Do children bring Alzheimer's patients "back to life"?

Throughout a two-year period, I have observed infants, toddlers and children as they interacted with residents who are cognitively intact and with those suffering from dementia and Alzheimer's disease. From what I have observed, having children speak to and touch these patients has immediate positive and even therapeutic effects. I emphasize, this is based on my observations as a Director of Nursing. It is not formal research, and I am not a scientific investigator. I have, however, drawn interpretations and conclusions from my observations, and I offer them in hopes of helping other caregivers who confront these challenges every day.

The Cognitively Aware Patient

For the cognitively aware patient, to hold a newborn or hold a small child in their laps often brings tears. Their hearts and minds overflow with memories of their own children or grandchildren, and then of course memories of their own younger years. Some of the residents, after becoming ill and homebound and then being placed in a skilled nursing home, have not seen or touched an infant in as much as 30 years. For some the tears are of sadness, a grieving for the loss of their active lives and healthier bodies. They grieve for their inability to interact, now in their so-called "Golden Years," with friends and families and children at a picnic or in church or at a family reunion - events that they are not able to get to anymore. Rightly or wrongly, those family members and friends don't remember to include them in gatherings, nor do they think to bring the gathering to the confined old person. "Either keep up with the crowd, or the crowd leaves you behind, and then forgets you all too easily," said one resident.

Assessing the benefit of holding an infant or talking to a youth for the cognitively aware is easy. The resident himself or herself will tell you. "Oh, she reminds me so much of my own Emmy when she was 3 years old," or "I haven't seen a cuter baby in years, let me hold them please, won't you?" Tears of joy roll out of their eyes. When toddlers jump about and stand on their heads, and tear up paper and roll a ball, the cognitively aware patient watches every move, and for long periods of time. One resident said, "I'd rather watch that little girl play with that ball than watch T.V. or eat."

The Impaired Patient

The greatest benefit I have observed, and the one that surprised me the most, was the effect children and infants have on demented patients. It was not just an occasional occurrence, or something that just happened once with one resident. Every demented or Alzheimer's patient that resides in the 82-bed skilled nursing home I work in has responded the same way.

Case #1: Resident C.K. -- female, East Indian, non-English speaking, spoke Hindi when she did speak, age 83. Diagnosis includes organic brain syndrome and Alzheimer's. If you were to watch her right now, you would see a fragile, long grey-haired, deep brown-eyed woman reaching for items in the air, as she sits in her reclining geri-chair. She speaks constantly, softly, mumbling in her native language. She gets very agitated if you have to move her body, to reposition her or to cleanse her. She plays with her food, and sticks her fingers in her drink, and playfully watches the liquid drip to the tray of her chair. She has no interest in her self, is not oriented to time, person or place. She does not respond to her family members, son or daughter, or husband, when they visit and speak Hindi to her. She neither smiles nor frowns, but has a mildly serious look on her face, as if she has much to think about. She fights with linen when you place her in bed, pulling it up and down, and shaking it around. She has had paranoid episodes in her past. She was placed in a geri-chair because when she sat in a wheelchair, she would lean forward so very steeply (to pick those illusive items off the floor that none of the rest of us could see) that she became a fall risk. She has decreased vision.

When a toddler walks up to her, however, her face lights up with immediate recognition. She pinches the child's cheeks, lightly, recognizing that a harder pinch would hurt (a contol she never shows with staff, especially when they are moving her or occupy her personal space). She talks to the child about their beauty and pink cheeks, and talks to them in baby talk, though in Punjabi. Her family and Punjabi aides have watched and listened, and have observed that she is totally reality-oriented to the fact that she is touching and talking to a child, and adjusts her tone of voice, talks sensibly and smiles and radiates with the glow of a motherly/grandmotherly love. At no other time nor with any other person or animal does she repeat this activity.

Case #2: Resident O.M., female, Russian ancestry, spoke English. Diagnosis includes organic brain syndrome, bi-point affective disorder, Alzheimer's, age 80. This patient used to be the facility's "Olympic Walker," and could have gone for the Gold, had she not experienced a decline in her ambulation due to arthritis and contractures. She suffered a rapid decline in mobility during an about 3-month period. She has always loved to kiss and hug anybody in her personal space, whether they want to participate or not. She has a permanent smile on her radiant face. She does not know who she is, or her husband of over 50 years, or her daughter. She has no attention span and does not communicate appropriately. All of her needs must be met by the staff.

I have witnessed her watching a toddler for 20 minutes, trying to talk to the child and reach for the child. But for her, the words do not come. If you look into her eyes, however, you know that the gibberish is intended to keep the child sharing her space and entertained. When the child is put into her arms, she hugs and kisses her and smooths her hair and pats her head very gently. She examines the child's clothes and shoes and plays with her socks. She speaks her non-language in gentle and lyrical tones. There is no question in this case, either, that when this patient who does not recognize food, day or night, warm from cold, is in the presence of a child, she wants to maintain connection with the child. When the child is carried away from her, she will extend her arms and moan, and look very sad.

Case #3: Resident F.E., female, Caucasian, age 84, with a diagnosis of dementia and congestive heart failure. This resident needs maximum assistance due to her total confusion. She has no attention span beyond 1-2 minutes, has totally inappropriate speech, constantly paces the facility, and of course gets tired quickly. She is not oriented to person, place or time, and has no interest in her environment. She can be hostile. We have placed her in activities next to the cognitively aware patients, hoping that will help her stay on track. She is resistive to anyone touching her, which is a problem when the time arises to clean her or get her into a dining room. She will hold hands with other dementia patients, but interestingly will not hold hands with the cognitively aware patients. She hardly ever focuses on watching anything, but rather looks all about her, picks lint off her dress, reaches for objects that the rest of us cannot see.

