Naomi Feil in her book The Validation Breakthrough identified four stages of resolution. People who suffer from cognitive impairment may progress through these four stages: 1) Malorientation, 2) Time Confusion, 3) Repetitive Motion, and 4) Vegetation. Feil believes people will “enter a period in their lives in which they feel the need to resolve unfinished business in order to die in peace.”

With each stage physical decline is evident and the sufferer draws inward mentally and emotionally. It is important to remember people are fluid and are not necessarily fixed in one stage or another. Therefore sufferers can move back and forth between stages and may have characteristics of two stages simultaneously. However, one stage will typically dominate.

Mal-oriented old people are often well adjusted in many areas of daily living. However, their behaviors are triggered by specific fears about losses brought about by the aging process. Sufferers will demonstrate short-term or remote memory loss, hold to present reality by a rigid and inflexible lifestyle, accuse others when belongings cannot be found, hoard, and realize and be threatened by their own disorientation. Physically they will have tense and tight muscles, fear of losing control of body functions, a quick and purposeful gait, and have focused and good eye contact during conversation. Sometimes they will clutch things, such as a purse, sweater, cane or stuffed animal and hold personal objects close to their body. They can do their own personal care. They will respond best to recognized roles and persons in authority, but have a negative response to those less oriented. They do not want insight into their mental or emotional condition. They can read and write unless blind or illiterate. They carefully follow rules and conventions and are concerned that others follow “the rules.” They can have a sense of humor, but are often moody.

Time confused persons respond to both verbal and non-verbal cues; therefore, they move from one stage to another throughout the day. The dominant characteristic is disorientation to time, place and person. They do not keep track of the time of day, day of week, month, year or season. They may not know where they are and may not recognize familiar people and their names. They may not know who they are and lose a sense of self. Physically, muscles are loose and they are aware of incontinence. They are slow and have smooth movements, without purpose, and have a dance-like gait. Their voice is low, but rarely harsh. They sing and laugh easily; eyes are clear and unfocused. Although often downcast, their eye contact triggers recognition. They substitute memories and feelings from the past to give meaning to the present, often recalling past experiences that are unresolved. Sometimes they are unable to control emotions. They need assistance to complete the ‘Activities of Daily Living’ (feeding, dressing, bathing, etc.). They do respond to a nurturing tone and appropriate touching. They smile when greeted and may call present caregivers by names from the past. They use symbolism in speech. They do not trust caregivers who argue, correct or pretend to agree with them. They can read, but no longer write legibly or coherently. They make up their own rules, retain intuitive wisdom and may use objects as substitutes for people.

Sometimes the disoriented will engage in repetitive behavior such as wandering, tapping and repeating the same words, phrases or rhymes over and over again. They often shut out most stimuli from the outside world. They have their own sense of time. Physically, they may slump forward, are unaware of incontinence and are restless, pacing or rolling in a wheelchair. Their eyes are half-closed or unfocused. They use repetitive body movements to express emotions. They require total care for ‘Activities of Daily Living.’ They use few common words, do not complete sentences and do not listen or talk to others. They are not motivated to read or write. Early memories and universal symbols are the most meaningful. They may repeat early childhood movements and sounds.

People in vegetation have lost speech and the ability to think logically. Often, they give no indication that they recognize family, visitors, old friends or staff. They have no sense of time or place. Physically, their breathing is shallow or soft; they barely move on their own initiative and often lay in the fetal position. Their eyes are shut much of the time and their face is often expressionless. There is no effort to control incontinence. Emotions are difficult to evaluate. They require total care for ‘Activities of Daily Living.’

People working with the cognitively impaired are trained to recognize the characteristics of each stage and apply specific techniques to forestall or prevent further progression.  In some cases, the stages can be reversed and the quality of life enhanced. I will share more about these techniques in my next article.