Brain Gym - Emerging From Dementia 424hv

EMERGING FROM THE SHADOWS OF DEMENTIA:

How

ELDERLY PATIENTS

BENEFIT FROM BRAIN GYM

Kathy Monahan, OTR/L, Massachusetts,

U.S.A.

first learned about Brain Gym@whenIread Carla Hannaford's book Smart Moves: Why Learning Isn't All in Your Head. Over the next several years, I pursued licensure as a Brain Gym@ Instructor. I initially used Brain Gym with children in my occupational therapy practice. Then, as fate would have it, I started working with the geriatric population. Many of my elderly clients have some degree of dementia. Besides showing evidence of memory loss, these individuals are often restless and physically agitated. A person who has dementia never smiles, is in fairly constant motion, and wears an anxious expression. In posture, he or she will be stooped, or curled up into the fetal position in bed. The sleep patterns are severely disrupted, Kathy Monahan so the quality of rest is poor, with the person sleeping in restless catnaps of no more than a few minutes here or an hour there. So, for months or even years, these patients live in what amounts to a constant state of fight or flight. Because they no longer know who or where they are, the world seems a frightening place for them. In working with these patients, I observed that an individual with dementia presents with sensory processing dysfunction as well as behavior, attention, and communication issues. These were the same issues I had found in children with attention deficit syndromes and autistic disorders. Both populations have great difficulty with new learning and with gross- and finemotor skills. In short, I was now dealing with the same kinds of problems on both ends of the age spectrum. In addition, my elder clients had very poor short-term memory. I started using Brain Gym with my geriatric clients, and was amazed at the changes that occurred. Some of those changes were not only dramatic but instantaneous.

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DEVElOPING

A STRUCTURED

ApPROACH

As I incorporated Brain Gym exercises and balances into my daily case load, I began to develop a structured approach to each individual and each session. Most of my clients are unable to grasp the concept of goal setting, so I have to carefully consider their past roles in life and current state of function. I often set goals around the present disability or dysfunction that is impeding a person's ability to successfully function within the present environment. I observe posture, balance, motor

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control, triggers of anxiety or agitation, verbal and nonverbal communication, and any apparent sensory defensiveness. (Sensory defensiveness is characterized by an extreme reaction to light, noise, texture, food, scent, or visual stimuli such as being in a crowded room. The reactions can include screaming, hitting, agitation, elopement attempts, or withdrawal into oneself, to name a few.) In the four years that I've been using the Brain Gym program with geriatric patients, I've discovered that all of my clients choose a certain Brain Gym activity-the Positive Points-as their first exercise. The Positive Points are enormously helpful in releasing my clients from the perpetual state of stress that plagues them. When I first place my fingertips on the two pulse points on the frontal eminences of the forehead, the pulse (very easy to locate on delicate, thin skin) is most often rapid, erratic, and asymmetrical. Within a minute or two, the pulse becomes slow and even, and eventually it becomes a steady beat or a gentle swishing feeling between my fingertips. I often work with a client who is lying down on a mat or in bed. Initially, I need to the head and neck with several pillows, as the individual is too anxious to allow his or her head to drop back onto the mat. Other pillows the arms and legs in a comfortable position. As I hold the Positive Points, the entire body relaxes and the head lowers back onto only one pillow or onto the mat. The entire body opens up, often for the first time in a long time, into a relaxed reclined position instead of a curled up, withdrawn posture. The anxious expression on the face relaxes, and the person falls into a deep, restful sleep. Some clients will sleep peacefully for an hour or more after I've held their Positive Points for several minutes. I've learned to detect with my fingertips the smallest of changes in the patient's pulse and state of muscle release. Upon awakening, the individuals will often lie quietly in a state of calm alertness, and will allow me to move their limbs through other Brain Gym exercises. Some smile and start to talk. A couple of nonverbal clients have taken my hands and placed them back onto their Positive Points as if to request more of this activity. I monitor blood pressure and pulse throughout the exercises, and note improvements in both areas during use of the Positive Points. When the residents are in a relaxed state, it's easier to give them their meds or help them perform self-care tasks that are usually met with combative resistance. Many dementia residents become agitated around other people on the unit, but after doing the Positive Points they are often able to tolerate the increased stimuli without agitation. After several sessions in which they used the Positive Points, some patients have even initiated social with staff and other residents. Clients who were previously restless and in constant motion are often able to sit quietly, and will smile at others on the uniteven during chaotic times such as shift changes. Posture becomes more open and balanced, reducing the risk of shortened muscle tissues and postural deformities, and personalities emerge from the darkness of dementia.

