I recently had the pleasure of working with a woman named Mary at her daughter’s home. Mary was a pleasant 88 year-old with moderate to severe dementia. She was quite mobile and busied herself by meandering around the house collecting and moving objects. She could carry on a conversation using the correct speech patterns and inflections, but the substance of her message consisted of incoherent speech. She was aphasic and spoke completely in word salad.
Mary and her caregivers spent a lot of energy trying to communicate with each other. Because she was “verbal”, her caregivers used verbal language as the primary means of communication- hoping that at least parts of their questions or commands would get through. The result was a lot of repeated questions, asked with a progressive rise in volume, and ending in the frustration of both parties.
Mary’s family and caregiver reported that Mary required significant physical assistance with all of her self care. They said she was completely unable to toilet herself, get dressed, or use any objects purposefully (comb, toothbrush…). When I watched them try to guide Mary through a toileting task, I noticed that the only cue they gave her was via verbal instruction. Actually, it was repetitive verbal instruction accented with the nuances of family dynamics, “Mom, pull your pants down. Get them down and then sit down. Are you wet? Hold on I’ll get, wait, Mom, stop, you need to go to the bathroom. Stand here. Move closer. Pull your pants, I’ll do it. Ok sit down. Mom, SIT DOWN!”
Over the next three visits, I guided Mary through each of the basic self care tasks- dressing, toileting, and grooming- without saying a word. The first and most important part was getting Mary’s attention. She was “busy in the brain” and talked to herself much of the time, so I would have to get in her visual field and wait for her to make eye contact with me. I smiled, she smiled. Connection.
I kept Mary’s attention by staying within one to two feet of her face, and making sure she watched my gestures. I pointed at the toilet, exaggerated the simulation of pulling my pants down, and gestured for her to do the same. I mimicked the act three times until she got it. Once she initiated the motor sequence, procedural memory did the rest. She completed each step of the task without my input. The quality of her actions wasn’t great, but it was a long way from dependent.
It played out exactly like a silent movie. And it had an excellent ending.
As I’ve said many times before, the secret to accessing function in the demented brain is through the visual cortex. The secret to performing function is through motor memory.
Mary could not name a simple object or demonstrate its use. She could pick up the toothbrush but not hold it in the correct grasp. Once I demonstrated what it was for and prompted her to put the toothbrush to her mouth, motor memory kicked in. Although I had to point and gesture each step of the task, turning on the water and rinsing, I did not have to physically help her.
Keep in mind that a person who is unable to use verbal language correctly is also unable to understand verbal language correctly. Alzheimer’s disease targets the language center very early in the disease, but leaves the visual and motor cortex largely intact until the end.
- Get in the visual field to capture attention.
- Demonstrate commands and actions.
- Self-initiation is key to kick start motor memory.
- Stop talking.