Reality Orientation (RO) was designed to reduce confusion and promote autonomy and happiness among institutionalized elderly persons. Serious methodological problems invalidate the results of most RO research. The few adequate studies available suggest that RO does sometimes help reduce confusion, but does not seem to increase autonomy or happiness among the elderly. More research is needed to define the population for whom RO is most appropriate, determine the effectiveness of different forms of RO, and explore possible alternative ways of reducing confusion while increasing life satisfaction among the institutionalized aged.
Reality Orientation for the Institutionalized Aged: Does it Help?
In 1975 slightly less than 5% of individuals over age 65 lived in institutions, and most of these persons lived in long term care facilities such as nursing homes and homes for the aged (Siegel, 1976). Until recently custodial care was all the aged could expect from such institutions. The fact that the aged might have psychological needs as well as physical ones was generally ignored. Our failure to provide psychological therapies for institutional residents was consistent with our stereotype of the aged as useless and unable to learn. Reality Orientation (RO) was one of the first therapies designed to provide the institutionalized elderly with psychological treatment. At its inception, RO was viewed as an early phase of the rehabilitation process for moderately or severely confused older persons. Through RO, the confused were encouraged to recall basic facts about reality such as their name, the date, the time, and the place where they lived (Stephens, 1969). This method of reducing confusion within their aged populations was rapidly accepted by nursing homes across the country, suggesting a growing concern for the psychological well-being of older individuals. Despite RO's widespread acceptance, the evidence that RO is an effective treatment is limited. The following review of research on RO should help define RO's place in the existing array of psychological therapies available to institutionalized elderly persons. 'Asst. Prof. College of Arts and Sciences, Grand Valley State Colleges, Allendale, Ml 49401.
Vol. 19, No. 4, 1979
What is Reality Orientation? The general features of RO have been described by various investigators (Barns, Sack, & Shore, 1973; Burnside, 1970; Cornbleth & Cornbleth, 1977; Folsom, 1968; Lee, 1976; Lehman, 1974; Patrick, 1967; Phillips, 1973; Stephens, 1969; Taulbee, 1968, 1976a, b; Taulbee & Folsom, 1966; VA Hospital, 1974; Wurm & McCown, 1965). In what follows, an attempt will be made to abstract the essential features of RO as it is characteristically presented. Goals of RO. — The primary goal of RO is to reduce confusion experienced by the elderly. One is considered confused if one is unable to accurately state time, place, date, etc. Secondary goals of RO seem to be increased autonomy and happiness. Implicit in most descriptions of RO is the notion that the oriented individual is more likely to be independent and happy than one who is not. Participants in RO. — Three types of persons are eligible for RO: the midly confused, those who have been confused for months or years (presumably the moderately or severely confused), and those who might become confused in the future (Taulbee, 1976a). RO may thus be viewed as remedial, preventative, or both. Taulbee (1976b) recognizes that confusion may result from a variety of causes (bumps on the head, malnutrition, arteriosclerosis, strokes, medication, etc.) but feels RO can be effectively used regardless of the source of confusion.
373
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
Mary Ann Schwenk, PhD1
In addition to orienting the older person, 24-hour RO is viewed as having other potential benefits. The technique requires no extra staff and, therefore, should be quite inexpensive to use. Almost anyone can learn to use it. Also, involved staff may feel significant and useful because they are part of a therapeutic effort. Classroom RO is a more intensive form of RO and can be used alone or as a supplement to 24-hour RO. Classes meet for 30 min each day. Consistency of meeting time and place, as well as instructor, contribute to the overall goal of reducing confusion. Nurses or nursing assistants may conduct the classes. Recommended class size for the very confused is four. Eight may be accommodated in advanced classes for mildly confused persons.
ment of its scientific credibility. Stephens (1969) offers the following explanation for the effectiveness of RO: The older patient often withdraws into himself, breaks off relationship with others, and in general reduces his awareness and concern for even the simplest things. Potentially usable parts of his brain soon cease to function. Reality Orientation attacks that process in two ways: by continually stimulating him by repetitive orientation, and by placing him in a group where he meets and competes with other patients, thus forcing him out of his isolation and back into his environment. That process can reawaken unused neurological pathways and stimulate the patient to develop new ways of functioning to compensate for organic brain damage that has resulted either from injury or progressive senility or from deterioration through disuse.