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2009

THE ALLEN SCREEN AS A COGNITIVE

MEASURE

JOE

Occupational therapists set short- and long-term goals for their clients, with the focus on improving activities of daily living, or ADL, such as bathing, dressing, grooming, and toileting. Brain Gym goals focus on accessing positive behaviors and releasing negative ones, and can often be incorporated into occupational therapy goals. Therapists document therapeutic interventions and the client's response to those interventions. We use many measures and standardized tests to document progress, primarily for insurance reimbursement purposes. The standardized measure that I use most often is the Allen Cognitive Level Screen, which measures the degree of the person's cognitive abilities and how that cognitive level impacts the functional abilities. Allen scores range from comatose to "normal" (i.e., no cognitive impairment). The Allen model is unique because its focus is to identify strengths as well as weaknesses, so that the person can maintain his or her best ability to function for as long as possible. I test individuals to obtain their baseline Allen Cognitive Level score during the initial evaluation. Then, as 1 introduce WITH BRAIN GYM, Brain Gym balances and MANY OF MY CLIENTS exercises, 1 periodically retest with the Allen Screen. All Allen SHOW AN IMMEDIATE scores and interventions are INCREASE IN THEIR documented in daily and weekly notes that are part ofthe patient's ALLEN SCORE, medical record. INDICATING IMPROVED After they do Brain Gym, COGNITIVE FUNCTION. many of my clients show an immediate increase in their Allen score, indicating improved cognitive function. It might be argued that an improved Allen score can be attributed to the client's ing doing the Allen screen previously. However, these increases occur in clients who have very poor short-term memory and who often don't what happened more than a few minutes ago. They seldom taking the Allen Screen previously, and they approach the test as something they've never done before. After determining goals and the Allen cognitive level, I start with the four PACE*activities. If the person has difficulty following commands, I will gently move their arms through the PACEsequence. I've also used many of Cecilia Freeman Koester's modifications of the Brain Gym movements from her book I Am the Child: Using Brain Gym@ with Children Who Have Special Needs. These modified movements are good to use with individuals who have severe physical disabilities, such as from degenerative t disease or stroke. After we do PACE,I'll often take the person through a Dennison Laterality Repatterning* (DLR) process to help restore wholebody movement, using advanced Edu-K processes for the balance when someone is unable to communicate or freely move his or her limbs. It was my use ofDLR that convinced me I was on to something big in using Brain Gym with my elderly clients. The story of a man I'll call "Joe" illustrates the power of this simple intervention.

