AD is a common neurological disorder, with more than 4 million persons affected in the United States. AD is more common in older populations, with no clear answer on prevention of the disease. What we can do as massage practitioners caring for clients with AD?
Alzheimer Disease (AD) is a progressive neurodegenerative disease that produces a typical profile of mental deterioration. This deterioration involves most areas of the brain, particularly the frontal and occiput regions, which affect processes of thinking, memory, and communicating. Alzheimer disease is also called Alzheimer dementia.
Many types of dementia have been identified. AD is the most common type. Vascular dementia is the second most common type. The two conditions often occur together.
The clinical picture for AD is loss of memory, inability to concentrate, impairment of reasoning, apathy, and changes in personality. The course of the disease is highly variable and may extend up to 10 years; the average is 8 years from diagnosis to death. These deaths are not directly related to AD but rather to decreased resistance to infection that normally occurs with age.
The exact cause is unknown, but AD is associated with advancing age. Genetic factors are present in 5% to 10% of cases. AD is characterized by the presence of abnormal clumps called senile plaques and irregular knots called neurofibrillary tangles on nerves located in the brain; these structures disrupt impulse transmission.
The New York University Medical Center on Aging and Dementia Research classified AD into seven stages, which are used by professionals and caregivers to chart the decline of persons with AD. Although these stages provide a blueprint for disease advancement, the length of time in and between stages varies widely. In fact, caregivers often report that their loved ones appear to be in two or more stages at once.
No specific treatment for AD has been developed. Most measures are supportive and include pharmacotherapy to treat depression, anxiety, and behavioral problems. Psychotherapy is usually not recommended because it contributes to the person’s mental confusion. Affected persons eventually require long-term care and rehabilitation services.
Massage and Alzheimer Disease: Massage applied with calming music or the client’s favorite music may reduce AD symptoms. Tailor the massage to the stage of disease, with very few adjustments needed in earlier stages to significant modifications for later stages. Early stage adjustments may include massage using light pressure and slower speed. An example of light pressure is 3 on a 10-point pressure scale or level 1-2 on the Walton pressure scale.
Patience and acceptance of behavior is essential, given these individuals experience personality changes. Consider asking a friend or family member of the client for ways to calm the client in case s/he becomes anxious or combative. Many people with AD become agitated when confronted about their confabulations (made up stories to fill memory gaps) or confusion, especially if they are constantly redirected or reoriented. Again, family members or friends of the client are a good information source to find ways to handle these situations.
Later stage adjustments may include few, if any, modifications to the client’s position. For example, if you arrive to the client’s residence and he or she is sitting in a recliner, massage the client in this position. Modify your massage technique for application through his or her clothing. These adjustments are appropriate as the client’s physical condition and ability to communicate deteriorate.
Research: A 10-minute head and face massage administered once a day for 10 days reduced agitation in elderly Alzheimer’s patients living in nursing homes (Keshavarz et al, 2018). A single 10-minute hand massage and calming music (Remington, 2002) or favorite music (Hicks-Moore & Robinson, 2008), individually or combined, significantly reduced agitation immediately following the intervention and also one hour post-intervention in nursing home residents with dementia. Viggo Hansen et al (2006) conducted a systematic review and found hand massage effective in reducing agitated behaviors among persons with dementia.
A 15-minute massage (called tender touch) administered twice weekly for 12 weeks reduced anxiety, agitation, and restlessness among elderly nursing home residents with AD. Tender Touch was defined as systematic, structured use of slow, gentle massage, stroking, and touching certain areas of the body that included the forehead, neck, shoulders, back, and hands. Seventy-one of the nursing attendants who provided the massage reported the experience improved their ability to communicate with the residents (Sansone & Schmitt, 2000). A 10-15 minute massage applied to the upper extremities (including head, shoulders, and hands) administered 6 times over 2 weeks significantly reduced agitation behaviors (wandering, verbally agitated/abusive, physically agitated/abusive, resistance to care). When analysis was restricted to residents with significant levels of agitation at baseline, the effects of massage on agitation were greater (Holliday-Welsh et al, 2009). A 20-minute massage applied to the back and lower limbs administered Monday through Friday for three months improved behavior and sleep disturbance, and increased participation in eating and rehabilitation among institutionalized dementia patients. These effects were maintained at two months after treatment completion. Ear acupuncture had the same results (Rodríguez-Mansilla et al, 2013). A 10-minute massage administered four times per week for 4 weeks reduced pain in elderly residents with dementia (Kapoor & Orr, 2017). Caregiver-provided slow-stroke massage decreased physical expressions of agitation such as pacing, wandering, and resisting among community-dwelling individuals with AD, but not verbal displays of agitation (Rowe & Alfred, 1999).
