December 04, 2020
A tiny tap on the leg tells him to lift his foot so I can slip off his shoe. My message is communicated so easily. His exhausted brain doesn’t need to struggle to find the meaning of words that can barely fit through his outdated hearing aides. It’s not a particular code we have worked out – it’s an intuitive understanding that would work in most instances.
Our skin is incredibly sensitive to information via touch. Nerve endings in the skin can differentiate between an amazing array of sensations, including temperature, pressure, pain, itch and gentle touch. Special receptors even recognize emotional messages conveyed through touch.
Technically known as haptics, communication via tactile stimulation is our earliest connection with the outside world. From before we are born we recognize and respond to pressure and vibration.
I'm not sure whether haptics would technically qualify as behavioral communication, but it is squarely beneath the umbrella of non-verbal communication. Touch is one of the best avenues we have to communicate with some people with dementia.
Beyond its potential as an avenue of communication, touch is also a human need that has consequences if left unmet. Some people with dementia have few opportunities to share meaningful touch with loved ones in their lives. For many, professional caregivers may be their only option for connecting with another human through therapeutic touch.
Brain degradation tends to occur in the opposite order of development. The abilities and senses that develop first are among the last to leave.
Touch is our first sense to develop, initially appearing about 8 weeks after conception. The first touch receptors appear around the lips and nose. More touch receptors develop on the palms of the hands and soles of the feet by around 12 weeks, and on the abdomen by 17 weeks. By the 8th month, an unborn baby can feel temperature, pressure and pain in every part of its tiny body.
Scientific studies show that unborn babies are more responsive to touch than sound, and are more responsive to their own mother’s touch than anyone else’s. Some researchers regard this response as a basic form of communication.
In fact, scientists are starting to discover that, despite what most of us realize, touch is our strongest form of non-verbal communication. Studies indicate we are far more adept at deciphering touch than we are at decoding facial expressions or tone of voice.
Verbal language is challenging for our brains to decipher and process. As neuroscientists put it: language carries a heavy “cognitive load”. I myself would tend to agree, especially by the end of certain days! But touch is different. Understanding touch is natural, intuitive and easy in many cases – although, there are exceptions, to be sure.
Touch messages tend to be somewhat vague and limited when compared to verbal messages, which can be highly specific. However, at the end of a long day, sometimes a gentle squeeze of the hand – or slap on the wrist – communicates all you need just fine.
Researchers have studied emotional communication in touch. In one such study, strangers were paired up with each other on opposite sides of a barrier, so they couldn’t see each other. One participant put an arm through an opening in the barrier. The partner was instructed to try to communicate an emotion simply through a one-second touch to the forearm. Researchers were blown away at how often participants correctly identified the emotion being transmitted! People were especially proficient at recognizing compassion.
This is likely because human skin has a special kind of touch receptor that distinguishes emotion. Known as C-tactile afferent fibers, these specialized receptors are designed to interpret emotional meaning in gentle touch, especially caresses. Customized for communication via touch, these fibers function best at the temperature of the human hand.
There is a mountain of evidence demonstrating that touch is a human need.
Sadly, numerous examples of overwhelmed orphanages over the last few centuries exist in which only a few nurses were available to tend to dozens or hundreds of babies and children. Many of these situations were documented and studied by science. They found that even though the children had their physical needs met — they were cleaned, changed and fed adequately — they overwhelmingly “failed to thrive”.
They didn’t gain weight at the expected rate, they were slow to meet developmental milestones. Many simply wasted away and died.
Scientists have studied this phenomenon at length, and while there are plenty of unanswered questions about the details, there is not one doubt left about the fact that humans need touch to develop properly.
And it doesn’t stop at development. Humans need touch throughout our lives for our physical, mental and emotional well-being.
A recent study highlighted the importance of touch for seniors in light of COVID-19 social distancing. Lack of positive physical touch has been linked to higher blood pressure and heart rate, lower oxytocin levels and higher levels of inflammation throughout the body. Inflammation has been shown to contribute to heart attacks, strokes, and infection, as well as a greater risk of mortality in general.
