Effect of therapeutic touch on agitated behavior in elderly patients with dementia: A review

Full text

Review
Effect of therapeutic touch on agitated behavior in
elderly patients with dementia: A review
Fei-Fei Cai
a
, Hong Zhang
b,*
a
Nursing Department, Liyuan Hospital of Tongji Medical College of Huazhong University of Science & Technology,
Wuhan, China
b
Public Health Department, Liyuan Hospital of Tongji Medical College of Huazhong University of Science &
Technology, Wuhan, China
article info
Article history:
Received 5 June 2015
Received in revised form
12 July 2015
Accepted 27 July 2015
Available online 9 October 2015
Keywords:
Therapeutic touch
Aged dementia
Agitation
Literature review
1. Introduction
The recent increase in life expectancy in China is also leading
to an increased incidence of dementia. Dementia is a com-
mon, chronic, organic disease, which manifests extensive
degenerative changes in the brain. In addition to cognitive
dysfunction, people with dementia often have additional
mental and/or behavioral symptoms, including verbal or
physical aggression, wandering, hiding, shouting, hallucina-
tions and paranoia; the most common and destructive of
these is agitated behavior [1]. Foreign studies have shown that
the prevalence of agitated behavior in elderly demented pa-
tients is 70e90% [2]. In China, the incidence of elderly
demented patients with agitated behavior living at home or in
nursing institutions was 86.1% and 90.8%, respectively [3].
Agitated behaviors increase nursing expenses and hospitali-
zation rate, as well as increase caregiver burden, and lead to
the patients being admitted to nursing institutions earlier
than they would in the absence of these behaviors [4e6].
The treatment of agitated behavior can be divided into two
types: one is drug intervention based on the biomedical
model, and the other is non-drug intervention based on pa-
tient [7]. However, currently, drug interventions are limited,
have low efficacy, and are often accompanied with numerous
and undesirable side effects, including increased mortality,
increased incidence of a cerebrovascular event, and the ac-
celeration of cognitive decline [1]. Non-drug interventions
focus on trying to improve agitated behaviors in patients with
dementia by fully considering the needs of the patients [8,9].
Therapeutic touch (TT) is one of the non-drug in-
terventions that has been widely used in other countries to
treat elderly demented patients with agitated behavior, both
in clinical practice and research settings, with remarkable
results [10e19]. The concept of TT was first introduced in
China in 1995, and has since been widely used on infants,
especially for newborn care and medical research [20e24],as
well as in the study of preoperative anxiety, postoperative
pain and sleep disorders on adults. However, intervention
studies on elderly demented patients with agitated behavior
have not previously been studied in China. Therefore, we
aimed to review the literature from foreign researchers on the
impact of TT intervention on elderly demented patients with
*
Corresponding author.
E-mail address: yifuxinrei@126.com (H. Zhang).
Peer review under responsibility of Chinese Nursing Association.
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agitated behavior to provide a reference for enhancing the
nursing environment in China for both the patients and
caregivers.
2. Agitation in elderly demented patients
and therapeutic touch as a treatment
2.1. Agitation
2.1.1. The concept of agitation
Agitated behavior is characterized by inappropriate verbal,
vocal, or motor activity that is not judged by an outside
observer to result directly from perceptible needs or confusion
of the agitated individual [25]. Agitation in persons with de-
mentia is manifested in a wide variety of verbal and physical
behaviors that deviate from social norms, including irrelevant
vocalizations, screaming, cursing, restlessness, wandering,
strange movements, and handling things inappropriately [26].
2.1.2. The types of agitation
Depending on the expressive characteristics, agitated
behavior can be divided into two dimensions: aggressive vs.
non-aggressive, and physical vs. vocal/verbal. Specifically,
agitation includes four categories: (1) physically non-
aggressive (inappropriate dressing and/or disrobing, inap-
propriate eating or drinking, exit seeking behaviors, handling
things, hiding things, hoarding, pacing, repetitious manner-
isms, and restlessness); (2) physically aggressive (biting,
grabbing, hitting, hurting oneself or others, falling intention-
ally, kicking, physical sexual advances, pushing, scratching,
spitting, tearing things, and throwing things); (3) verbally non-
aggressive (attention-seeking behaviors, complaining, nega-
tivism, and repetitive sentences or questions); and (4) verbally
aggressive (cursing, making strange noises, screaming, and
verbal sexual advances) [27].
