We go about our day-to-day routine, ever mindful that some tasks are mundane, and are much more attuned to tasks that are most meaningful to us. These tuned-in experiences make an impression on us. So it is with dementia patients, too. Or even more so.
The dementia patient may reel with anxiety when change happens, or routines are adjusted to suit caregivers. It has been theorized that one of the reasons Alzheimer’s patients wander, pace, or perform repetitive tasks is due to anxiety. Perhaps they are trying to perfect the task, remember the steps, or repeat the sequence until it becomes rote memory. We, in the non-dementia world, find such going-through-the-motions to be monotonous, a drag or pull from the other things we want to do. Not so with the dementia client. If my routine in dementia is the same, I find comfort in that. The steps are in order, I have structure, and the outcome will then be the same. Could it be that when we change the order in which things occur or caregivers for example, we rob them of their comfort in sameness? If my environment is structured and predictable, then my thoughts might be, too. At least I will be able to be in my environment with some degree of sameness or consistency. My thoughts might not be that way, I might not be able to ascertain why something happens a certain way or keep my train of thought, but my body can move along with what it knows comes next. Caregivers might try things in a different order, in a different way, “just to see if it works”. Perhaps a new approach will result in an easier way to accomplish a task. It might be easier for us to help the dementia client brush his/her teeth or get dressed in a new manner, but it might also prove to be a hardship for them to change.
We had a substitute caregiver for my father, someone who was not familiar with him at all. Mom met her for the first time when she arrived and expected to guide her through the steps and procedures for the tasks she needed help with. The caregiver decided to reverse some of the order of getting dad dressed for bed. What a disaster! Mom was irritated. “That’s not going to work,” she told her. The caregiver persisted. Dad was irate. How dare this unknown person show up and try to take his clothes off? And in a different sequence and manner than he was accustomed to? How dare she? And why was mom upset? Dad could always tell when mom was upset. It didn’t matter why; he could just tell after being married to her for 65 years. She looked upset, too. The social cues were all dad needed to get riled up. He even tried to bite the caregiver.
And so the story goes. Often, agitation occurs in concert with change of any kind. The time of day, setting in which a task is attempted, spatial changes, and sequencing disruptions can all wreak havoc with a dementia client’s reliance on routine for the external structure they do not feel internally.
In university, it was discussed that people’s personality characteristics are usually constant throughout the lifespan and can be defined by polarized traits. According to the Myers-Briggs Type Indicator, one is either an introvert or extrovert, sensate or intuitive in how we process information, make decisions primarily through thinking or feeling, and interpret the environment by judging or perceiving (MBTI basics. (2019, September 13). Retrieved from http://www.myersbriggs.org/my-mbti-basics/home.htm).
Of particular interest with dementia clients is the introvert/extrovert characteristic. If a client is an introvert, it is this author’s theory that dementia will be more pervasive to the client’s emotional functioning. They will have a more difficult time with the struggles of dementia and its accompanying depression. This is because a person with internal locus of control looks to their own internal resources to interact with the environment, contemplate decisions, and determine rationale for others’ behavior. The introvert will be more aware of variations in their own thought processes, more cognizant of differences in how other people interact with them and more focused on why and how dementia has changed them. The introvert perceives it is not in their repertoire, capacity, or capability to control what is happening. Dementia is viewed as something that has gone wrong or haywire in me if I have internal locus of control. It is my body this is happening to. It is part of me and pervades all aspects of my being.
In contrast, those with an extroverted personality and external locus of control see situations as being outside of their immediate control or occurring due to factors happening in their environment (Rotter, 1966). For example, these individuals see free will as a motivating force in coping with diversity, may rely more on luck or the ability to take advantage of circumstances surrounding an event. Extroverts rely on others for social stimulation to verify their impressions or affirm their choices. If I am an extrovert, dementia is happening to me, and does not define me. It shapes my choices and environment, but it is not me. Those with an external locus of control are easier on themselves. They try to structure their environment to produce the outcomes they desire, and may use notes, reminders, signs, etc. as ways to combat cognitive changes in early stages of dementia. These individuals are more likely to resist the depressive aspects of dementia and attribute those characteristics to choices others are making in response to the disease they are experiencing. It is thought that these individuals might fare better especially in the initial stages of dementia.
Sources:
Rotter JB. Generalized expectancies for internal versus external control of reinforcement. Psychological monographs: General and Applied, 1966;80(1):1-28.
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