who is that stranger in the mirror? a discussion of ...who is that stranger in the mirror? a...
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Who is that Stranger in the Mirror? A
Discussion of Mirrors for those with Dementia
Wyona M. Freysteinson, PhD, MN
June Kelsick, MSN
Texas Woman’s University
September 25, 2013
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Objectives
Examine one case study of a woman with
Alzheimer’s who saw “a stranger in the
mirror”.
Assess the “evidence”.
Review Lawton’s theory of environmental
gerontology and a phenomenology of the
mirror experience.
Discuss implications for research.
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What are your chances?
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Dementia/Alzheimer’s Statistics Adults 65 and older + Baby boomers will reach 115
million by 2050.
Accounts for 20% of U. S. population.
Projected increase to 71% by 2050.
Sixth leading cause of death
Caregivers accounts 15.2 million (friends/families).
Every 68 seconds someone develops AD
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Alzheimer’s statistics
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Problem?
Societal impact
Increase healthcare cost
From 200 Billion to 1.1
trillion (2050)
500 percent increase
Medicaid/Medicare
combined
Personal final strain
400 percent out of
pocket cost
Caregiver’s burden
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Inspiration for this Project
Personal
Diagnosis dementia / Alzheimer’s
Mom
Aunt
Trial and error/management of mirror
experience.
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Rose
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Rose’s Experience
Diagnosed with Parkinson at 76 y/o
Diagnosed with Alzheimer’s disease (AD) at 80
y/o.
Delightful
Active life style
Independent
Meticulous homemaker
Gardner
Farmer
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Rose
Raised several grandchildren, great
grandchildren.
Active member of her church.
Performed community services.
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Rose
Memory loss
Insidious forgetfulness
Frustration
Agitation
Depression
Hallucination
Delusion
Paranoia
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Rose
Morning routing care was challenging.
Mirror experience
Who’s that stranger
Rose gentle moved away from mirror.
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Rose
Observation
No agitation during oral care – looking
into half-length mirror in bathroom.
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Google appears provide the most
information (antidotal accounts) of
mirrors and dementia.
In addition, advice (often confusing and
vague) is offered regarding what to do
with the mirrors for those with dementia.
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Google Stories
I suddenly heard a shriek coming from
mom's room. Then a crash! "Mom, what's
wrong?" I cried as I entered, seeing her
jewelry box laying on the floor, fallen
open, with her staring at the mirror
looking terrified. She shrieked again and
pointed at the mirror. Looking at the
reflection, she put her hands on her face
and then threw a hairbrush at the mirror. http://ezinearticles.com/?Why-Mirrors-Can-Be-Stressful-for-Patients-With-Alzheimers&id=6193754
Article Source: http://EzineArticles.com/6193754
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Google Stories
A couple of months ago, I noticed dad
talking to himself in the mirror.
Sometimes he slips into his happy little
world of talking to himself and he goes on
and on with conversations.
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Google Advice
“Most of us are familiar with the
phenomenon whereby the Alzheimer
patients do not recognize their own
reflection any more, either in a mirror or
in a car window”.
Question: How do we become familiar with
this phenomenon?
http://www.caregiver.com/channels/alz/articles/altered_perceptions.htm
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Google Advice
I read recently that some Alzheimer’s
patients get confused when they look in
the mirror and see themselves. Well,
obviously they don’t see themselves, they
see a stranger. If that happens, it would be
a good idea to cover all the mirrors.
http://www.parentgiving.com/elder-care/home-safety-checklist-loved-ones-with-dementia/
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Google Advice
Mayo Clinic:
◦ Reduce the number of mirrors. People with
Alzheimer's may find images in mirrors
confusing or frightening.
Question: Which mirrors should one reduce?
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Observational “Study”
In 1996, nurses placed several mirrors of all
sizes on a dementia unit.
71% positive responses of laughter, enjoyment
and an apparent increase in self-awareness.
One man displayed anger and despair, followed
by calmness.
Limitations: No IRB, no control, etc.
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1960’s Grandma Fannie
1970’s Miss Peace
1974 Bed bath Lab
1990 Dean says No
Dr. Freysteinson’s Inspiration for
this project
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Inspiration for a Survey Study of Mirrors in
Long-Term Care (LTC)
In a study of women viewing
self in the mirror, one woman
living in a nursing home had
not seen her body from the
waist down in eight years.
Her greatest concern was she
could not see if her catheter
bag was showing (Freysteinson, 1994).
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Survey Study of Mirrors
in Long-term care (LTC)
Mirrors in an empty, single resident room in
ten LTCs were measured.
Mirrors for the bedbound, wheelchair bound
and full body view were examined.
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Results
One LTC had a
mirror for the
bedbound resident.
Mirrors appropriate
for a resident in a
wheelchair were
available in only 7/10
LTCs.
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View of the Whole Body
10% of LTCs had one
full length mirror in
which one could
view the full body.
This mirror was in a
public front foyer.
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What I could not publish…
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The Mirror Dilemma
At first, simply getting rid of the mirrors
for someone with dementia/Alzheimer’s
sounds like a relatively simple solution.
However, using Lawton’s theory of
environmental gerontology…let’s focus
on the value of mirrors.
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Lawton’s Theory of
Environmental Gerontology
Support
Therapeutic Environment
Maintain
Stimulate
Three Functions of the
Residential Environment
Lawton, 1989
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Maintain
The maintaining function of the environment is
to create an environment which feels like home.
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Maintain One’s Appearance
Mirrors within a
home like
environment allows
one to continue to
maintain one’s
physical appearance.
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Support
A supportive environment works to support
reduced or lost cognitive abilities.
