No one likes being told what to do, and that doesn’t change when dementia comes into the picture. When someone demands that you do something, isn’t your natural response a momentary why should I! or who are you to tell me what to do? But then, before you say something aloud, you think about who they are, what they may know that you don’t, and what the situation is. You do that because you have memory skills and rational thinking skills. But when dementia takes away our memory and rational thinking, we tend to say those instantaneous reactions out loud—and we truly wonder why the other person thinks they should be able to tell us what to do. Dementia and stubbornness, then, should not be surprising.
Dementia takes away the ability to understand what is in our own best interests
When we’re experiencing dementia, we often become unable to perceive or be aware of our own impairments, or limitations—either physical or cognitive. This condition is called anosognosia. We cannot see that we are no longer as capable as we once were, and we’ll be convinced that our companions have changed and are now trying to trick us or take advantage of us.
But even when we aren’t experiencing anosognosia as well, we lose our memory and rational thinking skills, which makes us less able to comprehend the results of our decisions. Think about it: if someone lacks rational thinking, they won’t be able to use analysis or comparative thinking to understand your explanations. And they won’t be able to know that what they want to do is not safe or the best choice.
This means that someone who’s experiencing dementia will often make poor choices, yet refuse to accept that their companions are giving them good advice or only have their best interests in mind. So what can we do to help our loved ones and clients willingly choose to do the things we know are in their best interests?
Strategies for managing stubbornness in dementia: Create a sense of empowerment
There are ways to enable someone’s ability to make good decisions and to enhance their sense of autonomy, but you’ll need to first understand why dementia seems to make us stubborn. When dementia takes away our memory skills, it becomes difficult to make decisions because we cannot hold the options in our minds for long enough to choose. And when dementia takes away our rational thinking skills, it becomes difficult for us to make good decisions—because we lose the ability to compare and contrast (analysis), anticipate likely outcomes (cause and effect), and see which choice is more important or better (prioritization). These skills are lost, but you can present information (choices) to your loved one or client in ways that work with the skills they haven’t lost.
Avoid open-ended questions
When you ask an open-ended question, you’re requiring the listener to use memory skills. Instead, ask a choice-enabling question by stating my options. So instead of asking me what I’d like for dessert, ask me whether I’d like a cookie or a piece of pie. Instead of asking me what I’d like to do, ask whether I’d like to go for a walk. And, if you know I prefer cookies to pie, say cookies last: I’m most likely to recall the last word in your sentence. If you know I’d benefit from some exercise and used to love going for walks, rather than telling me I need exercise or should go for a walk, ask me if I’d join you for a walk because it’s beautiful out or you’d rather go with me than alone.
When someone is losing memory skills, asking them an open-ended question inhibits their ability to exercise choice. But when we identify the options for them, we’re using our own rational thought and memory skills to enable them. Presenting options and identifying choices are two ways we can empower someone who’s experiencing dementia.
Make options visible
Another empowering technique for care partners is to be thoughtful about what is visible and not visible. Clutter makes things harder to notice and presents too many options—whether in the kitchen, bedroom or bathroom. It inhibits the person’s ability to choose. Be careful to be respectful of their preferences and wishes, but if possible, gradually clear a table or counter and leave out just the items you know are necessary and helpful.
To help someone choose to eat, you can set a colorful place at the table, with finger foods ready to sample on a plate and a favorite beverage already poured in a glass. Then, every time they walk by they can choose to nibble or take a sip. That’s much more empowering than being told you should or must eat or drink something. You can lay out an appropriate outfit on the bed, or put away everything except for the toothbrush and toothpaste by the sink. Making options visible removes the need for using memory skills or following several steps to accomplish a task (sequencing), so you are empowering the person to exercise choice and enabling them to act on their own behalf.
Offer a benefit not a reason
Does your loved one or client routinely refuse to shower or eat or hurry to get ready for appointments? It is a combination of lost skills and emotional needs that causes refusals. There are no simple answers, because people are not simple beings (this is why the DAWN Method is taught in eight lessons, not one). But there are effective ways to avoid refusals and, when an activity is consistently refused, we should recognize that it’s our approach that needs to be changed.
One of the most common mistakes care partners make is thinking that they can explain to someone who’s experiencing dementia why they should or shouldn’t do something. Think about what it takes to understand an explanation: rational thinking. So, rather than expect your loved one or client to use comparative thinking and see cause and effect when they’ve lost those skills, instead tell them about it as something they’d like to do. State a benefit, not a reason.
One of our clients didn’t like using the bathroom and seemed to be becoming incontinent. But when we took the time to watch and listen, we realized that her husband had been insisting that she go to the bathroom, and telling her why she should: he’d been embarrassing her and irritating her with his constant demands and forcefulness. But when her new care partner invited her to come look in the mirror so she could fix her hair, she was happy to head down the hall to the bathroom—and she used it just as happily once her hair was pretty. She loved having help with her hair and happily used the toilet once there.
Conclusion
When we feel out of control, our need to regain control in even small ways increases. Conversely, when we are routinely presented with options and given the ability to choose, we feel less need for control overall. Strength-based dementia care means learning what our loved ones and clients can do, and then proactively finding ways to increase their opportunities to exercise choice and feel in control. This is one of the best ways to lessen stress for both parties in the care relationship.
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FAQs about dementia and stubbornness
Is stubbornness a symptom of dementia?
Is there a better way to navigate dementia?
The odds are against you if you rely on your gut. Working with people who are experiencing dementia requires a new way of interacting. Family members and caregivers (even incredibly empathetic ones) who don’t truly understand this will inadvertently embarrass, frustrate or undermine their loved ones and clients. Learn why that is and how to navigate dementia more successfully in our DAWN Method courses and books.
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Who is Judy Cornish?
Judy Cornish is a former eldercare lawyer and the former owner of Palouse Dementia Care, a dementia care agency that provides in-home dementia care for people in Moscow, Idaho. She is the author of Dementia With Dignity and The Dementia Handbook as well as the creator of the DAWN Method of dementia care. Judy believes that, with training, families can provide dementia care at home and enjoy less stress and more companionship.