For touch to be healing it must be consensual, and it should come from someone the person trusts. When it does, there are reams of evidence to show that touch has many healing effects:
Reducing pain and fatigue
Strengthening the immune system
Improving social relationships
Impacting others more positively
Reducing the harmful effects of chronic stress
The reassuring touch of a spouse during a distressing discussion reduces physiological stress markers and improves the outlook of overcoming the challenge.
A hug from a loved one before a stressful event lowers cortisol levels, blood pressure and heart rate, and improves performance.
A hand squeezed lovingly during a painful procedure reduces perceived discomfort.
A weekly massage from a warm professional can shrink tumors in cancer patients and increase immune system cells in HIV patients.
Gentle rhythmic tapping on the arm or leg quiets the mind and eases the insomniac to sleep.
And the list goes on.
The evidence shows that many of the healing effects of touch benefits the touch-er as much as the… uh, touch-ee?
Caregiving is hard work. We give and give of ourselves. To avoid exhaustion and burnout, it's essential we don't deplete ourselves. One of the fastest roads to burnout is to give our own vital energy without replenishing it. (Ahem – replenishing it NOW. Not "later".)
People find different ways to maintain their vital energy successfully. Some do give directly of themselves, and then replenish it immediately. Others allow an outside energy flow through them. God, the Universe, Love… whatever form or name it takes is fine. This energy can actually replenish us as it flows through us and to them.
What better way to replenish that vital energy than in real time, sharing an intentionally healing touch with someone we care, and are caring, for?
It's not about taking their energy for our gain, of course. It's about a moment shared between two human beings, that benefits both profoundly.
The trouble with touch is that it can get somewhat… ahem... touchy.. at times.
As a whole, humans seem to be very good at conveying emotional messages via touch. However, on an individual basis, we sometimes stink at recognizing them. There are many factors at play here. For example, in one experiment, emotions were identified through touch alone 600% more often than expected (50-60% of the time versus 8% if left to chance), there was an interesting caveat. Exactly zero (0) percent of the attempts males made to express compassion to a female was it recognized. The female participants had no idea what emotion they were trying to convey! The same went for females expressing anger to males. Not one time did a male recognize anger in her mysterious message.
So, it isn't foolproof, to say the least. And this says nothing of individual experiences. Keep in mind that every one of us creates our own unique reality based on our current emotions, past experiences, and other customized building blocks.
Research has shown that who we think is touching us is more impactful on how pleasant or beneficial the touch is than who is actually doing the touching.
Two people in the same room often have widely differing views about what has happened. You may think you're being reassuring and compassionate; he might think you're flirting with him. This is an especially common occurrence with younger female caregivers and male residents. Pay special attention to the cues that he is using to piece together reality. Are you giggling, smiling, trying to take off his pants? Is your scrub top maybe a little tight or revealing? Pick the right places for touch so you don't end up triggering "inappropriate behaviors" from a man who is doing the best with what he's got. Instead, act confident, and project calm, matter of fact professionalism (even if you may not feel that way). Call him "Mr. Surname", "Sir" (or "Grandpa", if that works better). Maybe grab a white lab jacket to wear. Give him clues to work with as he tries his best to figure out why this girl is here and his pants are down. Introduce touch in less confusing ways. A firm handshake and a "Nice to see you, sir," each time you pass him in the hall may serve him better.
Culture is a big factor when it comes to touch. How comfortable are we with it? What parts are okay to touch, under which circumstances? Sometimes unwritten cultural norms are very complex, and rules may change depending on the gender, age, social status, profession, or other differences of the individuals involved in the interaction.
High contact cultures, such as Latin America and Southern Europe tend to stand close and touch often.
Northern Europe and North America are examples of medium contact cultures. They tend to stand close and touch each other occasionally.
Many Asian countries are low contact cultures, which stand further from each other and mostly avoid physical contact with one another.
