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Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders
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Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders

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This paper explores the use of touch in working with elders. It explores neurodegenerative disorders, challenges working with individuals with cognitive changes and how to develop a treatment plan …

This paper explores the use of touch in working with elders. It explores neurodegenerative disorders, challenges working with individuals with cognitive changes and how to develop a treatment plan that includes safe therapeutic touch.

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  • 1. Trauma at the End of Life… RUNNING HEADER: Trauma at the End of Life… Trauma at the End of Life: Somatic Experiencing and Other Touch Based Treatments for Neurocognitive Disorders By: Mike Changaris, Psy.D.
  • 2. ABSTRACT The experience of being given a diagnosis of Altzhiemer’s Disease or another neurodegenerative disorder can be shocking for both family members and the individual facing the cognitive changes. As neurodegenerative disorders progress, behavioral difficulties often arise that strain even the most resilient family system (Zarit, Orr, & Zarit, 1985). Many studies have shown touch therapies reduce cortisol levels, increase dopamine, serotonin, and oxytocin, while also bringing the emotion regulation centers of the medial prefrontal cortex online. High levels of cortisol, the stress hormone, are related to symptoms of depression, increased risk of apoptosis (programmed cell death) and anxiety (Kloet, Joëls, & Holsboer, 2005; Weaver, Grant, & Meaney, 2002; Weaver, 2007). This paper explores the symptoms of five major neurodegenerative disorders, the psychological, emotional and interpersonal impacts of a diagnosis of a neurodegenerative disorder addressing means by which therapists can develop touch-based interventions to de-escalate aggression, reduce anxiety, increase social support, and support their client to find meaning in the present moment. 2
  • 3. Trauma at the End of Life: Somatic Experiencing and Other Touch-Based Treatments for Neurocognitive Disorders 3
  • 4. She grabbed the therapist’s hand and said, “I am angry. Someone hurt me. I can’t remember who. I am scared. What if they do it again and I can’t remember who it is and I get really hurt? Has this ever happened to you? It is not fair. I worked hard all my life and now I am angry and can’t remember who I am mad at!” She had forgotten the event and yet her body remembered. The neurons in the hippocampus had not allowed for the formation of long-term memory but she knew she was angry; she could feel it. This is often what it is like living with forgetfulness, or what is more commonly known as Alzheimer’s disorder. The events from the recent past are lost yet the body still holds the feelings. A stress response requires nearly 100 minutes to be metabolized by the body. During that time the physical sensations of the emotions are still present. Individuals with forgetfulness try to make sense of decontextualized emotion and in the process can become afraid, feel lost and angry, and act out the feelings. Through contact presence therapists, families and care providers can help offer tools to soothe feelings, create safety and contextualize their experience. High levels of stress reaction could exacerbate the pathophysiology of neurodegenerative disorders (Sapolsky, R., Personal communication, November 10th , 2009) The experience of being given a diagnosis of AD or another neurodegenerative disorder can be shocking for both family members and the individual facing the cognitive changes. Common reactions include, “Why is this happening to me?” “I am going to lose my mind,” “I am worthless, just a burden to my family.” As neurodegenerative disorders progress, behavioral difficulties often arise that strain even the most resilient family system (Zarit, Orr, & Zarit, 1985). This paper examines the psychological, emotional and 4
  • 5. interpersonal impacts of a diagnosis of a neurodegenerative disorder and address means by which therapists can develop touch-based interventions to de-escalate aggression, reduce anxiety, increase social support, and find meaning in the present moment. The Experiencing Self and the Narrative Self Recent research into happiness has shown that humans have at least two major categories of happiness. These two categories sometimes overlap but often are quite divergent (D. Kahneman. Personal Communication, March 2010). These two broad classes are happiness for the experiential self and happiness for the narrative self. The experiential self is in the moment. It is a direct evocation of interacting with the flow of current events. The narrative self is the story of one’s life. The narrative self typically comprises a few key moments of major life change and the rest of the memories are relegated to the great blackness. The narrative self seeks happiness through the ideas of success, conforming to social expectation and the imagination of how an event will play out in the larger plot of one’s life. The experiential self seeks moments that are enjoyable as they are lived. The neurocognitive changes in several neurodegenerative disorders push the individual away from the ability to seek narrative happiness into the raw ability to have experiential happiness. In a case reported in the book Geriatric Neuropsychiatry by Attix, and Welsh- Bohmer (2006) an individual who normally had a sunny disposition even in his cognitive changes became agitated, began pacing and displayed symptoms of anxiety. The staff were worried. They began considering the use of medication to help him manage anxiety. Eventually, a staff member talked to the individual. At that time the client was able to 5
