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Growing Old with Massage
In Facility Care

By Dawn Nelson, C.M.T.

Copyright 2003. Associated Bodywork and Massage Professionals. All rights reserved.

While the changes accompanying aging can be unsettling and frightening to the elderly, it's comforting to know that something as simple as frequent touch can stimulate maturing minds and bodies, ensuring that the concomitant traumas of our later years are minimized. As a bodyworker, bringing touch to this facility-bound population can bring both heartache and joy, but the value of your work cannot be denied.

As most people age, they begin to notice a gradual slowing down of their physical and mental capabilities. Joints become worn, making them susceptible to crippling and painful conditions such as arthritis, bursitis and tendinitis. The skin loses some of its elasticity and moisture, as well as changes in pigmentation. Lung capacity decreases as does blood flow to the brain. Decreased mobility contributes to poor circulation and constipation, as well as a gradual loss of muscular strength and tone. And changes in physical and mental acuity, including hearing deficiencies and visual impairments, often lead to decreases in functional abilities.

Growing older also means facing a number of irreversible and potentially stress-producing life changes like retirement, relocation and widowhood. The losses associated with aging often are permanent (as opposed to losses in earlier stages of life from which we more readily recover) and occur closer together with less time to adjust between events. Chronic illness and functional limitations can increase anxiety about the future and create greater dependency on others.

As life spans increase, the number of people requiring long-term health care is also increasing. It is estimated that in the coming year, almost 9 million older Americans will need extended health care services. Some of these men and women transfer to nursing homes for rehabilitation after an accident or injury, or to convalesce after a serious illness. Others will live out their lives confined to care facilities. Those people may be too frail to take care of themselves and live safely, or they may suffer from a chronic illness and need medical attention. Family care may not be an option because there is no family member available, or because family members are unable to provide the care that is needed.


A Loss of Independence
The move into a health care facility signals a significant loss of independence and constitutes a major lifestyle change for both the person involved and their family. Relocation may create additional losses, including forfeiture of one's home, familiar surroundings and privacy. Treasured possessions may need to be sold, put in storage or given away. Also, those living their lives in care facilities usually have less contact with the outside world and fewer social relationships than those who live independently or with family.

When a person becomes a resident of a care facility, he or she is suddenly relegated to rules. Meals, rest periods and activities are scheduled for efficiency in management and convenience of caregivers rather than according to individual preferences, lifestyle choices or personal habits and rhythms.


Depression and Stress
Multiple losses combined with decreased mobility and functional impairments frequently lead to depression. According to a recent article by Paula Dranov entitled "Depression and the Elderly," the suicide rate among people over 65 is higher than any other age group.

Combined with health conditions requiring medical attention, a gradual decline in functioning and increased dependency on others can make these losses extremely stress-producing. While a certain amount of stress can be positive, we all know too much or prolonged stress can be unpleasant and unhealthy. Stress lowers resistance to viruses and can lead to more acute, chronic or even life-threatening health problems.

Massage therapists know stress affects the physical body by causing muscular tightness, tension, stiffness and restricted energy flow. Continued stress can lead to muscle spasms, as well as bodily contraction, restricted movement and rigidity. Other signs of stress may include headaches, backache, fatigue, insomnia, stiff neck, cold hands and/or feet, perspiration, shortness of breath, constipation, etc. Physical stress tends to produce more emotional stress, thus setting up a cycle of disease, discomfort and anxiety which can generate feelings of confusion, frustration, isolation and vulnerability for the elderly. Such feelings eventually lead to inertia, despondency, withdrawal and a "failure to thrive" syndrome.


Reaching Through Isolation
In his classic book, Touching: The Human Significance of the Skin, Ashley Montague says it is the "emotional involvement of touch that can reach through isolation."1 Touch can communicate love, affection and warmth which can help alleviate feelings of loneliness and separation. Touch becomes especially important for those confined to health care institutions who may receive few visitors from the outside world. Though basic needs are met, these individuals often remain starved for the nourishment that comes through caring, attentive touch and skin-to-skin human contact.

Massage and touch therapy are, in fact, ancient healing modalities which somehow became lost in the maze of modern medical technology, pills and paperwork. Back rubs were once routinely and effectively administered by nurses as a non-invasive therapeutic tool to promote rest and relaxation. Fortunately, massage is being rediscovered as a complementary and alternative therapy in caregiving. Age-appropriate, gentle massage and attentive touch techniques are particularly effective in providing comfort care and in enhancing quality of life for those who reside in a nursing home or extended care facility environments.

Massage therapy is well-known for its ability to reduce muscular tension, relieve minor aches and pains, increase circulation and induce a relaxation response in the body. Tiffany Field, through her research at the Touch Institute in Miami, has gained worldwide attention in discovering that therapeutic massage seems to stimulate the release of endorphins - the body's natural painkillers - into the brain and nervous system, boost the immune system and promote faster healing after injury, trauma or surgery.2 While little hard research is, at present, being conducted on the benefits of massage for nursing home residents, anecdotal reports from those working in this field have been extremely positive.

