By Shoshana Averbach, MSW, LMSW, MA, MT-BC, LCAT
Communicating with persons who have cognitive impairments such as Alzheimer's disease and dementia can be very challenging for the caregiver and the affected person. Cognitive impairments such as memory loss, delayed processing time for answering questions, repeating the same question or providing inaccurate information often leave the caregiver befuddled and feeling frustrated-and more so when the affected person denies or masks that anything is amiss with him or her. Futility, helplessness and hopelessness cause stress which can result in losing one's temper which does neither party any good and exacerbates the burdens of caregiving. Music, however, can be employed simply and effectively for alleviating caregiver strain, improving quality of life for the elderly patient, and injecting playfulness in a stressful situation. Even a person who has no musical training can utilize the techniques in this article.
Music Therapy and the Power of Music
The American Music Therapy Association (musictherapy.org) defines music therapy as "the clinical and evidence-based use of music interventions to accomplish individualized goals within a therapeutic relationship by a credentialed professional who has completed an approved music-therapy program." Music therapists discover what types of music and sound turn a person on or off and the associations with those compositions or sounds. Often, these associations and feelings are imbedded in long-term and the sensory memory and are more accessible than recalling what the person ate for breakfast earlier that day. One's most primitive memories are with smells and sound. The latter is the first sense to develop in the womb and is the last to go on the other end of life. Music bypasses the neocortex or thinking part of the brain, thus allowing those primitive images and associations to be easily accessible and utilized therapeutically. The ability to enjoy and benefit from music is not dependent on any physical or mental functional ability. Even comatose patients benefit from listening to music.
User-Friendly Techniques Even for the Nonmusician
Reminiscence and discussion stimulate memory, engage communication skills such as eye contact and promote social interaction rather than withdrawal and self-isolation. Reminiscence promotes self-esteem and personhood: "I know that!" "That's me!" "That's my Jewish identity and history!" Play a CD of the patient's favorite songs or songs the patient can relate: WWII, Yiddish, patriotic and holiday songs. Encourage conversation such as "Where were you when you heard this song? Who was with you? About how old were you? What was your address and telephone number?" Show the person recording jackets, pictures or photographs that go along with the music.
Music and movement go hand in hand, literally. If the affected person is ambulatory and steady on his/her feet, get up and dance! Dancing evokes positive feelings of joyful occasions and helps oxygen and blood circulation which are beneficial for memory and brain function. If one is not ambulatory, "dance" by taking the persons hands and feet and moving them. Move with a scarf which adds tracking-the ability to follow an object and stay engaged. For persons who tend to grab and cling, hold the underside of their forearms.
Rhythm-band activities such as shaking a maraca or tambourine in time to music promote awareness of one's surroundings and is a fun activity as if one is a member of the band or orchestra. Instruments can be purchased or made inexpensively. Make a shaker from beans, rice, or cloves in a plastic container. Bang a pot lid with a spoon. March in time to the music while playing.
Orientation songs help to ease transition times which often confuse dementia patients and cause them to be rigid. Take a song like "Bei Mir Bistu Shein" and insert words such as "We're going to eat lunch/go to bed/take a bath/get up." Sing melodies to prayers which are imbedded in long-term memory. Just as radio or TV programs have an opening and closing theme song, begin and end the day with the same song to help the person anticipate what will happen. This reduces confusion and promotes cooperation.
Communicate by singing and the person will probably understand you better because the language is processed by a different part of the brain other than the neocortex or thinking part of the brain. Make up a song to relate the day, date, person's name: Good morning to Moshe, good morning to you, good morning to Moshe and how do you do?"
Lining Out Songs is a technique that stimulates memory like "Name That Tune." Play a game called Can You Remember the Lyrics? Start humming a melody. Ask the person to say or sing the lyrics. If s/he cannot, feed the person with the first few words: e.g., Oh beautiful for ______ (spacious skies).
Listening to music quietly with dimmed lighting provides a calm and safe environment. This can be effective for persons who are agitated. Agitation often accompanies fear, anxiety and confusion. Provide verbal and tactile reassurance by holding the person's hand and saying you love him/her or "It's going to be OK., " "I am here with you."
Apparent feedback is wonderful but not always available. Trust that you are reaching someone, somewhere, somehow, in some way. Even on a spirit level, you ARE reaching him/her. Keep trying and use repetition. Maybe the person needs extra time to process what's going on or become accustomed to a routine. Look for subtle signs like change of affect (how emotion is shown on the face), breathing (deeper, faster, slower), eye contact or eye movement, twitches. Alzheimer's and dementia patients relate on a very basic feeling level. Just as young children are sensitive to facial expressions, vocal cues, and presence, so are these patients. They are used to being addressed in a certain tone of voice; don't belittle nor infantilize them. Reinforce any efforts to engage with you or the activity. Even making eye contact is a basic communication skill: Point to your eyes, look at the person directly, and say "Good looking Miriam!"
Caregiving requires tremendous strength of character. Endorse yourself for your efforts. Accept your limitations and forgive yourself. Listen to your own favorite music for comfort and strength. Your job is not to complete the task but, rather, to do your best to maintain the patient's quality of life and personhood. Utilize music to help you and the affected person accomplish this seemingly-monmouth task.
In conclusion, I would like to share this quotation from Sayings of the Moharash, Part B:
Most people who are nervous types, that is only because they have weak nerves, and that causes depression, anger, and murder. Their lives are not theirs at all because they are under internal pressure, and this completely destroys their life. Therefore, he who has weak nerves is behooved to guard his health very well: to eat, to drink and to sleep well, and to hear instruments of song and so, because of that, his nerves will be strengthened and he will merit a complete recovery and everything will pass.
Please feel free to contact me with feedback, questions, or to try a home-based session.
Shoshana Averbach, MSW, LMSW, MA, MT-BC, LCAT, has worked with geriatric clients for over 30 years in the fields of music therapy, social work, and recreation. She also is certified as an accredited healer, practicing energy and spiritual healing, and uses holistic approaches to optimize wellness in her clients. She is available for consultations and home and hospital visits. For more information, see her web site: www.healingnotes.com