This blog is a continuation of our series on Behaviors as Communication. To read other entries in the series, please click through to one of the following links below:
- Behaviors as Communication (Introduction)
- Behaviors as Communication: Agitation
- Behaviors as Communication: Collecting
- Behaviors as Communication: Wandering
- Behaviors as Communication: Sundowning Challenges
Some of the best movies leave the ending unresolved. As the credits roll, the director leaves several threads loose on the loom for the audience to connect, interpret, and provide with meaning. Maybe this is because the best directors truly understand the human condition and realize that our unique experiences, upbringings, and cultures provide a very different lens with which we each view the world.
During a trip to the movies – that feels as though it was years ago – I vividly remember a cliffhanger ending that left me dazed and confused. As the lights rolled up and we shuffled out into the lobby, I heard the many theories and spinning webs as each moviegoer shared their unique take on the unresolved ending. The more they talked, the more they convinced themselves of this personal truth, no matter how outlandish it seemed. Whether truly canon to the film or series, it did not matter, this was now their version of the movie's true ending. At this point that I realized a strange connection to two behaviors in memory loss, confabulation, and hallucinations.
What is it?
Confabulation or “honest lying” is a neuropsychiatric disorder wherein a patient generates a false memory without the intention of deceit. Those who experience and display Confabulation are simply “filling in the gaps” by using the contextual information around them, along with their current understanding of the world. For those with Alzheimer’s disease and related dementia, Confabulation is their way of making sense of things.
At first, Confabulation is more like an educated guess and the theories proposed are more realistic. As the disease progresses, however, Confabulation becomes more pronounced, with many even experiencing Hallucinations in conjunction, due to changes in the brain, and medication side-effects. When Hallucinations are introduced to the mix, Confabulations begin to fall far outside of reality.
With both Confabulation and Hallucinations, it is vital to stay aware of changes in your loved ones' cognitive abilities in order to understand how to best help and support them throughout the disease process. This first begins by understanding the causes behind Confabulation and Hallucinations.
Identifying Confabulation and Hallucinations
Confabulation is a symptom of an underlying disorder that causes changes in the brain. Disorders that cause Confabulation are numerous and wide-ranging, however physicians do know that most people who display Confabulation typically have damage in their brain’s frontal lobes and corpus callosum. Confabulations can be triggered by a question, event, or action, but are spontaneous in some cases.
Hallucinations are symptoms that are typically caused by mental illness, medication side-effects, or physical illnesses. These are sensory experiences that appear real but are created by the mind. Hallucinations are usually associated with visual disturbances but can affect all of the senses individually, or in conjunction. Add to this, the orientation challenges and attempts to discern reality in memory loss, and you have quite a difficult set of symptoms
For those with loved ones affected by Confabulation and Hallucinations, it is always best to seek medical expertise for your loved one or to ask your family physician to address these concerns. In many cases, it is possible to find a solution that will help alleviate these challenges.
In terms of encouraging and empowering your loved one who struggles with these symptoms, we have provided a few helpful suggestions below. These approaches can help those with memory loss by addressing Confabulations and Hallucinations with positive approaches and meaningful interactions.
With all of these approaches, safety is the number one priority. Interact cautiously and respectfully while keeping the individual, those around them, and yourself safe at all times.
Reality Orientation and Validation
Depending on the stage of the disease process, and the severity of the individual’s memory loss, reality orientation or validation may provide the best approach and resolution. First, ask yourself, is the individual in a state of mind that would be easily re-oriented? Would reality orientation help or harm in this unique situation?
In terms of Confabulation, would the individual respond positively to hearing that their personal truth is untrue? Or would they respond with anger and frustration – insistent that their memory serves true?
With Hallucinations, is the resident pleasantly talking with a loved one who has since passed? Or are they frightened by something they see, which is not really there?
It is important to evaluate each situation separately and consider the best approach and resolution. In some cases, it is not important or prudent to respond, and a resolution may not be required. Typically, reality orientation is useful when encouraging someone who is feeling down, and only when they are lucid enough to interpret the information presented. Whereas validation is more important when an individual is experiencing positive stories of confabulations, or hallucinations that are promoting positive feelings and interactions.
Re-Direct and Engage
If neither approach yields positive results, you might consider redirection as a possibility. Or instead of an individual solution, consider dovetailing multiple approaches to the situation. Starting with Reality Orientation or Validation Therapy may work, but then it may be helpful to redirect and engage the individual with a meaningful activity or purposeful project. This is especially true for those who struggle with short-term memory and may fall back into the same or similar behaviors even after attempts at reality orientation or validation.
What did the individual enjoy doing as part of their daily life? What schedules, routines, habits, and activities did they enjoy? How can you create a life filled with purpose during your visits, or even during daily caregiving tasks?
Start with research about the individual and their preferences, likes/dislikes, and favorite pastimes. This knowledge can equip you with conversation starters, purposeful activities, and the ability to pivot a negative response or emotion into a positive experience and opportunity for connection.
From here, it is helpful to start creating routines for each day. These can be built slowly at first by blocking out chunks of time for activities, times of rest, and even caregiving tasks. If one activity is more successful, continue with this approach. When something isn’t working, consider changing the schedule or activity slightly rather than removing it altogether. It can take a bit of time to fall into a comfortable rhythm, especially when moving to a scheduled approach to each day.
Keep a Diary
Speaking of schedules, it is also vitally important to track when, why, and how these behaviors occur. Does Confabulation occur more in the evening as Sundowning symptoms begin? Are Hallucinations typically in the early morning hours, when rooms have low-lighting and shadows?
By keeping a diary and diligent notes of an individual’s behaviors, you can start to more easily identify patterns and triggers for each response. If Confabulation mainly occurs during trips outside the home, you might consider that being in a strange environment is jarring for the individual, and confabulation is their way of coping with and providing answers to the unknown. If Hallucinations occur more in the evening, and in a specific part of the home that is particularly dark, you might consider increasing the lighting or even installing motion lights in that portion of the house to help reduce these symptoms.
We hope that this information has been helpful for you and your loved ones. However, even with all of these helpful tips, sometimes it can be overwhelming for the family caregivers and loved ones who are giving of their time, patience, and compassion each day.
If you, or someone you know, need a break or additional resources, please contact your local JEA Senior Living community for information on our Respite Stay programs or on how to approach Behaviors as Communication.
If you are curious about whether now is the right time for a Memory Care community, please check out our blog for more information on the timing around this transition – The Right Time for Memory Care.