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Joe was the first geriatric patient to whom I gave a Brain Gym balance. Being in an advanced stage of Alzheimer's-induced dementia, Joe was shuffling around aimlessly when I met him, rummaging through drawers and closets in a constant state of agitation. He spoke in mumbled gibberish, wasn't able to make eye , and couldn't focus on anything for more than a couple of seconds. His posture was stooped and he had a limited range of motion in his neck; when he turned his head, his body turned with it. He had tunnel vision, looking only at the floor, and seemed unaware of the presence of others. He would respond to hearing his name with only a barely perceptible nod, if that. He seemed to have no sense of himself or his midline, and his impulsive, erratic movements and lack of self-awareness were putting him at great risk for falls and injury. I evaluated Joe in his own room. He was in constant motion and difficult to redirect. When handed his socks, he looked at them for a second and then brought them up to his face as if to use them as washcloths. When handed his toothbrush, he ignored it and rummaged through his closet, constantly muttering to himself. He completely ignored my presence, and would have walked right through me if 1hadn't moved out of his way. Because he was unable to grasp the concept of a goal, I had to set a goal for him. I considered his stooped posture, garbled speech, and constant agitated movements, then thought about what he must have been like before the onset of Alzheimer's. The goal that came to me was: "1 walk with purpose, my head held high, my voice strong and clear." When I was finally able to get Joe to sit down, I did a modified DLR with him, using hand-over-hand techniques to move his hands and legs. He was unable to follow the commands to look up to the left and hum and look down to the right and count backwards. I honored his inability to follow my commands, performing that part of the DLR for him while I moved his hands and legs through the movements. Due to his constant jumping up and moving randomly around the room, it took a long time to move him through the repatterning, but eventually we finished. As soon as we were done, Joe sat down, turned his head independently of his body, looked me right in the eye, sighed, and stated clearly, "My mind just isn't what it used to be." He then smiled at me without breaking the eye . I suggested that Joe finish getting dressed so we could take a walk to look at the plants in the dayroom. When I handed him his socks, he put them on his feet without hesitation. He then took his toothbrush, went into the bathroom, and brushed his teeth. As we walked down to the dayroom, he told me in a clear voice that he had been a gardener and was always proud of the things he grew. He still shuffled, but his posture was straighter and he was able to tum his head to say hi to the staff and other residents. He spent the next hour showing me how to deadhead the plants in the dayroom, and was able to name each plant as well as any tree he saw from the window. His voice remained clear, and he had stopped muttering. Due to the degenerative nature of his Alzheimer's disease, Joe continued to decline. He would have periods of extreme

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agitation, especially at night (called "sundowning" in the geriatric care profession). Yet he never again lost the ability to speak clearly. Until he left, a few months later, to go to a facility that was closer to his family, he would always greet me with a wink and a smile when I arrived on his unit. CATHERINE One of my most challenging residents became central to one of my most rewarding Brain Gym experiences, primarily due to the Positive Points. "Catherine" was an elderly patient in the advanced stages of dementia who was often restless, agitated, combative, and difficult for the nursing staff to care for. The aides often emerged from her room with many scratches after getting her washed, dressed, and in her wheelchair. Swearing and expressing herself in a jumbled mix of nonsensical words thrown together, Catherine was unable to speak coherently and often yelled at people who weren't there. She was constantly pulling at and shredding her stockings, and would lick her hand very noisily, much to the disgust of other residents. She never smiled, and was unable to make eye . She seemed to be in another world, and would look right through any visitor who dared to approach her. Anyone who came near risked being bitten, scratched, or spat at. Because Catherine was unable to communicate any kind of goal to me, I considered her constant restless movement, her perpetually miserable facial expression, and the vacant, faraway look in her eyes. The Brain Gym goal that suggested itself was "to be still, joyful, and present," and my occupational therapy goal was for her to allow her self-care to be performed without agitation or combativeness. I worked with Catherine for several weeks, and held her Positive Points at the start of each therapy session. She would sit quietly and tolerate having her Positive Points held for up to fifteen minutes, and didn't pull at her stockings or lick her hands during our sessions. These were the longest times that she had been able to hold still (while awake) in months. I could feel her entire body relax, and her pulse would go from rapid and erratic to smooth and even. She never once tried to bite or scratch me, and would sometimes guide my hands into just the right spot on her forehead. Over the next several weeks, I was able to use all twenty-six Brain Gym activities with Catherine, and to help her through several balances. At the end of each session, Catherine was able to make eye with me and would watch me move around the room. She was calm, and sat quietly with her hands folded in front of her. After one particular session, she looked me in the eye and asked, "Are we done?" When I said that we were, she said, "Thank you very much." I told her that she was most welcome, and added, "I love you, Catherine!" She leaned forward and yelled, "I love you too, honey!" in a happy tone of voice. After a few weeks of the Positive Points, Catherine was much easier to take care of. She no longer licked her hands, and only pulled at her stockings when she was anxious (in a crowded lobby, for instance). She still called out, but swore less. She began to make eye when visitors approached

