Yoga for Caregivers of Persons with Alzheimer’s Disease

Lotus Pose (Padmasana)by Rev. Sharon Shanthi Behl, M.A., LPC, E-RYT 500®

“This is exactly what yogic life means: living a collective life and rising above selfishness, sharing the joy of everyone and the pain of everyone. Let us learn that first – to love and give, care and share. Then, we will really see a beautiful heaven on this earth.” –Sri Swami Satchidananda

Introduction: Yoga Helps Us Stand When We Are Brought To Our Knees

An ancient tale from India tells of a woman, recently widowed, torn by grief, who goes to the home of a wise monk. “Please, Sadhu (a term of respect), I implore you to bring back my husband. The depth of my pain is unimaginable, I cannot live without him. Please restore him to life and end my ceaseless torment.” The Sadhu agreed to fulfill her request but said, “First you must bring to me a mustard seed from the house of someone who has not known the loss of a loved one. When you bring me the seed, I shall restore your husband to you as he once was.” She quickly consented and hurried into the village to complete the bargain. When she came to the first home, a smiling young woman opened the door. The widow was surprised to hear that the young woman, who always had a kind word for everyone, had lost a child during labor. At the second home, the elderly man with whom she often crossed paths in the marketplace told her he had been recently widowed. The next villager she met grieved for the death of his sister in a rockslide.

Another woman told of her great sadness about her mother, whose recent mental infirmity permanently changed their relationship beyond recognition. At every home, her neighbors told her of the loss of a loved one. Feeling sadder, but strangely more peaceful, the woman returned to the monk and told him she was unable to do as he requested. She could not find a single house that had not known loss. Her husband was dead, that was true, she said, but she discovered something within the village. The woman found a new sense of support and friendship born of the bonds of shared grief and loss.

I would like to invite you to notice that you are most definitely not alone in this journey. Though the landscape of your life may be dominated by caregiving, and your loved one with Alzheimer’s disease is not the same person you once knew, there are others who are experiencing the same. In every walk of life and in every part of the world, there are men and women who understand deep in their bones what it is like to be where you are. As we explore the practices of Yoga together, I wish to keep emphasizing the word together and will encourage the notion that part of your self-care is being with others. My respected teacher, Sri Swamiji Satchidananda, taught the difference between wellness and illness. In wellness, there is the support of “we” and in illness, we are only focused on “I.”

According to the Alzheimer’s Disease Foundation of America, nearly 50 percent of Alzheimer’s disease caregivers eventually develop depression or other health problems. I will try to avoid implying, that if you would just practice yogic breathing techniques or sun salutations exactly right, that your journey as a caregiver will be less heartbreaking. Instead, I hope to share a bit of the richness of Yoga and how a practice can help you touch an inner source of strength and peace. And just maybe, like many other people who have traveled this decidedly rocky route with Yoga practice as a companion, you can rest deeply along the road.

Place your hand on your belly, take a deep breath in through your nose and slowly exhale through your nose (yes, right now, I’ll wait). Repeat. Now breathe naturally.  Know it to be true, that without any props, accoutrements, bells or whistles, you may come home to your Self for a precious moment or two whenever you choose.

In my role as a Yoga Educator and Therapist, I teach about the use of breathing techniques, gentle stretching postures, meditation, chanting of mantra (sacred Sanskrit words) and other aspects of the art and science of Yoga. I hope that you may find your own personalized way to experience the extraordinary challenge of being with a person with Alzheimer’s disease. I will share some portions of Yoga philosophy, insert practical techniques, and tell a few stories. Yoga practices create a fertile field for growing your awareness of the interconnectedness of life in its various forms and names. When I’m touching the sweetness of that deep well, I experience life with a heightened presence of mind and a richer bodily felt sense of joy and gratefulness, and yes, of sorrow and grief, as well. My daily activities feel more peaceful, easeful, and useful even in the midst of tumult.

What is Yoga?

Historians date the first written document of yogic teaching to over 5,000 years ago.  There is a vast reservoir of both written information and verbal teachings that have been handed down from teacher to student in unbroken lineages across generations. My spiritual lineage, brought from India to the United States in the 1970’s by Sri Swami Satchidananda, combines various methods of Yoga including chanting, eye exercises, breath practices (called pranayama), guided deep relaxation (called Yoga nidra), meditation, selfless service and a deep commitment to the inclusive acceptance of all spiritual paths. If you are of a certain age, you may remember that Swami Satchidananda led the Woodstock nation in the chanting of the sacred Sanskrit sound “Om” during the festival’s opening ceremonies. He spoke persuasively to the crowd about creating a peaceful gathering.

