By Cynthia Bologna
Originally published in Massage & Bodywork magazine, December/January 2006.
Some of the most rewarding work for massage therapists and bodyworkers is interacting with people afflicted with dementia. What makes it so rewarding is how beneficial it is to the clients.
People with dementia are a uniquely underserved population for the bodywork profession. Many family members and case managers who work with seniors often don’t think of massage as a viable service for the elderly. If they do think of bodywork, it’s often wrongly dismissed as being too strong a modality for someone whose body has become fragile with age. These caregivers may think of the massages they’ve had themselves, where a practitioner with deep-tissue experience worked out knots that had been plaguing them for months or when they were on vacation and were treated to an all-encompassing spa massage. But bodywork for the elderly, and especially for the elderly with dementia, is more often a soothing combination of massage, touch, and “deep listening,” and can give enormous comfort to the recipient. When practitioners are able to convey a concept of “comfort” massage rather than “curative” bodywork, nurses, social workers, or care managers working with the elderly are much more likely to embrace your services for their patients/clients.
Let’s create a picture to understand what this comfort massage might encompass and put you in the client’s shoes for a minute. Imagine sitting in your home or your room in an assisted-living facility. You don’t know what day it is, you’re not sure where you are, and you think you are supposed to be doing something, but are not quite sure what it is. You stare at your reflection in the bathroom mirror, then look at your toothbrush, back at your reflection, then notice your toothbrush again, and can’t quite remember whether or not you have already brushed your teeth. What once was an automatic morning task now seems daunting. And if you are at the beginning of your illness, you might still realize that you have become forgetful. You might smile, you may even laugh at your poor memory, or you might become terribly frustrated, even agitated.
Now imagine that a friendly face appears at your door. You wonder if you know her. This person seems to know you. She calls you by name and asks how you feel today. She introduces herself, tells you she is here to give you a nice, relaxing massage, and asks if that would be OK. She tells you she’s going to put soothing lotion on your feet and legs to start, and that the work will be gentle. You do not have to go anywhere or do anything special, you just need to sit in your familiar chair or lie on your bed, and she will spend some time helping your body feel better. She reaches out her hand to say, “Hello,” and by the tone of her voice, you can tell she cares about you and you start to relax.
It is not unusual to approach clients with dementia in this manner. It is an approach that does not put demands on clients to remember you, or to know what day it is, or even to know what a massage is. They are not pressed to know that you saw them just last week or have been working with them for months. They just know that a kind person is addressing them and wants to be helpful.
Meeting Your Client
In some cases, a family member or staff person may introduce you to your client. In other cases, you might be walking into a client’s living space on your own. In either situation, the way in which you enter a client’s room is extremely important. That initial introduction each time you arrive for a session sets the tone for the work to come. A smile on your face indicates you are happy to be there. A slow, centered gait and a tempered voice won’t startle your client. Talking to her, whether or not she herself is verbal, might spur some recognition in her of which you might not be aware. And always, it’s essential to ask her permission before starting a session. Even if a client does not respond to your presence, you can make your best determination based on her body language as to whether or not you have been given the go-ahead to proceed. But if your client indicates in any way she does not want a massage or does not want you there on this day, it is usually best not to try to cajole her into changing her mind.
Once you have been given permission to conduct your session, ask your client if she has any aches or pains that day or if she has a particular place she would like you to start. If she does not answer, or tells you she feels “fine,” or to start “where you think best,” it is often better to notice how she is holding herself and make declarative statements about what you would like to do rather than ask further questions. For instance, it is better to say, “I notice your right hand is clenched, so I think I’ll begin by massaging the back of your hand to help relax your fingers,” rather than ask “Do your fingers hurt?” Or, if she says, for example, “My feet feel sore today,” then tell her you will start with a gentle massage to her feet. Either way, this simple approach helps your client have confidence in your choices and relieves her of the burden of making decisions. Essentially, your introduction to your client is the first step in building trust.
After you have spoken briefly with your client, notice where she is in the room. Is she seated in a chair? Lying on her bed? Sitting in a wheelchair? Standing by the window? Will it be easier for both of you if you conduct the session where she is, or will it be helpful if you get help in assisting her to another seat or into another position? It is often more beneficial to ease into a session where the client is situated, since asking or helping her to move can be disorienting for her. If your client is lying in a hospital bed that can be adjusted electronically, this can often be done with minimal disruption. It is good to keep in mind that your own body mechanics are as equally important as your client’s comfort when working by the bedside or next to the chair of a person with dementia. In this work, it is very easy to get yourself into odd, contorted positions that are sometimes easier to get into than out of.
Another thing to remember before beginning a session with an elderly client is that she may come from a more modest generation than your own. This can be equally true for men and women. A client may feel shy about undressing or may not have had much experience with massage. Therefore, give your client the option of removing clothing or not. If she chooses not to, you can reassure her that you can provide just as good a session for her whether she is undressed or not, which can often give her a sense of relief.