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at her eye level. She still talked to people who weren't there, but her conversations were less agitated and more coherent ("Hey, how are you? How are you doing?"), and she would now spontaneously start to sing. She would take my hand and kiss it, or pull me in for a kiss on the cheek when I made with her. She was able to sit quietly for longer periods of time, with a relaxed expression on her face. Her wonderful, quick-witted personality emerged from the darkness, and Catherine met both of her goals. THE NATURE OF DEME T1A As Catherine's example illustrates, the Positive Points activity has been enormously helpful in releasing my elderly clients who have dementia from the state of fight, flight, or fright that they might have existed in for months or even years. I've worked with extremely agitated gentlemen who went from swinging at SKILLS THAT CAN AND me with their fists to, within DO IMPROVE INCLUDE minutes of my holding their Positive Points, blowing kisses GAIT, BALANCE, MIDLINE to me and calling me the love AND UPRIGHT POSTURE, of their life. THE SENSE OF WHERE The Positive Points is one of the most powerful Brain Gym ONE IS IN SPACE, GROSSexercises I've ever used for the AND FINE-MOTOR release of mental or physical COORDINATION, AND stress. It's been the vehicle that has allowed people lost SEQUENCING SIMPLE AND in a terrifying place to come COMPLEX TASKS ... back to a familiar world. Sadly enough, a goal of regaining memory almost never comes up in working with a person with dementia, for damaged short-term memory can almost never be recovered. Skills that can and do improve include gait, balance, midline and upright posture, the sense of where one is in space, gross- and fine-motor coordination, and sequencing simple and complex tasks such as the steps involved in bathing, dressing, and grooming. Language and communication skills also improve, as does swallowing. Unfortunately, dementia is a progressive disease that slowly kills the brain over time, in a process that is emotionally painful for both client and caregiver. In each stage of the disease, I consider what skills the person needs to function successfully within the environment. When the ability to walk is lost, I focus on seated positioning and balance, to ensure that the client is able to maintain an upright midline posture for eating until no longer able to tolerate sitting upright As the dying process commences, the use of Brain Gym maximizes circulation, range of motion, a sense of the selfin space (which is often lost when the person no longer bears weight on the feet), and an easing of the emotional stress of facing the final transition. Goals change, but the focus remains the same: to optimize the quality of life. As the client's neck muscles become weak, the diet texture is modified from regular, to finely ground, to pureed. Liquids need to be thickened to prevent their being aspirated into the

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_ . Certain Brain Gym exercises (primarily a modified Ann ctivation, the Thinking Cap, and the Energy Yawn) can be used to strengthen weakened swallowing muscles and delay the resorting to a downgraded diet for as long as possible. I work with speech therapists who monitor swallowing while I perform the modified exercises. There is always an improvement in swallowing after Brain Gym, so speech therapists are enthusiastic ing the Brain Gym activities with their clients. In preserving the memory and skills of a person with dementia, consistency is the key. Where this most helps is in the . use of Brain Gym activities and in the education of the nursing staff regarding the importance of a consistent approach and environment, to maintain the person's levels of ability for as long as possible. As a result of such even, appropriate treatment, I have seen the most dramatic improvements occur in an individual's anxiety level and social behavior. Residents who were unable to tolerate a noisy dining room or unit lobby are eventually able to sit with their peers and socialize appropriately. The need for anti-anxiety medications has decreased, as has the agitation and restlessness most commonly seen in the late afternoon. If a resident does become agitated, the use of the Positive Points and a weighted blanket helps to calm the person within a short period of time. One of the inevitable aspects of working with the geriatric population is preparing individuals for the transition from this world into the next. I've found Brain Gym to be a valuable tool in working with a dying elder, right up until the end. The dying process is physically, mentally, and emotionally challenging, yet modified Brain Gym movements help to bring peace to a restless body and mind during the final transition. Some of my most memorable Brain Gym experiences have been with dying patients, such as Michael. MICHAEl

