A major problem for many caregivers is how to help someone with dementia stand, sit down, and walk. These movements seem so simple, easy and natural that it is hard to imagine why the person with dementia can't seem to do them without help. Yet caregivers often find it difficult to get loved ones to stand up, to sit down, to go where they need to be, and to stay where they are safe.

Movement is a part of almost everything we do, so it can become a huge stumbling block when a loved one just can't get started or doesn't seem to understand what you want him or her to do. If you can't help a person move safely and effectively, the result is likely to be injury to one or both of you. A frequently cited reason for having to place a loved one in a facility is "problems with movement."

The desire and instructions to move all come from the brain. Each task and movement pattern is stored in the brain, then called up like a computer program. Similar to when we are thirsty and want a drink, a whole host of tasks must be realized and completed. We must interpret the thirst cues, decide if we want some water, determine how to get out of the chair, figure out where the water is, plan how to get there, figure out where the glasses are kept, get the glass, turn on the water, fill the glass, turn off the water, drink the water, ... and so on. 

People beyond the middle stages of Alzheimer's disease have four key problems with moving. They include getting started, sequencing the steps in the task, following directions, and stopping the activity when they are done.

Getting Started

Initiation of the movement (deciding to move) is one of the most challenging steps for people with dementia. They often appear to be stuck ­ they can't get the engine to kick over and allow them to start the action. But once in motion, they can often complete the action.

Visible environmental prompts can be helpful for people in the earlier stages of the disease.  Being able to see a destination is an effective cue. For example, leaving the bathroom door open frequently initiates the steps necessary for the person to get up and go to the toilet.

For individuals in the later stages, demonstration or imitation can be valuable aids. A person with dementia will often copy your movements. So if you want someone to stand up, first sit down next to them, then stand up as you give a simple instruction, like "stand up." This combination of visual and verbal cues helps people with dementia understand what you want.

Sequencing the Action

Standing may seem simple, but it is actually a complex series of tasks requiring "sequencing skills." To understand these skills, sit back in your chair and slowly stand up. Consider all the steps necessary for you to get to your feet. The sequence generally looks like this:

1. Pull your feet underneath you,
2. Hold onto the arms of the chair,
3. Lean forward,
4. Feel the weight move from your back and bottom to your feet,
5. Shift yourself forward in the chair,
6. Pull your feet out slightly so they are lined up under your knees,
7. Lean forward until the weight is transferred to your feet,
8. Look forward and slightly upward,
9. Push up with your arms, hands and legs,
10. Release the arm rests, and
11. Straighten your legs, hips, shoulders, and neck.

If you leave out any one step, the process will not work. For instance, if you don't lean forward far enough and your weight stays on your bottom, you will not be able to move to the front of the chair. If you forget to release the armrests, you will end up dragging the chair with you, or have to sit back down.

Unfortunately, when you became a caregiver, no one gave you an Information Sheet on how you move, or list of steps to follow. Most people aren't aware of all the steps needed to 'stand up' or 'sit down'. And without knowing the steps, it's very difficult to provide the right cues to others, especially those with dementia.

Knowing the steps makes all the difference. Armed with this knowledge, you can now guide them through the actions with a combination of words and touch, requiring minimal physical assistance.

Following Directions

As language skills deteriorate, it becomes more difficult for people with dementia to understand words and instructions. More words don't help; pushing or pulling simply results in resistance and frustration. You end up lifting and tugging, often without results ­ they just don't understand what you want them to do.

"Hand-under-hand Assistance"

A technique called "hand-under-hand assistance" can be very useful. This guidance system is effective for helping someone stand, walk, sit down, and a wide variety of other tasks that involve hands-on assistance.

First, identify the person's dominant hand. Always position yourself on that side of the person and use the hand that they prefer. So, if they are right-handed, you will use your right hand to hold their right hand. Approach the person from the front and go to their preferred side. Lower yourself to their eye level by squatting, kneeling, or sitting in a chair. Offer your hand to them, palm up, just like you were going to shake hands, right hand to right hand, or left to left. Once their hand is in yours, slide your fingers up and around the base of their thumb. You should now have a firm, but comfortable grasp. With practice, this will come easy. Next position yourself facing the same direction as your loved one and place your free hand on their back to further guide and assist them.

This hold should feel normal and relaxed to the person you are helping. It is a wonderful position to guide and help the person participate in various activities. But more importantly, this hand-under-hand hold allows you to effectively control movement of the wrist, forearm, elbow, shoulder, and trunk. It protects your fingers from excessive squeezing and (since you have control of the dominant arm) and it prevents grabbing of objects or surfaces that may hinder safe movement. With this hold you can guide and provide a sense of stability while you help the person lean forward, position their weight on both feet, and come to a full stand, without pulling on arms or arm pits.

Once you are standing next to the person, you can also use hand-under-hand technique to subtly guide their direction of movement, safely and effectively.  By holding their elbow gently against your chest and moving the hand and forearm in or out, you can  turn the person toward you or away. By tipping the hand downward, once the person is standing in front of a seat, you can prompt him or her to bend forward to sit down.

STOPPING THE MOVEMENT

Once they begin to walk some people with dementia can't seem to stop. They will walk until they are exhausted or fall down. They may sit only for brief periods, then get back up and start walking again. They may not stay seated long enough to even eat a meal, use the toilet, or get dressed. They are in constant motion. Attempts to force them to sit or stay in one place may only result in injury to you, them or both.

Again, the use of imitation, demonstration, or the hand-under-hand guidance can be helpful.  You will want to begin by moving with the person. Offer your hand and establish the hand-under-hand position. Then gradually slow the pace and begin to direct the movement. Indicate you need to rest and ask if the person will stop with you for just a few minutes. Have a food item or drink available and eat together, perhaps offering it without insisting on sitting at a table.

Suggest a seat in a rocking chair or gliding chair to provide continued movement. Use slow, calming music to encourage slowing down. Plan to stay seated yourself for as long as the individual will stay seated. Remember, if you get up, so will the person copying you.

Think about activities that can be performed while standing in one location. Tasks such as wiping off counters or tables, cleaning a window, dusting, sweeping, or vacuuming can be used to limit movement while still providing definition and purpose. Then encourage the person to sit down and rest when the task is done.

Summary: Movement is one of the most complex tasks we do every day. When working with people with dementia, it becomes clear that what seems simple and straightforward is actually challenging and difficult. By learning to observe and analyze motion, caregivers can help individuals with dementia to successfully engage in movements and actions that otherwise are beyond their abilities.

With movement, the old adage of 'use it or lose it' is very true. So, take the time to encourage and foster movement. Make it part of the daily routine and celebrate it. Sustaining the ability to move will make all other care easier, prevent injuries and accidents, and minimize other health care problems related to immobility.

For More Information: To help caregivers with mobility and movement skills, author Teepa Snow produced a  videotape and materials entitled, "A New Approach to Enhancing Mobility." To purchase the $20 tape, call Polly Godwin at the North Carolina Health Care Facilities Association at 919-782-3827.

Author: Teepa Snow, MS, OTR/L, FAOTA, is the Occupational Therapy Assistant Program Director at Durham {NC} Technical Community College, Lead Trainer for the Eastern Chapter of the North Carolina Alzheimer Association, and a Counseling Associate for Duke University's School of Nursing.  She has over 20 years of experience in geriatrics and occupational therapy in settings including UNC's School of Medicine, a head injury facility, a VA Medical Center, and long term care facilities. Teepa, a Fellow of the American Occupational Therapy Association, has received national and statewide recognition for her expertise in geriatrics, dementia care, optimizing functional abilities, and individualizing resident care.