Yoga and Dementia

Today, more than 5 million Americans have Alzheimer’s disease, and one in three seniors dies with Alzheimer’s or another type of dementia. Even given a recent decline in the overall prevalence of dementia, the number of cases will likely increase in the coming years, since those ninety and up are the fastest-growing segment of the US population and also the segment at greatest risk for this disability.

Recentstudies hint at yoga’s ability to reduce stress and improve memory function and to improve the cognitive functioning of elderly nursing home residents. One multifaceted program that used meditation and yoga succeeded in reversing some memory loss. Additionally, a small trial program in the UK that offered gentle yoga to caregivers and dementia sufferers together was both feasible for and well-received by participants.

Given yoga’s promise, some of us may wonder if yoga is a good idea for our relative, friend, or patient with dementia.

“It might be, or it might not be,” said Penny Garner in a recent phone interview. Penny is the founder and clinical director of the Contented Dementia Trust at its Centre of Excellence in Burford, England.

The Trust has incorporated, developed, and refined Penny’s SPECAL (pronounced “speckle”) method of managing dementia, which is now being scientifically researched by King’s College London. SPECAL was first used as an acronym some 27 years ago, when Penny embarked on her work of developing Specialized Early Care for Alzheimer’s and related dementias. To understand Penny’s statement that yoga may or may not be appropriate for people with dementia, it’s necessary to first understand the analogy at the heart of this method, which is “The SPECAL Photograph Album”—a conception of how normal memory works, what happens to all of us as we age, and the single change introduced by dementia.

The SPECAL Photograph Album—A Metaphor For Memory

Penny’s insight, gained through caregiving for her mother, who developed Alzheimer’s in the 1970s, was that this progressive disability was essentially a problem with the storage of new facts in our memory systems. “We are each given a memory system when we are born—a photograph album—and everything that we experience is recorded as a photograph and stored in our album unconsciously. This album, our personal reference point, is a precious resource: It contains a continuing record of everything we have just been doing, the facts and the associated feelings. Every time we say, ‘Let me think,’ it means ‘Let me look in my album,’” Penny explained.

“We consult our album all the time, retrieving information at lightning speed from this highly accessible database in order to make sense of what we are doing, with whom, where, when, and why. That’s how we keep up to speed with what is going on in the here and now. As we age, there is no change in the process of the unconscious taking and storing of photographs in our album, but we get slower at accessing them when we need them. This slowing of retrieval is normal and nothing to do with dementia,” Penny noted. “But for those with dementia, a new type of photograph starts to appear. This new type of photograph contains no facts relating to what has just occurred in their lives but has all the associated feelings. We call this dementia-related photograph a ‘blank.’ At first, the blank represents just a split second of missing factual information, but randomly, intermittently, and with increasing frequency, the blanks reoccur, until, by the time the person is diagnosed, their album is likely to contain up to 50% of feelings-only photographs, with long ribbons of these blanks.”

Penny stressed that those with dementia haven’t lost their reason or their ability to reason—just their recent facts. “They will very reasonably turn to pages much further back in their album—pages with facts as well as the associated feelings—to make a match to explain what they see around them today,” she explained.

The SPECAL method seeks to work positively with this coping strategy: to note which older photographs are most useful to the person and create practical links between those old photographs and the routine activities of daily life. SPECAL values the tried and tested activities and experiences of the person’s past and avoids challenging the person with new activities. “One of our mantras is ‘nothing new’!” Penny said, elaborating, “Undertaking new activities relies on a sequenced storage of new facts, and we know, for those with dementia, the storage of new facts is progressively compromised.”

If anything new is introduced into the day’s routine, one likely result will be anxious self-questioning by the person with dementia, who will be unlikely to find many useful matching photographs in her album. “Self-questioning with no available answers is exhausting and frightening,” Penny stated before enacting the distress a student with dementia might feel: “‘Let me think…Let me look in my album…Just checking…Where am I?…How long have I been here?…How did I get here?…Oh my goodness, there isn’t much information here about what I’ve just been doing...This is beginning to get really worrying…I must know, surely, but… ?’”

