Reality Orientation
REALITY ORIENTATION
Reality Orientation (RO) is a general philosophy of inpatient treatment for reducing confusion in geriatric patients. According to its philosophy, confusion results from (a) understimulation of the patient, (b) care providers’ lack of insistence or expectation that the patient perform normal behaviors, and (c) care providers’ nonreinforcement of desired behaviors when they are performed (Taulbee and Folsom; Folsom, 1968). It follows, therefore, that confusion can be reduced through mental stimulation, social interaction, and adjustment of behavioral contingencies.
Treatment approach
The primary goal of RO is to reduce confusion. In its initial conceptualization RO was believed to accomplish this goal through three components. The first component was staff maintenance of a specific attitude toward the patient, usually one of ‘‘active’’ or ‘‘passive’’ friendliness (Folsom, 1968). This component has been referred to as attitude therapy. The second component involved staff’s (a) presentation of basic orienting information during interactions with confused patients (e.g., reminding patients of who and where they are) and (b) involvement of patients in their environment, by commenting on what was happening in the environment at that time and by reinforcing individuals’ awareness of and interest in their environment. The third component entailed the use of basic and advanced classes in orientation as an adjunct to the second component. The use of props or environmental cues was encouraged, including signs, clocks, calendars, reality orientation boards (information about location, date, day, weather, holidays, etc.), newspapers, television, pictures, and personal belongings. Classes were small groups with an optimal size of three to six individuals meeting with one or two staff members (Woods, 1992). The second and third components make up, respectively, what is now known as twenty-four-hour reality orientation and classroom reality orientation.
Since RO’s conception, therapeutic goals have been elaborated, techniques have been more clearly defined (e.g., Drummond et al.) and manuals have been developed (e.g., Holden and Woods). Certain aspects of the philosophy have proliferated—for example, calendars and other orienting materials can be found in almost all long-term care facilities. The evolution of RO programs also has resulted, often, in the use of classroom RO without twenty-four-hour RO, despite the assertion by Folsom and colleagues that classroom RO will not be effective on its own. This modification deemphasizes the focus on social interaction with others in the environment that, increasingly, appears to be the most beneficial aspect of RO.
Use with individuals with dementia
RO was developed for reducing confusion in institutionalized individuals. The source of confusion could be any of various conditions (e.g., stroke, dementia, psychiatric disorder). However, little consideration has been given to whether there should be differences in RO according to the reason for confusion. In practice, RO is used most commonly with patients with dementia, but few attempts have been made to explain the way in which dementia might affect the individual’s ability to benefit from RO.
Some have suggested that RO permits the demented individual to build competency (e.g., relearning information), thereby reducing feelings of helplessness engendered by repeatedly failing to accomplish simple tasks because of progressive impairment. However, feelings of competence are contingent on the use of activities that are appropriate to the ability level and needs of the demented individual (Woods, 1979). Targets also must be carefully considered; for example, rote learning of the day, date, and time does no good the following day. These issues have led some professionals to recommend that care providers implement only techniques that will impact quality of life (Woods, 1992). For example, it has been argued that it may be better to teach a general mnemonic strategy such as use of a diary (e.g., Hanley and Lusty), or to implement ward orientation procedures (e.g., Williams et al.) rather than to directly teach orienting information that either is not very important or could be obtained from external sources (Woods, 1992).
In addition, when working with individuals with dementia, staff need to be aware of the effects of their body language, tone of voice, and facial expressions on patients. They also should be sensitive to the patients’ nonverbal communication because as verbal expression becomes more difficult, nonverbal gestures give cues about what individuals are trying to communicate (Woods, 1992).