Touch-based methods (therapeutic touch) applied twice daily to the back, neck, shoulders and head for 5-7 minutes administered for 3 days decreased cortisol levels (Woods et al, 2009), reduced behavioral symptoms such as restlessness (Woods et al, 2009; Woods et al, 2005), and vocalizations among nursing home residents with dementia (Woods et al, 2005).
Barquilla Ávila and Rodríguez-Mansilla (2015) conducted a literature review and noted massage reduces conduct disorders (aggression, anxiety, agitation, and resistance to care) among elderly patients with dementia participating in rehabilitation. Anderson et al (2017) conducted a review of randomized controlled trials and found both massage and human interaction effective methods to reduce pain and improve behavioral and psychological symptoms among individuals with dementia in critical care; aromatherapy was not effective. Finally, Margenfeld et al (2019) conducted a systematic review and found massage may provide an effective nonpharmacologic method to improve behavioral and psychologic symptoms in persons living with dementia. Watts et al (2019) compared the effectiveness of interventions used to treat aggression and agitation in adults with dementia and found massage and touch therapy, music combined with massage and touch therapy, and multidisciplinary care clinically more useful than usual care.
Picture and Table Credits:
Table courtesy of Susan Salvo’s “Mosby’s Pathology for Massage Therapists, 4th edition”
Anderson, A.R., Deng, J., Anthony, R.S., Atalla, S.A., Monroe, T.B. (2017). Using complementary and alternative medicine to treat pain and agitation in dementia: a review of randomized controlled trials from long-term care with potential use in critical care. Crit Care Nurs Clin North Am, 29(4), 519-537.
Barquilla Ávila, C., Rodríguez-Mansilla, J. (2015). Therapeutic massage on behavioral disturbances of elderly patients with dementia. Aten Primaria, 47(10), 626-35.
Hicks-Moore, S.L., Robinson, B.A. (2008). Favorite music and hand massage: Two interventions to decrease agitation in residents with dementia. Dementia, 7(1), 95-108.
Holliday-Welsh, D.M., Gessert, C.E., Renier, C.M. (2009). Massage in the management of agitation in nursing home residents with cognitive impairment. Geriatr Nurs, 30(2), 108-117.
Kapoor, Y., Orr, R. (2017). Effect of therapeutic massage on pain in patients with dementia. Dementia (London), 16(1), 119-125.
Keshavarz, S., Mirzaei, T., Ravari, A. (2018). Effect of head and face massage on agitation in elderly Alzheimer’s disease patients. Evidence Based Care Journal, 7(4), 46-54.
Margenfeld, F., Klocke, C., Joos, S. (2019). Manual massage for persons living with dementia: A systematic review and meta-analysis. Int J Nurs Stud, 96, 132-142.
Remington, R. (2002). Calming music and hand massage with agitated elderly. Nurs Res, 51(5), 317-323.
Rodríguez-Mansilla, J., González-López-Arza, M.V., Varela-Donoso, E., Montanero-Fernández, J., Jiménez-Palomares, M., Garrido-Ardila, E.M. (2013). Ear therapy and massage therapy in the elderly with dementia: a pilot study. J Tradit Chin Med, 33(4), 461-467.
Rowe, M., Alfred, D. (1999). The effectiveness of slow-stroke massage in diffusing agitated behaviors in individuals with Alzheimer’s disease. J Gerontol Nurs, 25(6), 22-34.
Sansone, P., Schmitt, L. (2000). Providing tender touch massage to elderly nursing home residents: a demonstration project. Geriatr Nurs, 21(6), 303-388.
Viggo Hansen, N., Jørgensen, T., Ørtenblad, L. (2006). Massage and touch for dementia. Cochrane Database Syst Rev, (4):CD004989.
Watt, J.A., Goodarzi, Z., Veroniki, A.A., Nincic, V., Khan, P.A., Ghassemi, M., Thompson, Y., Tricco, A.C., Straus, S.E. (2019). Comparative efficacy of interventions for aggressive and agitated behaviors in dementia: a systematic review and network meta-analysis. Ann Intern Med, doi: 10.7326/M19-0993.
Woods, D.L., Beck, C., Sinha, K. (2009). The effect of therapeutic touch on behavioral symptoms and cortisol in persons with dementia. Forsch Komplementmed, 16(3), 181-189.
Woods, D.L., Craven, R.F., Whitney, J. (2005). The effect of therapeutic touch on behavioral symptoms of persons with dementia. Altern Ther Health Med, 11(1), 66-74.
Dr. Susan Salvo is a massage practitioner, author, educator, researcher, explorer, and perpetual student. To learn more about Susan, check out the “About Susan” tab. You can contact Susan at firstname.lastname@example.org.