This post reviews an article by Amano & Toichi (2014) about on-the-spot EMDR sessions for people suffering from dementia.
Dementia, as a group of symptoms caused by organic changes in the brain, is a disorder that may be diagnosed consequent to diseases such as Alzheimer's or stroke. The symptomology, when behavioral, manifests as irritability, aggressiveness, wandering, screaming, inappropriate interactions, hoarding, cursing and sexual acting out; psychological symptoms include anxious and depressed mood, delusions and hallucinations.
Dementia features may appear in early, moderate or late stages of the disease. The early stage finds the identified client presenting with confusion and forgetfulness but retaining some insight, while the moderate stage causes ever increasing memory problems and confusion, and inability to properly complete activities of daily living without help. In the later stage, the individual will not be able to recognize people or objects, will lose the ability to speak, will become incontinent, and will suffer from severe memory loss.
In addition, those in the later stage of the disease will lose touch with reality, believing they are living in a different time, and will present with restlessness and increased aggressiveness at night; eventually loss of speech will occur, with individuals only able to cry out.
The American Psychiatric Association's guidelines for therapeutic interventions for dementia include cognitive, behavioral, emotion and stimulation-oriented therapies, while The Group for the Advancement of Psychiatry Committee on Aging recommends reminiscence and validation therapeutic work as a way to help individuals in the early stage of dementia address and process emotions that arise from confusion, memory loss and disorientation.
Individuals in the later stage of the disease will need the care of a psychiatrist or geriatrician who will prescribe medications; a nurse liaison; a psychologist creating the treatment plan; and a social worker/case manager to integrate the family into the treatment plan.
Literature Review
Dementia-care nursing home residents may wander, scream, become agitated and restless, and exhibit violent behavior and speech; these behavioral and psychological manifestations may arise from previous traumatic events. These manifestations become ritualistic and can be compared to symptoms of PTSD. EMDR is an evidence-based therapy for PTSD and has been used with younger survivors of trauma; the current undertaking seeks to modify standard EMDR protocol to fit the needs of an older dementia population in later stages of the disease.
Methods
Three nursing home residents in moderate to late stages of dementia participated in the 4-6 session study after their relatives or legal guardians gave consent. Behavioral and psychological symptoms were frequent in these patients, and had progressed to severe physical aggressiveness and irritability, with incidents of screaming, restlessness, confusion, wandering and agitation perhaps enhanced by previous traumatic experiences.
On-the-spot EMDR was modified from standard EMDR protocols to fit the needs of the patients. Phases of the EMDR protocol were addressed in the following ways:
Phase One, or history taking, was adapted to gather history from family members instead of the patients themselves;
Phase Two, or the preparation phase, enables the formation of trust within the therapeutic relationship; in the case of patients with severe symptoms of memory loss and confusion, each encounter began with introductions and rapport-building;
Phase Three assesses for target-memory reprocessing in standard EMDR treatment; on-the-spot EMDR assumes that memories are being acted out through uncontrolled emotions and behaviors;
Phases Four through Seven focus on reprocessing material in standard EMDR practice using bilateral stimulation, either with eye movements, listening to tones, or holding buzzers which alternate output; on-the-spot EMDR utilizes the tapping method only;
Phase Eight, or reassessment, utilizes chart review and staff observations to help determine success rates for the modified treatment.
When patients were in much later stages of dementia and expressing traumatic memories, EMDR followed a simple blueprint:
the physical position of the therapist vis-a-vis the patient remained straightforward;
eye contact was maintained by the therapist;
the therapist used calm demeanor and speech to deescalate agitation and high emotion;
the therapist repeated patient keywords and observed physical expression of emotion;
the therapist used EMDR tapping to install feelings and cognitions of safety;
when appropriate, and the patient was relaxed and no longer outside a window of tolerance, the therapist helped the participant develop inner, positive resources while identifying memories, sensations and images which were then be installed using tapping.
Results
All three participants benefited from the on-the-spot EMDR treatment and saw significant reduction and elimination of symptoms like screaming, cursing and physical aggression. The participants no longer endorsed or acted out distressing memories even after 6 months of treatment termination. These results surprised the researchers since study participants experienced severe cognitive deficits due to organic brain damage, including atrophy in the prefrontal cortex.
Discussion
Treatment-as-usual for dementia is effective only during the intervention itself. On-the-spot EMDR provided relief for up to 6 months post treatment . The resource development protocol matches reminiscence therapy since it facilitates the recall of positive memories; additionally, positive sensations can arise during tapping, and these, along with images, can account for return to and maintenance of a calm state.
Possible mechanisms of on-the-spot EMDR can be related to the reprocessing of traumatic material, the latter which may be enacted during aggressive, screaming and other episodes. Bilateral stimulation, and for these participants, bilateral tapping, can be seen as facilitating physical calming, desensitization of memories experienced as distressing, and enhancement of recall.
The authors of the study conclude that dementia may require a PTSD-like syndrome modifier which can be treated in a non-pharmacological manner using 4-6 sessions of on-the-spot EMDR with a therapist, and continued tapping moments from a caregiver.
- Amy Discepolo, LMHC, EMDRIA Certified Therapist
As a certified EMDRIA therapist, I am available to consult with you about this type of short programming that you can implement in your facility/agency. Please contact me with any questions at info@gentletherapyplace.com or call 904-344-8320.
References
Amano, T., & Toichi, M. (2014). Effectiveness of the on-the-spot-EMDR method for the treatment of behavioral symptoms in patients with severe dementia. Journal of EMDR Practice and Research, 8(2), 50-65.
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