By Jane Verity © dementiacareinternational
‘The end results of all ritual are increased balance, strength, energy and comfort.’
Angeles Arrien Cultural Anthropologist
Routines vs. Rituals
In our everyday care of people with dementia, we often talk about the daily routines we have to carry out. We do not usually connect these with joy. More likely, we see these routines as chores; experiences we need to get over and done with as quickly as possible. The actual experience is not the focus.
Routines are regular, unvarying or mechanical procedures. No wonder we cringe when we hear the word routine and then tend to approach a routine job with little enthusiasm or excitement.
Rituals, on the other hand, are enriching ceremonies which:
- lift the spirit and build trust
- create familiarity and the joy of recognition
- reduce insecurity and anxiety.
Creating ceremony means to transform the environment from the ordinary to the extraordinary with music, clothes, make-up, accessories, scents, lighting and other means.
It is also about the way we conduct ourselves. There is a certain celebratory experience of ease and success. Creating ritual is about the special way in which we perform an activity and the fact that we do it in the same way every time. Rituals build companionship.
People who have dementia often experience separation, misunderstanding and alienation. One way of healing such suffering is through personalised and meaningful rituals.
The rituals our ancestors used thousands of years ago focused on our relationships with the land, the seasons, the hunt with the tribe, and the relationships between tribes.
The rituals we speak of here are different from these ancient rituals; however, they carry the same essence.
Personalised, Meaningful Rituals
Developing and fine-tuning personalised, meaningful rituals is not about creating rituals where ‘one size fits all’. Instead, there is a need for openness to the unique differences, preferences and possibilities that emerge through close contact with the individual. It is a process that evolves over time, starting with one or two small rituals and building on these, one by one.
Rituals are the little things we need to say and do, in the same way, every time, every day. What sets rituals apart from chores is our tone of voice and the way we add opportunities to boost self-esteem and make the person feel extra special. For example: When you add smell to a ritual – Give Eric the aftershave to hold and smell for himself, saying, ‘Doesn’t that smell fantastic?’ Then after you dab scent on him, with enthusiasm, repeat, ‘Now you smell fantastic too.’ Once you receive positive feedback from Eric – confirming this ritual really works for him – you can then add it to the enriching rituals you use together every day.
By adding special phrases, words and unique touches – repeated every day – rituals turn the mundane into personalised, meaningful experiences. The bond and positive effects on all in your care will make these extra efforts so worthwhile and may actually even save you time.
The following morning rituals were created for people who have moderate to severe dementia and who are incontinent. They are meant as guides that you can pick from and adjust to the unique needs of your loved one, or your special residents, clients or patients.
Morning Rituals
The best way to begin a successful morning ritual is to greet the person with a beaming smile. Say that you’ll open the curtains so the person can see the new day.
The person may or may not like you going into their cupboard or drawers, so we suggest that you assist the person straight onto the toilet. Once seated, you can help to remove any pads or disposable pants, while constantly reassuring that you are going to get some FRESH ones. We’ve found it works best to use the word FRESH rather than clean or dry. Wet or soiled pants are likely to cause stress. If you add: ‘Nothing is a problem for us,’ the person will often think if it is not a problem for you then it ceases to be a problem for them too.
You can now suggest ‘a little sit‘ and ‘squeeeeeeeze‘. You may make a bit of loving fun by showing a squeeze using your whole face and body. The person is most likely to laugh and copy you. If it is safe to leave the person unattended, you can use this chance to pick out clothes for the day.
When it comes to ‘toilet activity’ our experience is that using expressive language such as a ‘squeeeeeeeze’ and calling a spade a spade, such as talking about making a ‘wee’ instead of urinating, works far better with the person in the middle to late stage of dementia. Some people may find using this language challenging or even demeaning, however, this approach has been proven to work, over and over, and the person responds in a positive way and is not offended. Isn’t what works what really matters?
Next, bring out two choices of clothing and use these exact words: “Today, is it your blue shirt/blouse or your green shirt/blouse?” Ask the question while you hold the two choices out in front, one in each hand. Then move the hand with the garment in question as you ask about that particular piece of clothing. This offer of choice helps the person to stay in control and have their self-esteem boosted. Once a choice is made, you can then repeat this little ritual with skirts or trousers or whatever the appropriate garments.