“I hope I’m not throwing a cat among pigeons,” Penny continued, “but if a person with dementia tries yoga for the first time, none of what’s done at your yoga session will be coherently attached to anything else in their album. Some—but increasingly less as the dementia progresses—of today’s factual information will be stored in interrupted sequences on today’s page, and these will not make sense when referenced only a few moments later. The context for their current experience will be far from clear.

The desire to do yoga has to come from the individuals with dementia. They should be the ones to say after being introduced to it, "I want to go back to that place for more of what I had."

“That doesn’t mean you won’t find some examples of people who enjoy the experience of yoga in spite of their dementia,” she acknowledged, “but the desire to do yoga has to come from the individuals with dementia. They should be the ones to say after being introduced to it, ‘I want to go back to that place for more of what I had,’ even if they aren’t quite sure what it was that they enjoyed. Unless you are guided by them and the feelings that they have stored, which you can only learn from them, you will be putting them under additional pressure which they could well do without.”

What if the caregiver is sure yoga would be of benefit? “Well, maybe it’s the caregiver who should do yoga,” suggested Penny. “But yoga may well be an excellent idea for someone with dementia if that person did yoga pre-dementia—that is, if yoga photographs have already been stored and can be referenced in the pre-dementia section of their album.”

Yoga, which was first widely practiced in America by the baby-boomer generation and has increased in popularity ever since, may prove to be a vital part of the photograph albums of some of those who will develop dementia. According to Penny, for those students, continuing their yoga practice throughout their lives might be valuable, especially if their teachers—and in some cases, fellow participants—are familiar with techniques aimed to enhance their well-being.

How Teachers Can Approach Yoga For a Student With Dementia

If asked to teach someone with dementia who has been a longtime yoga practitioner and would like to practice again, where should a yoga teacher start?

The first step is to be clear on your goals. “Your goal cannot be to defeat dementia,” Penny advised. “Dementia is already there. Rather, how can you accommodate it? What are positive ways of working with it and not against it? Our aim is to sustain well-being lifelong for the person with dementia, 24 hours a day, seven days a week, in spite of their condition. And we know that is possible.”

The SPECAL method, which is further elucidated by Oliver James in his book Contented Dementia, seeks to foster the components of well-being that Penny considers vital for any human being—and that need very careful consideration by caregivers of a person with dementia: feelings of personal worth (self-esteem), autonomy (the ability to make decisions and see them carried out), social ease (connecting to fellow human beings), and security (trust that everything will be basically okay).

“With a sense of these four elements of well-being securely in place, any person will feel a sense of confidence. With that confidence comes maximum competency,” said Penny. (Note: These four components are based on conversations that Penny had with Tom Kitwood, a pioneer in the field of patient-centered dementia care, in the early 1990s.)

The advice below, derived from the SPECAL method, is meant to be applied by yoga instructors working with individuals or small groups with dementia. Penny would not advise that a teacher attempt to include a student with dementia in a regular group class or even include their caregiver in an individualized practice tailored to that student, unless all participants are familiar with SPECAL principles.

Since students with dementia will have various physical needs, these suggestions concern approach rather than content. Some students may be physically fit and able to do many of the standing poses of hatha yoga. Others may have more limited mobility or be challenged by spatial relationships, which may make restorative or chair yoga better choices for them. As is explained more in #8 below, it’s important to let our students with dementia be our guides and develop practices that honor their abilities while also remaining responsive and open to their suggestions, even if that means broadening our notion of “yoga.”

Penny admitted that the Three Golden Rules (below), which are the bedrock of SPECAL, may seem counterintuitive. As she put it, “You might think, ‘I’m being asked to stand on my head here!’ But we have to learn the language of the person with dementia. We’re not going to change that person. But we can change how we relate to them, and that’s what we simply must do, in everyone’s interests.” 

Which yoga teachers would be qualified to work with a person with dementia?