Belgium researchers suggested 11/51 patients in
a post-comatose state tracked self in a mirror
but did not track anything else (Vanhaudenhuyse et al, 2008) .
Nurses in Israel found 100 elders with dementia
had increased self-recognition and a desire to
care for their own appearance when mirrors
were added to the nursing unit (Tabak et al, 1996).
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Stimulate
Stimulating
environments
enhance well-being
and social
interaction.
Mirrors provide a
novel array of stimuli.
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Questions
Are mirrors which
simply help to make
an environment feel
like home are
appropriate in homes
(including LTC
homes) where a
person with
dementia may live?
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Phenomenology of Mirror-ing
Two studies (Freysteinson 1994 and 2011)
uncovered the phenomenology of the
experience of mirror-ing for individuals
who do not have dementia.
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Phenomenological Interpretation
Four key meaning moments emerged in the
interpretation of viewing self in the mirror:
I am
I decide
I see
I consent
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I Am
Genetics, life experiences and environment help to
create a unique way of being-in-the-world.
I am self-conscious.
I am wise.
I am very blessed.
I am Scandinavian.
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I Decide
Curiosity
I think it is just a natural curiosity to look and see what’s happening to you.
Medical Care
I thought that (bathroom) was the most logical place (to change the dressing).
Keeping up Appearances
You make your self look better (with the mirror) by
using prosthesis or whatever means there are for beauty.
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I See: With my Mind’s Eye
Apprehension
I was going to have a mastectomy so I used to see myself in the mirror, and try to imagine how I would look.
Expectation
This scar is uglier than I thought it would be. I thought it would be a little bit prettier.
Hope
I used to imagine before I went to the mirror that my breast would still be there, that this has all been a dream.
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I See: With my Eyes
It depends on how your eyes are I guess because my eyes
aren’t good either.
Also I’ve got macular degeneration and I’ve already had
glaucoma …One side (of the mirror) is magnified and the
other one isn’t. So I really can get a good look.
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I See the Meaning: Understanding
All women understood part of their body to be
unattractive, unsightly or repulsive.
Many emotions accompanied this understanding:
shock, surprise, disgust, unworthiness,
anger/frustration, fear, sadness, relief & happiness.
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I See the Meaning: Understanding
(I was) looking in the mirror constantly. …It was gross, it was
so disgusting. I couldn’t hardly face myself or look at it
because it was so disgusting.
But I was so ecstatic that it (mastectomy incision) was
closed! See the attitude change? I’m like look at this, it’s
stitched closed!
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I See the Meaning: Understanding
Distanciation
You’re seeing that every time you stand in front of the mirror.
It looks real ugly.
Appropriation
My scar is beginning to fade.
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I See the Meaning: Explanation
Medical
I don’t know how to explain what I am talking about. It is like they (doctors) took a lot of flesh off of me.
Theological
You know that’s the devil in there.
Societal You’d be surprised what men say about this, this surgery. They can’t cope with it.
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I Consent
Suffer
You have your days where you could sit there and have a pity party.
Acceptance/Acquiesce I still do look in the mirror and wish I had more you know up there but may have to learn to accept it, the way it is.
Thrust Forward into the Future
I sure hope they can fix the bruises on my face so that I do not look bad in the coffin.
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Questions
In offering or having mirrors available in LTCs
do nurses provide an enhanced opportunity for
residents to recognize self, enhance well-being,
and social interaction?
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Questions
One can find antidotal information in
Google that the “strangers” an individual
with Alzheimer's sees in the mirror may:
◦ Be a sign of early Alzheimer's
◦ Occur in Mid-stage Alzheimer's
◦ Occur Late-stage Alzheimer's
How do we best determine at what stage
“mirror confusion” may occur in this
population? 46
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Questions
How do we explore the experience of the
mirror for those with dementia/Alzheimer’s?
Is mirror distress a sudden symptom or is there
a mirror distress trajectory pathway from
better to worse?
How do we develop a tool to measure mirror
distress?
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Questions
Do persons with
dementia see
“strangers” in some
mirrors more than
other mirrors?
Large mirrors? Mid-
size mirrors? Small
handheld mirrors?
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Questions
Does lighting effect the mirror
experience?
Are mirrors commonly used for ADL’s
less likely to cause mirror distress as
compared to mirrors that a person with
dementia does not commonly look in?
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Questions
If a person sees a “friend” or a delusion of
an earlier self in the mirror, should we
remove the mirrors? How do we best
assess this for this experience?
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Questions
Does the addition of accessible mirrors
enhance the ability of a person with dementia
to perform activities of daily living?
Does the person with dementia who has access
to mirrors have a greater chance of self-
recognition?
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Questions
How do we objectively determine the
number and kinds of mirrors for this
population?
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Questions
How can loved ones and other caregivers
in the home determine how to balance
the potentially positive value of mirrors
with the potential mirror distress?
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Discussion
What and how do we begin to research
this phenomenon in this fragile
population?
What should this research trajectory look
like?
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Rose Wife
Mother
Grandmother
Sister
Aunt
…was my beloved mother.
Rose died on May 13, 2001 a the age of 86.
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Rose’s Family
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Discussion
Need for research in this area.
Research regarding the use of mirrors in the dementia/ Alzheimer’s population group will uncover a broad spectrum of knowledge.
Nursing and caregiver implications must be addressed.
Rose may have benefited from such knowledge.
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In Conclusion
Evidence in this field appears to be an
essentially unexplored field.
Currently we do not know how many questions
there are and what those questions may be.
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Contact Information
Wyona M. Freysteinson, PhD, MN
June Kelsick, MSN
References available on request.
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