Originally published in Massage Bodywork magazine, December/January 2006. Copyright 2006. Associated Bodywork and Massage Professionals. All rights reserved.
Chances are you either have a family member diagnosed with Alzheimer's disease or you know someone who does. The devastating impact of Alzheimer's and related dementias on our American society is steadily growing. The Alzheimer's Association puts the number of people currently diagnosed with Alzheimer's (the most prevalent dementia) at 4.5 million, double that in 1980. As life expectancy increases, so does the rate of those afflicted -- 1 of 10 by age 65, 1 of 2 by age 85. In addition to the staggering national cost of care at $100 billion a year,1 there is the personal cost for both patient and caregiver.
Whether provided in a specialized facility or at home, care for the dementia patient is a challenge. Neurologist Barry Reisberg coined the term "retrogenesis," meaning "back to birth," to describe the process of Alzheimer's disease. Through research, he determined that destruction of the brain occurs in a systematic reverse of the stages of brain development. This is why problems in short-term memory (stored in the hippocampus, the last symptom to develop) are the first to surface while other basic functions, such as physical movement and autonomic regulation, remain intact longer.2 By later stages of the disease, the person has lost much of the brain's filing system. What remains is a child-like state of helplessness, frequently accompanied by behavioral and emotional symptoms. As the inability to communicate, reason, remember, and perform diminishes, the Alzheimer's patient becomes more sensitive and vulnerable to change, exhibiting signs of agitation, distress, paranoia, and anger. This can turn a simple mealtime into a battlefield or bath time into a major war if handled inappropriately. Agitation can also spur patients to wander endlessly, searching for some lost fragment of their past -- a home or relationship long gone, but still in their memory bank -- anything that assuages their fear and confusion.
These behaviors, and others equally challenging, impact quality of life for both caregiver and recipient. While there are pharmaceuticals targeted at decreasing these behaviors, their efficacy is questionable. Side effects are a major concern, especially in the elderly whose body systems may be frail or who are taking drugs for other medical problems. The use of non-pharmacologic interventions, such as behavioral approaches that evoke a relaxation response, are increasingly recommended by dementia experts for implementation in care facilities and at home.
Studies of alternative approaches to lessen dementia behaviors have trickled in over the years, gaining momentum during the past decade. In one of the more recent, involving use of therapeutic touch, Woods et al. (2005) point to review findings from the Quality Standards Subcommittee of the American Academy of Neurology which indicate that "non-pharmacological interventions showing the most consistency and promise involve sensory." In addition to massage/touch therapies, these include music, light, pet therapy, and video/audio tape of family.
Researchers began as early as 1975 exploring the use of these techniques with geriatric patients. (For a more complete review, see "It's Never Too Late to Touch: Massage Emerges as a Lifeline to Dementia Patients," Massage Bodywork, June/July 2000.) Although early studies were small with limited results, massage, therapeutic touch, and calming physical presence began to emerge in the 1990s as viable alternatives in dementia care. Various forms of gentle touch, such as hand treatments, proved effective in decreasing problematic behaviors. A study of in-home use of slow-stroke massage to the upper body showed a reduction of the physical behaviors, such as pacing, wandering, and resisting, but no reduction in verbal expression of agitation.4
As highlighted by Woods et al. in their report, restlessness and problematic vocalization are the most frequent and disturbing behaviors encountered in cases of Alzheimer's and related dementias. As such, this became a major focus of their therapeutic touch study which we will review here. Previous studies have shown therapeutic touch to elicit a relaxation response and Woods' team surmised this approach would have a positive impact on institutionalized dementia patients. They note only two previous investigations examined use of therapeutic touch for dementia behavioral problems in nursing home populations. A small 1995 study, fraught with limitations, compared therapeutic touch, hand massage, and presence, with mixed results.5 In a preliminary to the 2005 study, Woods and Dimond (2002) conducted a within-subject, time-interrupted study in which therapeutic touch showed promise as an effective intervention with problematic vocalization and pacing. Although limited by small sample size (10 subjects) and lack of randomization and control group, the study was significant for the inclusion of cortisol measures.6 Results showed that reduction of agitated behaviors through application of therapeutic touch was accompanied by a decrease in cortisol. (Woods continues investigation in this area with studies underway to examine the interrelationship of cortisol, dementia agitation, and therapeutic touch intervention.7)
Designing a larger, more scientifically rigorous trial, Woods et al. randomized 57 participants equally to three groups: Therapeutic Touch with contact on neck and shoulders; placebo consisting of a mimic treatment resembling therapeutic touch; and routine care. Alzheimer's patients, ranging in age from 67 to 93, were selected from three special care units of long-term residential facilities similar in philosophy of care and staffing. Prior to enrollment, subjects were administered the Mini Mental State Exam (MMSE) to screen for cognitive impairment. Criteria for participation was a MMSE score below 20 (range 0-30, with lower range representing severe impairment). These scores were also used for demographic data, classifying subjects according to dementia level. Additionally, the Revised Memory and Behavior Checklist was used to screen for frequency of behaviors targeted by the study.8