374
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
Basic classes begin with members greeting Methods of RO. — RO utilizes two basic approaches: 24-hour RO and Classroom RO. each other by name and writing their own names In 24-hour RO all institutional staff in contact on the blackboard. Then the RO board, containwith the older peson can function as orienters. ing information about the time and place of the Nurses, aides, and other personnel are involved class, is read to participants. Afterwards particiin presenting basic information about current pants are expected to recall this information on circumstances during their normal interactions their own. In addition, clocks are sometimes with the confused person. Information about used to practice telling time, and calendars are who he is, where he is, and so on, is presented provided so participants can mark off each day. repeatedly until the individual is able to retain it. Other activities during class time may include An example of the technique being used by a constructing scrapbooks of common objects and nursing assistant at lunch might sound like this: playing word-letter games. Positive reinforcements for appropriate be"Hi, Mr. Bismark. It is now 12:20 in the afternoon and I have brought your lunch. Today the havior are used as an integral part of classroom kitchen is serving tuna sandwiches." This ap- activity. Accurate recall of desired information proach to the older person is viewed as superior is praised and punch and cookies can be served to a simple "Hi. Here is your lunch." because after an especially good session. The reinforcement is viewed as a means of motivating the much more information about reality is conelderly to attend classes and to perform well veyed. while there. Taulbee (1976b) notes that mechanically preIn advanced RO classes similar activities are senting RO information to the confused will not, provided; however, participants are expected to in itself, reduce confusion. The orienter must perform more quickly and accurately. In addibe genuinely and consistently concerned about tion, up to sixth grade material in math, history, the older person. It is important also for the and geography may be provided. Participants orienter to maintain a calm environment and are graduated when they no longer seem conhave a set routine for the patient. She is encour- fused in their daily activities. Taulbee (1976a) aged to give clear, simple responses to patient suggests dropping individuals who fail to questions and ask clear, simple questions. She progress in a two-month period; however, some should speak in a friendly but not condescending may be re-enrolled at a later date. Ideally, gradumanner. Instructions to patients should be brief, ates are advanced to other therapies and eventudefinite, and consistent. They should then be ally discharged. enforced kindly but firmly. Rambling in speech or action should be actively discouraged (Taulbee, 1976b). Twenty-four hour RO then Rationale for RO's Effectiveness The question of how or why RO works to describes how best to communicate with the reduce confusion and promote happiness and confused elderly as well as what to communiautonomy is, of course, central to the establishcate to them.
Folsom (1968), Taulbee (1976b), and Lee (1976) suggest RO's success is based on more than activation of unused neural pathways. The program may provide the elderly with a sense that someone has an investment in them and expects them to perform better than they have in the past. Observed improvements grow out of the social stimulation that the program provides as well as the actual class exercises given. Does RO Reduce or Prevent Confusion?
Vol. 19, No. 4, 1979
375
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
Many studies answering this question affirmatively provide only anecdotal evidence that the program succeeds (Burnside, 1970; Folsom, 1968; Folsom & Taulbee, 1966; Lehman, 1974; Trotter, 1972). Other supportive studies lack appropriate control groups (Browne & Ritter, 1972; Letcher, Peterson & Scarbrough, 1974; Salter & Salter, 1977a, b). There are only three studies, without serious methodological problems, showing that RO has positive effects on confusion. The first study used state hospital patients, suffering mainly from organic brain syndrome (OBS) and syphilis, who received five months of 24-hour RO, classroom RO, and attitude therapy (Harris & Ivory, 1976). Comparisons of the experimental group (mean age = 67) and the control group (mean age = 71) at the end of treatment demonstrated statistically significant differences between them on six of nine measures of verbal orientation (p < .05). Two problems exist in interpreting these results. First, it appears that aides working with the experimental subjects had higher expectations for their charges than did aides working with the controls. Second, the age difference between the two groups may explain the results better than the treatment differences. Brook, Degun, and Mather (1975) studied 18 nursing home residents (mean age = 73) suffering from mild to severe disorientation. After 16 weeks of RO classes, nurses' ratings of experimental and control groups indicated significant differences on intellectual and social scales (p < .01). Patients initially high on social and intellectual functioning improved most as a result of treatment, but this trend could not be confirmed statistically because of the small number of persons in the groups. Citrin and Dixon (1977) observed their experimental group (mean age = 84) improve significantly on the Reality Orientation Information Sheet (ROIS) as a result of six to seven weeks of both 24-hour and classroom RO (p < .005). The control group
(mean age = 83) showed nonsignificant declines, on the ROIS, which taps information taught in RO classes. The 25 subjects were all mildly disoriented. Several studies show that RO has little effect on confusion. Zepelin, Wolfe, and Kleinplatz (1977) found that, after a year of 24-hour RO, attitude therapy, and some supplementary therapeutic measures, experimental subjects (mean age = 85) performed no differently on the Mental Status Questionnaire (MSQ) than did control subjects (mean age = 81). The MSQ asks for information rehearsed in RO classes. All participants in the study suffered from strokes or chronic brain syndrome (CBS) and varied in degree of confusion. Similarly, Zepelin and Wade (1975) used the MSQ to measure orientation before and after six weeks of RO classes for both experimental participants (mean age = 81) and controls (mean age = 82). All were severely disoriented elderly suffering from strokes, dementia, and CBS. No treatment effects were found. Finally, Barnes (1974) found no effect of six weeks of RO classes on six senile patients (mean age = 81), used as their own controls, and assessed on a questionnaire requiring knowledge of information taught in the classes. These two sets of studies are obviously contradictory. Two of the positive studies used a combination of 24-hour RO and classroom RO, while two of the negative studies used only classroom RO. It could be that the effects of the two forms of RO are quite different. Twentyfour hour RO basically teaches staff how to communicate adequately with elderly patients. In fact, Citrin and Dixon (1977) suggest that RO may help institutional staff primarily and their elderly charges only indirectly. Classroom RO, on the other hand, involves much repetitive drill of relatively trivial information.This drill may be less helpful to the elderly than regular conversational contacts with staff in natural situations. Another possibility is that all confused elderly are not equally likely to benefit from RO. In the three studies affirming the effectiveness of RO, patients were either relatively young (Harris & Ivory, 1976) or only mildly confused (Brook et al., 1975; Citrin & Dixon, 1977). In one negative study mentioning the degree of confusion present among patients, the confusion was severe (Zepelin & Wade, 1975). In the other, degree of confusion varied (Zepelin et al., 1977). Perhaps RO works best with mild confusion.
