World War II had interrupted his studies at the University of Minnesota. After the war, he did what many other GIs with a family to support did: He found a job related to what he was trained to do in the military. He entered public health and was highly successful in his field. But he did not become a doctor. After the surgery, his mind pushed reality away and insisted that he was an M.D. Explaining reality to him brought spontaneous hostility, compromised his dignity, and made him feel that we, his family, were the enemy.
 
As his primary caregiver, I followed my gut instinct. I used my computer to make him a medical degree. He was ecstatic. More awards and degrees followed as his delusional mind summoned other projects for me to complete. He needed a purpose in life, and for a man of his generation, that meant a career. And this career required a secretary, which turned out to be me. Our projects gave Dad a sense of accomplishment and peace.
 
Later, I found out I had been practicing what is now called validation. Psychiatrists came to realize that people with Alzheimer’s and other forms of dementia are often simply incapable of understanding reality as we see it. It’s far more effective, when possible, to agree with them. It hurts no one to nod along when an Alzheimer's patient says he or she was a film star. It hurts no one to let them live in a reality that may be more reflective of their dreams than the life they actually lived.
 
"It is seldom harmful to enter into a patient's fantasy world as long as one does it with a caring heart," says geriatrician Dennis McCullough, author of My Mother, Your Mother: Embracing "Slow Medicine," the Compassionate Approach to Caring for Your Aging Loved Ones (Harper Collins, 2008). "Going along with, and even embellishing, these short periods of a different reality can provide comfort and reduce confusion."
 
Exceptions to Every Rule
 
Since he couldn’t tell the difference between television and reality, my father was not supposed to be allowed to watch TV news, but the nursing home staff occasionally slipped up. One morning when I visited Dad, he was terrified. It was during Desert Storm, and he had seen coverage of the war. Certain that we were in the middle of an attack, he begged me to get him to safety.

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This was not the time for validation. I explained that the war was thousands of miles away, but he couldn’t or wouldn’t believe me. Sometimes we can’t do anything to soothe our loved one’s pain but be with them. I just had to let time move him forward. By the next morning, Dad’s fear was gone.

The Rewards of Contentment

Generally, though, agreeing with Dad worked. Not arguing about whether he’d been a doctor, or a big band director, or a member of our local zoo board, was only logical. Dad could, at least temporarily, have a feeling of accomplishment. And I could feel good that he was reasonably content. That was the payoff for me. Given a choice between torturing Dad with reality and letting him be content, it was no contest.

And then there were those rare moments of clarity. I hold those brief breakthroughs close to my heart as I remember that kind, intelligent man reaching out to his daughter from the depths of his dementia to say thank you. Those moments were gifts precious beyond words.

 
Author and speaker Carol Bradley Bursack has cared for six relatives and a neighbor, experiences that inspired her to create a "portable support group" — her book, Minding Our Elders, as well as a website and blog offering resources for other caregivers. She has a weekly syndicated column, speaks at workshops and conferences, and writes on senior issues for several websites.