refusal of care disappeared. Scores for (e) diurnal rhythm disturbances decreased from 1 to 0, and she stopped waking frequently in the night and was able to sleep deeply. Scores for (b) hallucinations did not change (3 pre and post), and there were no change in visual and auditory hallucinations. Similarly, scores for (d) aggressiveness (3 pre and post), (f) affective disturbance (1 pre and post), and (g) anxieties and phobias (1 pre and post) did not change. Discussion The aim of the present study was to examine the effects of tactile massage on changes in cognitive function and BPSD in the everyday life of elderly patients with severe dementia through a 6-week course of tactile hand massage. Previous studies have reported reductions in aggressiveness during hand massage intervention in elderly patients with severe dementia,12-14 but the present study focused on the effects of tactile massage on changes in daily life behaviors and BPSD at times other than the intervention sessions. The time period during which tactile intervention was conducted was 16:00 to 17:00 hours in the afternoon. This time was selected to reduce disruptions to the circadian rhythm, which can cause daytime unrest and nighttime disquiet, and to minimize the effects of sundown syndrome,22 the period from dusk to night when fretfulness and delirium often occur. An easing of the state of nighttime disquiet was seen in some of the participants. The overall score for all participants for diurnal rhythm disturbances on the BEHAVE-AD was reduced, although this change was not significant. The results of this study showed a significant reduction on the GBS for both intellectual function and emotional function in the control group. These items were maintained for the intervention group, and maintenance is important in a situation where the effects of aging can bring about functional decline in even 6 weeks. Hall and Buckwalter (1987) showed that elderly patients with severe dementia find it more difficult to accept and cope with sensory stimulation due to impairment of cognitive function, and this leads to anxiety behavior due to lowering of the stress threshold.13 In the present study, changes in salivary CgA measurements, used as a stress index, the intervention group showed a significant reduction after intervention. All 4 participants from whom samples were obtained showed reduction in stress after intervention because it was difficult to obtain the saliva sampling of elderly patients with severe dementia baseline and pre- and postintervention, and it can be supposed that the reduction of psychological stress was connected to a tendency toward improvements in BPSD and aggressiveness. Intellectual function and emotional function decreased in the control group, which did not receive tactile massage, but were maintained in the intervention group as a result of reduced aggressiveness. The present authors have reported significant reductions in salivary CgA levels as a result of music therapy,4,5 and it is possible that similar significant reductions could be achieved through the use of tactile massage. The number of participants in the present study was small, therefore, further investigation will be conducted on a larger number of participants to fully elucidate the effects of tactile massage and reduced psychological stress on aggressiveness and other symptoms related to dementia. In the case of elderly patients with severe dementia, if the participant is not willing to have tactile massage or a good relationship with the person giving tactile massage, there is a possibility that anxiety will result because of the perceived infringement of personal space. In research on touch with elderly patients with severe dementia, Marx et al found that aggressiveness increased, but strange movement decreased.20 In this study, the intervention was conducted over a relatively long period of 6 weeks as it was predicted that tactile massage would not influence daily life behaviors and BPSD if a good relationship of trust was not formed between the patient and the person giving tactile massage. The fact that tactile massage can be effective in nonverbal communication may also account for the maintenance of intellectual and emotional function in the control group. As shown in the individual cases presented herein, there were recognizable improvements in BPSD symptoms such as delusory notions, behavior impairment, aggressiveness, and diurnal rhythm disturbances, and nurses reported that the results, such as the fact that participants were sleeping soundly at night, reduced their burden of care. It can be assumed that stress and anxiety have a major effect on the deterioration of BPSD for elderly patients with severe dementia. In particular, elderly patients with severe dementia often have trouble communicating, and the present study suggests that using tactile massage as a nonverbal communication tool helps deepen mutual understanding between the patient and nurse. Promoting relationships of trust through conducting tactile massage may also have helped nurses deepen their understanding of dementia, thus increasing their motivation to provide care. Kitwood claims that, in terms of the main psychological needs of people with dementia, love is central, and the 5 overlapping needs that contribute to this are comfort, attachment, inclusion, occupation, and identity.23 It