boring and useless. More research is needed to corroborate this finding; but, if some elderly do experience the classes as boring and useless, participation may create morale problems. It could be that RO classes are especially demeaning to relatively intact older persons. MacDonald and Settin's (1978) sample was quite young (mean age = 64) and no mention was made of the degree, type, or duration of their confusion. The evidence then does not favor the notion that RO promotes either autonomy or happiness. In fact, it is possible that RO classes may reduce happiness in some elderly persons.
The whole problem of for whom RO is most helpful has yet to be resolved. Since confusion can result from such a wide variety of causes, ranging from isolation to malnutrition to strokes, it would not be surprising to find that RO works with only certain types of confusion. Wershow (1977) estimates that at least 50% of nursing home residents are confused because they have irreversible OBS. He suggests that our efforts to do more for these persons than make them comfortable is a waste of precious time and money. Degree of confusion, type of confusion, and duration of confusion, then, may all influence the effectiveness of an RO program.
As a result of initial differences in capacity for self-care between experimental and control groups, as well as nonsignificant declines in capacity in the controls and increases in the experimentals, Citrin and Dixon (1977) did find significant differences in autonomy (between the two groups) at the end of RO training (p < .05). They did not feel that this difference on the Geriatric Rating Scale was a treatment effect. In contrast, Zepelin et al. (1977) found significant declines on an activities-of-daily-living measure among experimental subjects (p < .001) which were not observed among control subjects after a year of RO. These decl ines were unrelated to the degree of confusion experienced by participants. The evidence does not support the notion that RO promotes autonomous functioning in the elderly. Only two studies have tried to ascertain the relationship between RO and life satisfaction. MacDonald and Settin (1978) found decreases in life satisfaction which approached significance (p < .10) for the experimental group exposed to classroom RO and remotivation therapy; and increases in life satisfaction (p < .05) for the group exposed to a sheltered workshop experience. During the workshop, items for exceptional children at a nearby institution were produced. Zepelin et al. (1977) found increases in belligerence (p < .01) and decreases in social responsiveness (p < .05) after a year of 24-hour RO and supplementary therapy, which included sensory training and encouragement of social interaction. Existing research suggests that RO may actually reduce life satisfaction in some cases rather than increase it! Classroom RO may be the problem. MacDonald and Settin (1978) report that some RO participants described the classes as
We might also ask whether RO should be used always with elderly whose confusion could be reduced by the technique. Butler and Lewis (1977) suggest that senility, of which confusion is a major symptom, may represent an attempt to deny the realities of old age. The older person who thinks she is at home with her loving family in the year 1944 may be using her confusion as a defense mechanism. It is too painful for her to face the reality of being alone and in a nursing home. One wonders about the wisdom of removing such defenses in the name of therapy, if the individual is happier in a confused state than he would be in an oriented one. Gubrium and Ksander (1975) describe the case of a pleasant, cooperative nursing home resident who became upset and difficult when forced through RO to give up her belief that she was at home. Whether RO is helpful or harmful in this type of situation is a question which must be confronted by anyone involved in RO. Are There Effective Alternatives to RO?
Little research has been done comparing RO's effectiveness with other forms of treatment. MacDonald and Settin (1978) found that involving the elderly in a gift-making project for exceptional children, in the context of a sheltered workshop, resulted in greater increases in life satisfaction (p < .05) than did RO classes combined with remotivation therapy. The study represents an initial attempt to compare RO's effectiveness with other treatments. The rationale given for RO's effectiveness does not eliminate the possibility that, when the program works, it works because it makes the elderly feel significant. There are other ways of accomplishing this end such as friendly visitation. They should be explored in view of the lack of strong
376
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
Should RO Be Used Always In Cases Where It Can Work?