Touch, even with the best of intentions, can lead to discomfort, emotional turmoil, “behavioral outbursts” or “inappropriate sexual behaviors” on the part of the person with dementia. It can also lead to allegations of sexual misconduct or abuse on the part of the professional.
With all the cultural and individual differences in perceptions regarding how much, what type, and under which circumstances is touch considered “appropriate”, there’s no way to outline exactly what is okay and what isn’t. Many facilities, schools and other organizations have therefore had to develop laws or policies essentially disallowing most kinds of touch.
Obviously: follow the laws of your land and policies of your workplace.
Beyond that, here are some further thoughts on the matter:
* Always be mindful of the person's cultural and personal preferences. *
* No one has a right to touch another person. *
* Get consent before touching. Consent isn't always verbal – it can be behavioral. A great way to get consent for a hug is to open your arms wide, non-verbally inviting them to take the next step. The same goes for handshakes. Stick out your hand and wait for them to reciprocate. *
* Start slowly and build trust over time. *
* Hands and forearms are generally considered the most neutral place to touch someone, so it may be a good idea to limit touch to these areas initially. *
* Pay attention to their non-verbal communication. Do they shrink away from touch or lean into it? Is their body language rigid or relaxed? What kinds of touch do they seem comfortable with? *
* People tend to be most open to hugs, pats and touch when they are grieving, or intensely happy. *
* Stroking touch tends to be the easiest to misinterpret as sexual misconduct. *
It's not okay to touch any person against their will. This includes people with dementia who need help with care. In fact, it's not even considered okay by most standards to change or bathe someone against their will. You have to figure out how to get consent.
Communicating via touch is one of the best ways to do this with someone with later stage dementia. Don't muck everything up with words.
1. Hold out your hand, allow time for them to take it.
2. Walk hand in hand to the bathroom.
3. Hand over the baby, hum their favorite tune, turn on the music or [insert custom distracting pleasant activity here].
4. Tap their hip.
5. Make eye contact. Smile. Nod.
6. Gentle tug downward on pants so they know what to expect.
7. Nod for reassurance.
8. Pull down the pants.
9. Tap their hip, tap the toilet.
10. Pat yourself on the back for a job well done.
Setting aside some time for a special manicure or massage can be a wonderful way to work more touch into the lives of people with dementia. However, professional caregivers are often limited in their ability to increase the amount of time they are spending with a specific person. Fortunately, incorporating more therapeutic touch into your interactions doesn’t necessarily require extra time. There are plenty of ways to incorporate touch into someone with dementia’s life simply by bringing a little more awareness to the moments you are already sharing.
Try not to interact with the intent to complete this task as quickly as possible, and then move onto the next. Make a point of tuning into the person during these few moments.
Feel, think or say the message you’d like your touch to convey – perhaps something along the lines of “I wish you comfort, peace and connection”, or “I am happy to be here with you right now.”
Some people love to have their hair combed! What a great way to connect and comfort with touch and tactile stimulation.
Petting or cuddling with an animal can be a great source of touch, tactile stimulation and connection. It’s not always an option, but if it is, it’s a great one.
Handshakes offer valuable opportunities for touch. They can communicate respect, especially to men of older generations.
Handshakes also perfectly segue into Teepa Snow’s Hand under Hand technique, an extremely effective method of communication that can be used to connect with a person with dementia largely through the power of touch.
Applying lotion to arms, legs or back after a shower or bed bath is healthy for their skin, and can provide the perfect chance to respond to their need for touch.
Mani-pedis, or routine hand hygiene, can offer a great opportunity for connection. They may include some or all of the following steps:
- Washing hands or feet with a warm washcloth.
- Soaking hands or feet.
- Filing nails.
- Applying lotion.
- Painting fingernails.
Massage therapy can go a long way towards fulfilling a touch-starved senior’s needs. Mountains of evidence espouse the wonderful benefits of massage for people with dementia:
Anxiety is calmed.
Mood is enhanced and sleep improved.
Immune system is strengthened.
Depression is lessened.
