A Crabbèd Old Woman

The body it crumbles. Grace and vigor depart.
There now is a stone where I once had a heart.
But inside this old carcass, a young girl still dwells,
And now and again my battered heart swells.
I remember the pain, and I remember the joys,
And I’m living and loving all over again.
And I think of the years, all too few, gone too fast,
And accept the stark fact that nothing will last.
So open your eyes, nurse, open and see
Not a crabbèd old woman,
Look closer: See me.

These words, from a 90-year-old woman in a nursing home in England, depicting so acutely her struggle to be seen as something other than a decrepit body, brings us in touch with the plight of today’s elderly.¹ Their body betrays their mind, and sometimes their mind betrays their heart. For some, like this woman, they are aware of who they are inside, but no longer have the physical power to put it into play. Many of them have been diagnosed with Alzheimer’s disease or some other form of dementia. They will never recover. They can only submit to the ravages of disease as they struggle to find a lucid moment here or there, some kind of connection that allows the “me” inside to have contact with the world around them.

When dementia knocks it comes to stay, bringing with it a suitcase full of challenges for both the victim and caregiver. It was once called senility. Today the syndrome is neatly metered out into specific clinical categories. Whatever the cause, the symptoms are fairly common throughout. Memory loss, disorientation, agitation, and changes in mood and behavior all take their toll on the quality of life for the patient, nursing home staff and family.

A century ago, the elderly were cared for by their children and grandchildren at home, where they were nurtured, loved and touched until the end of their lives. Today they are sent to nursing centers and assisted living facilities. For many, touch and nurturing are harder to come by. Care is provided by strangers rotating through their daily routine on pre-set schedules. But as recent research has shown, touch is what our elders need and may very well be the catalyst to making contact with that inner “me,” calming the agitation and disorientation of a confused mind and bringing moments of comfort to failing bodies.

A Growing Problem

The Alzheimer’s Association states that, “Approximately 4 million Americans have Alzheimer’s disease,” and if no cure is found, we may expect that number to climb to 14 million by mid-century. The disease has affected nearly half the elderly population over the age of 85 and one of every 10 of those over age 65.² While Alzheimer’s accounts for more dementia than any other cause, another 60 diseases can contribute to Alzheimer’s-like symptoms, including strokes, AIDS, Parkinson’s and Pick’s Disease.³ In addition to the phenomenal costs of caring for those with dementia, there is the daily challenge of handling difficult behaviors, such as agitation and aggression, brought out by the affliction.

Dementia is described as a progressive deterioration of mental function leading to loss of memory, striking changes in behavior and mood, and inability of the person to continue self-care. The deterioration is uneven, in that parts of the brain remain functional while others are destroyed. This accounts for the drastic personality changes noted and the unexplainable outbursts and resistant behaviors of patients. As the loss of memory and cognitive function increases, the patient becomes anxious and confused, often feeling vulnerable.⁴ For caregivers, this behavioral reaction complicates daily tasks and can sometimes act as a barrier to patient interaction. A gesture on the part of the caregiver may be accepted one moment and rejected an hour later. Finding a way to connect with these patients, as their numbers in nursing homes increase by the day, is essential to providing them with the quality of healthcare management and the nurturing they deserve.

“Hands-On” Approach

In the traditional medical world of the past, management of dementia behavior was handled by administering pharmaceuticals and physical restraints. But as in many other fields of health, geriatric caregivers are beginning to turn to alternative therapies as a means to provide patient-centered care. The 1987 Omnibus Budget Reconciliation Act made it “imperative that health care workers explore the use of alternatives to physical and pharmacological restraints for the management of agitation behaviors.”⁵ But even before this mandate surfaced, the quest for more humane, behavioral interventions had begun.

As early as 1975, researchers in France studied relaxation as a non-pharmacologic approach to treating geriatric patients, but surmised that dementia may be contraindicated for this technique.⁶ Throughout the 80s, researchers tried their hand again, many times without success, at zeroing in on a specific approach that would break through communication barriers with this population. In a 1987 study conducted in Sweden, researchers utilized music, touch and object presentation to elicit appropriate behaviors from dementia patients. The small study of only two patients was basically unsuccessful in regard to touch stimulation, described as “small circular stroking movements” applied to various parts of the subjects’ bodies. However, the study team gleaned some insight into their methodology of assessing the subject’s reactions, noting that autonomic responses may not be readily observable through their behavioral criteria.⁷ Others were slightly more successful, obtaining a modicum of improvement here and there, concluding that “the use of touch, as a form of nonverbal communication alleviates anxiety in situations of stress through providing comfort, reassurance and support to patients with dementia.”⁸