  • 6. convey that his feet hurt. Reducing the pain this individual felt on a moment-by-moment basis reduced his agitation, pacing and anxiety (Attix, & Welsh-Bohmer, 2006). This is a classic example of the disruption that can happen when the experiencing self and its happiness are not attended to. Procedural memory and the experiencing self are intact in a wide array of neurodegenerative disorders. Mice who have their hippocampus genetically impaired when dropped into a water maze will not remember the solution to the maze the first 10 times exposed (S. Tonegawa, personal communication, June 12th 2003). Normal controls will remember the maze quickly. Mice with hippocampal damage will remember the solution to the maze like normal controls if given enough trials. Researchers found that emotions lingered in individuals with dense amnesia long after the ability to remember the event that caused the emotions (Feinsteina, Duffa, & Tranela, 2010). When showed an emotionally rich movie clip, hours later reported emotions that matched those in the movie. However, they could not remember a single scene of the movie. People with forgetfulness will remember felt experiences of interactions with people, combined with the expectancies they built over a lifetime of relationship. The Autonomic Nervous System and Touch Treatments In many animals, including humans, touch plays a major role in affect regulation. In early childhood and infancy touch is the main mode of communication and is the central tool care providers have to soothe and comfort the infant. Through these interactions the brain areas responsible for affect regulation grow and develop. Even in adulthood, touch remains an excellent means to soothe stress. Many studies have shown 6
  • 7. touch therapies reduce cortisol levels. These same studies have found that touch increases dopamine, serotonin, oxytocin and norepinephren, while also bringing the emotion regulation centers of the medial prefrontal cortex online. High levels of cortisol, the stress hormone, are related to symptoms of depression, increased risk of apoptosis (programmed cell death and a key factor in the pathogenesis of neurodegenerative disorders) and anxiety (Kloet, Joëls, & Holsboer, 2005; Weaver, 2007; Weaver, Grant, & Meaney, 2002). In Cushing’s syndrome a disorder in-which damage to the hippocampus is seen due to high levels of cortisol secretion, the hippocampal tissue loss can be reduced by a re-regulation of cortisol production (Starkmana, Giordanib, Gebarskic, Berentb, Schorke, & Schteingartd, 1999). Understanding the stress response could help the clinician create touch-based interventions that effectively reduce agitation and anxiety and increase the felt experience of being in relationship with others. In the traditional model of the autonomic nervous system there are two branches, the sympathetic and the parasympathetic (Blumenfeld, 2002). The stress response is how the body mobilizes to protect itself when under threat. The sympathetic branch (fight/flight) stimulates the gut to stop digestion, the pupils to dilate, the breath rate to increase, and blood flow to increase to the limbs. The body is maintained by balance between the activation of the sympathetic nervous system and the parasympathetic nervous system. The parasympathetic branch allows the body to rest, rebuild structures, and digest food. When the parasympathetic system is engaged, pupils constrict, breath slows, muscle tone relaxes, and gut motility begins again. According to Porges, (1995) an examination of the parasympathetic nervous system from an evolutionary perspective reveals that it breaks into two branches: A 7
  • 8. myelinated fast acting newer system mediates social engagement (Venteral Vagal Complex-VVC) and an evolutionarily older unmyeolinated slower acted parasympathetic system meditates the evolutionarily older freezing defensive response (Dorsal Motor Nucleus of cranial nerve ten-DMNX). According to this model when the individual experiences a low level threat the newer parasympathetic branch mediating social engagement disengages and the sympathetic branch activates. After the threat is reduced the sympathetic tone is reduced and the social engagement system re-engages. When there is significant threat the social engagement system disengages, the sympathetic branch engages and as the individual exceeds their ability to tolerate the stress level, the older unmyeolinated freeze response engages, shutting down the system. Being able to read where in these phases of autonomic functioning the individual is can help the clinician choose interventions to meet the needs of the situation more effectively (Foundation for Human Enrichment, 2007). The SE Model of Touch Treatment According to the SE model the process of threat--orienting, arousal, defensive response--follows a reliable pattern that if interrupted can lead to the creation of symptoms of trauma (Foundation for Human Enrichment, 2007). In this model anxiety, anger, aggression and freezing are all natural attempts at re-establishing health in the nervous system. The clinician providing therapeutic interventions works with these defensive responses to help them complete their natural patterns (Levine, & Frederick, 1997). The full enumeration of these techniques is beyond the scope of this paper. However, in short three things can be very helpful. 8
