Chronic pain in the elderly is usually treated with drug therapy. However, alternative therapies have become more widely accepted. One example is massage therapy, which has made progress in aiding drug therapy, and in some cases replacing it, to relieve pain. Because of the direct contact that massage therapy offers, it provides those with Alzheimer's disease a way to relax, thereby reducing the anxiety associated with the disease. Massage also provides stimulation, helping residents communicate physically. This article features the massage therapy programs at the Masonic Home in Charlton, Mass., and The Willows at Westborough, Mass. All residents at the Masonic Home can have a massage, either in a full session or a modified version that meets their needs and accommodates their personal situation. At The Willows, massage therapy is offered to residents in all three living units, with a focus on stimulation. These two profiles of massage therapy programs demonstrate the effects of massage on elders with varying health conditions, specifically those with Alzheimer's disease.

Importance of Massage Therapy

Treating chronic pain in the elder population is especially important because pain is prevalent in most seniors' lives. Nearly 80 to 85% of people past the age of 65 will experience pain caused by a health problem. (1) Of these elders, 25 to 50% will admit to having significant pain, and of those living in nursing homes, this percentage increases to 45 to 80%. (2) The shared experience of chronic pain coupled with decreased social contact at this point in their lives makes massage therapy a particularly effective treatment approach for seniors. Massage therapy reduces the pain of chronic disease and minor injuries, decreases muscle spasms and stiffness, and increases mobility, while providing more physical and social interaction for elders. (3)

For residents with Alzheimer's disease, these benefits also apply, as well as some additional observations. Because massage therapy can be used in two ways, either to relax or to stimulate, it elicits both calming and responsive effects. Massage can alleviate some of the anxiety associated with Alzheimer's by inducing relaxation, but it can also stimulate the nervous system to maintain nerve passageways in decline because of the disease. Touch therapy through massage can offer great relief and even aid the drug therapy that elders with Alzheimer's disease are often prescribed.

Massage Therapy Program at the Masonic Home

The Masonic Home has three living units, including a rest home, in which residents have their own rooms and need minimal care; a nursing home, in which two residents live in each room and need basic care; and a special care unit (SCU) for residents with Alzheimer's. The Masonic Home provides massage therapy to all residents with a doctor's approval. The focus is always on relaxation rather than a strict therapeutic massage because a complete one-hour, full-body massage may be inappropriate for some residents with a lower level of mental or physical functioning. The residents of the rest home can receive the full massage. They make an appointment with the massage therapist and use a private room set up for massage treatments. A hospital bed is used so that transferring is easy, and a bathroom is adjacent for convenient access. The cozy atmosphere of this room, enhanced with music and candles, still follows facility guidelines to ensure that a resident's safety and comfort are maintained.

In addition to music therapy, aromatherapy may also be used to enhance the setting. Aromatherapy is the use of essential oils, either through inhalation or external application, to enhance the benefits of massage by reducing stress, promoting relaxation, stimulating circulation and, in general, awakening the body's and mind's healing energies. (4) Before each massage, the resident chooses an essential oil according to its specific attributes, such as rosemary to increase circulation or sweet marjoram for pain relief. (4) This additional therapy helps to increase the effectiveness of the massage.

Massage Therapy Program at The Willows at Westborough

Massage therapy at The Willows is available for residents in all three units, including the independent living units (The Willows), the assisted living residences (Whitney Place), and the Skilled Nursing and Rehabilitation Centers housed in the Beaumont building. This 11-year-old program focuses on stimulation mainly through weekly one-hour massages. In some cases, the massages are more frequent, and other alternative therapies such as shiatsu, reflexology, tai chi, and yoga are incorporated. These forms of therapy lead to increased strength, better posture and balance and, consequently, to an increased ability and confidence in performing daily activities.

In addition to these direct benefits, the massage therapist often incorporates reminiscence therapy or music therapy as part of the overall experience. Reminiscence therapy is a way of calling the past to mind, particularly positive events, people, or places, to improve elders' outlook on the present by increasing socialization and self-esteem, improving communication skills, and reducing isolation and anxiety. (5) This therapy is used not only by psychotherapists, but also by those in the medical field, e.g., by physical and occupational therapists. (5) According to the massage therapist at The Willows, reminiscence therapy paired with music is regenerative, and thereby changes the self-image of seniors. Listening to music and telling stories stimulate elders to resurrect these memories and focus on what remains. The massage therapist can act as a stimulus by encouraging elders to reminisce during muscle toning.