For clients who are all right with removing their clothes, many of them will need assistance with the task. It is good to practice helping a friend or partner dress and undress prior to a session to make sure you are proficient at it before helping your client. And you need to remember to allow enough time in your session at the beginning and end for helping her out of and then back into her clothes.
Conducting Your Session
Once you have decided how you are going to start, move slowly and gently. Sudden movements can be startling or upsetting. If you have decided to start with your client’s feet and legs and have already informed her of this, then untie her shoes, remove them, and set them aside. Then remove her socks, all the while stating what you are doing. Your client will then be more likely to connect your words to what is happening. Take a good look at your client’s feet. Don’t rely solely on the strokes you learned in massage school or count on your experience with the last client you saw in your office. These feet are unique. They have supported your client for many years, through numerous experiences, and have a story to tell if you pay attention.
Your client has already said her feet were sore, so you want to begin gently but not tentatively. A tentative or apprehensive approach can make your client feel uneasy. Spend some time holding, warming, and using mild pressure on her feet to ascertain the extent of your client’s discomfort. Tell her what you are doing. Watch your client. Is she moving toward or away from your touch? Is she “dropping down” into her chair or bracing against your next move? Is her face tranquil or in a grimace? Your client’s body will communicate a lot about how effective your touch is, especially if she cannot tell you verbally.
You might choose to use some massage lotion or gel that has been formulated especially for the thinner skin of elderly people. Since many elderly people have a tendency to be cold no matter what the room temperature is, you will want to make sure that your hands and lotion are warm. When starting, support her foot in one hand while stroking with the other to make sure that the work is soothing and not overstimulating. Work gently and without distraction. Being able to stay focused and in the moment will help you maintain an even touch, which in turn helps your client remain connected to her body. In essence, you want to “mold” your hands to the shape of your client’s foot and apply light pressure from your palm rather than “press” from your fingertips. Most importantly, make sure your movements are slow.
When you have finished working a particular area, in this case the feet, put the socks and shoes back on immediately. This keeps your client warm and also provides a sense of security.
Move around her body, working in this fashion. Hold an elbow while massaging the upper arm; lay her hand over your wrist while working the lower arm. It is also good to bring a stool to sit on for some parts of the work. At other times, you may choose to sit on the floor or a cushion. Try to keep your back straight at all times without too much bending forward or sideways. It is also good body mechanics to move from the pelvis, even when sitting cross-legged on the floor. It is easy to get so involved with your work and noticing your clients’ reactions that you end up providing most of your strokes from your shoulders instead of involving your pelvis and legs.
Working with the client’s back, for example, can pose tricky problems, especially when she is seated in a chair or lying on her back in bed. A former teacher who specializes in working with the elderly (Irene Smith of San Francisco) once said to “work with the parts of the client that are available.” For instance, you may not be able to provide a back massage in every session if her back is not physically available to you. It is not a good idea to try to reposition a client once she is finally situated comfortably. If she is already lying on her side, then it is quite easy to sit by her bed and massage her back, especially if her bed can be raised or lowered to meet the level of where you are sitting. But if a client is seated in a wheelchair, for instance, then it is best to work with her there rather than try to move her to the bed. A nursing assistant who has been specially trained in transferring clients is often the only one who can safely move or reposition them.
If your client is seated in a wheelchair, then you can massage her neck, shoulders, and upper back during the session. Sometimes a client is able to lean forward to provide access to her lower back, but if she is not wearing a waist restraint in the chair, then you run the risk of having her tumble out of her seat and onto the floor, causing serious physical and emotional injury. When working with this population of clients, it is essential you remain aware of their physical and mental limitations from the moment you enter their room to the moment you leave.
When Massage is Too Much
For some clients, even the gentlest massage can be overstimulating and may increase confusion or agitation. That is why it is necessary to become skilled in different types of touch that can be beneficial to your client. Diverse styles of somatic bodywork can be applied when working with a client with dementia. The modalities you have been trained in — reiki, Rosen, Feldenkrais, etc. — can be a valuable component of what you offer during a session.
For example, I once worked with a client who was deeply confused and agitated. When he was in this state, his body became rigid, almost as if he were going into a seizure, even though he had no such history. He would also moan or scream loudly. During one session, in his confusion, he began saying numbers out loud. So I found the rhythm of his counting and began counting out loud with him. As I did this, I had one hand on his upper chest and gently tapped the area in time with our counting: “22, 23, 24,” etc. Both the counting and the touching seemed to calm him. On that day, we counted out loud for about 30 minutes. His breathing slowed to a normal pace, his face softened, and his body relaxed against his bed. It seemed as though both the sound of my voice and the measured touching had a soothing effect on him. He eventually fell asleep, and I was later told that he napped for a good hour after our session.