In Yoga’s early days  in the United States, the word Yoga often conjured up a picture of turbaned East Indian men in pretzel-shaped contortions performing for photographers from Life Magazine. As a child, I remember how the word Yoga was often mistaken for the word yogurt. For many decades in the United States, Yoga was viewed primarily with suspicion. Fast forward to the current day, we see an explosion of Yoga images and references in popular culture. Photos of people doing Yoga poses are as ubiquitous as Starbucks cafes. Open a random magazine and you are likely to see a photo of a young lithe leotard-clad woman, arms outstretched at shoulder height, standing in warrior pose on a purple mat touting the benefits of diet soda, a hotel chain or even a car! Needless to say, this popularity has its downside. With the commodification of Yoga, and the widespread images in magazine advertising, television and movies, one of the unfortunate results is that many older, bigger, or stiffly-jointed Americans cannot identify with these commercialized images and avoid giving yogic practices a go.

If you have that concern, there is good news for you!  In the process of Yoga becoming mainstream in the United States, teachers have adapted yogic techniques for people of practically every age, size, shape and physical or mental condition. Just a quick search of the word Yoga on the internet today reveals 89,600,000 results. Type in Alzheimer’s disease + Yoga and you see over 2,000,000 citations. Caveat emptor! If you want to explore Yoga, consult a credentialed or otherwise reputable teacher. Accessible yogic practices abound for everybody!

The benefits of Yoga become quickly apparent when, after even a little bit of intelligent practice, people report a lessening of tension in the body, increased clarity of thought, and feelings of well-being. Breath is the starting point for connecting oneself to the present moment and for the feeling of relaxation. Scientifically speaking, the relaxation response begins a cascade of physiological responses that ease the knots of tension in our muscles and unclench the tightness in our belly. Our lymphatic system, hormone levels, nervous system, cardiovascular system, muscles and bones, and last but certainly not least, our mind and emotions are beneficially impacted by practice of Yoga. Quieting our mind sets the ground for skillful action and decision-making.

My Life is Already Too Complicated!

Let me tell you something. It may sound irrational, but the following statement is totally true for me. When I practice Yoga first thing in the morning for at least 15 minutes before I start work, I absolutely have more time in my day! I accomplish more tasks and the time between events seems more spacious. This is unrelated to what time I woke up, the number of deadlines looming over my head or the state of my appointment calendar. My mood is more even. I experience set-backs, jammed copiers, words that will not form on the page, and people who cut me off in traffic with much less drama. I am more fully engaged with my day and yet it is easier to cultivate a more peaceful sense of detachment from stressors. I feel a wider sense of compassion and patience with those whose viewpoints are, let’s say, different than mine. The positive effects are also evident when a true crisis emerges. I am often called upon for my calming presence to deal with someone who is angry or irrational. I attribute this phenomenon to the practice of Yoga. I have noticed this effect for years. I also notice the waves of frustration, impatience, judgment and anxiety swelling within me when I have neglected my practice for even two or three days. I encourage you to see how Yoga can show up in your own life.

Now, let us read on to the next section to see how Al and Jean engaged in the practice of Yoga.

Practicing Yoga Together in the Last Days of Life

On a brilliant autumn morning, Al and Jean (not their real names) hesitantly entered the hospital classroom where our first Yoga class was being held. They were smartly dressed in new matching navy blue sweat pants and sweatshirts. Al was wheeling a portable oxygen tank alongside his bent but still imposingly tall frame. Al wore a look of puzzlement and did not speak when I welcomed them. Jean quickly and somewhat anxiously explained their situation. She was hoping they could attend class together.  Last month, Al had been diagnosed with Alzheimer’s disease. Jean shared that it was actually a relief for her to hear the diagnosis. It explained many of the odd behaviors her husband of thirty-five years had been exhibiting over the past year. For example, just this morning, he became very anxious as Jean was driving them to class. He was quite convinced that the car they were in belonged to someone else and he was afraid of being arrested. She was, as she put it, at her wit’s end and feeling desperate. Years ago, she had taken a Yoga class at her local recreational center and lately she thought maybe a therapeutic Yoga class could bring Al that same sense of peace she had experienced back then. In addition, a friend had recently mentioned Yoga was good for stress management and thought Jean might benefit due to the extraordinary stress she was experiencing as a full time caregiver.