When she sees a child, she will throw her head back and laugh out loud, while clapping her hands together. She will stand up and start singing a song and dancing a jig, performing for the child. She reaches for the child and tries to dance with him or her, smiling and singing all along. She will sit down and try very hard to pick up the child, but due to arthritis and generalized weakness, can't. When you place the child in her arms, she looks all around and makes noises as if she is trying to talk. I believe she is saying, "Hey everybody, look at me, and look what I am holding, aren't I the lucky one?" She is not very eager to let the child go, and there have been times when I get a bit anxious. But she lets go, especially if the child starts to fuss. She recognizes when the child is unhappy, and honestly does not want to make the baby cry. At no other time, does F.E. get so animated and so purposeful with her movement and body language as when she is with a baby or toddler.

Case #4: Resident G.I., male, age 81, formerly a professional cowboy. Diagnosis includes Alzheimer's and senile dementia, ASHD. This man occasionally can make his needs known, and seems to understand other people's communication as well. This resident's memory or mood problem requires that some or all of his ADL's be broken into a series of sub-tasks so that he can perform them. He attends group activities and seems at ease. He often falls asleep, even during the most noisy and active events. He has no visitors. He likes to watch T.V. He doesn't bother anyone, does not actively seek out help, nor does he spontaneously speak. He will for the most part speak only if spoken to, and his response may be more often inappropriate than correct. He calls all the female staff "Sis." He will watch T.V., but rarely shows an interest in any other activity for more than 1-2 minutes.

If a child comes into the room where he is, or into his immediate personal space, G.I. comes alive. He will reposition himself (which he rarely does because he typically lacks spontaneous self-movement) and "hanker on down" to the child's level. He will clap his hands, or whistle to draw the attention of the child. He will smile and laugh, and try to touch the child if he or she is not within his personal reach. I have heard him say clearly, "What a cutie," "How old is she?" and other appropriate questions or comments, several in a row, in a way that he is not capable of manifesting at other times.

The Littlest Staffers?

It became obvious after a year of observation that family, animals, friends, or familiar staff just did not have the same immediate and profound effect in reaching out and bringing the demented patient into reality as a baby or toddler does. As long as a child is in their reach or vision or touch, the demented patient acts, talks and looks "normal" in all respects. I can immediately remove the child and try to evoke the same response from the patient or have an aide or nurse step in and try to do so, and it never happens. The door to the demented patient's mind opens for the child and slams for everyone else.

Volunteerism

In trying to stretch the health care dollar, what a "bargain" it is to expand an activities department with the presence of babies and toddlers participating in simple exercises and singing and playing ball with the elderly residents. Meanwhile, the unemployed and the housewives and single parents who are home, raising their children, could gain personal benefit by volunteering their time and children for visiting skilled nursing homes. A recent research study indicated that when depressed, self-absorbed, dissatisfied-with-life-and-environment people volunteered their time to the disadvantaged and ill, their self-esteem improved and their level of mental health improved. Bringing their children to nursing facilities may brighten their day, as well as the residents'.

However, there are a few considerations a facility must take into account when allowing toddlers/babies to be with patients. The volunteer must be informed regarding: infection control, areas of the facility to avoid, the space in which they can function, safety guidelines and the concept that you are working with. They need help in picking out one or two patients for the volunteer to work with consistently so that they can learn the patient's idiosyncrasies. Most of this is information that you give to all adult volunteers, so there is not too much more that you have to prepare for in welcoming the very young toddler/infant volunteer (and Mom or Dad).

Potential for Research

It would be a great relief to many families if research discovered whatever it is in the demented mind or the Alzheimer's mind that reacts positively when in the presence of a baby. That "magical answer" could be incorporated into a person's life well before the disease advances beyond the early diagnostic stage. Perhaps if young children roamed freely in skilled nursing homes, senior residences and senior apartments, older people's mental deterioration would stop altogether, providing that no other pathology was obvious, i.e. brain tumor, reduced O2 to the brain, etc. If we cannot return to the society of the nuclear family, where grandma and grandpa and aunt and uncle were cared for in the home by other family members, the next best thing would be to have children throughout our society visiting homes and facilities, to bring their "innocent and therapeutic healing" to the elderly.

The nursing home is an ideal setting for combining child care and elder care. I believe that many of the residents of skilled nursing facilities could indeed babysit children in pre-school child care. Even patients with limited functional abilities can change diapers of infants on changing tables built to wheelchair level. As for rocking babies and holding toddlers while rocking them, what better arms to hold a child than that of an experienced elder. All of the elderly patients in this skilled nursing facility love to see children, and always hold out their arms to touch them. Feeding a child in a small chair or an infant would be no chore for the elder resident who retains most of his or her arm range of motion. The elderly working in the child care end of the facility do not have to be ambulatory, just mobile via a wheelchair Most child care functions can be done in a sitting position: reading, singing, rocking, feeding, drawing pictures, building blocks, even tucking children away for a nap.

As always, regulations are a concern. For example, California has too many bureaucratic restrictions to combine eider care and child care. Other states may prove to be less restrictive and more creative in this area. Certainly, there would be benefits for Alzheimer's research in permitting such a set-up, if these observations of Alzheimer's patients and children are valid at all.

Sandra Stuart Siddall, RN, MSN, is Director of Nursing at the Valley Oaks Health Care Center, Gridley, CA.