According to Penny, not necessarily teachers who have received higher levels of yoga training, but rather teachers who have familiarized themselves with the SPECAL Photograph Album, the Three Golden Rules and the tips mentioned below, and who have perhaps enhanced their understanding of the SPECAL principles with the help of courses such as those offered by the Contented Dementia Trust. They should also have experience putting that understanding into practice in various interactions with people with dementia.

“A basic understanding of the SPECAL approach needs to be developed and practiced outside of yoga,” Penny counseled. “Only then can the yoga teacher consider how best to apply those principles to a person with dementia who wishes to continue a long-standing and familiar practice of yoga.”

Tips for Teaching Yoga to a Student with Dementia

SPECAL’S Three Golden Rules

1. Don’t ask direct questions.

“If you only take away one thing about working with someone with dementia, make it this: Don’t ask direct questions,” said Penny. Many of us, yoga teachers and non–yoga teachers alike, ask questions—from “How was your morning?” to “Would you like to do triangle pose now?”—as a means of gaining information, showing consideration, and beginning to build relationships. But questions can catapult a person with dementia into a distressing awareness of their lack of the factual information they will need in order to answer that question.

“There will be a large number of missing facts on today’s page of your students’ albums, making it hard for them to answer even simple questions; after all, whether or not they want to do triangle is dependent upon having factual information in their albums about what triangle pose means and so on. An added complication is that the question you have just asked may not store.” In that case, your expectant look as you await an answer may itself be a source of further confusion. “Life can quickly become complicated for both of you,” Penny acknowledged.

However, since it is vital to engage your students with dementia in conversation, try other means of engaging them, such as chatting in a general way that invites your students with dementia to pick up on anything you say and chime in to the conversation if they choose. “Change your fly like a fisherman,” Penny recommended. “When it’s attractive, the fish will come to it.” You could also try her “Questionless Question Technique.” For instance, you could say, “I wonder if it might be nice to do triangle pose now.” Beginning statements with “I wonder,” “I suppose,” and “Maybe we could” invite participation without putting a student with dementia on the spot.

2. Listen to the expert—the student with dementia—and learn from them.

“We need to listen to our students and learn from them. If you stop talking as soon as they start and listen to their statements and questions, which are like gold dust, you will pick up invaluable clues as to the language you should be using and what kinds of things they need to know and would like to talk about,” Penny said.

Additionally, the caregivers for your students with dementia might be able to inform you of what Penny calls their “finest-hour stories”—the defining experiences your students most love to talk about, taken from the best-loved pages of their album. (If you have not learned anything about your students from their caregivers, seek to uncover these memories from your students with the Questionless Question Technique.)

When talking about one of these stories, your student is on firm and familiar ground. Any time your student appears be worried or uncertain, or when you simply want to forge a connection with them, you can offer the touchstone of a key word they frequently use in a favorite story to guide them toward that story.

For instance, a comment from you such as “I’ve always wanted to go to India,” might spring a student back to telling a beloved story about her own trip there. (But be aware that mentioning her trip directly—“That trip to India you once took sounded grand”—could get you into trouble because your student might not have stored the fact that they’d told you the story before and might privately wonder how you came to have personal information about them. “Anyone is likely to become uneasy if you appear to know a lot about them and they cannot find any information at all in their album about you!” Penny cautioned.)

3. Don’t contradict.

It is likely that your student with dementia will from time to time say something that seems to you to be factually incorrect. According to Penny, it is best not to correct your student: “The question is not, ‘Is this is true or is this false?’ it’s ‘Whose album are we talking about?’ We all use our own album when speaking and our own experiences, so don’t argue with them about which photographs they choose to use. Just listen carefully and start where they are at.”

For instance, if your student with dementia tells you, “We haven’t done shoulder rolls yet,” when you just did them, don’t disagree, just follow her lead and do shoulder rolls again.

