Finding the Rhythm in Dementia Care
Support Best Possible Functioning with the Power of Rhythm
Support Best Possible Functioning with the Power of Rhythm
Photos by Yuting Gao and Máximo at Pexels
*Resident names and any identifying details have been changed for privacy.
April 02, 2021
Rhythm can be found everywhere in the universe.
From Britannica:
Rhythm, in music, the placement of sounds in time. In its most general sense, rhythm (Greek rhythmos, derived from rhein, “to flow”) is an ordered alternation of contrasting elements. The notion of rhythm also occurs in other arts (e.g., poetry, painting, sculpture, and architecture) as well as in nature (e.g., biological rhythms).
The pattern of alternation between opposing elements, we perhaps first associate rhythm with music, as the patterns between notes and rests.
However, rhythm is more than music. It’s everywhere, and everything. It’s the waxing and waning of the moon, and the familiar cycle of the seasons. It’s the alteration of day and night, and our routines of activity and rest. It’s when we tend to eat, and our patterns of elimination. It’s our bedtime routines, and how we awaken. It’s every breath we take in, and every exhalation.
Some rhythms are greater than us – the seasons, the lunar cycle. Some rhythms are unique to us – our daily routines, our gait.
How often can you tell who’s coming down the hall simply by the pattern of their footsteps?
Living in rhythm means recognizing the natural cycles and patterns that affect us. The cycle of the moon, the changing seasons, and our body’s own 24-hour circadian rhythm are part of the multi-layered orchestra of influence impacting our energy level, mood and behavior at any given time.
These influences are powerful. When we live out of sync with them, we end up exerting a lot of extra energy. We try to force action when we need rest, or we have difficulty falling asleep. We wake up tired and craving junk food, which leaves us sluggish and in worse shape yet. It’s just not efficient. We simply function better when we live in harmony with the rhythm of nature.
Living in rhythm does not mean forcing a daily routine where it doesn’t fit. It means noticing the internal and external forces at play, and the needs and desires of the moment. When we are aware of these things we can respond to them by focusing our attention and effort accordingly. Utilizing routines where helpful can be a smart strategy, and a key part of the process.
When we live in rhythm there is an effortlessness about it – a natural ebb and flow. When disrupted, it can be a challenge to rediscover the balance. It can be hard enough for us to self-regulate and reestablish rhythm in life. With dementia in the mix, the challenge is even bigger. Fortunately, we can do quite a bit to help those in our care.
We’re best positioned to support others to live in rhythm when we are doing so ourselves.
Sleep cycles can be altered by dementia. It’s not uncommon for people with dementia to spend several days (mostly) awake followed by several days of sleep. If the person is living well in this rhythm let them be. It tends to be difficult – and ineffective – to change a sleep cycle altered by dementia.
However, if the person's sleep is affected by something else – pain, constipation, disturbing delusions, depression or other problems – we must resolve the underlying need as soon as possible. Sleep disturbance can profoundly affect their behavior and ability to function, and can quickly spiral out of control.
Once any core needs or problems have been resolved, support a healthy sleep-wake cycle with a daily routine that includes predictable periods of:
- Physical exercise
- Meaningful activity
- Social, creative, and intellectual stimulation
- Rest
It’s widely known that following a daily routine is best practice in dementia care.
Establishing predictable patterns in daily care, with the same few caregivers to the extent possible, can create beneficial natural rhythms in the lives of people with dementia. It reduces the effort and exertion we're asking of their brain and body, which allows them to function better throughout their day.
Habits help our brains conserve energy, which is key to enabling people with dementia to function at their best.
The amount of energy it takes to think, speak, process language and function in general is utterly exhausting!
I had just a taste of this as an exchange student in South America. I was staying with a family who didn’t speak English, and my Spanish was rather sub-par. It took an astounding amount of energy to think about every single thing I needed to say and comprehend. By the end of the day, I was spent!
Having dementia is exhausting. Getting through a good day takes more effort for people with dementia than most of us realize – getting through a stressful day is just too much. (Ever spend a few days with someone who is sick in a hospital? How does it affect your energy level, behavior and mood?)
I’m convinced that exhaustion is behind many cases of sundowning. Their behavior, mood and cognition crashes because they have been working so incredibly hard just to get through the day. They’re shot by the afternoon or evening. Introducing an after-lunch nap into the routine has made a big difference for many.