Does RO Promote Autonomy and Happiness?
evidence that RO is universally beneficial to the elderly. It is also possible that training institutional staff directly in communication skills might generate benefits similar to benefits from RO. This possibility should be explored because it is not clear whether RO is therapeutic for the staff or the elderly. Summary and Conclusions
References Barnes, J. A. Effects of Reality Orientation classroom on memory loss, confusion, and disorientation in geriatric patients. Gerontologist, 1974, 14, 138-142. Barns, E. K., Sack, A., & Shore, H. Guidelines to treatment approaches. Modalities and methods for use with the aged. Cerontologist, 1973, 13,, 513-527. Brook, P., Degun, C , & Mather, M. Reality orientation: A therapy for psychogeriatric patients. A controlled study. British journal of Psychiatry, 1975, 127, 42-45. Browne, L. J., & Ritter, J. I. Reality therapy for the geriatric psychiatric patient. Perspectives in Psychiatric Care, 1972, 10, 135-139. Burnside, I. M. Clocks and calendars. American journal of Nursing, 1970,70, 117-119. Butler, R. N.,& Lewis, M. I. Aging andMental Health, Mosby, St. Louis, 1977. Cornbleth, T., & Cornbleth, C. Reality orientation for the elderly. American Psychological Association, Washington, DC, 1977.
Vol. 19, No. 4, 1979
377
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
RO is a therapeutic program designed to combat confusion and increase autonomy and happiness among institutionalized elderly persons. Much of the literature extolling the virtues of RO lacks scientific credibility. The few methodologically sound studies of RO suggest that, when it works, it works to reduce or prevent confusion. It seems to have little positive effect on autonomy or happiness. Part of the reason for the lack of support for RO in the literature may be the failure of almost all studies to differentiate treated subjects in terms of degree, source, and duration of confusion. Additional studies are needed to determine for whom RO is most effective. Limited evidence suggests that the effects of classroom RO may be different from the effects of 24-hour RO. This suggestion also needs to be confirmed through additional research. Other methods of treatment for the institutionalized elderly exist. They should be explored as possible alternatives to RO in view of the failure to establish RO as a universally effective treatment.
Citrin, R. S., & Dixon, D. N. Reality Orientation: A milieu therapy used in an institution for the aged. Gerontologist, 1977, 17, 39-43. Folsom, J. C. Reality Orientation for the elderly mental patient, journal of Geriatric Psychiatry, 1968, 1, 291-307. Gubrium, J. F., & Ksander, M. On multiple realities and reality orientation. Gerontologist, 1975, 15, 142-143. Harris, C. S., & Ivory, P. B. An outcome evaluation of reality orientation therapy with geriatric patients in a state mental hospital. Gerontologist, 1976, 16, 496-503. Lee, R. E. Reality Orientation: Restoring the senile to life. Part 1. journal of Practical Nursing, January, 1976,34-35. Part 2, February, 1976, 30-31. Lehman, E. Reality orientation: Doing it better. Nursing, March, 1974, 61-62. Letcher, P. B., Peterson, L. P., & Scarbrough, D. Reality orientation: A historical study of patient progress. Hospital and Community Psychiatry, 1974, 25, 801-803. MacDonald, M. L., & Settin, J. M. Reality orientation versus sheltered workshops as treatment for the institutionalized aging, journal of Gerontology, 1978, 33, 416-421. Patrick, M. L. Care of the confused elderly patient. American journal of Nursing, 1967, 67, 2536-2539. Phillips, D. Reality orientation. Hospitals: journal of the American Hospital Association, 1973, 47, 46-49, 101. Salter, C. L., & Salter, C. A. Regression among institutionalized elderly patients following interruption of a therapeutic program. Hospital and Community Psychiatry, }977,28, 101-102. (a) Salter, C. L., & Salter, C. A. Effects of an individualized activity program on elderly patients. Gerontologist, 1977, 15, 404-406. (b) Siegel, J. S. Demographic aspects of aging and the older population in the United States. USGPO, Washington, DC, 1976. Stephens, L. P. (Ed.), Reality orientation, American Psychiatric Association and Community Psychiatry Service, Washington, DC, 1969. Taulbee, L. R. The A-B-C's of reality orientation for rehabilitation of confused elderly persons, 1976. (a) Taulbee, L. R. Reality orientation and the aged. In I. Burnside (Ed.), Nursing and the aged. McGraw-Hill, Hightstown, NJ, 1976. (b) Taulbee, L. R., & Folsom, J. C. Reality orientation for geriatric patients. Hospital & Community Psychiatry, 1966, 17, 133-135. Trotter, R. J. Reality orientation. Science News, Dec, 1972, 411. VA Hospital, Tuscaloosa. Guide for reality orientation, April, 1974. " Wershow, H. F. Comment: Reality orientation for gerontologists; some thoughts about senility. Gerontologist, 1977, 17, 297-302. Wurm, E., & McCown, P. O. Orienting the disoriented. American journal of Nursing, 1965, 65, 118-119. Zepelin, H., & Wade, S. A study of the effectiveness of reality orientation classes. Paper presented to the 28th Annual Meeting of the Gerontological Society, Louisville, 1975. Zepelin, H., Wolfe, C. S., & Kleinplatz, F. Evaluation of a year long reality orientation program. Paper presented to the 30th Annual Meeting of the Gerontological Society, San Francisco, 1977.
