In the years after her mother was diagnosed with Alzheimer's disease, Karen Stobbe remembers listening to a Beatles song and hearing her mother tell her she had dated one of the musicians. Stobbe's initial urge was to dispute her mother's claim as impossible. Instead, she recalled her training as an improvisational actor and replied, "Yes, and tell me which one you dated? What was that like?"

"Yes, and..." is a basic tenet of improvisational acting: You accept whatever the other person says and build on it. When the principle is applied to interactions with people who have Alzheimer's, "it allows the conversation to continue in a more positive way and leads to less frustration," says Stobbe, who lives in Black Mountain, NC. "So often, we focus on changing the behavior [of the person with Alzheimer's] when we need to change ours."

Based on her experience with her own parents, both of whom died from the disease, and what she learned about dementia from conferences and seminars, Stobbe developed a series of workshops that apply principles of improvisational theater such as "yes, and...," "be in the moment," and "step into their world" to interactions with people with Alzheimer's disease.

Stobbe tested the workshops at four health care facilities in Milwaukee for a year. The feedback was so positive that she created In the Moment, a nonprofit company and website where caregivers can access the training materials for free. The workshop tools include an introduction to Alzheimer's, information about verbal and nonverbal communication and listening skills, and behavior and caregiver tips, as well as suggested exercises and resources.

An exercise called "Yes, let's!" helps caregivers go with the flow. The group forms a circle and the leader says, "Let's walk." The whole group shouts, "Yes, let's!" and they all walk in place until someone shouts out a new action starting with "Let's..." and the group responds, "Yes, let's!"

Stobbe and her husband, Mondy Carter, also an actor who specializes in improvisation, explained their concept in an interview on National Public Radio in 2014 and in a TEDMED talk in 2016, which led to a surge of interest in their techniques.

Other organizations exploring the principles include the Memory Ensemble in Chicago; an Alzheimer's resource center at Indiana University in Bloomington; and Scripted-IMPROV, a program at 13 residential facilities in New York and Massachusetts.

"Programs that incorporate improvisational techniques draw upon remaining strengths and emphasize imagination rather than memory," says Daniel C. Potts, MD, FAAN, attending neurologist at the Tuscaloosa VA Medical Center in Alabama. Participants tend to be more engaged and less apathetic, with fewer behavioral disturbances, he says. "Improvisational programs can build relationships and community while also rewriting the 'tragedy narrative' of dementia."

The Memory Ensemble

Christine Dunford, PhD, a co-founder of the Lookingglass Theatre Company, collaborated with Darby Morhardt, PhD, and Mary O'Hara, two licensed clinical social workers and researchers at the Cognitive Neurology and Alzheimer's Disease Center at Northwestern University Feinberg School of Medicine, to form the Memory Ensemble.

The program consists of 90-minute workshops in a hospital conference room facilitated by teaching artists and social workers. Participants with mild to moderate dementia warm up with breathing and stretching exercises, then practice improvisational skills such as listening closely to a partner, observing someone or something in detail, and saying yes to ideas. These activities help participants prepare for more complex activities such as pretending to meet someone at a bus stop and initiating conversation.

Mary Whalen, 83, who was diagnosed with mild cognitive impairment in 2018, participated in the Memory Ensemble program last spring. She particularly liked the "Yes, it is" game, which starts with several objects such as a sweater, a pen, or a set of keys placed in the center of the room. Each person takes a turn walking to the center and handing the next person an object. With some coaching, that person uses her imagination to transform a pen, for example, into a miniature violin. With each transformation, the group responds with a resounding "Yes, it is."

The activity is meant to be challenging, but in a safe environment, says Dr. Dunford: "We intentionally put people in situations where they feel a little anxious because they don't know the answer to something. By learning to stop, breathe, observe, and use their imagination, they learn that whatever happens will be okay."

Preliminary research published in Research in Drama Education: The Journal of Applied Theatre and Performance in June 2017 suggests that over time these skills help patients navigate moments of uncertainty or anxiety better. 

Indiana University

Dayna A. Thompson, an educator at the Alzheimer's Resource Service at Indiana University Health, developed a program for its Alzheimer's patients with Jim Ansaldo, PhD, founder and co-creator of Camp Yes And, which uses improvisation for teenagers with autism spectrum disorders.

The program's three improv-based workshops are offered twice a year, with homework in between. Patients and caregivers play games that teach various nonverbal communication skills, says Thompson.

Ryder Timberlake attended the free workshops at a community church in Bloomington last year with his 75-year-old father, who is in the mid to late stage of Alzheimer's disease. "It was easier for my father to follow some of the simpler games, such as one called Whoosh, Bang, Pow," Timberlake says. "People stand in a circle and someone says 'Whoosh' with cupped hands to the person next to him or her. That person can receive it, or return it to the sender by crossing her arms and saying 'Bang,' or send the whoosh to someone across the circle by pointing and saying 'Pow.'"

Thompson explains, "The game is designed to help participants let go of mistakes and the need to be right. For example, if someone says 'Bang' and does the whoosh action instead, we realize that we worry more about getting it right than having a good time, and it really doesn't matter in the end."

"It was a fun way for my father to interact socially, which I think was the biggest benefit for him," says Timberlake. "For me the game was a metaphor that I can accept mistakes I make and keep going."

Scripted-IMPROV

In 2011, John Zeisel, PhD, CEO and president of Hearthstone Alzheimer Care in Woburn, MA, and president of the I'm Still Here Foundation, created Scripted-IMPROV. Its improvisational scripts were developed with the help of Chris Gage, director of Ladder to the Moon, a London-based organization that trains nursing home staff to engage people with dementia using drama techniques, and Evan Bass (Dr. Zeisel's son) and Miranda Noelle Wilson, two theater actors based in New York City.

With funding from the National Institutes of Health/National Institute on Aging, Dr. Zeisel and Hearthstone's research division then tested the program in 12 senior residential facilities in New York and Massachusetts. For a week, 178 residents diagnosed with dementia—mostly white and female, with a median age of 86—participated in two different plays under the guidance of professional actors. Before starting, the participants underwent tests to assess depression, engagement, and quality of life.

The results, which were published online in the American Journal of Alzheimer's Disease & Other Dementias in March 2018, showed that participants whose scores on the depression test were in the clinically depressed range experienced a significant reduction in symptoms. Scores for constructive and positive engagement increased by 31 percent and 13 percent, respectively, while distracted behavior—looking out the window, falling asleep—decreased by 79 percent.

A limitation of the study was the short treatment period of two sessions in one week. "I would like to see a treatment period of 12 weeks," says Dr. Zeisel. He'd also like to implement the program without professional actors. As a first step, Dr. Zeisel and his team developed a facilitation guide that provides descriptions and templates enabling residential staff to provide three months of programming (scriptedimprov.com). The cost of the materials is $250.

So far, 13 residential facilities in New York and Massachusetts have implemented Scripted-IMPROV, which works best when staff have time to engage in online training and put on 90-minute improvisational performances. Staff also must be comfortable being on the same level as residents rather than being in charge, have a sense of humor, and be willing to act, be silly, and relax. Importantly, they must have a desire to create a more participatory and engaging experience for residents.

"Our biggest challenge," says Dr. Zeisel, "is shifting the mindset of staff caring for people with dementia from one of doing things for them to one of doing things with them."