So much of what you will do with a client will be trial and error based on your best judgment. This is true for your work as well as for other professionals working with people with dementia. A nurse, for instance, will have to decide whether or not a client who is shouting out is in physical pain or emotional distress, and then treat one, the other, or both. There was one client in a facility who would yell continually in the morning and the staff was having a difficult time determining what was wrong. After making numerous, ongoing attempts to ease the client’s distress, the director of nursing decided to move the client out from his room to sit by the nurses’ station. Almost immediately, he stopped yelling. It appeared he simply wanted to be in a place where he could have more human contact and could observe the comings and goings of people on his unit.
It is fairly common that you (as well as the nursing staff) may make an initial error in judgment when trying to discover what will help in a situation where a client cannot verbally tell what is wrong or what he needs. But these are precisely the situations that call for you to let go of a prescribed sequence of massage “moves” and rely on the culmination of all your various types of training to guide you toward determining what sort of touch is needed in any particular moment.
Deep Listening and Somatic Assessments
You also need to be prepared for times when you might become frustrated with the “success” you are having with a client. You have tried everything you can think of to do, and your client still seems uncomfortable or unhappy. This is not a “failure” as a bodyworker on your part, but may simply be a problem with communication.
The skill of “deep listening” is essential when your client has dementia. Your client’s spoken words may not follow the sequence of a full sentence, but the words themselves may hold a meaning that she is trying to convey to you. Upon greeting your client, she may respond to your, “Good morning,” by saying something like, “No food.” She may be trying to indicate that she is hungry and has not eaten or that she does not want any food brought into her room. It is sometimes difficult to tell. You have the options of finding out from staff whether or not your client has indeed eaten, or you can reassure her that a meal is forthcoming (if it is). This may settle her enough so that she can relax into your session. Or, her words may have no meaning, and she may be incoherent. The important thing is that when a client with dementia seems to be trying to communicate in earnest with you, you remain interested, focused, and listen to your best ability, as you would with any other client.
Another way to know what is needed for a client with dementia is by making “somatic assessments.” By that I mean continually watching how her body is responding when you are talking to her or touching her. It is necessary to also pay attention to her breathing to see whether or not the pace of it is rapid or slow and the strength of it is shallow or deep. So much is communicated without words that it is important to become proficient at making assessments at all times during a session. And when a client is unable to tell you precisely what she wants or needs, it is doubly important.
Somatic assessments are basically decisions you make about what will benefit your client at that moment in time, based on your observations of her in totality, including her mood. Some people refer to this as intuition, but on closer examination, what is actually happening is that something is being communicated to you on a conscious or subconscious level and you are interpreting it in rapid time. You then take this assessment and put it into action that will be beneficial to your client, all of which can happen within seconds. It is a very good skill to cultivate, especially when working with people with dementia.
Many of you have probably had an experience in which a client is lying on your table in front of you and you feel moved to place you hands, say, under her neck and relieve some tension there. The client’s head and shoulders immediately relax and she gives a big sigh, letting you know that was precisely what she needed you to do. You knew where to go and what to do, but what was missing perhaps was how you knew what to do. This was not just luck. Something about how your client was presenting herself communicated what she needed, and you understood and acted on it. Practitioners make somatic assessments all the time, many times without knowing it. And the good news is that if you already possess these skills when working with clients in your office, a simple matter of sharpening these skills and becoming more aware of how you make your decisions will make you an excellent candidate for working with people with dementia.
Why Does This Work?
People living with severe forms of dementia often respond positively to massage and bodywork. In an otherwise perpetual state of confusion, they can find calm and reassurance from a soothing and caring touch. While they are in a session, clients get a momentary respite from the bewilderment they face when trying to accomplish the most ordinary tasks. Massage and bodywork helps them not only to deeply relax, but connects them to their bodies and the pleasant aspect of human contact. This is a huge benefit for those living within the throes of dementia who often have to live separately from family and friends. A kind smile and comforting touch from a skilled and compassionate practitioner can ease the fear and loneliness that often accompanies dementia.
Your clients will of course benefit physically, too. Massage and bodywork for those who have to sit or lie in one position for long periods of time can stretch and release tense muscles, increase circulation to avoid pressure sores, and help clients regain range-of-motion in underutilized parts of the body. It is the unique combination of focus on both the emotional and physical aspects of this work that makes it so valuable for your clients.
Many assisted-living facilities have staff members and directors who are aware of the benefits of massage and bodywork for their residents. Others require help in recognizing the need. It only takes one bodywork practitioner working with one client in one facility to show that this profession is as viable a part of a client’s care as nursing or social work. Practitioners who choose this population of clients to work with may eventually make massage and bodywork as routine a part of ongoing care as giving a shower or feeding a meal.
And people with dementia will be the beneficiaries for years to come.