Before supporting the person in getting dressed, suggest that you will wash their bottom with a warm face washer to freshen them up. Afterwards, if cream is necessary, give the person the jar to hold and enjoy smelling the lovely lavender scent etc. You could then say, ‘You have the softest, freshest bottom in the southern/northern hemisphere.’ This will quite likely bring a laugh.
Help the person to sit down again on the toilet and assist in putting on disposable pants, trousers or skirt, socks and shoes, and then hand them bra or singlet and shirt etc, one at a time, in the right order. Most often the person will prefer to do as much independently as possible. This gives you a chance to make the bed; once again, only if it is safe to leave the person unattended.
Sometimes people with dementia do not like you to strip the bed or remove their washing, so it is easier to do so during mealtimes or when they are busy getting dressed. Rather than saying the bed is wet or clothes are dirty, as this can cause offence and embarrassment, try using the explanation that, ‘Today is ‘big wash day.’
Evening Rituals
Going to Bed
Start by setting the scene. Turn off the main lights in the bedroom area from 7 p.m. and only have the minimum of lighting switched on.
People with dementia do not always have a sense of day and night and are often surprised when it is time to go to bed. This means that sometimes they are not ready or do not think the time is right.
When you begin a night-time ritual, avoid saying, ‘It is time to go to bed.’ Instead, bring out two choices of nightwear, holding one in each hand, and then say, ‘Aren’t these pretty?’ or ‘Aren’t these groovy?‘and wait for the response… ‘Yes they are very pretty/groovy.’ Then, while slowly moving the hand holding the matching colour nightwear up and down, say, ‘Tonight, is it going to be the striped or the blue nightie/pyjamas?’ In this way, you divert the focus from going to bed to simply making a choice about an object; in this case the nightwear.
Next, while you both walk to the bathroom; say, ‘Let’s go and put on this pretty nightie or groovy pyjamas.’ If you show the person the toilet and say, ‘Let’s start here with a wee,’ the person is most likely to follow you. It is always a good idea to stay close by to prevent a fall if the person is not steady on their feet.
Once the person is seated on the toilet, it is easier to help him or her remove shoes, pants and pads, while you reassure that you are going to get some FRESH ones. Again, using the word FRESH rather than clean or dry is usually far more successful. Remember that the saying, ‘Nothing is a problem for us,‘ can work equally as well in the evening ritual too.
You can also repeat the ‘sit’ and ‘squeeeeeeeze’ ritual from the morning at this time.
Hint: If the person forgets why he or she is taking off their clothes, simply show the nightwear and this can often be enough of an ‘explanation’ to keep things moving.
A special and loving part of a night-time ritual for people with dry skin can evolve by you taking the time to apply cream to feet, hands, or wherever necessary, in soothing, slow, gentle strokes. You may even sing or hum a familiar and favourite evening hymn or song.
Now it’s time for teeth and/or dentures. With encouragement, the person can usually take out their own dentures. If the person is struggling, offer encouragement by saying, ‘You can do it – just think it is easy.’ Mimic the necessary action with a finger movement in front of your own mouth so the person only has to mirror it.
You may need to brush the dentures or assist the person to brush their teeth and rinse their mouth. One little ritual that worked exceptionally well with my own mother for leaving out/storing her dentures overnight was to put her dentures into their ‘waterbed’ (a covered jar of water).
Now to bedtime. Music or a story playing can serve as a ‘carrot’ to help excite and entice a reluctant sleeper into bed. Tapes or CDs that stop automatically soothe into sleep and can prove highly successful in easing restless night-time behaviour.
Of course, the above are only guidelines and suggestions to explore in developing rituals best suited to the person for whom you care or to your individual residents. Meanwhile, we have included detailed tips here to help avoid some of the frustrations and challenges that can keep our mindset in the drudgery of routine. These tips turn our focus to positive strategies designed to set up for successful, meaningful and enriching rituals.
Tips, Triggers & Overcoming Challenges
People with dementia often develop a heightened sensitivity to touch and temperature, especially in personal care situations. A highly successful strategy from Holland – for use during dressing and undressing – is to wear cotton gloves to prevent negative reactions to cold fingers and hands. The gloves can also be kept on and used as a face washer when you are showering the person.