2.2. Therapeutic touch
2.2.1. The concept of therapeutic touch
In the early 1970s, Dolores Krieger and Dora Kunz first
described TT, defined as an intentionally directed process in
which the practitioner uses the hands as a focus to facilitate
the healing process [28]. TT is a treatment method that fuses
both ancient medicine and modern technology, and involves
an energy exchange between the implementer and a service
object. The emphasis is on creating a balance in the whole
body instead of focusing only on abnormal functional sites
[29], with the intent of speeding up the recipient's healing
process by restoring harmony and balance to their energy
system.
2.2.2. The types of therapeutic touch
TT includes three types: caring touch, protective touch, and
task touch [30]. Caring touch is defined as physical contact
outside the domain of the nurses' procedural tasks, such as
face touching, head touching, hand-holding, placing an arm
around the client's shoulders, and/or the placement of the
nurse's hand on the client's arm or hand. Protective TT is
employed as a means of emotionally and physically protecting
both the client and the nurse, such as the use of physical re-
straint and control, helping the patient relax, thereby
increasing the potency of the drug. This type of touch is geared
at older adults who are cognitively impaired and those who
have psychiatric diagnoses. Task touch is the physical contact
that is incidental to client care procedures.
2.2.3. The mechanism of therapeutic touch
A previous study found that patients will subconsciously
stimulate the system after they have received TT, which
triggers the release of enkephalin and endogenous hormone
[23]. The physiological role of these two endogenous chem-
icals acts similar to morphine by easing pain locally, as well as
acting through the endocrine system to increase the thera-
peutic effect throughout the body. Currently, the mechanism
of TT intervention on elderly demented patients with agitated
behaviors is still in the exploration stage. One possible
explanation for its effectiveness may be that TT excites the
nociceptive pathways in patients, helping the patient relax
mentally and physically, thereby ameliorating the agitation.
2.2.4. The use of therapeutic touch as a treatment
Since the 1950s, the benefits of TT have been widely recog-
nized in the United States. The United States has even set up a
TT certification program that has been approved by the
American Holistic Nurses Association. Studies have shown
that TT can not only relieve pain and anxiety, promote pa-
tients to relax, and improve the quality of life, but it can also
help treat some diseases by enhancing immune function [31].
3. Review of literature on the effects of
therapeutic touch on elderly demented patients
with agitated behavior
3.1. Therapeutic touch promotes relaxation and
alleviates the symptoms of agitation
Restlessness is one of the most frequent and disturbing be-
haviors experienced by patients with dementia, and it is the
outward manifestation of patients' inner tension [10]. There-
fore, taking effective measures to relieve that restlessness is
extremely important when trying to decrease patients'
agitated behavior. In a 2009 study by Woods et al., researchers
examined the effect of therapeutic touch on agitated behavior
among 65 nursing home residents using a double blind
experimental interrupted time series ABAB design [10]. The
practitioner delivered the intervention according to a specific
protocol that began with a mental intention to therapeutically
assist the participant, followed by centering (quieting) by the
practitioner. The practitioner then focused her attention on
the participant and concentrated on the wholeness of the
person with dementia. Standing behind the person, the
practitioner then used contact TT, resting her hands on the
participant's shoulders, and performing a series of gentle
movements (down, then up the back, up the neck, and behind
the ears) and rested one hand on the forehead while making
contact with the back of the neck with the other hand. At the
end of the session, the practitioner again rested her hands on
the participant's shoulders and directed thoughts of balance
international journal of nursing sciences 2 (2015) 324e328 325

toward the participant. TT was delivered twice a day for three
days at the same time each day (between 10:00 and 11:30 a.m.
and 3:00 and 4:30 p.m.). The intervention lasted 5e7 min.