Depending on your particular role, consider suggesting, advocating for, or arranging regular professional massage sessions for those you think may appreciate these benefits.
Working in a quick, informal foot rub, backrub or shoulder rub when appropriate can also be helpful. A word of caution: Check with the person’s doctor or nurse first, in case there are any special precautions necessary. A painful calf that feels warm to the touch should not be rubbed – it should be reported to the doctor. Avoid rubbing skin that is reddened, rashy, injured, or close to open sores. Avoid rubbing deeply. Keep rubbing light and skin-deep, such as might be used to apply lotion, gently stimulate circulation or just connect with touch.
While cuddling a stuffed animal isn’t the same as touching another living being, there is plenty of scientific evidence that snuggling with one can reduce feelings of stress, anxiety and loneliness in adults. The effect is especially powerful if the stuffie has sentimental value to the individual. Cuddling a teddy bear has also been shown to increase positive social behavior in adults who are feeling socially excluded, by the way. So feel free to try this tactic when the time is right.
I know from my own experience that holding a soft stuffed animal can help reduce fear and anxiety in many people with dementia during toileting, brief changes or repositioning in bed.
Holding a baby doll, too, can have a profound effect on someone with dementia. Carol was a tiny, contracted woman in her mid 90s who fought for her life anytime she was assisted in the bathroom – which is to say every 2-3 hours. Lovingly handing her a baby doll before entering the bathroom was extremely effective in absorbing her attention, bringing out her soothing maternal instincts, and promoting what scientists call "prosocial" behavior. Basically, when adults are around kids, kids' music, kids' belongings or even in proximity of a school, they tend, for the most part, to be more likely to act in ways that benefit society and help others. So… feel free to turn that tidbit into a useful tactic, too. 😉
Science is beginning to recognize that not all of the benefits of touch are strictly dependent on touching another being. Like the teddy bear example above, touching objects can have therapeutic effects at times.
For example, scientists have documented many of the same benefits of massage when participants sit in a massage chair. They have demonstrated in animals, who show the same detriments as humans when deprived of touch in infancy, that simulating maternal touch with inanimate objects can prevent, minimize or reverse the ill-effects.
Weighted blankets have also been shown to have a positive effect on anxiety, insomnia, mood and pain relief as well, which is attributed to the deep pressure stimulation.
While human contact may be preferable when possible, alternatives such as these may also be worth trying.
Feeling various fabrics — Perhaps sorting velvet, corduroy and other fabric squares for a quilting project.
Winding up balls of yarn
Sanding wooden toys, craft sets, birdhouses or furniture. Oil them with vegetable oil afterward and talk about how much the children will benefit from this great work.
Be aware that seniors and people with dementia often have an increased startle response. Always approach from the front and be sure they see you before engaging in touch. Touching them from behind can startle and stress them – negating all those wonderful benefits of the touch in the first place!
When CT fibers or other touch receptors aren’t working properly, even a gentle touch may feel painful or unpleasant. Some people with dementia experience hypersensitivity to touch or temperature. Sheets on the toes, sprinkles from the shower head, lotioning a leg or a soft touch on the hand, can be very distressing for certain individuals. Always pay attention to their reaction to ensure that touch is registering as pleasant and supportive.
A few other examples of how touch can be used to communicate in dementia care include:
Squeezing someone’s hand gets their attention and automatically prompts them to look at your eyes. Be sure to check out Teepa Snow's Hand Under Hand Technique for more excellent information about using this inborn reflex for communicating in dementia care.
A sturdy hand on the small of the back as a senior struggles up from a chair can help them stand up much more easily - without lifting them a bit. The touch seems to boost confidence and convey the message that you are there with them if they need you.
The gentlest pulling downward or backward on the hips can easefully guide them to their seat as they slowly sit.
A soft touch or downward stroke on the throat can stimulate a swallow for someone holding food in their mouth.
A touch of the lips with a spoon or glass can communicate that it's time for a bite or sip.
How have you communicated via touch in dementia care?
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