Music therapy offers an alternate form of expression, relieving seniors of their burdens and anxiety. (5) Music can communicate, especially to those who are otherwise nonverbal. It also encourages movement, even for those with physical handicaps. (5) These benefits are especially desirable for residents with Alzheimer's. The music's rhythm is a source of liveliness and a possible stimulus of memories; even being able to sing some familiar song lyrics gives elders confidence and an opportunity for further verbal expression. (5) Nevertheless, a caregiver must be aware that music may not create the same response in an elder with Alzheimer's. (5) Overall, such a union of body and mind therapies often leads to a deeper, fuller healing experience.

Benefits of Massage Therapy

In general, massage therapy offers a welcome release of tension from frequent aches and pains. Since May 2001, when the massage therapy program began at the Masonic Home, not one resident has refused a massage or any other relaxation treatment. In terms of physical benefits, it has been reported that massage reduces stress, deepens relaxation and breathing, lowers blood pressure, stimulates circulation, relieves joint pain, reduces swelling, stimulates bowels and flow of lymph, improves sleep, releases endorphins, decreases fear and anxiety, and creates a sense of well-being and decreased isolation? (3,6,7) Such stimulation is especially necessary in the nursing home unit of the Masonic Home, where many residents are less active and sit most of the day.

The massage therapist at The Willows has provided this therapy for 11 years and believes in its ability to promote activity and strength. For example, Kevin J., who has a history of chronic back pain, treated for most of his life through bi-weekly trips to a chiropractor, has received massages since the beginning of The Willows' program. A classic, Swedish massage is followed by trigger-point therapy and the therapist's encouragement to exercise every day. Over time Mr. J's pain has been greatly reduced.

Elders, in general, experience a loss of sensitivity to touch, (8) which a massage can help reinvigorate. Willows resident Susan M., who receives a weekly massage, is in the advanced stages of Alzheimer's disease, and massage therapy has aided her level of functioning. Although she is almost completely nonverbal, massage provides Ms. M an opportunity for physical expression. The massage therapist serves as a stimulus, eliciting a response through touch. For example, the massage therapist often uses reflexology with Ms. M, gauging how much deep foot massages can trigger nerve passages affected by Alzheimer's. Thus, it is a way to recognize any loss or plateau in functioning she experiences. Although this use of massage is nontraditional, its potential effectiveness is reinforced by this case.

Massage has other benefits for residents with Alzheimer's disease. In a one-year demonstration project at Schervier Nursing Care Center in Riverdale, New York, the facility offered a Tender Touch massage; findings indicated that massage therapy can also help eliminate anxiety in a resident with dementia and also decrease the amount of pain experienced by residents. (9) An added benefit was also reported by the CNAs who were administering the therapy: Massage created a closer bond between the staff and their residents. (9) Touch carries an implication of intimacy and emotional connectedness. Some of this touch therapy was also done by family members, eliciting positive results through increased contact and communication. (9)

Concerns About Elder Massage Therapy and Possible Solutions

Modesty. Sensitivity is important when offering massage therapy to an elder because of the concerns and stereotypes surrounding this age group. A common assumption, for example, is that the effects of age on an elder's body would make having to undress for a full massage uncomfortable or stressful since it can be time consuming and immodest. The issue of modesty has not arisen at the Masonic Home because residents' concerns are considered. To prevent problems, the therapist at the Masonic Home waits outside of the room to give the resident plenty of time to undress and put on a hospital gown at the beginning of the session. In addition, she makes sure to leave enough changing time at the end of the treatment. Such simple considerations forge a better relationship between the therapist and the resident, and they allow the massage to progress without adding any anxiety.

Cost. At the Masonic Home, the facility has hired a therapist, so residents do not pay for individual treatments. On the other hand, residents pay privately for massage therapy at The Willows. Cost, therefore, can be a common discouragement because many insurance companies do not offer reimbursement for massage therapy. One possible solution, however, is that families could hire a massage therapist for several residents as a special gift. Finding an appropriate gift for this age group, especially those afflicted with Alzheimer's, often proves difficult. Thus, massage therapy would be a well-suited possibility. With the consent of the residents, a facility could also contact a massage-therapy school and offer the residence as a place for practice. This connection could increase students' familiarity with giving massages to the elder population.

