Background
Validation therapy was developed by Naomi Feil between 1963 and 1980 for older people with cognitive impairments. Initially, this did not include those with organically-based dementia, but the approach has subsequently been applied in work with people who have a dementia diagnosis. Feil's own approach classifies individuals with cognitive impairment as having one of four stages in a continuum of dementia: these stages are Mal orientation, Time Confusion, Repetitive Motion and Vegetation. The therapy is based on the general principle of validation, the acceptance of the reality and personal truth of another's experience, and incorporates a range of specific techniques. Validation therapy has attracted a good deal of criticism from researchers who dispute the evidence for some of the beliefs and values of validation therapy, and the appropriateness of the techniques. Feil, however, argues strongly for the effectiveness of validation therapy.

Objectives
To evaluate the effectiveness of validation therapy for people diagnosed as having dementia of any type, or cognitive impairment

Search methods
The trials were identified from the Specialized Register of the Cochrane Dementia and Cognitive Improvement Group (CDCIG) on 5 August 2005 using the terms validation therapy, VTD and emotion-oriented care. The Specialized Register at that time contained records from the following databases: MEDLINE, EMBASE, CINAHL, PSYCLIT, and SIGLE plus many ongoing trials databases.

Selection criteria
All randomised controlled trials (RCTs) examining validation therapy as an intervention for dementia were considered for inclusion in the review. The criteria for inclusion comprised systematic assessment of the quality of study design and the risk of bias.

Data collection and analysis
Data were extracted independently by both reviewers. Authors were contacted for data not provided in the papers. Psychological scales measuring cognition, behaviour, emotional state and activities of daily living were examined.

Main results
Three studies were identified that met the inclusion criteria (Peoples 1982; Robb 1986; Toseland 1997) incorporating data on a total of 116 patients (42 in experimental groups, and 74 in the control groups (usual care 43 and social contact 21, 10 in reality orientation). It was not possible to pool the data from the 3 included studies, either because of the different lengths of treatment or choice of different control treatments, or because the outcome measures were not comparable.

Two significant results were found: 
Peoples 1982 - Validation versus usual care. Behaviour at 6 weeks [MD --5.97, 95% CI (-9.43 to -2.51) P=0.0007, completers analysis] favours validation therapy. 
Toseland 1997 - Validation versus social contact. Depression at 12 months (MOSES) [MD -4.01, 95% CI (-7.74 to - 0.28) P=0.04, completers analysis] favours validation. There were no statistically significant differences between validation and social contact or between validation and usual therapy. There were no assessments of carers.

Authors' conclusions
There is insufficient evidence from randomised trials to allow any conclusion about the efficacy of validation therapy for people with dementia or cognitive impairment.

Validation therapy for dementia

This study describes the development and implementation of a programme of cognition-based therapies for dementia. The programme was designed by distilling the evidence of the effectiveness of Reality Orientation and related approaches, following a broad-based systematic review. The most beneficial elements identified from previous studies were extracted and incorporated into the programme, using the expertise of specialists in the field. The programme comprised of 15 45-min, twice weekly sessions. It ran in one day centre and three residential homes, involving 27 people with dementia (17 treatment and 10 control subjects). The results of the pilot study showed positive trends in cognition, and trends towards reduced depression and anxiety following treatment. No negative effects were identified. We discuss how the outcomes of the pilot study were used to modify the programme, which now has a stronger cognitive element. This refined programme is currently being tested as part of a large multicentre, random...

Can reality orientation be rehabilitated? Development and piloting of an evidence-based programme of cognition-based therapies for people with dementia

BACKGROUND: Reality Orientation (RO) was first described as a technique to improve the quality of life of confused elderly people, although its origins lie in an attempt to rehabilitate severely disturbed war veterans, not in geriatric work. It operates through the presentation of orientation information (eg time, place and person-related) which is thought to provide the person with a greater understanding of their surroundings, possibly resulting in an improved sense of control and self-esteem. There has been criticism of RO in clinical practice, with some fear that it has been applied in a mechanical fashion and has been insensitive to the needs of the individual. There is also a suggestion that constant relearning of material can actually contribute to mood and self-esteem problems. There is often little consistent application of psychological therapies in dementia services, so a systematic review of the available evidence is important in order to identify the effectiveness of the different therapies. Subsequently, guidelines for their use can be made on a sound evidence base. OBJECTIVES: To assess the evidence of effectiveness for the use of Reality Orientation (RO) as a classroom-based therapy on elderly persons with dementia. SEARCH STRATEGY: Computerised databases were searched independently by 2 reviewers entering the terms 'Reality Orientation, dementia, control, trial or study'. Relevant websites were searched and some handsearching was conducted by the reviewer. Specialists in the field were approached for undocumented material, and all publications found were searched for additional references. SELECTION CRITERIA: All randomised controlled trials (RCTs), and all controlled trials with some degree of concealment, blinding or control for bias (second order evidence) of Reality Orientation as an intervention for dementia were included. The criteria for inclusion/exclusion involved systematic assessment of the quality of study design and the risk of bias, using a standard data extraction form. A measure of cognitive and/or behavioural change was needed. DATA COLLECTION AND ANALYSIS: Data were extracted independently by both reviewers, using a previously tested data extraction form. Authors were contacted for data not provided in the papers. Psychological scales measuring cognitive and behavioural changes were examined. MAIN RESULTS: 6 RCTs were entered in the analysis, with a total of 125 subjects (67 in experimental groups, 58 in control groups). Results were divided into 2 subsections: cognition and behaviour. Change in cognitive and behavioural outcomes showed a significant effect in favour of treatment. REVIEWER'S CONCLUSIONS: There is some evidence that RO has benefits on both cognition and behaviour for dementia sufferers. Further research could examine which features of RO are particularly effective. It is unclear how far the benefits of RO extend after the end of treatment, but and it appears that a continued programme may be needed to sustain potential benefits.

Reality orientation for dementia

Reality orientation is now extensively used with psychogeriatric patients. The evidence for its effectiveness is reviewed and the underlying philosophy and assumptions are critically examined. Whilst reality orientation does appear to have some effect, the benefits are small and restricted in range. It can be argued that it is not directed at the most appropriate therapeutic goals. Reality orientation should be seen as the starting point for the development of more effective intervention techniques for use with this client population and not as an end in itself.

Reality orientation: a critical appraisal.

This abbreviated version of the Acute Confusion/Delirium Research-Based protocol provides clinical guidelines for the assessment and management of acute confusion/delirium in the elderly individual. A screening and ongoing surveillance program that is based on identified risk factors is recommended to prevent or minimize episodes of acute confusion in this age group. This protocol is part of a series of protocols developed to help clinicians use the best evidence available in the care of older adults.

Acute confusion/delirium protocol.

Use of reality orientation with elderly confused patients in a nursing home setting was evaluated. Although no significant differences were found in degree of confusion, as measured by the questionnaire developed for this study, between an experimental group who participated in a concentrated three-week reality orientation program and a control group, many effects were positive. Nursing home staff were cooperative and helpful. Families of some of the patients were pleased with improvements in their relatives. Many patients became less confused, more open, and appeared to be more alert.

Use of reality orientation with aging confused patients.

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Use of reality orientation with aging confused patients.