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BATHED IN MEMORY

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A Connell School project aims to ease fear in Alzheimer's patients

Professor Ellen Mahoney. By Lee Pellegrini

Joseph Sheridan's Purple Heart hangs in a case on the wall near his bed, alongside the other honors he received during World War II. He fought at Guadalcanal, lost part of his arm and hip during another clash in the South Pacific, and overcame malaria.

More recently, however, Sheridan's toughest battle was getting out of bed in the morning. The 79-year-old Natick, Massachusetts, resident, who suffers from Alzheimer's disease, wasn't necessarily sleepy, or lethargic, or depressed. But, with his wife Helen's coaxing and explaining, he understood that he was headed for the shower. And like many Alzheimer's patients, Sheridan loathed that routine activity most of all.

Sheridan didn't resist bathing as forcefully as many patients with dementia. He might complain, or push aside Helen's hand. "He's not our most horrific case, where somebody's punching or biting or really being physically resistant," says BC's Scott Trudeau, project manager of an experimental study at the Connell School of Nursing focusing on Alzheimer's patients and bathing. The three-year study is designed to determine whether reminiscence therapy—the purposeful use of pleasant memories—can distract and relax Alzheimer's patients so they get through, or possibly even enjoy, the bath they once dreaded. Led by nursing professor Ellen Mahoney (photo above), the study is funded by $800,000 from the National Institute of Nursing Research.

Helen Sheridan is the sweetheart Joe asked to wait for him when he went to war at age 18, and now his wife of 57 years—including the four since he was diagnosed with frontal lobe dementia. A natural storyteller, she embraced the notion that memories could calm her husband. And so, over an eight-week period, she bathed her husband as Scott Trudeau and members of his team observed and taught her reminiscence techniques. Trudeau studied how Helen approached the task; what techniques, including reminiscences, she used; and whether they were effective. And he gauged the patient's resistance and comfort level.

After Trudeau completed his observation, a nurse from the program worked with Helen, helping her pin down topics that might elicit some of the pleasant recollections still remaining in her husband's long-term memory.

Now, at bath time, Helen routinely talks about the couple's trip to the Australian town where Joseph recuperated after the war. She talks about growing up together in their old neighborhood, about a 1938 snowstorm when milkmen delivered their goods on giant sleds, and about their nine children.

"Reminiscence has the potential to enter into that place that is still intact and craving human connectedness," Mahoney says. The professor has developed a scale for measuring resistiveness, distinguishing 13 behaviors, from saying no to hitting to kicking. Still in its early stages, her project eventually will educate 120 spouse-caregivers in reminiscence therapy and compare the bathing experience with and without the intervention. Three BC undergraduates and four graduate students are part of the team.

The study focuses only on patients living at home. That's where more than 70 percent of America's 4 million Alzheimer's patients reside, according to the Alzheimer's Association. Caregivers struggle with a wide range of resistive behavior, particularly around personal health and hygiene—eating, dressing, going to the bathroom, bathing. "It could be Alzheimer's patients feel a loss of control," Mahoney says. "It could be a loss of personal preference. It could be [the perception of] threat, or pain." Aggressive behavior, she adds, is generally a last resort, when other cues or complaints have gone unnoticed or ignored.

Trudeau, an occupational therapist who specializes in patients with dementia, says that patients to a degree are aware of their regression. "There's the whole issue of compromised dignity," he says. "On some level, people know they are adults and should be able to do this for themselves." In addition, a confused person may not comprehend the sudden noise of the shower or the need to undress. "If you don't understand that you need a shower, it's very easy to see how people could misinterpret that," Trudeau says. "What are we getting naked for? If I'm not sure, I'm probably going to resist that."

Trudeau has found it particularly helpful when caregivers elicit water-related memories. One patient in the study, formerly an avid fisherman, would scream and resist strongly at bath time. His wife, instead of begging and cajoling her husband to step in the shower, learned to divert him with memories of a fishing trip when waves crashed over the side of the boat. "The caregiver got good at using the handheld shower to depict the waves," says Trudeau. "Before you knew it, he was wet and he wasn't screaming."

Doctoral candidate Susan Ruka, MS'97, who has written her dissertation on reminiscence therapy during bathing, tried using memories specifically related to water on the four nursing home patients she studied. Two showed significant improvement. One of them, a 69-year-old woman, had attended a White House dinner during the Ford administration. Instead of focusing on memories of the event, Ruka would talk about how the woman showered and prepared for the party, helping her to accept the bathing process more calmly.

At least one spouse in Mahoney's study, the husband of an Alzheimer's sufferer, has taken the power of reminiscence beyond the bath, strategically placing stacks of photographs around the house. "If he gets in a resistive situation," says Trudeau, "he uses the photos to distract, reframe the situation, and move on."

Mahoney's approach helps preserve an overall climate of adult respect. "The person who is 70 or 80 or 90 is not a two-year-old," says Mahoney. "Alzheimer's patients have a lifetime of experience. They have ways of coping. They have a sense of self that may be changed, but it's not lost."

In a small way, reminiscing helps Helen Sheridan see her husband as he once was. Learning to call up pleasant memories at bath time has changed a dreaded chore into a calmer, private interval. "It used to be just another job. Now it's a peaceful few minutes together," Helen says. "Afterwards, when he puts his arms around me, he lets me know he's pleased and he's content." The old ordeal has become, she says, an opportunity, a "time for getting close to someone who's becoming a stranger."

Gail Friedman

 

Gail Friedman is a freelance writer based in the Boston area. The reminiscence therapy study is recruiting participants through January 2005. For information call (866) 576-4484.

 

Photo: Professor Ellen Mahoney. By Lee Pellegrini

 

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