Empirical evidence
It is beyond the scope of this entry to examine individual studies of RO. However, a number of reviews (see Kasl-Godley and Gatz; Spector et al.) cover empirical investigations of RO with both demented and nondemented older adults. Investigations tend to focus almost exclusively on the evaluation of classroom RO. In general, these investigations find that RO has circumscribed cognitive effects, largely on orientation, and little to no effect on behavioral functioning. When improvement is observed, it is usually in mildly impaired individuals. Continuation of gains after the discontinuation of treatment is uncommon. Conclusions, however, must be considered in light of a number of design issues. These issues include use of small sample sizes, use of mixed diagnostic groups, nonrandom assignment or lack of a comparison group, lack of standardized assessment, use of training material in the evaluation of the technique, and variability in the administration of intervention techniques. Interventions vary in duration of treatment, frequency and length of individual sessions, and use of additional potentially therapeutic components, such as increasing the number of activities available to residents. Nonspecific treatment effects (e.g., increased communication with staff, involvement in social activity, attention to appropriate behavior) apparently do help to explain treatment outcomes (see Woods, 1979; Gerber et al.). These results suggest that improvement in orientation may be facilitated through social activity and raise questions as to whether social activity (ongoing interactions with care providers that focus on maintaining communication and contact) is the more useful component of reality orientation.
Julia Kasl-Godley
See also Alzheimer’s Disease; Dementia.
BIBLIOGRAPHY
Drummond, L.; Kirchhoff, L.; and Scarbrough, D. R. ‘‘A Practical Guide to Reality Orientation: A Treatment Approach for Confusion and Disorientation.’’ The Gerontologist 18 (1978): 568–573.
Folsom, J. C. ‘‘Intensive Hospital Therapy of Geriatric Patients.’’ Current and Psychiatric Therapies 7 (1967): 209–215.
Folsom, J. C. ‘‘Reality Orientation for the Elderly Mental Patient.’’ Journal of Geriatric Psychiatry 1 (1968): 291–307.
Gerber, G. J.; Prince, P. N.; Snider, H. G.; Atchison, K.; Dubois, L.; and Kilgour, J. A. ‘‘Group Activity with Cognitive Improvement among Patients with Alzheimer’s Disease.’’ Hospital and Community Psychiatry 42 (1991): 843–845.
Hanley, I. G. ‘‘The Use of Signposts and Active Training to Modify Ward Disorientation in Elderly Patients.’’ Journal of Behavior Therapy and Experimental Psychiatry 12 (1981): 241–247.
Hanley, I. G. Manual of the Modifications of Confused Behavior. Edinburgh: Lothian Regional Council, Department of Social Work, 1982.
Hanley, I. G., and Lusty, K. ‘‘Memory Aids in Reality Orientation: A Single-Case Study.’’ Behavior Research and Therapy 22 (1984): 709–712.
Holden, U. P., and Woods, R. T. Reality Orientation: Psychological Approaches to the Confused Elderly, 2d ed. Edinburgh: Churchill Livingstone, 1988.
Kasl-Godley, J., and Gatz, M. ‘‘Psychosocial Interventions for Individuals with Dementia: An Integration of Theory, Therapy, and a Clinical Understanding of Dementia.’’ Clinical Psychology Review 20, no. 6 (2000): 755–782.
Powell-Proctor, L. and Miller, E. ‘‘Reality Orientation: A Critical Appraisal.’’ British Journal of Psychiatry 140 (1982): 457–463.
Spector, A.; Davies, S.; Woods, B.; and Orrell, M. ‘‘Reality Orientation for Dementia: A Systematic Review of the Evidence of Effectiveness from Randomized Controlled Trials.’’ The Gerontologist 40 (2000): 206–212.
Taulbee, L. R., and Folsom, J. C. ‘‘Reality Orientation for Geriatric Patients.’’ Hospital and Community Psychiatry 17, no. 5 (1966): 133–135.
Williams, E. M. ‘‘Reality Orientation Groups.’’ In Working with Older Adults: Group Process and Techniques. Edited by I. Burnside and M. G. Schmidt. Boston: Jones and Bartlett Publishers, 1994. Pages 139–152.
Williams, R.; Reeve, W.; Ivison, D.; and Kavanagh, D. ‘‘Use of Environmental Manipulation and Modified Informal Reality Orientation with Institutionalized, Confused Elderly Subjects: A Replication.’’ Age and Aging 16 (1987): 315–318.
Woods, B. ‘‘Reality Orientation and Staff Attention: A Controlled Study.’’ British Journal of Psychiatry 134 (1979): 502–507.
Woods, B. ‘‘What Can Be Learned from Studies on Reality Orientation?’’ In Care-Giving in Dementia: Research and Applications. Edited by G. M. M. Jones and B. M. L. Miesen. New York: Tavistock/Routledge, 1992. Pages 121–136.