Sensitivity to health conditions particular to the elder population. Awareness of different health conditions is necessary prior to giving a massage so the technique can be adapted to residents' needs. Some conditions to be aware of are blood clotting, vein inflammation, severe swelling, skin lesions or bruises, and abdominal aneurysm. (3) Patricia R., another resident of The Willows, waited to resume her massages after falling and spending a week in the hospital because a massage could cause clotting. Awareness of possible complications is critical for massage therapists; in elders with Alzheimer's disease, this awareness is key. The Willows' massage therapist indicates that one of the most important aspects of giving a massage is recognizing how various health conditions affect people differently and modifying a massage accordingly. For elders with Alzheimer's, the therapist may encounter resistance to massage, depending on which areas of the body can respond to the therapy.

When a therapist considers elders' unique needs, a massage can improve their physical and emotional well-being, and emotionally, a massage can become a treasured outlet for an elder. Response to massage can measure elders' decline in daily functioning over time, serving as a gauge of their physical health. Therefore, a therapist must be patient and attentive, even when the resident undresses or continues to tells stories while the therapist tries to depart (3) Such sensitivity heightens the experience for the elder and the therapist.

Adaptations of Massage Therapy at the Masonic Home

Modified massages for residents of the nursing home unit. In addition to the standard massage given in a private room to rest home residents, the massage therapist offers modified massages to the residents in the nursing home unit of the Masonic Home. These modified massages take place in the resident's room, where a curtain is drawn around the resident's bed. Lasting about 30 minutes, this type of massage does not require residents to undress. This adaptation allows the massage therapist to see each resident of the nursing home unit at least twice a month.

Tactile-touch program for Alzheimer's residents of the SCU. This program allows residents of the SCU to participate in a noninvasive, comforting therapy to ease their anxieties. At the Masonic Home, the massage therapist rotates throughout the unit, especially during scheduled activities, because that is when she is able to see a majority of the residents without interruption. This tactile-touch program emphasizes simple massages and small movements to stimulate elders' sense of touch. An example is soothing residents with lotion while they are sitting. The therapist may also rub their shoulders or hands. Kim and Buschmann observed the effects of physical touch on patients with dementia and concluded that less anxiety and fewer occurrences of dysfunctional behavior resulted. (10)

The Masonic Home holds weekly care-plan reviews to discuss residents' overall well-being. The massage therapist attends these meetings to offer advice and determine who needs her attention. For example, she may share with the nurses which residents have been practicing poor hygiene lately, while the nurses can tell the therapist which residents are overly nervous or uncharacteristically anxious. At the University of Texas at Tyler, a study of the effectiveness of slow-stroke massage on the more physical expressions of anxiety associated with Alzheimer's disease found that it provides some relief from such anxious expressions as pacing, wandering, and resistance. (11) Caregivers can perform this type of massage with a small amount of training. (11)

Adaptation of massage therapy for the dying. Other than the three care units in the Masonic Home, hospice care is also available for some of the residents. With permission from the resident and his/her family, the massage therapist will spend time daily with a hospice patient to soothe some of the anxiety and pain that come at the end of life. Of course, a full massage is unnecessary and impractical for these circumstances. Thus, for short periods every day, massage therapists perform a routine similar to those done for residents with Alzheimer's or the residents in the nursing home, paying strict attention to each person's degree of pain.

In a particular case at the Masonic Home, the massage therapist reduced a dying woman's anxiety through reflexology treatments on her feet. Reflexology is a massage that emphasizes the feet or the hands. Ten zones of the body correspond to our 10 fingers or toes, and massage can relieve anxiety in those zones. (6,7) Nurses can give such a massage, and residents often welcome them because this form of touch communicates intimacy and empathy. (12) However, for some, moving certain body parts may ca use immense pain, which would be a drawback to giving a massage. (12,6,7) Also skin that has deteriorated resulting in painful ulcers and lesions should not be massaged. (13)

Adapting Massage Therapy at The Willows

As previously stated, massage therapy can both relax and stimulate a resident with Alzheimer's. The uniqueness of each elder with Alzheimer's requires caregivers to pay attention to his/her particular needs, thus improving treatment. The following is a summary of an interview conducted at The Willows with a couple, Sam and Susan M., who have been married for 52 years.