A third measure for behavioral symptoms was used during the study to gather data for intervention comparison. Modifying the Agitated Behavior Rating Scale, which documents frequency of manual manipulation, escape restraints, searching/wandering, tapping/banging, and vocalization, researchers added a classification for pacing/walking. These behaviors were recorded by trained observers (blinded to study purpose and intervention protocols) every 20 minutes over a period of 10 hours per day, for three days pre- and post-intervention. As added measure to blinding, observers were not present in the facility when interventions took place.9
The experimental protocol -- Therapeutic Touch -- was administered twice daily, over three days, on a specific time schedule. Practitioners, including the principal investigator (Woods), had received training (5 to 8 years) from originators of the modality, Dora Kunz and Dolores Krieger. Having no prior research on which to base determination of the length of time appropriate for intervention, the team combined input from the modality's originators, Woods' clinical expertise in this area, and consideration of the subject's neurological status and restlessness to guide the timing, with sessions lasting 5 to 7 minutes. Therapists began the session with intentioning, centering, and focusing attention and concentration on the wholeness of the subject. Contact then included gentle touch to the shoulders, back, and upper neck, concluding with resting "one hand on the forehead while making contact with the back of the neck with the other hand." The session was ended with a final resting of hands on the shoulders and directing "thoughts of balance toward the participant."10
For the placebo treatment, intervention was delivered, according to the same schedule and duration as the experimental approach, by research assistants with no prior knowledge of Therapeutic Touch and, as with the observers, blinded to the purpose of the study. Although movements involved in the placebo protocol mimicked that of therapeutic touch, practitioners were instructed to perform mental calculations during the treatment session by subtracting increments of seven from 100. This strategy supported distracting them from entering a meditative state and/or directing purposeful intention for wholeness to the recipient.11
Of the individual behaviors tracked through observation, only manual manipulation (restlessness) and vocalization showed a significant decrease for the Therapeutic Touch group as compared to controls, with differences between placebo and experimental groups not reaching statistical significance. The results, however, did show a decreasing trend from control to placebo to experimental group for vocalization and restlessness. In overall behavioral symptom score, there was also a statistically significant change from pre- to post-intervention for Therapeutic Touch as compared to both placebo and control groups. In addition to the measured results, researchers say staff at the facilities commented on their own observations of decreased patient agitation and more calm environments in their units. One such remark came from a staff member who, having been on vacation, was unaware the study had taken place.12
In discussing study outcome, the team has some interesting suggestions regarding the effect of the placebo treatment. The linear trend, as described above, in decreasing behaviors from experimental to placebo and control groups, may involve a potency difference in the interventions. While the mimic treatment was not as effective as true Therapeutic Touch, it did involve a calm presence of nurses and a nursing aide, "all of whom had skilled nonverbal behavior ... and were using touch in a non-custodial context." Even though the practitioners were purposely distracting thought away from the recipient, it may be that one-on-one interaction, compassionate touch, or nursing presence contributed to the decrease of behavioral symptoms in this group. All of these factors, authors say, have been shown to have positive effects.13
It is heartening to know that Woods is continuing this line of study. With the increasing population of Alzheimer's/dementia patients and concurrent rising cost of care, it is imperative for both families and care facilities to find low-cost, effective approaches for dealing with the day- to-day challenges of behavioral symptoms. The stress of caregiver burden is magnified when simple tasks of daily activities like mealtime and dressing are accompanied by abusive vocalization and resistance from the patient. Escalating restlessness can result in wandering and attempts to "elope" the facility or home, putting the patient in danger. As a non-pharmacologic approach, Therapeutic Touch offers some hope. It can be applied in a variety of environments, requires no equipment, and can be easily taught to family and staff.14
As research moves forward, Woods' investigation into the relationship of cortisol and agitation could shed even more light on this area of study. The two behaviors attenuated significantly by Therapeutic Touch in this trial are noted to be the most frequent and disturbing of dementia behavioral symptoms -- disruptive vocalization constituting 24 percent to 28 percent and restlessness constituting up to 44 percent. For the other four behaviors measured (searching/wandering, tapping/banging, physical restraint, and pacing/walking) no significant effect was found. Thus, the team suggests vocalization and restlessness may differ qualitatively in terms of physiological or neurological origins of distress. Further examination of physiological correlates of stress and other factors, such as timing and loading dose, would be valuable in determining optimum effectiveness of Therapeutic Touch for behavioral symptoms of dementia, authors say.15References
1 Alzheimer's Association. Statistics about Alzheimer's Disease. Available at www.alz.org/AboutAD/Statistics.asp. Accessed August 2005.
2 Shimer, Porter. New Hope for People with Alzheimer's Disease and Their Caregivers. Roseville, CA: Prima Publishing; 2002. 58-59.
3 Woods, Diana Lynn, et al. The Effect of Therapeutic Touch on Behavioral Symptoms of Persons with Dementia. Alternative Therapies in Health and Medicine 2005 January-February; 11(1): 67.
4 Vanderbilt, Shirley. It's Never Too Late to Touch: Massage Emerges as a Lifeline to Dementia Patients. Massage Bodywork 2000 June/July: 141-142.
5 Woods, et al. 67.
6 Woods, Diana Lynn, and Dimond, M. The Effect of Therapeutic Touch on Agitated Behavior and Cortisol in Persons with Alzheimer's Disease. Biological Research for Nursing 2002 October; 4(2): 104-14.
7 UCLA School of Nursing. School News. Available at www.nursing.ucla.edu/faculty/lynn_woods.asp. Accessed August 2005.
8 Woods, et al. 68.
9 Ibid. 68-70.
10 Ibid. 69.
12 Ibid. 71-72.
13 Ibid. 73.