  • 9. First, if an elder has a stressful encounter, helping them soothe by evoking a relaxation response can be quite helpful. The care providers and family can be taught to use multiple soothing techniques. Having one positive emotion following a stressful event speeds the reduction of the stress response significantly (Fredrickson, Mancuso, Branigan, & Tugade, 2000; Lai, et al., 2005). Positive emotions can be evoked in the experiencing self through vision, smell, touch, sound, taste and social engagement (Linehan, 1993; Foundation for Human Enrichment, 2007). Social engagement can include positive safe social contact, mirroring of emotions, decoding of feelings, validation, soothing touch, and eye contact. The second supporting defensive responses can facilitate return to rest. The clinician can support the impulses behind these feelings (i.e., running away or fighting back) by providing a containing presence while the emotion is present, asking the individual to notice the somatic marker of the impulse and to imagine the completion of the defensive response (e.g., running away or fighting back) (Foundation for Human Enrichment, 2007). Fight-flight activation could also be triggered by a moment of disorientation from fluctuation in awareness, memory or impulsiveness. Third, helping the elder orient to the felt experience or the somatic markers of the feeling and then move their attention to safety in the current environment can support decoupling or desensitizing the fight/flight or freeze response from the environmental triggers. Touch Treatment with Elders Touch can be used in many aspects of therapy with elders. The three key ways identified in this paper are: to create the felt experience of connection, meaning and closeness; to support reduction of behaviors that interfere with maintaining the elder in 9
  • 10. their current level of care; and to reduce emotional discomfort, agitation, depression and anxiety. Touch can be a central way that people express intimacy. While different cultures have widely variable norms for the use of physical contact, it is often a way to communicate emotions. Love, anger, sadness, fear and jealousy are all emotions that are readily communicated and decoded through physical touch (Hertenstein, Holmes, McCullough, & Keltner, 2009). When words fail an individual with frontal-temporal dementia semantic type or in the later stages of AD, the simple holding of a hand can create the sense of closeness without the need for verbal exchange. Regular supportive touch has been shown to increase how well spouses view each other, oxytocin secretion and reduce stress hormone production. Teaching family members to connect to their loved one through touch could reduce agitation, increase the feelings of connection and reduce the experience of feeling alone. High levels of stress hormone secretion are associated with behavioral difficulties. Touch reduces stress hormone secretion and increases dopamine, norepinephrine, and serotonin. Several studies have shown that touch therapy reduces agitation, wandering, and aggression. Staff, family members, friends and other loved ones can use touch as a tool to help their loved one to reduce agitation (Woods, Craven, & Whitney, 2005; Woods & Dimond, 2002; Kima, & Buschmann. 1999). The therapist can teach family, primary care providers, and friends a touch-based tool and then teach these individuals to be able to teach others the tool. Teaching the tool includes recognizing the “signs of agitation” in elders. It is important to teach the care providers to recognize if the individual they are supporting is in a low, medium or high level of agitation as well as if their main tendency is fight or flight (anger or fear). Different tools will be more effective 10
  • 11. at different levels of agitation and different tools will be more effective with fight responses than with flight responses. It is important to note that the individuals providing the interventions should regulate themselves, using an affect regulation tool such as mindfulness, imagery, progressive muscle relaxation, etc., prior to providing the intervention. Touch is an excellent communicator of emotions, and the care providers will be more effective if they regulate their emotional state prior to providing contact (Hertenstein, Holmes, McCullough, & Keltner, 2009). To provide effective touch-based interventions, it is important to have a good assessment of current functioning. The first step in this process is to obtain neuropsychological evaluation. In later stages of the disease process this may not be relevant, as it could not offer any new information for treatment. The second step is to identify patient/caregiver goals and current coping strategies. It is important to note that some challenges simply need to be accepted, some need be adapted to, and some corrected. Third, assess motivation and beliefs about healing/health. This can give the clinician insight into how to create and teach effective touch-based interventions. The fourth is to assess the level of insight the client displays about the cognitive changes. Many neurodegenerative disorders impact an individual’s ability to self-reflect (Blumenfeld, 2002; Attix & Welsh-Bohmer). One’s description of treatments and types of treatments can be affected significantly by the client’s level of insight about their functioning. Finally, it is important to assess both the strengths and challenges an elder has personally, in their social context and environment. Touch can be used as a tool for multiple aspects of treatment, including: a) as an 11