Jean was, understandably, concerned about her husband becoming upset during class or wandering away. Interestingly, once class began, it was Jean, not Al, who took longer to settle down. Jean had a difficult time staying focused and I often observed her sneaking a look at her husband in the middle of a pose. After some time, when she was assured that he was safe and quietly going along with the instructions, she seemed to attune more deeply to her own body and her facial tension began to melt.

Al and Jean showed up for class once per week for approximately two and a half months before Al suddenly passed away from complications of a chronic respiratory illness.  However, during the weeks they attended, you could see an easefulness grow in Jean’s physical body. At first unable to comfortably get from sitting on the floor to standing, she progressed to easily standing without assistance. Jean reported that her back no longer troubled her, even after giving Al his bath, an activity that previously caused her lower back muscles to knot up with tension. Jean also shared that she was more patient with Al’s pacing and found that she did not feel like screaming at him quite as often.  In fact, she confided, she started to be much more playful and silly with Al. This made sense to me. When we deeply relax emotionally and physically, we can experience stressful situations with some humor and an appreciation of the absurdities that life brings us. We can instead, quite literally, laugh with compassion toward ourselves and others when our hearts are breaking.

Now, let us experience one posture that I taught in every class. Jean particularly liked to do this while standing on line at the grocery store. This is called mountain pose or tadasana.

Stand with your feet parallel and a few inches apart. Imagine the sole of each foot as a rectangle and let your weight be equally distributed across each of the four corners.  Allow the knees to soften and feel a sense of lengthening up the legs. Begin lifting up the front of the body. Lift the ribcage away from the pelvis and hips and feel a sense of widening and opening across the center of the chest (known as the heart center). Lift the shoulders up towards the ears, roll them back behind you giving a good squeeze as if you could touch the shoulder blades together, and then roll the shoulders down away from the ears. Repeat 3-4 times and then repeat rolling in the opposite direction. Bring the shoulders to stillness allowing them to continue dropping away from the ears and relax the arms and hands heavily by your sides as if you are holding a gallon of water in each hand. Finally, gently press the crown of your head up to the sky, even while you press your feet into the earth below. Stand in this manner, tall as a mountain, and breathe naturally for 3-5 minutes (or as long as it takes you to move to the front of the check-out line!)  

Mountain pose brings with it a bodily-felt sense of the qualities of a mountain.  It helps one cultivate patience and steadiness in the midst of the emotional storms of life.

Pranayama: Yogic Breath Work

Now, let us take a moment, right now, to feel our own energy. I will provide instructions as if you are sitting, but, if you wish, you may practice this exercise while standing in mountain pose.

Sit up tall, lengthen the spine and place the feet flat on floor. Press the feet into the ground even as you press the top of the head toward the ceiling. Relax the hands lightly on the lap and release the shoulders down away from the ears. Soften the belly muscles. As you breathe in through the nose – lengthen through the crown of the head. As you breathe out through the nose, release the shoulders and press feet into the floor.  Continue this practice and turn your awareness to sensations along the spinal column.  Feel the upward flow as you breathe in and the downward flow as you breathe out.  It is perfectly fine if you feel the opposite movement.  The important aspect is to sense any movement along the spine. You may not initially feel the movement of your energy.  However by first imagining it, you will later actually feel the upward and downward flows of energy along sushumna, the central core of energy.

The language used in Yoga is Sanskrit, and in Sanskrit, postures are called asanas. The process by which we deliberately alter our breathing is sometimes called breath work. In Yoga, it is called pranayama, or guidance of the prana. Prana is the energy that animates all life and we can consciously guide that energy using two subtle mechanisms. First and easiest to start with, is with breath work. We can deliberately extend, shorten, retain and otherwise direct the air we breathe in a variety of ways in order to guide the prana.  Second is the mechanism of directed attention, also known as our intention. Where are thoughts go, our prana goes. An integrated pranayama practice utilizes both the breath and our focused attention.

