control, triggers of anxiety or agitation, verbal and nonverbal
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
I 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 fine-
motor 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.
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
12 BRAIN GYM@ JOURNAL
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
their first exercise.
Positive Points-as
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 support 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 support 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 contact with staff
members 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 unit-
even 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.
- JULY 2009
THE ALLEN SCREEN AS A COGNITIVE MEASURE
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
exercises, 1 periodically retest MANY OF MY CLIENTS
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,
many of my clients show an COGNITIVE FUNCTION.
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 remembering doing the Allen screen previously.
However, these increases occur in clients who have very poor
short-term memory and who often don't remember what
happened more than a few minutes ago. They seldom remember
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 joint disease or stroke.
After we do PACE,I'll often take the person through a Dennison
Laterality Repatterning* (DLR) process to help restore whole-
body 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.
BRAIN GYM@ JOURNAL
JOE
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 contact, 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 contact.
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
- JULY 2009 13
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
contact. 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
contact 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 contact when visitors approached
14 BRAIN GYM@ JOURNAL
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 contact 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
ONE IS IN SPACE, GROSS- the most powerful Brain Gym
exercises I've ever used for the
AND FINE-MOTOR
release of mental or physical
COORDINATION, AND stress. It's been the vehicle
SEQUENCING SIMPLE AND that has allowed people lost
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
- JULY 2009
 _ . 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
about using 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
BRAIN GYM@ JOURNAL
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
contact with her in a very long time. We were both in tears.
Michael passed away peacefully just a few days later.
A 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 ON PAGE 19)
- JULY 2009
 EMERGI G FROM DEMENTIA
(CONTINUED FROM PAGE 15)

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 ...

AL - JULY 2009 19