(If your student makes a proposal that is inappropriate or downright dangerous, such as “Let’s do headstand”—or any pose beyond her physical capabilities—Penny recommended suggesting a rest at that point and blaming it on one’s own shortcomings rather than the student’s. “I would have no problem in saying, authentically, that I could do with a brief break before proceeding,” Penny observed. “Given that facts—like the proposal of doing headstand—are most definitely not storing in any sequential way, after the break will come a whole new chapter. In this way you are working positively with the disability of dementia.”)

Additional Tips 

4. Make the most of demonstrations and gestures instead of giving complicated verbal direction.

Some of us teachers often demonstrate very little and are given toward a great amount of verbal detail, offering our students long, precise lists of directions, such as “Root down through the balls of your feet and your heels, then track your knees toward your second toes. Now lengthen your spine and lift up through the crown of the head. Roll your shoulders back…”

For your student with dementia, whose record of recent factual information is increasingly unreliable, something much simpler is required. Instead of giving many directions, use the simplest possible phrase—for example, “Press your feet down”—stated while miming the action.

Demonstrate whenever possible, prioritizing eye contact to create a sense of connection, and use gestures. “Gestures speak a thousand words,” said Penny. “Gesture conveys feelings, and these are storing in every new photograph, whereas words are factual and are more often than not lost almost as soon as they are said.” Perhaps there is an ebullient gesture you could give that means “Lift your heart” or “Lift up through the crown of your head,” which could substitute for or accompany a verbal instruction.

If you do not feel that a student would be safe in a particular pose without more alignment details, then skip the pose.

5. Give nothing but good news.

If you take it as a given that your student with dementia will not be storing new factual information in the normal way, it’s easy to see how introducing negative information, however nonchalantly, could lead to worry. Penny gave this example: “You arrive to class late and explain that you got held up in traffic because of an accident. Well, those of us without dementia will understand, thinking to ourselves, ‘Oh, just traffic, I’m glad you made it and that you’re fine.’ However, the person with dementia may store only the phrase terrible accident, which, when referenced later, might very likely trigger anxious self-questioning: ‘Whose terrible accident?...What has happened?...Who is involved?…What do I need to do?’ This is not a useful photograph for them to have stored. It’s better by far to just say on arrival, ‘It is so good to be here!’—authentically, with a smile—and simply get on with your practice.”

Since your student will likely pick up on insincere enthusiasm, it’s important to challenge yourself to see the positive in a situation and let that naturally influence your affect, instead of challenging the person with dementia with negative news or emotional undertones. “After all, if you are late and have seen a terrible accident, wouldn’t you be glad to have arrived safely and be making contact with the student?” asked Penny.

Penny acknowledged that keeping bad news from your students could be construed as creating an unreal existence for them, but in her view, “They’ve already had enough bad news to last a lifetime!” Keeping in mind the difficulties your student is already enduring as a result of their dementia, it makes sense to avoid any additional stress. Don’t mention the car accident you passed or the catastrophe on the news. Give signs throughout class that everything, in the room where you’re practicing and outside it in the wider world, is going well. “The feeling of trust that ‘things are okay’ will store and be so much more useful than unexplained anxiety,” assured Penny.

6. Be generous with praise.

Pepper your student with compliments throughout the yoga practice, like “You’re good at this!” If you can come up with one- or two-word compliments, so much the better: Perfect! Great! Outstanding!

“Consider that the diagnosis of dementia has driven a cart and horse through your students’ well-being. They have clear evidence that they are facing a memory change, which is disconcerting and potentially alarming,” said Penny. "When confidence gets low, people with dementia are especially bad at navigating their albums. Lower confidence leads to less competence in finding useful matches with their pre-dementia pages of their album.” As a yoga teacher, you have the power to increase the confidence and self-worth of your students with dementia by making them feel that they are doing well.

As is the case when conveying nothing but good news, Penny pointed out, “There’s a narrow line between being nice and being patronizing.” It’s important to be authentic; realize that your student is doing well under incredibly challenging circumstances, and commend them for it often and sincerely. Penny said, “Facts might not be storing coherently all the time, but your students are storing feelings continuously and will have even more space for feelings as their storage of new facts diminishes. They are relying on feelings rather than facts, and this means that they will be quick to pick up on any insincerity on your part.”