Reality Orientation for the Institutionalized Aged: Does it Help?
In 1975 slightly less than 5% of individuals over age 65 lived in institutions, and most of these persons lived in long term care facilities such as nursing homes and homes for the aged (Siegel, 1976). Until recently custodial care was all the aged could expect from such institutions. The fact that the aged might have psychological needs as well as physical ones was generally ignored. Our failure to provide psychological therapies for institutional residents was consistent with our stereotype of the aged as useless and unable to learn. Reality Orientation (RO) was one of the first therapies designed to provide the institutionalized elderly with psychological treatment. At its inception, RO was viewed as an early phase of the rehabilitation process for moderately or severely confused older persons. Through RO, the confused were encouraged to recall basic facts about reality such as their name, the date, the time, and the place where they lived (Stephens, 1969). This method of reducing confusion within their aged populations was rapidly accepted by nursing homes across the country, suggesting a growing concern for the psychological well-being of older individuals. Despite RO's widespread acceptance, the evidence that RO is an effective treatment is limited. The following review of research on RO should help define RO's place in the existing array of psychological therapies available to institutionalized elderly persons. 'Asst. Prof. College of Arts and Sciences, Grand Valley State Colleges, Allendale, Ml 49401.
Vol. 19, No. 4, 1979
What is Reality Orientation? The general features of RO have been described by various investigators (Barns, Sack, & Shore, 1973; Burnside, 1970; Cornbleth & Cornbleth, 1977; Folsom, 1968; Lee, 1976; Lehman, 1974; Patrick, 1967; Phillips, 1973; Stephens, 1969; Taulbee, 1968, 1976a, b; Taulbee & Folsom, 1966; VA Hospital, 1974; Wurm & McCown, 1965). In what follows, an attempt will be made to abstract the essential features of RO as it is characteristically presented. Goals of RO. — The primary goal of RO is to reduce confusion experienced by the elderly. One is considered confused if one is unable to accurately state time, place, date, etc. Secondary goals of RO seem to be increased autonomy and happiness. Implicit in most descriptions of RO is the notion that the oriented individual is more likely to be independent and happy than one who is not. Participants in RO. — Three types of persons are eligible for RO: the midly confused, those who have been confused for months or years (presumably the moderately or severely confused), and those who might become confused in the future (Taulbee, 1976a). RO may thus be viewed as remedial, preventative, or both. Taulbee (1976b) recognizes that confusion may result from a variety of causes (bumps on the head, malnutrition, arteriosclerosis, strokes, medication, etc.) but feels RO can be effectively used regardless of the source of confusion.
373
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
Mary Ann Schwenk, PhD1
In addition to orienting the older person, 24-hour RO is viewed as having other potential benefits. The technique requires no extra staff and, therefore, should be quite inexpensive to use. Almost anyone can learn to use it. Also, involved staff may feel significant and useful because they are part of a therapeutic effort. Classroom RO is a more intensive form of RO and can be used alone or as a supplement to 24-hour RO. Classes meet for 30 min each day. Consistency of meeting time and place, as well as instructor, contribute to the overall goal of reducing confusion. Nurses or nursing assistants may conduct the classes. Recommended class size for the very confused is four. Eight may be accommodated in advanced classes for mildly confused persons.
ment of its scientific credibility. Stephens (1969) offers the following explanation for the effectiveness of RO: The older patient often withdraws into himself, breaks off relationship with others, and in general reduces his awareness and concern for even the simplest things. Potentially usable parts of his brain soon cease to function. Reality Orientation attacks that process in two ways: by continually stimulating him by repetitive orientation, and by placing him in a group where he meets and competes with other patients, thus forcing him out of his isolation and back into his environment. That process can reawaken unused neurological pathways and stimulate the patient to develop new ways of functioning to compensate for organic brain damage that has resulted either from injury or progressive senility or from deterioration through disuse.