  • 12. adjunct treatment for mood disorders, b) to reduce cortisol secretion and behavioral disruptions (Field, Hernandez-Reif, Diego, Schanberg, & Kuhn, 2005; Woods, Craven, & Whitney,2005; Woods, & Dimond,2002), c) to reduce anxiety, d) to reduce aggression, e) to support de-escalation if the individual becomes agitated, f) for pain reduction (Hernandez-Reif, Field, Krasnegor, & Theakston, 2001), g) to increase social support, h) to increase meaning and emotional communication (Hertenstein, Holmes, McCullough, & Keltner, 2009), and i) increase sleep (Ferber, Laudon, Kuint, Weller, & Zisapel, 2002). Massage therapy has been shown to reduce symptoms of depression as well as lower cortisol and increase serotonin and dopamine (Field, Hernandez-Reif, Diego, Schanberg, & Kuhn, 2005; Field et. al., 1997). Touch-based treatments have been shown to reduce pain and re-regulate the sleep cycle. Although, this liturature often has multiple methodological concerns and not all studies have found positive results, in elders multiple studies have shown that touch therapy reduces agitation, aggression, wandering behavior, and pacing (Kima, & Buschmann. 1999; Hawranik, Johnston, & Deatrich, 2008; Woods, Craven, & Whitney, 2005; Woods & Dimond, 2002). Touch in family systems has been shown to increase self-reported quality of relationships and positive interactions (Matthiesen, Ransjo-Arvidson, Nissen, & Uvnas-Moberg, 2001). These studies have not been duplicated in elders but the increase in positive relationships likely would affect this population as well. Touch therapies enhance oxytocin levels, which mediate attachment and emotional bonding (Matthiesen, Ransjo-Arvidson, Nissen, & Uvnas-Moberg, 2001). Touch Techniques 12
  • 13. Touch techniques can fall into several categories: self-regulation techniques, co- regulation techniques, and de-escalation techniques. Self-regulation techniques teach an individual to use touch to sooth anxiety or agitation. These techniques can include self- touch (e.g., self-massage, tapping, pushing feet into ground, and self-squeezing), contact with an animal (e.g., house pet, health advocate animal, therapy animal), or seeking contact with care provider (e.g., hand holding, asking for contact on an area that would feel reassuring, pressure on outside of shoulders to create containment). Co-regulation techniques are techniques that a therapist, family members or care providers can use to provide containment, desensitization to triggers and containment for dysregulated affect (e.g., providing listening, containing, or supportive touch; using touch to evoke the relaxation response; supporting the prefrontal emotional regulation areas to come online through orienting the individual to the internal sensations and the outer world, with touch used as a stabilizing anchor). Schore (2003) postulates that co-regulation requires that the clinician can in a contained manor, mirror on a physiological level the clients affective state. He describes this as being with a self-regulating other. De-escalation techniques can be used to reduce agitation and anxiety and increase positive mood (e.g., supportive touch on back, hand holding, asking to squeeze the care provider’s hand, mirroring movements, allowing the person to take your arm and lead you). Cultural Impacts: Ableism and Neurocognitive Changes The disability rights movement has categorized several core belief structures people hold about disability. These belief models have implications for help-seeking behavior, prognosis and ability to maintain social support systems. The first of these 13
  • 14. models and the oldest is the religious/moral model of disability. This model views disability as a moral failing. People who have this belief will often explain disability as the effects of poor choices/moral failing. The second is the medical model, which views disability as an illness or deformity to be fixed (Marks, 1997; Orto, & Power, 2007). Much current theory of neurodegenerative disorders uses this model. Third is the social construct or disability rights model. This model views the differences in function as a reality but also recognizes that many difficulties an individual faces are due to the inflexibility of social systems and biases held by those who are currently able- bodied/minded. Major Neurodegenerative Disorders There are many types of neurodegenerative disorders; this paper will explore four major classes of disorders (Attix, & Welsh-Bohmer, 2006). These are memory-based disorders classified as Alzheimer’s dementia, movement-based disorders including Parkinsonian dementia and Lewy body dementia, the frontal-temporal disorders including Picks disease, primary progressive semantic dementia, and vascular dementias. Understanding the unique presentations of each of these could help the clinician better support their clients. Alzheimer’s Dementia (AD) Diagnostic factors and neurocognitive changes. The primary presenting problem for individuals who meet the diagnostic criteria for AD is poor memory and forgetfulness (Blumenfeld, 2002). The middle stages are characterized by loss of ability 14