During the study, behavior was observed and recorded every
20 min for 10 h per day from 8:00 a.m. until 6:00 p.m. Research
assistants with fiveeeight years experience performed the TT
intervention. A modified Agitation Behavior Rating scale
(mABRS) was used to measure the frequency and intensity of
agitated behavior. This study found that restlessness was
significantly reduced in the experimental group compared to
the control group (p ¼ 0.03), and suggests that therapeutic
touch may be effective for management of symptoms like
restlessness. In a separate prospective study conducted by
Holliday-Welsh et al. researchers tested the effect of TT
intervention on agitated behavior in 54 cognitively impaired
residents in a nursing facility [11]. Data was collected for three
days to establish a baseline, for six days during the interven-
tion, and again at a follow-up at XX. Five aspects of agitation
were assessed: wandering, verbal agitation or abuse, physical
agitation or abuse, socially inappropriate or disruptive, and
resisting care. The type of TT used in this study is defined
under classic Western massage techniques. Lotion was used
in some instances to reduce the friction between the hands
and the skin. The primary areas of the body massaged for this
study were the upper extremities, including head, shoulders,
and hands, and subjects remained clothed during the inter-
vention. In this study, the TT intervention was provided by a
physical therapy assistant trained in TT techniques. At each
observation, agitation was scored five times during the one-
hour window of observation. The subjects' agitation was
lower during the TT intervention than at baseline, and
remained lower at follow-up. Of the five agitated behaviors
examined in this study, TT was associated with significant
improvement for four of them, including wandering, verbal
agitation or abuse, physical agitation or abuse, and resisting
care. In this study, they found that decreased levels of agita-
tion persisted at seven and fourteen days following the TT
interventions. We believe that this long-term effect may have
been mediated by the presence of the observer recording the
level of agitation at follow-up.
Previously, Azermai et al. made a systematic review non-
pharmacological interventions about TT on agitated
behavior respectively in elderly patients with dementia and
use the language of love and encouragement, which will help
patients feel relaxed and decrease agitated behavior [12,13].
This is consistent with the findings of the previous studies
[14]. Collectively, these studies indicate that TT can promote
relaxation and alleviate the symptoms of agitation.
3.2. Therapeutic touch improves daily behavior and
cognitive function, as well as improves quality of life
The agitated behaviors expressed in elderly demented pa-
tients affect their daily behavior and cognitive function, hin-
dering daily activities and relationships, and making family
members and caregivers feel helpless and angry [15]. Ulti-
mately, this can decrease their quality of life. Rodrı´guez-
Mansilla et al. performed a controlled, randomized longitu-
dinal study that included one hundred twenty elderly subjects
with dementia institutionalized in residential homes in
Extremadura (Spain) [16]. These patients received treatment
based on TT and ear acupuncture over three months. Behavior
alterations, sleep disturbances, and participation in rehabili-
tation and eating were assessed every month during the three
months of intervention, and again at follow-up one and two
months after the end of treatment. The TT therapy group
received a relaxing TT by a physiotherapist every day from
Monday to Friday. The TT was applied in the back and lower
limbs for 20 min. The TT techniques used were superficial
effleurage and deep kneading with moisturizing cream. The
study was performed over five months, with three months of
experimental treatment and two months with no treatment.
Both TT and ear acupuncture positively affected on measured
variables (such as participation in therapy and eating) in the
third month of intervention when compared to the control
group (p < 0.001), and these benefits were maintained two
months after completing the treatment (p < 0.021). A separate
study by Hansen et al. also found that hand TT for the im-
mediate or short-term can reduce agitated behavior, and the
addition of touch to verbal encouragement to eat can
normalize nutritional intake [17].
In another study, Moyle et al. examined the effect of TT for
four weeks on patients with a diagnosis of dementia and a
history of clinically significant agitation [18] .For this study, 17
men and 5 women (mean age 84.7 years) received a 10-
min foot TT each day for 14 days. The intervention method
was as follows: trained TT therapists provided participants
with a standardized 5-min TT on each foot, once a day, for 14
days. All TTs were conducted between 1 pm and 6 pm. Light
pressure TT with long, gliding, rhythmical strokes of the
entire foot and ankle was used. Unscented sorbolene was
applied as a lubricant for the TT. Agitation and related
behavioral problems were assessed three times in the study,
once as a baseline before TT, immediately following the end of
the two week TT treatment phase (posttest), and two weeks
after the cessation of TT therapy (two week follow-up).
Assessment was conducted using the short form of the
Cohen-Mansfield Agitation Inventory (CMAI-SF), and the
Revised Memory and Behavior Problems Checklist (RMBPC).
The result shows that CMAI-SF and RMBPC scores were
significantly reduced at the posttest and remained signifi-
cantly lower than baseline at the follow-up. This study pro-
vides preliminary evidence suggesting that limited short-
duration foot TT reduces agitation and related behavioral
problems in people with dementia, and that these behavior
changes are maintained after the TT ceases.
