Stand up and laugh

“It was the best she had been for years,” said John, on watching his wife Liz performing comedy sketches. “She was so happy … [it] showed me for a moment the person I had lost.”

Liz had just completed an eight-week Stand Up for Dementia programme at her day centre in the Byron Bay area of New South Wales, Australia. What makes this programme special is that it’s all about laughter. It’s an unusual approach to a disease which is no laughing matter, causing a progressive decline in memory, thinking and social skills.

Also unusual is the fact that the person who developed this approach is not a medical specialist but a comedian. Meet Mandy Nolan. Despite performing and teaching comedy for over 30 years (international comedy sensation Hannah Gadsby is a former student), the situation Nolan initially encountered in the care centre put all of her skills to the test.

Focus on the now

“The programme was born out of desperation,” Mandy admits. “I’d been hired to work with carers of dementia patients, but the patients were right there in the room with us. It seemed cruel to ask the carers to talk about their experiences, and how difficult their charges could be, right in front of them.”

Instead, Mandy decided to concentrate on the 16 patients, all in the early stages of dementia. However, she soon found that they didn’t respond to any of her usual techniques. By the third week she was feeling increasingly despondent, when she suddenly had a breakthrough: “I realised all they have is this moment. I can only work in the now.”

Based on this insight, Mandy created improvisational roleplays rather than her usual complex comedy scenarios. She used real-life situations that participants could relate to, such as going to a medical appointment, a job interview, or lying in bed with a snoring partner.

Finally, people started to respond. “It was like finding a key. I’d say, ‘You’re the doctor, this person’s pregnant. What do you do?’ Somehow, the participants would instinctively know what to say to raise a laugh.”

A tentative start

Mandy developed their skills and confidence over the programme’s eight sessions. Each session opened with an exercise involving a ball. Mandy would gently throw the ball at a participant and ask them to tell her something they loved or something that irritated them. The next step was acting out the emotions. And then using them to develop roleplays.

She acquired a pile of props and costumes to help participants get into character, from a Zorro cape, to a policeman’s hat, to an Arabian princess’s veil. Dressing up for each other was a favourite part of the workshops. People interacted even if they hardly spoke at home or during other activities.

At first, participants could maintain an improvised dialogue for no more than 30 seconds, but the sketches eventually ran to 10 minutes. This was despite the fact that they wouldn’t be able to recall what they had learned from one session to the next. “But they always knew we had fun.”

Improvisation masters

Dementia is often associated with a loss of sense of humour. To her own surprise, that’s not what Mandy experienced. “Laughter is a high cognitive function. To understand what’s funny you have to understand what deviance is. And for deviance you have to understand the norm. But somehow, that seemed pretty intact.”

Because it doesn’t involve memorising dialogue, the improv comedy of the Stand Up programme is well suited to people who find it very difficult to remember storylines. Having dementia is even an advantage, tapping into skills they already have. “People with dementia often have difficulty orienting in space, or knowing what’s happening,” explains Mandy. “So they improvise a lot to get through their day.”

Still, there were multiple challenges. Loss of cognitive and interpersonal skills makes social engagement difficult. This often leads to withdrawal, depression and agitation. Many of the participants were also physically frail, needing a lot of time, help and encouragement to even get out of a chair. Some did not talk, creating a particular challenge to communication and participation.

“I would invite everyone to take part, but I could pick up the signals if they didn’t want to do it. Then I’d wait for them to show that they were ready. It was about maintaining people’s dignity and allowing them to take risks.”

In her twenties, Mandy trained as a vocational teacher of adults with learning disabilities. This helped her ensure the workshops were always respectful and inclusive. At the same time, she believes that her lack of theoretical knowledge of dementia was a good thing. “It stopped me from having preconceived ideas of what the participants could and couldn’t do.”

Talking and joking

Juliet, who took part in the same workshops as Liz, seemed very shy and quiet at first. Even so, Mandy was able to engage her to the point that she was the star of the hour-long final performance. Asked to choose between two suitors, she deadpanned, “I’ll have a go at them both and keep whoever lasts the longest.”

Mandy only discovered afterwards that Juliet hadn’t been verbal in two years. “Mum had not spoken or communicated effectively for years,” said Juliet’s daughter Marianne. “And there she was, roleplaying to perfection. It was incredibly funny and moving at the same time.”

The positive physiological and psychological effects of humour on the elderly and people with dementia are well-documented. Many countries run programmes where patients might watch funny films or be visited by clown doctors. But the active nature of Stand Up for Dementia made it very different from most initiatives. “It’s laughter they’re in charge of,” Mandy says. “They’re the creators.”

Carers noticed that levels of self-esteem, social interaction and memory rose during the programme. John, quoted at the beginning of this article, was initially reluctant to let his wife take part in the sessions. He worried that people would laugh at her failures, humiliate her. But he was entirely won over: “This programme should be everywhere and run all the time. I would want her to do this again and I know she would too.”

Proven medical benefits

Word soon spread. Mandy spoke at a TEDx event and her husband, John Stevens of Southern Cross University, published a study of the programme in the Australian Journal of Dementia Care, a peer-reviewed medical journal.

According to the study, “dementia did not prevent participants from laughing appropriately or successfully creating and performing comedy… therapeutic benefits such as improvements in memory, learning, sociability, communication and self esteem were demonstrated”.

Nevertheless, the programme is currently dormant due to lack of funding. When the plug was pulled, Mandy had just trained her first cohort of 20 facilitators, aiming to reach far more dementia patients than she could on her own. She’s keen to pick it up again. “Stand Up is orchestrated play,” she says. “It’s fun. And people with dementia need to have fun.”