  • 15. to conceptualize, reduction of coherent expressive speech, reduction of language comprehension and praxis (motor planning) (Attix, & Welsh-Bohmer, 2006). In late stages individuals with AD often display behavioral difficulties, agitation, delusions, and hallucinations. Although the gold standard for diagnosis is post-mortem autopsy of brain tissue, in studies neuropsychological assessment has identified AD correctly in 85% of cases (Attix, & Welsh-Bohmer, 2006). Other factors that are highly associated with AD are loss of executive functioning and fluid reasoning capabilities. Loss of executive functioning is correlates highly with behavioral disruptions and loss of Activities of Daily Living (ADLs). Reduction in fluid reasoning ability (the ability to solve problems) is most correlated with reduction in more complex life skills. The loss of fluid reasoning was most predictive of the decline in levels of functioning. Changes in cognitive functioning were predicted best by changes in verbal skills. Functional deterioration mirrors physical loss of nerve paths between the hippocampus and the entorrinal cortex. By late stages the hippocampus is isolated from the rest of the brain. Often depression may precede the onset of AD (Attix, & Welsh-Bohmer, 2006). Depression can, however, occur throughout the disease. High levels of cortisol has been associated with depression (McEwen, 2003; McEwen, & Lasley, 2002). Depression is an important differential diagnosis because in older adults depression can mimic dementia (e.g., cognitive slowing, lack of initiation and poor memory). Depression has been noted to lead to loss of hippocampal tissue (also affected by AD). Diagnosing and treating depression is important because it can also exacerbate symptoms of dementia (Attix, & Welsh-Bohmer, 2006). 15
  • 16. Psychological reaction to the diagnosis and cognitive changes. Individuals who experience these cognitive changes may have a difficult time admitting to themselves that changes have occurred. They tend to attempt many ways to hide their cognitive changes. The diagnosis of AD can feel like a life sentence. To the individual it can feel like a deadly disease that has no cure and will inevitably rob them of everything they have. People with AD can feel disoriented as their cognitive abilities change. Once familiar streets look strange. At moments memories wash over them out of the blue. Trying to find memories can feel difficult, overwhelming and embarrassing. It can often feel like one is waking up again and again without the narrative of recent moments or even the past week to help put this moment in context. People can often feel angry at having to go through the cognitive changes; they may have traumatic guilt and blame themselves; they may feel betrayed, and questions of existential value can surface. Parkinson’s Disease (PD), Parkinsonian Disease Dementia (PD-D), and Lewy Body Dementia (LBD) Diagnostic factors and neurocognitive changes. These disorders are likely a spectrum of disorders that affect the sub-cortical movement, motivational and affective centers of the brain (Blumenfeld, 2000). All of these disorders present with tremors, slowing of movement, difficulty initiating movement, difficulty with balance and cognitive slowing. Individuals with PD will have difficulty accessing memories but cognitive strategies will suffice to manage symptoms. PD has no clear dementing process and is a slow-progressing neurodegenerative disorder (Attix, & Welsh-Bohmer, 2006). PD-D has the symptoms of PD but includes changes in cognitive and executive 16
  • 17. functioning; it occurs in about 33% of all people diagnosed with PD. LBD is characterized by fluctuating levels of arousal and attention, motoric disruptions, cognitive losses similar to AD, and visual and auditory hallucinations (Attix, & Welsh-Bohmer, 2006). All three of these disorders are characterized by flat affect and in the case of LBD and PDD, there are heightened activations of the Dorsal Motor Nucleus of the Vagus nerve, which in the poly-vagal theory of the autonomic nervous system mediates freezing/dissociation and autonomic shutdown in traumatic stress. Psychological reaction. Depression is common in all forms of basilar dementia disorders (Attix, & Welsh-Bohmer, 2006). Many individuals will express flat affect, lack of interest in life, lethargy, depressed mood and other signs of depression. Individuals who experience these disorders often face very real social stigmas that impact the quality of their relationships. Individuals with LBD particularly experience paranoia and have difficulty distinguishing dreams from reality. Individuals with PD-D and LBD often can also feel isolated and excessively sleepy. Depression and PTSD are highly comorbid (O’Donnell, Creamer, & Pattison, 2004). Traumatic loss has a high correlation with comorbid of depression and symptoms of Post-Traumatic Stress Disorder (PTSD) (Momartin, Silove, Manicavasagar, & Steel, 2004). Assessing individuals with these disorders for grief at the changes and providing treatment can be very beneficial. In all neurodegenerative disorders there are fluctuations in functioning, but these fluctuations are more pronounced for people with LBD and make it quite challenging for both the individual with LBD and their family. Levels insight may vary across the disease process, on a day-by-day basis and fluctuate with attention and arousal levels. For individuals with LBD, hallucinatory content can contain the full range of experiences, from quite difficult 17