374
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
Basic classes begin with members greeting Methods of RO. — RO utilizes two basic approaches: 24-hour RO and Classroom RO. each other by name and writing their own names In 24-hour RO all institutional staff in contact on the blackboard. Then the RO board, containwith the older peson can function as orienters. ing information about the time and place of the Nurses, aides, and other personnel are involved class, is read to participants. Afterwards particiin presenting basic information about current pants are expected to recall this information on circumstances during their normal interactions their own. In addition, clocks are sometimes with the confused person. Information about used to practice telling time, and calendars are who he is, where he is, and so on, is presented provided so participants can mark off each day. repeatedly until the individual is able to retain it. Other activities during class time may include An example of the technique being used by a constructing scrapbooks of common objects and nursing assistant at lunch might sound like this: playing word-letter games. Positive reinforcements for appropriate be"Hi, Mr. Bismark. It is now 12:20 in the afternoon and I have brought your lunch. Today the havior are used as an integral part of classroom kitchen is serving tuna sandwiches." This ap- activity. Accurate recall of desired information proach to the older person is viewed as superior is praised and punch and cookies can be served to a simple "Hi. Here is your lunch." because after an especially good session. The reinforcement is viewed as a means of motivating the much more information about reality is conelderly to attend classes and to perform well veyed. while there. Taulbee (1976b) notes that mechanically preIn advanced RO classes similar activities are senting RO information to the confused will not, provided; however, participants are expected to in itself, reduce confusion. The orienter must perform more quickly and accurately. In addibe genuinely and consistently concerned about tion, up to sixth grade material in math, history, the older person. It is important also for the and geography may be provided. Participants orienter to maintain a calm environment and are graduated when they no longer seem conhave a set routine for the patient. She is encour- fused in their daily activities. Taulbee (1976a) aged to give clear, simple responses to patient suggests dropping individuals who fail to questions and ask clear, simple questions. She progress in a two-month period; however, some should speak in a friendly but not condescending may be re-enrolled at a later date. Ideally, gradumanner. Instructions to patients should be brief, ates are advanced to other therapies and eventudefinite, and consistent. They should then be ally discharged. enforced kindly but firmly. Rambling in speech or action should be actively discouraged (Taulbee, 1976b). Twenty-four hour RO then Rationale for RO's Effectiveness The question of how or why RO works to describes how best to communicate with the reduce confusion and promote happiness and confused elderly as well as what to communiautonomy is, of course, central to the establishcate to them.
Folsom (1968), Taulbee (1976b), and Lee (1976) suggest RO's success is based on more than activation of unused neural pathways. The program may provide the elderly with a sense that someone has an investment in them and expects them to perform better than they have in the past. Observed improvements grow out of the social stimulation that the program provides as well as the actual class exercises given. Does RO Reduce or Prevent Confusion?
Vol. 19, No. 4, 1979
375
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
Many studies answering this question affirmatively provide only anecdotal evidence that the program succeeds (Burnside, 1970; Folsom, 1968; Folsom & Taulbee, 1966; Lehman, 1974; Trotter, 1972). Other supportive studies lack appropriate control groups (Browne & Ritter, 1972; Letcher, Peterson & Scarbrough, 1974; Salter & Salter, 1977a, b). There are only three studies, without serious methodological problems, showing that RO has positive effects on confusion. The first study used state hospital patients, suffering mainly from organic brain syndrome (OBS) and syphilis, who received five months of 24-hour RO, classroom RO, and attitude therapy (Harris & Ivory, 1976). Comparisons of the experimental group (mean age = 67) and the control group (mean age = 71) at the end of treatment demonstrated statistically significant differences between them on six of nine measures of verbal orientation (p < .05). Two problems exist in interpreting these results. First, it appears that aides working with the experimental subjects had higher expectations for their charges than did aides working with the controls. Second, the age difference between the two groups may explain the results better than the treatment differences. Brook, Degun, and Mather (1975) studied 18 nursing home residents (mean age = 73) suffering from mild to severe disorientation. After 16 weeks of RO classes, nurses' ratings of experimental and control groups indicated significant differences on intellectual and social scales (p < .01). Patients initially high on social and intellectual functioning improved most as a result of treatment, but this trend could not be confirmed statistically because of the small number of persons in the groups. Citrin and Dixon (1977) observed their experimental group (mean age = 84) improve significantly on the Reality Orientation Information Sheet (ROIS) as a result of six to seven weeks of both 24-hour and classroom RO (p < .005). The control group
(mean age = 83) showed nonsignificant declines, on the ROIS, which taps information taught in RO classes. The 25 subjects were all mildly disoriented. Several studies show that RO has little effect on confusion. Zepelin, Wolfe, and Kleinplatz (1977) found that, after a year of 24-hour RO, attitude therapy, and some supplementary therapeutic measures, experimental subjects (mean age = 85) performed no differently on the Mental Status Questionnaire (MSQ) than did control subjects (mean age = 81). The MSQ asks for information rehearsed in RO classes. All participants in the study suffered from strokes or chronic brain syndrome (CBS) and varied in degree of confusion. Similarly, Zepelin and Wade (1975) used the MSQ to measure orientation before and after six weeks of RO classes for both experimental participants (mean age = 81) and controls (mean age = 82). All were severely disoriented elderly suffering from strokes, dementia, and CBS. No treatment effects were found. Finally, Barnes (1974) found no effect of six weeks of RO classes on six senile patients (mean age = 81), used as their own controls, and assessed on a questionnaire requiring knowledge of information taught in the classes. These two sets of studies are obviously contradictory. Two of the positive studies used a combination of 24-hour RO and classroom RO, while two of the negative studies used only classroom RO. It could be that the effects of the two forms of RO are quite different. Twentyfour hour RO basically teaches staff how to communicate adequately with elderly patients. In fact, Citrin and Dixon (1977) suggest that RO may help institutional staff primarily and their elderly charges only indirectly. Classroom RO, on the other hand, involves much repetitive drill of relatively trivial information.This drill may be less helpful to the elderly than regular conversational contacts with staff in natural situations. Another possibility is that all confused elderly are not equally likely to benefit from RO. In the three studies affirming the effectiveness of RO, patients were either relatively young (Harris & Ivory, 1976) or only mildly confused (Brook et al., 1975; Citrin & Dixon, 1977). In one negative study mentioning the degree of confusion present among patients, the confusion was severe (Zepelin & Wade, 1975). In the other, degree of confusion varied (Zepelin et al., 1977). Perhaps RO works best with mild confusion.