Encouraged by previous results in the use of touch, researchers of the 1990s expanded their sample groups and continued to work around the concept of massage. The team of Snyder, Egan and Burns from the University of Minnesota began exploring the use of hand massage, therapeutic touch and physical presence. Working with patients in an Alzheimer’s care unit, they found that massage, more so than therapeutic touch, significantly increased relaxation in their subjects. On the basis of their findings, they pursued the study of hand massage as a means of ameliorating the frequency and intensity of agitation behaviors associated with care activities.⁹

The team’s subject group of 26 patients in Alzheimer’s care units ranged in age from 60 to 97. A Swedish massage protocol developed in the original pilot was administered prior to care activities, 2 1/2 minutes on each hand, with the result of a documented decrease in agitation during the morning session, but not in afternoon sessions. These differences may be explained in terms of degree of stress on the patient and less enthusiasm from the staff members participating in the study as the day wore on.¹⁰

Aromatherapy was added to the massage approach, with mixed results, in an English study published in 1997. Only one of four study subjects benefited to a degree of statistical significance, while two subjects demonstrated an increase in agitation behaviors. Protocols included massage of the hand and lower arm with and without aromatherapy, and aromatherapy alone. What was most notable in this study is the variation of individual reactions of the subjects. This led researchers to propose that single case methodology may be more appropriate than group design to pinpoint specific needs of each patient.¹¹

In 1998, Australian researchers working with a dementia day-care population reported success in using a gentle hand treatment applying essentials oils. The study took place over a period of 18 months and utilized not only the center’s staff for administration of the procedure, but also family caregivers. Among the benefits to the patients were increased alertness, improvement in sleep, and a decrease in agitation, withdrawal and wandering. Family caregivers also reported improvements in their own lives, such as improved sleep and less distress, along with decreased difficulty in managing their relative’s difficult behaviors.¹²

Building on findings of the past two decades, some of the most recent research highlights an expansion of the previous hand massage techniques and incorporation of what has been learned regarding the positive effects of a calming, physical presence.

The team of Kim and Buschmann at Taejon University in South Korea utilized soothing speech and an intermittent gentle touch to the arm and shoulder just before and after hand massage. The 30 subjects, with a mean age of 76.58 years, demonstrated a reduction in anxiety and dysfunctional behavior as assessed by behavioral scales and measurement of pulse rate. The study team concluded that, “Expressive physical touch with verbalization effectively keeps individuals feeling safe and calm before catastrophic events occur. Therefore, it behooves caregivers and family members to use expressive physical touch and verbalization when caring for these patients, since it is cost-effective in improving and maintaining patient’s high quality of life.”¹³

In 1999, investigators in Texas published results of a study using a highly detailed, slow-stroke massage protocol administered in the patient’s home. Community-based family caregivers were recruited from the local Alzheimer’s Association to participate in a three-week study sequence, with training in the use of the protocol and rating scales being provided by the research team. Of the 14 original subject families, nine patient-caregiver dyads completed the project, with one patient dying and two others being admitted to long-term care facilities. The patients’ age range was 68 to 90 and their caregivers’ ages ranged from 54 to 82. The first and third week of the sequence were used to establish baseline data, with treatment being provided during the second week. Massage was administered with the patient seated in a chair, leaning over a table onto pillows. Gentle strokes were applied to the shoulders and upper back, base of the skull and upper neck, and the spine.

Caregivers had noted that agitation behaviors occurred more frequently in early morning, associated with dressing and feeding, and also increased in later afternoon and evening. For these caregivers, the study offered an easily applied treatment to diffuse the agitation behaviors and in some cases ward off potential aggressive behaviors.¹⁴

The study findings indicated that while verbal expression of agitation was not reduced, “the more physical expressions of agitation, such as pacing, wandering and resisting were decreased when slow-stroke massage was applied.”¹⁵ In light of the adverse affect of agitation behaviors on both patient and caregiver, this model offers the family hope in their attempt to successfully manage their loved one at home. In conclusion, the study team suggested that, “Any member of the health care team, at a moment’s notice, can administer massage effectively to diffuse agitated behaviors. It requires no special tools, education or certification,” and may contribute to “maintaining the patients in a familiar environment for a longer time.”¹⁶

It’s Time to Touch

Ashley Montagu, the late pioneer and revered expert in the field of touch, stated, “...it might be conjectured that the course and outcome of many an illness in the aged has been greatly influenced by the quality of tactile support the individual has received before and during the illness.”¹⁷ He notes that especially in the aged, there is an inherent hunger for touch and the absence of touch from others may inhibit the patient from seeking it. For those suffering the isolation of dementia, reaching through to that need becomes even more essential. In Montagu’s piercing words, “A perfunctory peck on the cheek is no substitute for a warm embrace, nor is a conventional handshake capable of replacing a caressing hand...It is especially in the aging that we see touching at its best as an act of spiritual grace and a continuing human sacrament.”¹⁸