When we say we are tired and have no energy, what we are really saying is that our energy is blocked. Not only do we need breath to live, but how we breathe can profoundly affect our degree of physical well-being; it can regulate our emotions, and it can deplete, sustain or increase our experience of aliveness. Prana is constantly fluctuating and moving throughout the universe. According to Yoga philosophy, it flows throughout the living body in exquisitely determined whirlpools and currents. The wonderment of the yogic system is asana and pranayama practice allows our innate energy currents to flow as nature intended.

Here is a lovely pranayama practice to use with an agitated individual who is “sundowning.” You may be familiar with this phenomenon. Mayo Clinic clinical neuropsychologist, Glenn Smith, Ph.D., describes sundowning as a state of confusion at the end of the day and into the night. Sundowning isn’t a disease, but a symptom that often occurs in people with dementia, such as Alzheimer’s disease. Smith lists several factors that may aggravate late-day confusion including fatigue, low lighting, increased shadows and the disease’s disruption of the body’s internal clock. You may find that focusing your loved one’s attention on this practice calms them, and you.

Face your loved one. Read these instructions slowly out loud as you demonstrate the movement.

Let us do the Butterfly Breath together. Face your palms toward the heart center at center of the chest. Interlace your fingers with thumb pointing up to the ceiling.  Place your hands on your chest and keep your awareness at this heart center as you breathe deeply and slowly in and out the nose. Can you feel your heart beating? Can you feel how much you are loved? Notice the rise and fall of your breath. Feel the warmth of your hands on your chest. 

Add this option for yourself: Notice any feelings or thoughts as you breathe naturally. As you breathe in, see your feelings and thoughts like bubbles of air rising from the bottom of a lake, breathe out and imagine the bubbles silently bursting as they reach the water’s surface.

If You Want To Take Excellent Care of Your Loved One, You Must Take Excellent Care of Yourself

You have probably heard people tell you that you must take care of yourself when you are the caregiver. You probably know something about “burn-out” and compassion fatigue, and perhaps you are looking for ways to prevent complete exhaustion. On the other hand, you may already feel burnt to a crisp.

According to a report published by the UCLA Newsroom, the incidence and prevalence of clinical depression in family dementia caregivers approaches fifty percent. Dr. Helen Lavretsky, professor of psychiatry at the University of California at Los Angeles (UCLA) Semel Institute for Neuroscience and Human Behavior, has noted that since many caregivers tend to be older themselves, they are at risk for what Lavretsky has termed an “impaired resilience” to stress and an increased rate of cardiovascular disease and mortality. To investigate, she and her colleagues conducted a study where caregivers were taught a 12-minute chanting practice. The participants in the study practiced every day for eight weeks. Their findings suggest that simple daily practice can lead to improved cognitive functioning and lower levels of depression for caregivers. Lavretsky, et. al. reported that, “…our study suggests a simple, low-cost Yoga program can enhance coping and quality of life for the caregivers.”

Reassuringly, studies such as these are becoming more common and medical science is confirming what practitioners of Yoga have known all along. The practice of Yoga asana, pranayama, chanting and meditation profoundly benefits the mental health of the practitioner.

When we are burned out, we think we can feel better by doing more. Our mind is mistakenly convinced that we can solve a problem with the same thinking that created the problem in the first place. We soldier on as if we can handle everything ourselves, instead of opening up to the comfort and support of others. Often we must learn to “try softer”, rather than harder, and “let go” rather than grasp more firmly. Instead, we must listen to our heart’s inner promptings. The wisdom of Yoga teaches us the value of non-doing, being still, and sitting with equanimity with whatever life presents.

The caregiving staff at Grandma’s Cottage personally reported the benefits that Yoga class had on themselves and their residents. This story illustrates how caregivers at a facility increased their consciousness of saucha (purity) and ahimsa (non-violence) and improved their own sense of well-being with that of their residents. (The names of the people and the agency have been changed in the interest of compassion). Angelique Stokes worked as a head nurse at Grandma’s Cottage, a clean and pleasantly furnished memory-care facility that provided twenty-four hour care. Angelique contacted me looking for someone to teach Yoga to their staff. Grandma’s was run with an air of professionalism and it was clear that management wanted to invest in the care of their staff in order to better serve their residents. It was also clear that their staff members were in danger of compassion fatigue or burn-out.