boring and useless. More research is needed to corroborate this finding; but, if some elderly do experience the classes as boring and useless, participation may create morale problems. It could be that RO classes are especially demeaning to relatively intact older persons. MacDonald and Settin's (1978) sample was quite young (mean age = 64) and no mention was made of the degree, type, or duration of their confusion. The evidence then does not favor the notion that RO promotes either autonomy or happiness. In fact, it is possible that RO classes may reduce happiness in some elderly persons.
The whole problem of for whom RO is most helpful has yet to be resolved. Since confusion can result from such a wide variety of causes, ranging from isolation to malnutrition to strokes, it would not be surprising to find that RO works with only certain types of confusion. Wershow (1977) estimates that at least 50% of nursing home residents are confused because they have irreversible OBS. He suggests that our efforts to do more for these persons than make them comfortable is a waste of precious time and money. Degree of confusion, type of confusion, and duration of confusion, then, may all influence the effectiveness of an RO program.
As a result of initial differences in capacity for self-care between experimental and control groups, as well as nonsignificant declines in capacity in the controls and increases in the experimentals, Citrin and Dixon (1977) did find significant differences in autonomy (between the two groups) at the end of RO training (p < .05). They did not feel that this difference on the Geriatric Rating Scale was a treatment effect. In contrast, Zepelin et al. (1977) found significant declines on an activities-of-daily-living measure among experimental subjects (p < .001) which were not observed among control subjects after a year of RO. These decl ines were unrelated to the degree of confusion experienced by participants. The evidence does not support the notion that RO promotes autonomous functioning in the elderly. Only two studies have tried to ascertain the relationship between RO and life satisfaction. MacDonald and Settin (1978) found decreases in life satisfaction which approached significance (p < .10) for the experimental group exposed to classroom RO and remotivation therapy; and increases in life satisfaction (p < .05) for the group exposed to a sheltered workshop experience. During the workshop, items for exceptional children at a nearby institution were produced. Zepelin et al. (1977) found increases in belligerence (p < .01) and decreases in social responsiveness (p < .05) after a year of 24-hour RO and supplementary therapy, which included sensory training and encouragement of social interaction. Existing research suggests that RO may actually reduce life satisfaction in some cases rather than increase it! Classroom RO may be the problem. MacDonald and Settin (1978) report that some RO participants described the classes as
We might also ask whether RO should be used always with elderly whose confusion could be reduced by the technique. Butler and Lewis (1977) suggest that senility, of which confusion is a major symptom, may represent an attempt to deny the realities of old age. The older person who thinks she is at home with her loving family in the year 1944 may be using her confusion as a defense mechanism. It is too painful for her to face the reality of being alone and in a nursing home. One wonders about the wisdom of removing such defenses in the name of therapy, if the individual is happier in a confused state than he would be in an oriented one. Gubrium and Ksander (1975) describe the case of a pleasant, cooperative nursing home resident who became upset and difficult when forced through RO to give up her belief that she was at home. Whether RO is helpful or harmful in this type of situation is a question which must be confronted by anyone involved in RO. Are There Effective Alternatives to RO?
Little research has been done comparing RO's effectiveness with other forms of treatment. MacDonald and Settin (1978) found that involving the elderly in a gift-making project for exceptional children, in the context of a sheltered workshop, resulted in greater increases in life satisfaction (p < .05) than did RO classes combined with remotivation therapy. The study represents an initial attempt to compare RO's effectiveness with other treatments. The rationale given for RO's effectiveness does not eliminate the possibility that, when the program works, it works because it makes the elderly feel significant. There are other ways of accomplishing this end such as friendly visitation. They should be explored in view of the lack of strong
376
The Gerontologist
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
Should RO Be Used Always In Cases Where It Can Work?
