Canadian Association of Occupational Therapists

Emotional awareness and emotional memory

The Mind ... is not the heart
I may yet live, as I know others live,
To wish in vain to let go with the mind-
Of cares, at night, to sleep; but nothing tells me
That I need to let go with the heart.

— Robert Frost

As expressed in the above poem, the persisting capacity and need for emotional expression and for giving and receiving affection is common in literature. The clinical literature also emphasizes the capacity for, and the importance of, emotional expression;

Moreover, throughout much of the course of the illness those with Alzheimer's disease remain very capable of giving and receiving love, of sharing warm interpersonal relationships, and of participating in a variety of meaningful activities with family and friends. (Cohen, 1988, p. 149).

The capacity to experience the full range of emotions — love, joy, fear, anger and sorrow — persists (Mace, 1990; Office of Technology Assessment, 1987; Zgola, 1987). In many ways the dampened rationality of the person with Alzheimer's disease enhances emotional sensitivity and means that the person tends to communicate more on an emotional level. The person is very aware of the emotions and moods of others, and often very susceptible to picking up these moods. If a happy and lighthearted mood is set by the caregiver, this spreads to the person. Conversely, in long-term care, if one resident on a dementia unit becomes upset, it doesn't take long to spread to others. When we are angry or frustrated they will feel it and may also become upset. Be aware of facial expression, voice tone and language, so as not to convey any negative personal emotion to the person with Alzheimer's Disease .

Another dimension of emotional awareness is an apparent heightened spiritual intuitiveness, making the continuation of life-long spiritual practices especially important.

Even though emotions are felt, it becomes more difficult to express them, particularly verbally. It also becomes harder to interpret the environment and make an appropriate emotional response. The onus is on caregivers to facilitate the expression of emotion, especially through non-verbal methods. Simplifying and clarifying the environment helps to facilitate appropriate emotional expression.

There are many activities that encourage non-verbal emotional expression. For example:

  • Caring for plants or pets (express feelings of caring, affection, satisfaction, responsiveness from living things);
  • Listening to favourite music or singing (recalls the feelings associated with the music);
  • Repetitive, physical activity such as walking, digging the garden, or shredding papers for recycling (provide a release for feelings of frustration);
  • Holding hands, hugging, brushing hair, rubbing on hand cream or other adult uses of touch (acceptable, adult expressions of caring and concern);
  • Simple household chores, such as dusting, drying dishes, or preparing vegetables (enhances feelings of usefulness and self-worth).

It is important to let people know that you are aware of their feelings. Read non-verbal cues (e.g. facial expression) and the tone of the voice to determine the nature of the feelings, then check it out with them by saying something like, "John, you seem to be very upset. Is that true?" Then, "Are you upset because..........?" Even if you can't determine the source of the upset, letting the person know that you realize how they are feeling often helps reduce distress.

Emotional memory

Emotional memory is the memory of the feelings associated with an event, as opposed to the facts of the event. Emotional memory is a persisting asset of persons with ADRD. This asset can be capitalized on by ensuring that activities and self-care routines have positive emotional associations, thereby encouraging future participation. Previous happy emotional memories can be triggered by using reminiscence materials and other positive emotional cues such as favourite songs, pieces of clothing, pictures, or foods.

Alice was in the advanced stage of Alzheimer's disease. She required 24-hour care and assistance with all activities of daily living, which was provided in a nursing home. In spite of these severe deficits, Alice went to church with her son and his family every Sunday and afterwards to their house for dinner. Usually she sang along and smiled happily during the hymns at church. At dinner, she was sometimes able to help set the table or mix the salad. Whatever she was able to do or not do, she smiled happily when surrounded by her family and was free of the restlessness that so often disturbed her at the nursing home. During the Easter church service, Alice didn't smile or hum during the music and had to be fed the communion bread. She dozed through much of the service and during the car ride home. Her family decided that Easter dinner would be just too much and drove back to the nursing home. When the car stopped at the entry doors, Alice sat up with a start and opened her eyes wide. In a clear voice she demanded, "What am I doing back here already?" Alice was not able to articulate the factual order of what she did on Sundays, but she had a strong emotional memory of a pleasant family time after church.