The man I'm calling Michael was an elderly gentleman in the last stages of dementia. Once the captain of the fire department in a large city, he was now dependent in all aspects of self-care, and couldn't even tolerate sitting up in a wheelchair. He sat positioned, instead, in a recliner chair (also called a "geri chair"). He didn't open his eyes when awake, and he had "premorbid agitation," which is the state of physical restlessness before dying. Michael had to have a seat belt on while in his chair to stop him from falling out. His arms and legs were in constant motion, and he had a pained expression on his face. He spoke in mumbled whispers, was constantly pulling at his clothes or blankets, and did not respond when spoken to. It took me quite a while to figure out a goal for Michael, as he was so restless that it was hard to keep my hands on him to "listen" to what he needed. Before anything else could be tried, he needed his Positive Points held for a long time to calm him down. Eventually, the goal of being peacefully at rest came up, and Michael's occupational therapy goal was to tolerate being out of bed in his geri chair and maintain good posture without agitation so as to achieve a position for safe eating. For this balance, the Focus Dimension came up as the priority*, with the Movement/Structure realm as the Learning

Menu*. I traced an X (from Think of an X) on Michael's back, to connect shoulders to hips, and gently guided his arms in the pattern of Lazy 8s. Movement Reeducation* both below and above the waist was also indicated, and the other Brain Gym movements that came up were the Positive Points, the Calf Pump, and the Footflex. It took us a very long time to work through this balance. At the end of the balance, Michael relaxed and fell asleep with a peaceful expression on his face. In the following days, he was less restless and more relaxed in his chair. He still kept his eyes closed and continued to speak in mumbles, but he didn't pull at his clothes so often. Also, his posture in the chair was good and he was calmer. A week after the balance, I had the opportunity to show Michael's niece some Brain Gym activities that she could use with her uncle to help him relax. I had shown her the Positive Points for calming him, and was explaining the Footflex as I moved his feet (I had been doing the Footflex with Michael, in addition to the Positive Points, almost every day during the prior week). I told her that one of the more interesting aspects of the Footflex is the spontaneous verbalization that sometimes occurs following that particular movement. At that moment, Michael opened his eyes. I told him that his niece was there. He looked up at her for a moment, and said simply, "That's nice." He then went to sleep, his body becoming totally relaxed. His niece told me that he hadn't said anything coherent in weeks, and that it was the first time he had made eye with her in a very long time. We were both in tears. Michael ed away peacefully just a few days later.

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BRIDGE TO EACH INDIVIDUAL

Brain Gym is the bridge that allows me to find the way to each individual, no matter what the state of withdrawal or unresponsiveness. The body responds when the brain cannot. And, as a result, the person becomes calmer and less agitated and anxious. The whole person relaxes into a state of peacefulness. The Brain Gym activities and balances that I've done with dying patients are among the simplest and most powerful interventions for bringing balance to the body-mind system and calming even the most anxious individuals in preparation for their final journey. The use of Brain Gym with elderly dementia patients has been life-changing for them, and for me as well. I have learned to not project my own goals or needs onto my clients. I've become a more perceptive therapist, and can notice the slightest changes in my clients through touch. I've learned that even a person functioning at a very low level can communicate through pulse, respiration, body movement, or facial expressions. I've learned to honor where my clients are in time and space and work with them in their world. I've learned to be still and to listen with an open heart and with patience when working with nonverbal clients. I've learned to trust the process of each balance. Out of all my tools of occupational therapy, when working with elderly people who have dementia, the Brain Gym exercises and balances are the most successful interventions I've ever used. (CONTINUED

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EMERGI G FROM DEMENTIA (CONTINUED

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The power of these simple, elegant movements never ceases to amaze and humble me. Kathy Monahan is an occupational therapist and rehabilitation director in a nursing facility in Providence, Rhode Island. She has been using the Brain Gym activities in geriatrics for several years. and says that they have been a great tool for working with many diagnoses to improve balance. coordination, speech and swallowing disorders. and cognitive impairments. Kathy has used the activities tofacilitate numerous "little miracles" in her clients who haveAlzheimer:S disease. She lives with her husband and two of her three children in Uxbridge. Massachusetts ..•.

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