After our first class, I entered the living room where many of the residents sat in a semi-circle and watched television after breakfast. The screams of a woman being pursued by a hideous groaning monster emanated from the TV set and rang throughout the building.  My experience was visceral and immediate as muscles tightened, adrenaline coursed through my body, my field of vision narrowed and my entire system kicked into the kind of response our bodies are wired to do when faced with real and immediate danger.

After a brief moment, my senses confirmed that I was not at risk of being eaten by a large wild animal, yet for many minutes after, my shoulders remained tight and I could feel the beginnings of a slight headache. Most of the residents could not voluntarily leave the room and appeared to be in various states of discomfort. Some had their eyes closed but I could see them startle each time the woman screamed. One resident sat in her wheelchair with her torso twisted away from the TV screen and stared at the wall. Not one person appeared to be enjoying this horror film. In contrast, staff members were busy with the post-breakfast chores and moved in and out of the room talking amongst themselves.  They appeared to have no awareness of what was taking place with the residents.

I gently approached Angelique. She said she could see nothing wrong with leaving this kind of movie on. She explained it was a classic horror movie from the residents’ childhood years and she thought most of them enjoyed it. She conceded that it was a little loud, however and she would turn it down if it bothered me. I felt it would be unskillful to continue to push my point, but soon another opportunity presented itself.

A few weeks later, Angelique took me aside to share this story. It seems that last week, in class, she had experienced the deepest sense of relaxation she had felt in a long time. “I felt the way I used to feel as a young child floating in the pool.” “I had no fear or tension and felt absolutely safe.” She continued, “After Yoga class, I passed the TV on the way to the kitchen and felt like a wall of water just smacked me down. There was a program on where two people were insulting each other and every few seconds the laugh track came on. Well, I used to think this show was funny, but this time, when I heard the laugh track it was like being punched in the stomach. What’s going on here?”

We went on to have a great conversation about how our environment affects every level of our being. I introduced Angelique to the yogic concepts of saucha (purity) and ahimsa (nonviolence). We talked about the effects of negativity and of the opposite effect when one surrounds oneself with sattvic (balanced) elements such as peaceful uplifting sounds, beautiful colors and images, pleasant smells, joyful people, and healthy and delicious food and drink. Finally, we talked about the effects a steady stream of TV, movies, magazines, radio and other media has on us and sadly laughed at the many kinds of negative messages we are subject to during an average day. Basically, advertising is designed to make us feel incomplete or incompetent unless we buy the product that is being sold.

At this point, Angelique realized immediately how the residents were being affected by some of the staff’s choices of entertainment. It became clear to her that it could be a win-win situation for staff and the residents if the sounds and sights of the day were more peaceful, joyful and uplifting. Indeed, as the weeks went by, she happily reported that mornings went more smoothly when she instructed staff to avoid horror movies and programs with emotionally jarring material and find something like Animal Planet or the Cooking Channel. Better still, they began to use music more frequently and even became aware of the tone of their voices when speaking to each other and the residents.

Take several deep breaths and look around your immediate environment. Identify three things that strike you as harsh, negative or stress inducing. It could be the annoying hum of an appliance, a scary photo on a book jacket, the lingering odor of an overripe banana or the scratchiness of a cheap blanket. Then identify three things that are beautiful, calming, inspiring or relaxing; perhaps a bowl of dried lavender petals, the sight of golden sunbeams across a clean carpet, the feel of a smooth seashell or the sound of soothing classical music. Notice the effect each thing has on your breathing and your emotions. Right now, make one change in your environment that will reduce your sense of unease and increase your sense of peace.

Yoga teaches us, through experience, to pay attention to the world around us. It sensitizes us to how things affect us and to how we affect each other. In practical terms, the more that Grandma’s staff provided calm, peaceful and uplifting stimuli to the residents, the greater the sense of well-being for both the staff and the residents.

