Dementia: Common Sense GuidelinesPage 10 of 20

8. Be Selective with Reality Orientation

guideline 7

Do not use reality orientation except for early-stage dementia.

Reality leaves a lot to the imagination.

John Lennon
Beatles Singer-Songwriter

Reality orientation is a program designed to improve cognitive and psychomotor function in persons who are confused or disoriented. It is often employed in long-term facilities to help residents focus on their immediate surroundings. With this technique, caregivers actively and repetitively present information needed to orient patients to the time and day, as well as their environment and the people around them. This process is most helpful for the person in early stages of dementia. While sensory stimulation is helpful in the later stages, attempts to orient the person to date and place only serve to confuse and agitate them.

Have you ever awakened in a strange bedroom and momentarily forgot that you are in a hotel or another person’s house? Were you frightened by this? Imagine going through the day with the same kind of fear. This is similar to what happens when a person develops dementia.

For most of us, knowing this information is essential to get through the day. But reality orientation won’t help if the person has mid-stage dementia. Short-term memory loss and cognitive deficits make it impossible to remember or even understand much of this information. Trying to get the individual to focus on reality when significant confusion and cognitive loss are issues can serve to increase the confusion and cause agitation.

Try this common sense approach instead: When a person with dementia has a delusion or hallucination, “get into their reality” to allay fears, solve the problem, or figure out the cause of it.

Delusions (false beliefs) that do not distress the person with dementia can probably be left alone. They will pass as the dementia progresses. Delusions that do cause distress should be treated. This is usually done by medication.

Hallucinations are caused by the misinterpretation of sensory input. Taking time to experience what the person hears, sees, and feels (putting yourself in their place) may well lead to discovery of the reason the hallucination is happening.

A good example is something that occurs frequently in the later stages of dementia. Because of memory loss, people in the mid- to-late stages of dementia will not recognize themselves in the mirror. This occurs because they have aged and memory loss has progressed to the point that, in their minds, they are much younger than their reflection appears to be. This is also why at some point they cease to recognize spouses, children, and friends as they are today.

Put yourself in the place of someone in late-stage dementia. Your ability to understand your reflection is gone. You go into the bathroom and see another person looking at you. How would you feel?

If you do the exercise above it will help you to understand why reality orientation does not work in the later stages of dementia.

What can be done to help this person?

Two things can happen when a dementia patient does not recognize herself in the mirror. She can either perceive her reflection as friendly (and may even talk to it) or see it as someone to fear. If the reflection does not cause distress, simply monitor the situation, but if the reflection is frightening to the person or causes anxiety of any kind, it’s better to remove or cover the mirror.

Since sounds, reflections, smells and other sensory input can be misinterpreted and bring on delusions and/or hallucinations, most memory care units today use full-spectrum lighting. This helps to avoid shadows easily misinterpreted as other people or animals. Rugs and satin gloss flooring are chosen to reduce glare for the same reason. Overhead paging is also eliminated or reduced to avoid misinterpretation of the voices and announcements, which can be a trigger for delusions.

When hallucinations or delusions do occur, and reality orientation does not work, it’s common sense to use therapeutic “little white lies” to help the person with dementia.


Rose was upset at noises she heard during the night. She was convinced that animals were living in the ceiling of her room and would hurt her. Because she was so frightened by this, Rose started sleeping in a recliner by the nurses’ station.

When I heard about this, I asked a staff member “put herself in Rose’s place and listen for the noise” by staying in her room for a while. Surprisingly, around midnight the staff member heard scratching noises from above.

An investigation of the noise discovered a tree branch was scraping the roof of the one-story facility when it was windy. It was removed the next morning, but Rose was still frightened and would not go into her room. No amount of explanation or “reasoning” with her would help. In her mind, she was in danger from the animal in her room.

Once again we thought about what we needed to do for Rose. We even considered changing her room, but eventually the staff decided to “get rid of the animal.” They brought in a ladder and a paper bag. Removing a ceiling tile, one of the housekeeping staff climbed up and made some banging noises. Inflating the bag, and twisting the top, he came down the ladder with the “animal” in tow. Rose, who had been watching from the door, was relieved, and since the noise from the branch was gone, the “animal” never came back.

These examples show why reality orientation won’t work with mid- to late-stage dementia patients who lack the ability to understand what they cannot see or hear for themselves, and who can easily misinterpret the sensory information they do perceive.