Susan, now in the advanced stages of Alzheimer's, has received care primarily from her husband for eight years. Each week for about two years, Sam has brought Susan to The Willows for a massage. The therapist, Bruce, and Sam have built a small step for Susan so she can climb onto the massage bed. Susan no longer walks up or down stairs and is almost nonverbal. However, she exhibits bodily responses to stimuli, especially during these massages. Making these connections with Susan at this stage of her disease makes it possible for Sam and others to have life affirming, effective interactions with her.

In these sessions, Bruce targets a series of stimuli that will challenge Susan's network of motor neurons and receptors to maintain their functioning. As a result, Sam's daily encounters with Susan have been enhanced, because of this source of resistance to the physical deterioration caused by the disease. Bruce's work with Susan makes her strong, especially her shoulders, and maintains a range of motion in her upper body so that she does not need to be strapped into a chair or bed throughout the day, as many would be at this stage of the disease.

During the night, Susan often clenches her fists so tightly that it is difficult to open her hands in the morning. Sam has learned to apply pressure in the space between the thumb and first finger slowly, but not forcefully. He has recognized that using more force makes Susan resist even more. Bruce, in his work with Alzheimer's residents, has often observed such resistance. He attributes resistance to a fear of losing control or balance. Bruce allows Susan to let go during his massages, and she effectively uses her strength to regain some balance. The tension in her muscles manifests a fear or burden to which her brain has become accustomed. This tension is a learned behavior. It is easier to contract the muscles than to let them go flaccid, Bruce says. His massage therapy stimulates these passageways, disrupting the pattern and allowing a new pathway to form.

During these sessions, Susan wears a gait belt so Sam can guide her as she walks in response to the passageways that have been opened during the massage. To start her walking, Sam sings his "left, left, left" song. This repetitive stimulus and a few tugs on her belt enable her to start walking. This physical and musical communication demonstrates the importance of these therapies, especially in critical cases.

Conclusion

The benefits of massage therapy related to Alzheimer's disease are only beginning to be realized. However, its implications are promising. Massage therapy not only can offer relief through relaxation or stimulation, but it can also serve as an educational forum for family members, especially in cases of behavioral problems. Caregivers can adapt some simple forms of massage, thereby improving negative behaviors stemming from anxiousness, fear, or tension.

Massage therapy benefits the elderly not only by relieving pain, but also by protecting their overall well-being. It maintains and rebuilds the nervous system's response to stimuli, enabling seniors to resist physical and mental declines. In particular, elders with Alzheimer's disease respond well to massage therapy as another form of communication and as a source of strength and intimacy. The diverse programs of massage and other alternative therapies at the Masonic Home and The Willows at Westborough are models for future programs in similar residences, especially in caring for Alzheimer's residents.

Acknowledgment

The authors wish to thank Ginger Iozzo, massage therapist at the Masonic Home, and the many residents of The Willows at Westborough, especially Joe and Marie Strain, for their generous contributions to this article.

This article is based on a poster presented at the Massachusetts Alzheimer's Disease Conference in May 2002.

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(10.) Kim EJ, Buschmann MT. The effect of expressive physical touch on patients with dementia. Int J Nurs Stud 1999;36:235-43.

(11.) Rowe M, Alfred D. The effectiveness of slow stroke massage in diffusing agitated behaviors in individuals with Alzheimer's disease. J Gerontol Nurs 1999;25:22-34.

(12.) Amenta MO, Bohnet NL. Nursing care of the terminally ill. Boston: Little, Brown, and Company, 1986.

(13.) Robbins J, Moscrop JE (Eds.). Caring for the Dying Patient and the Family. San Diego: Chapman & Hall, 1995.

Jessica Trombley is a student, class of 2003, at College of the Holy Cross. Bruce Thomas, BS, LMT, is a graduate student at Assumption College, and massage therapist at The Willows at Westborough. Pearl Mosher-Ashley, PhD, is professor of psychology, Worcester State College. For further information, e-mail Thomas at brutea@net1plus.com or Dr. Mosher-Ashley at pmosherashley@ worcester.edu. To comment, send e-mail to trombley1003@nursinghomesmagazine.com.

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