Suzuki et al. performed a controlled, randomized trial to
clarify the effects of a 6-week TT on changes in physical and
mental function, symptoms of behavioral and psychological
symptoms of dementia (BPSD) among elderly patients with
dementia [19]. A TT group consisting of elderly patients with
dementia received TT therapy a total of 30 times each for
about 20 min between 4 p.m. and 5 p.m. In the control group,
the mean scores for “intellectual” and “emotional function”
score decreased significantly after six weeks (p < 0.05); how-
ever, no change was observed in the TT group. These data
suggest that TT can protect patients' cognitive function, and
delay the process of its decline. Livingston et al. systematically
reviewed the evidence for clinical effectiveness and cost-
effectiveness of non-pharmacological interventions for
international journal of nursing sciences 2 (2015) 324e328326

reducing agitation in dementia [15]. The review found that the
differences in the scores for agitation behaviors, daily
behavior, cognitive ability and quality of life in patients who
have received TT as compared to controls are statistically
significant. They concluded that TT has a positive impact on
the lives of the dementia patients. Importantly, it is a non-
invasive and non-pharmacological intervention that is easy
to learn, easy to implement, and easy to be grasped by nurses
and family members of patients, and therefore, can be widely
used in clinical practice.
4. Reflections and prospects
Our research on the application of TT intervention for the
treatment of agitated behavior in Chinese patients with de-
mentia is still in its infancy. Currently, a big gap exists be-
tween what we can do in China as compared with other
countries, in both theoretical verification and practical
exploration. A major hurdle for this treatment is embedded in
the Chinese culture. As a nation, the Chinese are not good at
using body language to express kindness, and physical con-
tact with a stranger is easily misunderstood as a sexual in-
nuendo, which can easily cause resentment. Both nurses,
patients and their families will find it very difficult to accept
this form of treatment psychologically, and therefore it will be
difficult to implement in clinical practice.
Other additional hurdles exist before we will be able to
implement TT as a treatment for dementia. One major hurdle
is the belief of many people that dementia is a natural phe-
nomenon of aging, and therefore the mental or behavioral
abnormalities in elderly patients with dementia are often
misunderstood. The first inclination of many families is to
ignore the initial symptoms of cognitive function decline,
blaming verbal or behavioral abnormalities, such as name-
calling, suspicion, possession of garbage, etc., on quirks or
send them to a mental institution to be given antipsychotic
treatment. Unfortunately, this treatment will worsen the
symptoms of dementia. Another hurdle is that even when the
patient is diagnosed with dementia, some families will take a
negative attitude towards the treatment, decreasing the effi-
cacy of the treatment and increasing the symptoms in these
patients. The last hurdle that must be overcome is that it is
very difficult for non-specialist doctors to make a correct
diagnosis of dementia, which causes a high rate of missed
diagnosis.
Currently, research on the effect of TT on agitated behavior
in elderly demented people is rare, and this means that there
is a lack of relevant evidence-based research, which in turn
limits the implementation and promotion of the therapy.
According to the figures, the prevalence rate of people in
China with dementia over the age of 60 years is about 5%, over
65 years is 5e10%, over 65 years is 20e50% [32]. Faced with an
increasing number of elderly demented people, it is very
necessary to carry out related research on TT to control
agitation behaviors. The development of TT intervention will
hopefully not only effectively improve the quality of life of
patients and help them live with dignity until the end of life,
but it will also reduce caregiver burden, the rate of hospitali-
zation and save medical resources. Fortunately, more and
more people have recognized these benefits and have started
to give TT more attention.
In the future, we should focus on learning from previous
advances f rom other countries, and be mindful of th e
shortcomings of this research. When we select samples, we
should follow the inclusion and exclusion criteria rigorous ly
to improve the consistency of elderly patients with de-
mentia in type, degree and other aspects in order to control
for confounding factors. We should also expand the sample
size appropriately and use a double-blind design to enhance
the statistical power. We can carry out randomized
controlled trials to provide more evidence for clini cal prac-
tice. We should in crease th e implementation of our findings
based on our national condition, such as accelerat ing the
construction of China's elderly specialist care and specific
key nursing specialties. We can encourage and sponsor
research on the appli cation of relevant theory and pr actice
by elderly care personnel. We can laun ch knowledge lec-
tures and skills training on TT to improve their skills for
clinical nursing staff. We should strengthen the propaganda
and guidance to gradually change people'straditional
concept of dementia by raising the public's awareness o f
disease prevention and treatment of dementia. With these
measures taken simultaneously, we believe we will get good
results.
Conflict of interest
We declare no potential conflicts of interest with respect to
the research and/or publication of this article.
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