Standing in front of the person with dementia while they use the toilet can sometimes seem threatening and frustrating. If you can stand off to the side or even in the shower area, you may avoid causing distress and subsequent challenging behaviour.
Adding an extra pad inside disposable pants is helpful when the person might go to the toilet alone during the day and remove the loose pad without replacing it with a fresh one. Though this may not matter if the person is wearing disposable pants, it can reduce the number of times where it is necessary for you to lend a hand if this proves an area of challenge.
If the person is reluctant to allow you to remove their clothes for washing, I suggest hanging even dirty clothes neatly on a coat hanger, saying: “Let’s hang these here to air during the night.” At a later stage, they can easily be taken out ‘on the quiet’ for washing.
The person who has dementia can be frustrated less if we avoid commenting on every move or action and instead encourage by saying occasionally: “Terrific” or “Thank You”. One sentence to avoid is: “Good Girl/Boy.” We can see the frustration building immediately when the person hears these words. We need to remember: This is not a school room; nor are we the person’s mother. we are simply there to set up for success through encouragement and support.
Keep in mind that what works one day doesn’t necessarily work the next, and what works for one person may not work for another. That is just a part of caring for someone with dementia.
People who have dementia strongly disapprove of being rushed and like to do things in their own time. It pays to invest time to gain time and it is often quicker to stand back and wait rather than hurry them along. Allowing ample time and ensuring body language and tone of voice are kept calm and relaxed is helpful too.
One thing that can understandably frustrate people with dementia is when others talk about them in their presence saying ‘she’ or ‘he’. It is both respectful and a good idea to avoid this. Instead, speak directly to the person so they are included.
People with dementia can easily become overloaded with too much information. This can be avoided by explaining things one at a time rather than clumping three things all in a row.
If something doesn’t work one minute, leave it and then present it again as if for the first time. On the next occasion it may work.
There is a fine balance between supporting peoples’ independence and helping them out, but if this is done in a gentle, caring and subtle way, they usually respond much better than when they feel they are being told what to do or being bossed around. Avoid any phrases offering ‘Help’ such as: “I am here to ‘help’ you.” This only serves to create anger and frustration. Instead, where possible, stand back and ask: “What if I give you a hand?” Offer an arm to support, so it’s there if wanted. Sometimes, the action of offering is less resented and easier to accept than when the same is offered in words.
Expect the unexpected; don’t take it personally. Bad tempers and outbursts last only for a short time. The most embarrassing and challenging moments will no doubt give the most laughs when looked back on ‘fondly’. Be creative, and try, try, try again.
Be ready to laugh together at the silliest things. Think ritual, not routine, and then joyful moments and easier, more meaningful experiences will ensue for both you and all those in your care.
Further reading – Click topic
- How to Communicate with Someone who Can’t Speak – Jane Verity (Learn 4 body language techniques to show people with dementia that you are really listening; learn the importance & the difference between intuition & logical, rational thinking & which is most effective in communicating with people who have dementia; learn strategies & effective questions to uncover unmet needs &to draw out the person’s feelings & needs; learn question techniques to check on your guesses & 6 steps to being a good communicator.)
- Hugs not Drugs – Jane Verity (Discover 3 factors behind attention-seeking behaviour, the 5 secrets to ‘great’ hugs & 5 hints to check if a hug is creating discomfort in another person plus a wonderful non-threatening excuse for exchanging a big hug.)
- Turning Hassles into Highs – Jane Verity (Discover simple techniques to create sunshine in everyday tasks & situations.)
- Successful Solutions to Showering – Jane Verity (Learn 10 reasons why people with dementia might refuse to shower & their 10 successful solutions, plus more helpful hints & choices.)
- Creative Thinking Solves Toilet Challenge – Community Story (A professional carer’s tip to solving the challenge of a resident going to the toilet everywhere, but in the toilet, plus a fantastic question to ask when seeking constructive solutions to challenging behaviours.)
- Ribbons Turn Around Challenging Shower Experience –Community Story – (Read how one professional care discovered successful showering through the magic of colour.)