Does RO Promote Autonomy and Happiness?
evidence that RO is universally beneficial to the elderly. It is also possible that training institutional staff directly in communication skills might generate benefits similar to benefits from RO. This possibility should be explored because it is not clear whether RO is therapeutic for the staff or the elderly. Summary and Conclusions
References Barnes, J. A. Effects of Reality Orientation classroom on memory loss, confusion, and disorientation in geriatric patients. Gerontologist, 1974, 14, 138-142. Barns, E. K., Sack, A., & Shore, H. Guidelines to treatment approaches. Modalities and methods for use with the aged. Cerontologist, 1973, 13,, 513-527. Brook, P., Degun, C , & Mather, M. Reality orientation: A therapy for psychogeriatric patients. A controlled study. British journal of Psychiatry, 1975, 127, 42-45. Browne, L. J., & Ritter, J. I. Reality therapy for the geriatric psychiatric patient. Perspectives in Psychiatric Care, 1972, 10, 135-139. Burnside, I. M. Clocks and calendars. American journal of Nursing, 1970,70, 117-119. Butler, R. N.,& Lewis, M. I. Aging andMental Health, Mosby, St. Louis, 1977. Cornbleth, T., & Cornbleth, C. Reality orientation for the elderly. American Psychological Association, Washington, DC, 1977.
Vol. 19, No. 4, 1979
377
Downloaded from http://gerontologist.oxfordjournals.org/ at University of Exeter on June 6, 2016
RO is a therapeutic program designed to combat confusion and increase autonomy and happiness among institutionalized elderly persons. Much of the literature extolling the virtues of RO lacks scientific credibility. The few methodologically sound studies of RO suggest that, when it works, it works to reduce or prevent confusion. It seems to have little positive effect on autonomy or happiness. Part of the reason for the lack of support for RO in the literature may be the failure of almost all studies to differentiate treated subjects in terms of degree, source, and duration of confusion. Additional studies are needed to determine for whom RO is most effective. Limited evidence suggests that the effects of classroom RO may be different from the effects of 24-hour RO. This suggestion also needs to be confirmed through additional research. Other methods of treatment for the institutionalized elderly exist. They should be explored as possible alternatives to RO in view of the failure to establish RO as a universally effective treatment.
Citrin, R. S., & Dixon, D. N. Reality Orientation: A milieu therapy used in an institution for the aged. Gerontologist, 1977, 17, 39-43. Folsom, J. C. Reality Orientation for the elderly mental patient, journal of Geriatric Psychiatry, 1968, 1, 291-307. Gubrium, J. F., & Ksander, M. On multiple realities and reality orientation. Gerontologist, 1975, 15, 142-143. Harris, C. S., & Ivory, P. B. An outcome evaluation of reality orientation therapy with geriatric patients in a state mental hospital. Gerontologist, 1976, 16, 496-503. Lee, R. E. Reality Orientation: Restoring the senile to life. Part 1. journal of Practical Nursing, January, 1976,34-35. Part 2, February, 1976, 30-31. Lehman, E. Reality orientation: Doing it better. Nursing, March, 1974, 61-62. Letcher, P. B., Peterson, L. P., & Scarbrough, D. Reality orientation: A historical study of patient progress. Hospital and Community Psychiatry, 1974, 25, 801-803. MacDonald, M. L., & Settin, J. M. Reality orientation versus sheltered workshops as treatment for the institutionalized aging, journal of Gerontology, 1978, 33, 416-421. Patrick, M. L. Care of the confused elderly patient. American journal of Nursing, 1967, 67, 2536-2539. Phillips, D. Reality orientation. Hospitals: journal of the American Hospital Association, 1973, 47, 46-49, 101. Salter, C. L., & Salter, C. A. Regression among institutionalized elderly patients following interruption of a therapeutic program. Hospital and Community Psychiatry, }977,28, 101-102. (a) Salter, C. L., & Salter, C. A. Effects of an individualized activity program on elderly patients. Gerontologist, 1977, 15, 404-406. (b) Siegel, J. S. Demographic aspects of aging and the older population in the United States. USGPO, Washington, DC, 1976. Stephens, L. P. (Ed.), Reality orientation, American Psychiatric Association and Community Psychiatry Service, Washington, DC, 1969. Taulbee, L. R. The A-B-C's of reality orientation for rehabilitation of confused elderly persons, 1976. (a) Taulbee, L. R. Reality orientation and the aged. In I. Burnside (Ed.), Nursing and the aged. McGraw-Hill, Hightstown, NJ, 1976. (b) Taulbee, L. R., & Folsom, J. C. Reality orientation for geriatric patients. Hospital & Community Psychiatry, 1966, 17, 133-135. Trotter, R. J. Reality orientation. Science News, Dec, 1972, 411. VA Hospital, Tuscaloosa. Guide for reality orientation, April, 1974. " Wershow, H. F. Comment: Reality orientation for gerontologists; some thoughts about senility. Gerontologist, 1977, 17, 297-302. Wurm, E., & McCown, P. O. Orienting the disoriented. American journal of Nursing, 1965, 65, 118-119. Zepelin, H., & Wade, S. A study of the effectiveness of reality orientation classes. Paper presented to the 28th Annual Meeting of the Gerontological Society, Louisville, 1975. Zepelin, H., Wolfe, C. S., & Kleinplatz, F. Evaluation of a year long reality orientation program. Paper presented to the 30th Annual Meeting of the Gerontological Society, San Francisco, 1977.
