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How Therapeutic Fibbing and Diversion Can Help Loved Ones with Dementia and Alzheimer’s

Tactics to comfort, alleviate stress and meet individuals in ‘their reality’

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It was hard, at first, for Jim Mangi to tell his wife what she wanted to hear.

Mangi’s wife, Kathleen, was beginning to lose her memory as a consequence of what turned out to be Alzheimer’s disease. Like other people in that situation, she sometimes slipped back into her past or became confused about her surroundings.

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“At the beginning of the journey, I didn’t know any better than to tell the truth all the time,” says Mangi, now 74, who lives in Saline, Michigan. When his wife asked about her sister, for example, he’d remind her that her sister had died. “And then after Kathleen had wept for a while, she came right back to me and asked me the same question and I did the same thing. What a terrible thing to have to do.”

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That’s why many caregivers and their advocates have come to embrace a practice they consider a less terrible thing to do: therapeutic fibbing, a euphemism that basically means lying to people with dementia or other cognitive impairment when it can give them calm or comfort.

“I’ve had many times when I needed to confront the question of whether I was going to be a truthful person or a loving person because I could not always be both at the same time,” says Mangi, whose 73-year-old wife is now in a memory care center where he visits her for several hours a day.

“A person with dementia is in a different world. Their reality is different,” he says. “Nothing we can do or say is going to bring them out of the reality they’re in. In that sense, if she felt her sister was still alive, who am I to tell her that it isn’t true?”

Fifteen years after his wife first showed Alzheimer’s symptoms, Mangi says he’s recognized that “many times the most loving thing to do is not tell the truth. I consider it to be a loving lie.”

A new approach

Now many experts in the field are refining their approach to therapeutic fibbing, beginning with the name. They talk today about “creative communication techniques,” which include diverting the attention of people with cognitive impairments, or distracting them.

Instead of lying outright, says Maureen Beck, a gerontological nurse practitioner at UTHealth Houston’s Center for Healthy Aging and assistant professor at McGovern Medical School, “you can start a different conversation. You redirect them to a memory or to a task, get them busy, get them moving.”

Mangi’s wife, for instance, “used to ask, “Where’s my daddy?’ ” he says. “And I would say, ‘Well, he’s not here right now,’ which has the virtue of being true. And then I would go into, ‘He used to work as a telephone lineman, right?’ And we got into a conversation. It was a connection rather than a correction, and that made all the difference.”

A patient in her 80s in a nursing home where Monica Moreno once worked would often ask about her mother. Well-intentioned staff would remind the woman that her mother had died, says Moreno, who is now senior director for care and support at the Alzheimer's Association.

Because of the emotional toll that took on the patient — after all, “her reality was that she was 37 years old and her mother was still alive,” Moreno says — the workers changed their tactic. “I want you to know that everyone who loves you knows that you’re here and that you’re safe and you’re happy,” they would say.

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“Really it’s about connecting in the moment and trying to connect to what the person is feeling,” Moreno says. “It’s about their reality and us putting ourselves into their world and their reality rather than trying to get them to be part of ours.”

The challenges of telling well-meaning mistruths

Entering that world can sometimes include telling lies, Beck says. But just as medical professionals use some medications only when there isn’t any other option, she says, she recommends against lying in all but the most extreme situations.

For one thing, lying to a loved one can take a toll on a caregiver, as research at the City University of New York (CUNY) has found. “It is the reflex not to lie, especially to a parent, and the emotional hurdle of overcoming that, which is the greatest difficulty surrounding this technique,” the research concluded.

For another, even people with short-term memory loss might be able to sense a lie.

“It's often experienced as disrespectful to think that people with dementia don’t know the difference between the truth and the fib,” says Susan Wehry, associate professor of geriatrics at the University of New England College of Osteopathic Medicine. “People who have memory impairment retain a lot of their sensibilities, a lot of their awareness about interpersonal connection. There is a level at which they can sense that something shifted in a relationship that was heretofore based on trust.”

And since some dementias cause paranoia, Beck adds, “they’re already suspicious. You’re going to worsen the situation if you lie.”

Wehry uses the example of a resident of a congregate living facility who tries to leave every day at noon believing that it’s time to fix lunch for long-grown children. “Instead of saying, ‘No, I’m fixing their lunch’ or, ‘They’re going to a neighbor,’ you can say, ‘You have three kids, right? Remind me of their names.’ You make the assumption that their kids are on their mind. That’s a clue to where their reality is right now.”

Sometimes even distraction doesn’t work. If a person with dementia misplaces something, for example, a caregiver may try to change the subject, Wehry says. “What I teach instead is to say, ‘I’m sorry your watch is missing. Would you like me to come and help you look for it?’ You’re validating that they’re worried. Then as you’re walking with them, you say, ‘I think you told me you were knitting a sweater for your niece,’ or anything you know is a positive connection. And now you’re working with a person in a different mood.”

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Finding a middle ground

Wehry acknowledges that there are times when a caregiver might sidestep the truth. “I’m not someone who says you need to keep reminding someone that their spouse has died or that they don’t have to worry about taking care of their children.”

In separate surveys in the U.K. and Australia, therapists, nurses and other health care professionals said they generally believed it was in the best interest of dementia patients to occasionally lie to them. One U.K. study asked early-stage dementia patients themselves about this; they said they supported lying if it was done with good intentions and at the more advanced stages of memory loss.

“In many cases, therapeutic lying can actually create a feeling of safety for such patients,” the CUNY research concluded, based on interviews with nonprofessional caregivers of people with Alzheimer’s. “For a mid-disease person, who finds comfort in the belief that he is living in his childhood home along with his parents and siblings, it serves absolutely no purpose to remind him that he is living elsewhere and that his parents have been long deceased.”

People with dementia are often frightened and emotional, notes Marina Martin, clinical associate professor on the geriatric medicine faculty at Stanford University’s School of Medicine. “The most respectful and compassionate approach to that is to meet them as much as possible in their reality to soothe them a little bit. You don’t have to participate in some elaborate set of lies, but maybe skirt the question of what the truth is and get at the emotion.”

At her practice, for example, Beck says patients can be agitated at being put through memory tests they weren’t aware were part of an examination. “They know they’re going to see a nurse practitioner or physician but the intention of the family is to delve into memory problems. You have to handle that very carefully,” she says. So the staff explains that every new patient undergoes a memory assessment, averting the potential for feelings of anger or betrayal.

One caregiver tells of overcoming her husband’s resistance to enrolling at an adult day facility by telling him he was going there to volunteer. In cases such as that, Moreno advises making sure that the staff at the center also knows about the tactic, and gives the husband small tasks to do. “It’s really an act of kindness rather than deception,” she says. (The Alzheimer’s Association offers other communication strategies and caregiver support groups; the Family Caregiver Alliance provides practical advice on relating to someone with memory loss.)

Even after 15 years, says Mangi, it can be hard to be less than honest with his wife.

“The important thing is, what is the most loving thing to do? There’s no virtue for the caregiver to say, ‘Well, I have never told a lie in my entire life.’ Isn’t it more desirable to say. ‘I’ve always been a loving person?’ ”

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