7. Foster an alliance between you and your student with words and gestures.

Penny recommends fostering what she calls a “we” relationship. “Create the impression that you and your student are in this together, that you are both members of the yoga club,” she suggested. You can encourage this sense of connection by using words and phrases like we, let’s, and as we know, using plenty of eye contact, mirroring their gestures and poses, and enthusiastically acknowledging their contributions and suggestions.

If a student wants to do a pose, thinks it’s time to get out of the pose, or wants to have a break to get a drink of water, second the motion. “I was just thinking that too!”

8. Let your students be the experts.

“You need to pitch your conversation just right. Position your capabilities as being below theirs in some respects,” advised Penny. “Whenever possible, let your student be the teacher.”

To promote a sense of self-worth, readily accept the guidance or assurances you receive from your students. For example, if you say, “I think this is how triangle goes,” you might find you earn a comment from them like “That’s right” or “You’ve got it!”

“It should become difficult for the casual observer to know who is teaching whom,” said Penny. And if your student isn’t inclined to do the pose you’re trying out, well then, never mind that one. Try mirroring her in the position she’s in, meeting her where she is and then following her lead—which might also help to create the positive sense in the student that you two have a connection (#7). “From there,” Penny noted, “you could use those good feelings as a springboard from which you can casually suggest changes, almost as though you are thinking out loud.” For example, rather than issuing commands or asking questions, you could say, “That’s a very good position. I wonder what would happen if we rolled our shoulders back a little…”

9. Try using different words, gestures, and strategies to find out what works best.

In the course of conversation and practice, try different things, and take careful note of what works and what doesn’t. Mentioning the beautiful day doesn’t work to kickstart a conversation? What if you talk about how you wish your mother or husband would do yoga? Does that lead anywhere? Stepping a foot back doesn’t work? Does stepping the other foot forward get you to the pose? Your student won’t stay in savasana? If you keep your hands on her shoulders, does that work to keep her at rest a little longer? Rather than asking questions, observe and note which moments go well and which go less well. “Find this out as fast as you can, so that you are able to minimize the worst and maximize the best,” Penny recommended.

10. Learn to love repetition of whatever promotes your student’s well-being.

While yoga teachers often work to create novel classes, if we’re teaching students with dementia, we’re relieved of the burden of invention. Instead of teaching new poses, embrace the familiar.

“One of the joys of working with individuals with dementia is that they will never tire of the repetition of what they enjoy,” assured Penny. The shoulder rolls they enjoy will delight them again and again. If the comment you make about happy baby pose also being called “dead bug” cracks them up, it is likely to crack them up every time. Repeat the familiar, and keep using the simple words that you’ve discovered trigger positive reactions from your students.

11. Be open to possibility.

If the only thing that really works is holding your students’ hands, then hold their hands. If the only pose your students seem to love is savasana, make that the focus of your yoga class. If what your students really want to do is have a cup of tea and tell you a favorite story, then have tea together and listen to them with interest and pleasure. Join in with them whenever possible, even if that means broadening your conception of what a yoga class can be. As Penny put it, “A SPECAL yoga class might look nothing like a ‘traditional’ yoga class to someone without their SPECAL spectacles on, but that doesn’t mean it’s a lost session. On the contrary, when measured using SPECAL criteria, it will be a success because it has enhanced your student’s well-being.”

At the end of a yoga class for a student with dementia, that student may not have learned new poses or gained greater expertise in tracking her knees toward her second toes. She may or may not have broken a sweat and may or may not have relaxed into her final savasana. But you will have made a valuable contribution to her feelings of personal worth, autonomy, social ease, and trust. “By listening to them and exploring the practice together in a ‘we’ relationship, you will have enhanced their quality of life in a sustainable way,” Penny concluded. “That is a pearl of great price, and the primary focus of all SPECAL care.”