Supporting healthy sleep and activity cycles throughout the night and day helps make efficient use of natural contractions and expansions of energy. We move with the river rather than against it.
Scientists have found that the auditory and motor neural systems are closely connected, which may explain some of the power rhythm has over movement. In fact, research shows that motor areas of the brain are activated simply by hearing rhythmic music, even when we aren’t moving. It’s no wonder that music is so effective for getting us up and going!
Rhythm, of course, goes hand in hand in music. In fact, rhythm is the sole element that music can’t exist without. The therapeutic power of music in dementia support is one of the better known interventions, with research supporting its impact on mood, behavior, sleep, mental health and cognition.
The rhythm, or cadence, of speech makes a big difference in how we understand it. (Try reciting your phone number in a different rhythm than usual – your brain will struggle to recognize it.)
Generally we want to use a natural cadence when speaking to people with dementia, although a slower rate of speech can sometimes help. Brief pauses, or a bit of extra emphasis at key points, can enhance comprehension in a tired brain.
“When you’re ready… we’ll count to three… and stand up… … ... One… two… THREE!”
One of the easiest and widely used rhythm-based techniques in dementia care is the simple three count. There's a reason why this old standby is so effective. Both parties’ brains can anticipate the timing of the "three" based on the simple little rhythm, and coordinate actions accordingly.
Marching
“Okay, Sam, let’s march!” I cried with enthusiasm, holding the gait belt firmly to steady the man. His Parkinson’s had left his shuffling steps tiny, ineffective, and dangerous. A retired Colonel, marching was in his blood and embedded deeply in his brain. “ONE, two, three, four. ONE, two, three, four.” His legs came to life immediately. When he marched, his steps were confident and steady. He covered ground easily, a big grin on his face at the silliness of the situation.
When assisting someone with advanced dementia to eat be mindful of the rhythm of their chewing and swallowing. Swallowing is a surprisingly complex process that involves the coordination of over fifty pairs of muscles. The brain must orchestrate all these muscles, and a number of nerves, for every swallow. It makes sense, then, that many people in the later stages often take a bit of time to get started eating – and interrupting their rhythm of chewing and swallowing often means that mealtime is over.
Synchronizing our breath with theirs is an excellent way to connect, using mirroring techniques. It’s also possible to influence their breathing rhythm – for example to help them calm down if anxious – by either modeling a steady, in-and-out breath or by synching breathing rhythm and gradually adjusting it as they follow suit.
Take note when the rhythm of their breathing changes. This can be a clue that something is amiss, especially for those with limited verbal or cognitive capacity. Pain, anxiety and fear are a few of the culprits that can alter the rhythm of our breathing.
Rhythm Therapy
Jim Donovan, M.Ed., a professional musician and Assistant Professor at Saint Francis University worked out a way to “trick” the brain into relaxing enough to fall asleep using rhythm – in about 4 minutes.
His TEDx Video on the topic went viral
How to Trick Your Brain Into Falling Asleep 6 minute Tutorial Video
Rhythmic auditory stimulation (RAS) synchronizes gait to movements. By listening to rhythmic music while walking for 30 minutes per day, one study of participants with Parkinson’s disease showed significant differences in:
- Overall reduction in falls
- Improved stability
- Fewer freezing episodes
- Improved stride times
- Increased confidence / reduced fear of falling
Other studies have shown similar results in participants with Alzheimer’s dementia, stroke, cerebral palsy and multiple sclerosis.
New research on a phenomenon known as multi-sensory gamma stimulation holds promise for the future of dementia therapy. Gamma brain waves (which are weak in individuals with dementia) are stimulated via rhythmic lights, sounds or vibrations.
In preliminary studies with mice, exposure to these rhythms essentially jumpstarted targeted brain activity, significantly improving brain function in a number of key areas. The hallmark plaques and tangles associated with Alzheimer’s disease were considerably reduced, while their sensory processing, working memory and spatial navigation improved.
Although this research is in its infancy, scientists are excited about their findings and see a great deal of therapeutic potential for preventing, minimizing or even reversing cognitive decline in people.
New York State’s Department of Health has published this thorough guide for facilities or contract musicians interested in providing Therapeutic Drumming and Rhythm Based Activities groups for people with dementia.
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