This anecdote illustrates the persistence of emotional memory, and reminds caregivers that in spite of inability to verbally recall what they have done, persons with ADRD carry emotional memories, or memories in their hearts. What we do DOES make a difference.

References/ Readings

Cohen, G. (1988). The brain in human aging. New York: Springer Publishing.

Mace, N. (Ed.) (1990). Dementia care: Patient, family and community. Baltimore, MD: Johns Hopkins University Press.

Office of Technology Assessment, U.S. Congress. (1987). Losing a million minds: Confronting the tragedy of Alzheimer's disease and other dementias. (OTA-BS-323) Washington, DC: U.S. Government Printing Office.

Zgola, Y. (1987). Doing things: A guide to programming activities for persons with Alzheimer's Disease and related disorders. Baltimore, MD: Johns Hopkins University Press.

Zgola, Y. (1992). The tea group: A special programme for the "difficult" resident in long term care. Physical and Occupational Therapy in Geriatrics, 104 (4): 1-16.

Excerpt from
Canadian Association of Occupational Therapists & Alzheimer Society of Canada. (1998). Living at home with Alzheimer's disease and related dementias: A manual of resources, references and information. Ottawa, ON: CAOT Publications ACE.

Available from CAOT at 1 (800) 434-2268, ext. 242 or by e-mail.

This book was researched and written for CAOT in conjunction with the Alzheimer Society of Canada by Carol Bowlby Sifton. It is a guide for both caregivers and professionals on how to work collaboratively to enable people with Alzheimer's disease and related dementias (ADRD) to live at home for as long as possible.

Other excerpts from the book appear on the following skills for the job of living tip sheets:

Related consumer tip sheet: Reducing Caregiver Stress


Bowlby-Sifton, C. (1997). The dementia story: Challenging the art of occupational therapy. Canadian Journal of Occupational Therapy, 64, 3-6.

The art of occupational therapy may be understood as getting in touch with the life story of our clients, and the science, finding ways to enable the continuing unfolding of that story. The story of Frank and Emily is an illumination of the ways in which occupational therapy practice can participate in this unfolding, with persons with Alzheimer's Disease and Related Dementias (ADRD).

For the full paper in Acrobat DPF format download ADRDBowlby97.pdf 

Book Reviews

Keeping busy: A Handbook of Activities for Persons with Dementia. (1995)

James R. Dowling

The Johns Hopkins University Press
2715 N. Charles St.
Baltimore, Maryland,
USA, 21218-4319
178 pages

Keeping Busy is based on the experiences at the Alzheimer's Care Centre in Maine, USA as described by the author, James Dowling. This is a residential care facility for individuals with Alzheimer disease and Related Dementias. The intent of the book is to provide practical ideas and share successes and failures for others to use. It would be of greatest benefit to caregivers in established residential settings looking for new programming ideas, as well as those implementing a new programme.

Dowling is described as an activity specialist, who frequently conducts workshops on behaviour management of persons with dementia. He demonstrates an empathy toward the need of the older adult with cognitive impairment and an obvious enthusiasm for his work, however the ideas presented are not unique. The principles are congruent with the practice of occupational therapy, with an emphasis on purposeful activity and task breakdown to meet individual client needs. Activity is described for a person with dementia as "everything a person does" with the "most valuable dementia activity as work that is tied to the life of the home".

The book is divided into 12 chapters, focusing on different activities such as music, cooking, gardening, art and exercise, all with many practical suggestions, and includes a variety of anecdotal stories about certain residents. Appendices include an overview of Reality Orientation, a daily activity schedule and the five basic steps of Remotivation Therapy. There is a list of (American) resources, a bibliography and a well-organized index.
Although this book reiterates much in the field of programming for the cognitively impaired, it does provide a broad overview in an easy to read format.

— By occupational therapist Catherine Brock


Other sources of information

The Alzheimer Society of Canada has a nation-wide network of provincial and local organizations that provides support, educational resources and programs for people with Alzheimer's Disease and their caregivers. Visit their web site at

For a copy of the brochures "10 Signs of Caregiver Stress" and "Reducing Caregiving Stress" call your local Alzheimer Society or 1 (800) 616-8816.