  • 18. to a moderately pleasant dream. Individuals with LBD may feel that they cannot trust reality. For all the movement-based disorders falls occur regularly (Blumenfeld, 2002). Falls can be traumatic, damaging and embarrassing. Frontal Temporal Dementias (FTD): Picks, Primary Progressive Aphasia Diagnostic factors and neurocognitive changes. This group of disorders is not likely a unitary disorder but a family of related disorders (Attix, & Welsh-Bohmer, 2006). For the frontal disorders there are two distinct developmental pathways. First symptoms are often loss of nouns or verbal or semantic recall. In early stages symptoms are lack of spontaneous speech, then economy of speech, stereotyped speech, later repeating the phrases of others, preservative content and mutism. Second is the behavioral disinhabition pathway. The individual with these symptoms can look antisocial; they can lack social awareness and neglect their hygiene, engage in unrestrained sexual expression, and are impulsive (Attix, & Welsh-Bohmer, 2006). Psychological reactions. The lack of verbal abilities can be embarrassing and lead to isolation. People can limit the scope of their social life due to fear that they cannot communicate effectively with others. As the capability for verbal expression decreases, it can be difficult for these individuals to find and create connections. Most individuals in Western cultures communicate primarily through verbal expression. Non-verbal expressions and interactions are not a part of normal exchanges. The skills for creating relationships non-verbally can be taught and can improve the quality of life for individuals with the primary progressive aphasia presentation of these disorders. As these disorders progress, the loss of ability to express their needs, emotions and motivations 18
  • 19. verbally can amplify their aggression. For individuals who initially display behavioral impulsivity, this behavior can impact their loved ones, their professional standing and their economic viability. They can ruin their reputation with impulsive, unethical actions. Many individuals, due to the loss of prefrontal functioning, do not have insight into their behaviors. They can appear cold, rigid and impersonal. This can isolate them from their loved ones. Vascular Dementias Diagnostic factors and neurocognitive changes. These disorders are highly heterogeneous (Attix, & Welsh-Bohmer, 2006). They reflect damage to the brain from multiple classes of ischemic attacks, including burst blood vessels, occlusions and aneurisms. The initial presentation reflects either the area of the brain damaged in the ischemic attack or a reduction in global functioning due larger scale damage. This disorder is a slowly progressing disorder and some have hypothesized that it cannot be classified as a neurodegenerative disorder due to tissue loss not being caused by a dementing process. However, this disorder is second only to AD in the number of Americans affected. Psychological reactions. This disorder often has a sudden onset. The suddenness and the severe consequences of the cognitive changes can impact the family and individual as a traumatic loss. The family needs to adjust to the changes in their loved one’s functioning, ability to work and emotional sustenance for the family system. The individual’s level of awareness of the changes is highly variable. If a cognitive system that relates to self-monitoring and self-awareness is intact, then the individual may have 19
  • 20. perfect awareness of the cognitive changes. If those systems are affected or there are more global changes, they may have limited awareness of the changes. If an emotional regulatory center is damaged, this can lead to behavioral changes that can impact the family strongly. Integrating the experience of shock due to the suddenness of the changes could help both the individual and the family adjust. Conclusions Touch therapy has a role to play in elder care. It has been shown to enhance the quality of interpersonal relationships. Although not all touch studies have had solid methodology, a 2006 study used solid methodology and found that touch treatments reduced agitation, aggression and pacing behaviors in elders. Touch is only one aspect of treatment and is far from a panacea. A full model of treatment planning would include other non-touch-based interventions, movement interventions, family therapy, building a treatment team, assessing the needs for pharmacotherapy, cognitive training, and respite care. Although touch treatment has some good studies supporting it, very few studies have been conducted with elders, and the literature still abounds with poorly controlled studies. More studies that focus on the use of touch with elders for multiple emotional, behavioral, movement oriented and cognitive outcomes could help these interventions become a larger part of mainstream treatment with elders who suffer from neurodegenerative disorders. References Attix, D. K., & Welsh-Bohmer, K. A. (2006). Geriatric Neuropsychology: Assessment 20
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