In 1996, a six-month pilot program on the use of massage therapy as an intervention for problem behaviors in nursing home residents with dementia, conducted at the Methodist Home in Chicago, found correlations between certain types of massage - and where it was applied on the body - and managing specific behaviors. For example:
- Back rubs worked wonders for those confined to wheelchairs, for people in chronic pain and for residents exhibiting irritability or even anger.
- Foot massage proved calming for those exhibiting hyperactive behavior or restlessness and "wandering" behavior.
- Hand massage or face stroking seemed to help those exhibiting anxiety, worry, sadness and fearfulness.
- Massaging the temples, scalp and forehead helped reduce headaches and tension, and shoulder and neck massage seemed useful for those exhibiting tiredness, irritability or mild upset.3

An unpublished report from a case study conducted by Christine Gruschke, nurse consultant for Beverly Health and Rehabilitation Services, Inc. (1997), showed a tremendous improvement in mood and anxiety levels in residents receiving geriatric massage therapy in a Florida nursing home once a week for an average of three months. Perhaps most noteworthy was the documented reduction in medications (representing a significant financial savings) taken for pain management for many of the 21 residents in this particular study.

Nursing manuals have long prescribed massage to help in the prevention of skin ulcers (pressure sores), a chronic problem for the frail elders who spend most of their time in a bed or wheelchair. Even very gentle massage can help improve circulation.

The focused attention afforded in massage and touch therapy sessions to residents of health care facilities also has significant psychosocial benefits, including:
- one-on-one attention
- skin-to-skin contact
- tactile and sensory stimulation
- an opportunity for social interaction
- nurturing
- comfort
- reassurance
- pleasure

Touch is a universal language. Gentle massage is a way of communicating with those who are non-verbal or unable to express themselves well orally. The practitioner who is able to keep her attention on the individual who inhabits the body and who is alert to the subtle nuances and changes in the physical being, breathing patterns and so on, will have little trouble understanding what the person needs.

Massage therapist Jeannie Battagin tells a beautiful story about sitting next to a lady in an intermediate care facility who was seldom able to speak in intelligible language but would babble for long periods of time as though she was trying to communicate.

"As she continued to 'talk,' I put my hand on hers. I began to slowly stroke down her arm from the shoulder, very gently. She seemed to relax into this, so after a little while I did the same thing with her other arm, stopping to spend extra time massaging her hands. For some reason, I felt drawn to put one of my hands on her cheek. She closed her eyes at this point, as if she was savoring the touch there. So I put my other hand on her other cheek and just stayed there cradling her face in my hands. A minute or so went by and I realized by the weight of her head and by her breathing that she had let go enough to fall asleep."4


Combating Dementia
At least half the population in most skilled nursing facilities suffer from some form of dementia. Massage offers therapeutic support for such people by increasing body awareness and helping to ground those who are confused and disoriented, bringing them back into present time and physical reality.

The use of conscious and compassionate touch helps address quality-of-life issues common among residents of long-term care facilities:
- touch deprivation
- low self-esteem
- anxiety
- boredom
- depression
- lethargy

In addition, skilled touch is a great aid in managing challenging behaviors sometimes characteristic of those living with dementia-related conditions, like Alzheimer's disease, restlessness, wandering, agitation, fearfulness and withdrawal. Utilizing skilled touch can help in such situations by focusing and engaging attention, redirecting energy, promoting interaction and calming.

A back rub or lotion massage to hands or feet might also be used as a distraction, if necessary, to help in accomplishing the tasks of daily care. Years ago, nurses were taught how to give back massages, instead of pills, to help lull their patients into restful sleep at bedtime. Unfortunately, most nurses these days are kept so busy dispensing pain-reducing and sleep-inducing medications they have no time to give their patients one-on-one attention or to touch them in a conscious, caring way.

Much has been made of the fact that human contact in the form of touch is crucial during the early stages of life. Research has proven that institutionalized infants deprived of caring touch soon stop eating and fail to thrive. Similarly, my observation and experience in working with the elderly has shown that those who are deprived of nurturing physical contact experience a diminishing quality of life, a lessening of their desire to relate to others and a weakening of what may already be a fragile relationship with physical reality.

As a therapeutic modality, age-appropriate massage is a cost-effective, non-pharmacological resource for reducing stress, managing challenging behaviors and enhancing quality of life for the elderly and ill, particularly those who are confined to care facilities. Montague writes, "The use of touch and physical closeness may be the most important way to communicate to ill and aged persons that they are still important as human beings."5

Unconditional, caring touch is a powerful acknowledgment to the individual that, regardless of the condition of the physical body, he or she is still a part of the human race, and still has value as a whole human being. This is healing in its true and deepest sense.

Dawn Nelson, CMT, founder and director of Compassionate Touch(R) for those in later life stages, is an internationally recognized speaker, author and educator, and a pioneer in the effort to include massage in care plans for those in Alzheimer's facilities, nursing homes and hospice programs. Her first book, Compassionate Touch: Hands-On Caregiving for the Elderly, the Ill and the Dying has been recommended by one Kaiser Permanente medical director as "essential reading for all caregivers." For a list of training workshops and resource materials offered through Compassionate Touch, call 925/935-3906 or e-mail cttrain@jps.net.

References
1. Montague, Ashley. Touching: The Human Significance of the Skin, 3rd ed. (Harper and Row: New York, 1986).
2. Field, Tiffany. Keynote to AMTA National Convention, Nov. 7, 1997, Salt Lake City, Utah.
3. Belle, Cynthia. 4th National Alzheimer's Disease Education Conf. presentation, Chicago, Ill, July, 1995.
4. Battagin, Jeannie, CMT. Personal Communication, 1997.
5. Montague.




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