As Alzheimer’s disease (AD) progresses into its middle stage and later, word-finding skills diminish and meaningful verbal communication becomes increasingly impaired or even nonexistent. The thoughts, desires, and emotions of a person with AD still remain, but how can a caregiver discern what they might be?
The answer may, in part, be located in the research and writings of Charles Darwin; specifically, in his book “The Expression of the Emotions in Man and Animals,” first published in 1872, and long regarded as a seminal work in psychology. Here, Darwin makes the case for the instinctual or inherited nature of the facial expressions and body language that accompany our simple or primary emotions — anger and fear, surprise and disgust, joy and sadness, and other more complex emotions, too. Darwin terms these facial expressions and body language “the language of the emotions,” and deems them a product of natural selection, a process of evolution.
For the most part, the simple emotions are generally easily detectable to an alert observer, but complex emotions — for instance, grief, indignation, helplessness, cheerfulness, and perplexity — are more subtle, less well known.
The facial expressions and body language that accompany the simple and also the most important of the complex emotions are instinctual or innate, but a few, such as weeping and laughter, require repetition by an individual to achieve their fullest expression. Others, like the act of devotion, are first adopted by imitating other family members and later become habitual with practice and the passage of time. A person in a devotional or prayerful state of mind often lifts his or her eyes upwards or skywards, and presses the palms of their hands together.
If an individual regards another who is present with only contempt or scorn, he or she is apt to look angry, but may also sneer or smile scornfully: lips are drawn back to reveal grinning teeth, and sometimes the upper lip on one side is elevated to show a canine tooth. This facial expression mirrors the snarl of our animal ancestors.
Homo sapiens almost certainly experienced and then expressed many of these simple and complex emotions by using the language of the emotions for many thousands of years before we had the words — spoken, and later printed — to verbally communicate them to others.
One Wednesday morning, a majority of residents of the memory unit at the Cactus Ridge assisted living facility in Scottsdale, Arizona, attended the always popular bingo event held weekly in the activities room. Seated among them were Carl and Clara, both in their mid-80s, both residents at Cactus Ridge for the past several years. Carl and Clara’s relationship was hampered by either a personality conflict or long-running feud of murky origin, perhaps fueled by delusional thoughts. During the later portion of the bingo game, Carl muttered indistinct insults directed at Clara, and also glared at her.
At the conclusion of the game, the residents and the two staff caregivers who were present all exited the activities room. Suddenly Clara and Carl jostled one another, probably inadvertently, but perhaps intentionally. Several seconds later in the adjacent hallway, they stood just a few feet apart, staring at one another. Carl was angry but not yet in a rage; Clara was fearful but not yet terrified.
In fact, Darwin provides us with an accurate description of their appearances at this moment, as each utilized the language of the emotions to express the powerful feelings of fear and anger. Carl stood with his face flushed, mouth and lips closed tightly, frowning, his head held erect and chest expanded, feet planted solidly on the floor and arms held at his sides with fists clenched. Clara stood still with her eyes and mouth opened wide, breathed rapidly, her skin pale and perspiring — in effect, in a cold sweat. She had slight contractions of her muscles, and an unclear or even inaudible voice when she spoke.
An episode of verbal aggression and even perhaps a physical confrontation appeared imminent. Fortunately, the two memory-unit staff members present recognized the potential danger of the situation, separated Carl and Clara and redirected them to more constructive activities — Carl to the garden courtyard for a walk, Clara to a sing-along activity; thus they helped to defuse the crisis. A half hour later, both Carl and Clara felt and appeared more relaxed.
Many individuals in the middle or even late stages of AD still possess the ability to communicate their emotions — both simple and complex — by means of their facial expressions and body language. If family members, other caregivers and geriatric healthcare professionals all strived to focus their own emotional intelligence and remained sufficiently patient and observant, then perhaps persons with AD could “tell” us about their emotions long after we thought of them as unable to do so.
Of course, recognition of these visual signals is not a panacea for the entire serious issue of
psychological and behavioral symptoms that often develop in AD, but it is probably helpful for many of its victims some of the time. An important goal is to prevent or at least minimize the escalation of negative emotions into more severe psychological symptoms and increasingly
For family members and other caregivers of individuals with advanced Alzheimer’s disease, communicating with them is a challenge each and every day, and often frustrating. But some assistance is available from a distant and somewhat unlikely source. Charles Darwin’s research and writing on human emotions and facial expressions completed in the mid-19th century is relevant to the needs of any person with middle- or late-stage Alzheimer’s disease today.
Stephen Nash holds an M.D. from SUNY Buffalo and a master’s of public health in epidemiology from Emory University. He is the co-author of “Putting Evidence into Practice: Palliative Care,” a British Medical Journal report, and “Reclassification of Simvastatin to Over-the-Counter Status in the United Kingdom,” published in the American Journal of Cardiology.