Chanting

You may be familiar with the use of chanting sacred sounds in Yoga practice. One result of chanting is that it helps to replace the negativity that flows through our minds on a daily basis. Stop and think for a moment. When you talk to yourself, do you tend to encourage, praise and cheer yourself on? Or do you more readily berate yourself for something you did not do, or replay a conversation that went badly with a friend? In all likelihood, the words we tell ourselves do little to improve our well-being. I am fond of saying that if we talked to our friends the way we talk to ourselves, we would not have any friends! Chanting is one way to clear our minds, to counterweight the negativity we have absorbed from the world around us and to return to that relaxed and resourceful state of mind. Chanting the name of whomever or whatever you hold sacred is a powerful option, but chanting does not have to be religious. You may think of it as repeating an uplifting sound to replace the internal chatter. Like the old song says, “Accent the positive, eliminate the negative.”

In Yoga, we repeat Sanskrit terms such as “Om” or various names for God. In my tradition, we use repetition of sacred Sanskrit words in a manner that has been used for thousands of years. You may pick a prayer from your own religious tradition, or you may pick a more common word that has positive and peaceful vibrations such as “love” or “peace.” You can also personalize this practice by chanting the names of your beloved family or friends. You may choose a phrase that holds meaning to you such as, “May all my actions be born of compassion,” or “For the highest good of all concerned,” or “Let go, let God.” It is best to pick one and stick with it for a few months rather than switching it up.

At first, you may wish to count your repetitions to keep your mind focused. You may wish to seek instruction in the use of a 108 bead necklace called a mala, or use a rosary.  Each bead helps to hold your count and keep your attention as you slide the beads between your fingers. Another way is to set a timer and simply set a goal of a certain number of minutes instead of repetitions. Starting with three minutes, you can work your way up to thirty minutes. Please take a moment to practice this “mental shower” using the techniques of chanting. 

Sit up tall, lengthen the spine and place the feet flat on floor. Press the feet into the ground even as you press the top of the head toward the ceiling. Relax the hands lightly on the lap and release the shoulders down away from the ears. Soften the belly muscles. As you breathe in through the nose—lengthen through the crown of the head.  As you breathe out through the nose, release the shoulders and press feet into the floor.  Release into natural breathing. Let nothing distract you as you silently repeat your special word or phrase. Set a goal of 18 repetitions to start and work your way up to 108 or more if you wish.

Conclusion

Yoga offers many doorways through which we can find our own true nature of peace.  The regular practice of any of the above yogic techniques will reveal benefits for every level of being: physical, energetic, mental, emotional, and spiritual. May you find a useful practice that can carry you through the difficult challenges of caring for your loved one with Alzheimer’s disease. Just like the woman in the old Indian tale at the start of this chapter, you, too, may learn about the grace of neighborly support. My wish for you is twofold: may you find wellness in the support of others, and may you feel the limitless peace that can be found within. Namaste (The light and wisdom in me honors the light and wisdom in you).

References:

  1. A pilot study of yogic meditation for family dementia caregivers with depressive symptoms: effects on mental health, cognition, and telomerase activity.  H. Lavretsky1, E.S. Epel, P. Siddarth, N. Nazarian, N. St. Cyr, D.S. Khalsa, J. Lin, E. Blackburn, M.R. Irwin.  Article first published online: 11 MAR 2012.  DOI: 10.1002/gps.3790,  International Journal of Geriatric Psychiatry.
  2. Healing From Disaster, Sri Swami Satchidananda, Integral Yoga Publications, Yogaville, 2006, Virginia.
  3. Alzheimer’s Disease, Gary Smith, Ph.D., Mayo Clinic Health Letter, http://www.mayoclinic.com/health/sundowning/HQ01463, January 21, 2013.

 

IY.Shanthi Behl© 2013 Rev. Sharon Shanthi Behl M.A., LPC, E-RYT 500®

 

Rev. Sharon Shanthi Behl, MA, LPC, E-RYT. Rev. Shanthi Behl is an ordained minister through the Integral Yoga Seminary. She is certified in Integrative Yoga Therapy and is an Integral Yoga and Raja Yoga Teacher. Shanthi is a founding Board member of Yoga Alliance, Board emeritus of Yoga Teachers of Colorado and former Advisory Board member of Rocky Mountain Institute of Yoga and Ayurveda.  For many years, Shanthi specialized in counseling trauma survivors and remains a national trainer in the fields of domestic violence and sexual trauma. Shanthi provides Yoga instruction to hospice patients and their caregivers by integrating contemporary Western psychology with Yoga’s profound wisdom as taught by her beloved Guru, Sri Swami Satchidananda.

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