the evidence developed throughout my time working on this project. Your availability, encouragement, feedback, and support allowed me to make this project into something I am proud of. Thank you to the many others including Dr. McAlister, Dr. Duke, and Dr. Miller for your feedback, time, and development of my project. I also want to thank my parents, brother, and fiancé James for your support, love, and motivation. Finally, I would like to dedicate this to my grandmother Mimi who struggled with agitation due to her Alzheimer’s and was the reason I chose this topic. MASSAGE THERAPY FOR AGITATION 4 Executive Summary Dementia is a progressive disease that eventually results in cognitive and functional decline as well as behavioral and psychological symptoms. Age is a significant risk factor for dementia and due to an increase in longevity, the number of people with dementia is rising. Matthews et al. (2018) estimates that 13.9 million individuals in the United States aged 65 years or older will be diagnosed with dementia by 2060. According to the National Institute of Aging (NIA) there is a need to improve care and support for people with dementia (Gutis, 2019). Expanding research on dementia and management interventions should be a priority due to the nature of the disease, its impact on healthcare, and its emotional effect on both the individual and family. Over prescription of medication for behavioral and psychological symptoms in dementia has been identified as problem in long-term care facilities. The current practice at many longterm care facilities is prescription of medication for management of agitation despite evidence suggesting non-pharmacological interventions as first line therapy. This benchmark project has identified evidence supporting the effectiveness of implementing massage therapy as a nonpharmacological intervention to improve the quality of life of those with dementia. Additionally, it aims to better educate healthcare providers on the evidence to assist in management of care of those who struggle with agitation associated with dementia. Teamwork and collaboration amongst stakeholders is key in order to provide individualized care within a long-term memory care facility. Therefore, it is recommended that massage therapy be implemented in long-term care facilities as it could effectively manage agitation while also improving quality of life, reducing distress amongst caregivers and families, and decreasing inappropriate medication use. MASSAGE THERAPY FOR AGITATION 5 Massage Therapy for Agitation in Dementia Benchmark 1. Rationale for the Project The objective of this benchmark project is to assess the effects of nonpharmacological and pharmacological interventions, and create a recommendation that health professionals can use to manage agitation and increase quality of life. Agitation is a common neuropsychiatric symptom and occurs in approximately 70% of dementia patients (Ijaopo, 2017). Treating agitation is currently challenging for health professionals due to the many behavioral and psychological symptoms of dementia (BPSD) that present in patients. Additionally, long term health facilities currently lack individualized implementation of alternative interventions for agitation (De Oliveira et al., 2015). As a result, antipsychotic medications are often used as a first line treatment over nonpharmacological interventions, leading to increased mortality rates (De Oliveira et al., 2015). Family Nurse Practitioners and many other healthcare professionals play a role in managing care and offering support to those living with dementia. According to the American Nurses Association (ANA, 2015) Nursing Code of Ethics, the nurse is to promote, advocate and protect the rights and health of the patient. With a better understanding of the literature regarding non-pharmacological interventions, providers can better manage and advocate for those who may no longer be capable of advocating for themselves due to the progressiveness of dementia. The aging population and prevalence of dementia led to the formation of the following clinical question: In dementia patients who are agitated (P), how do nonpharmacological interventions (I) compared with pharmacological therapy’s (C) affect behavior outbursts (O) within one month of treatment (T)? 2. Literature Synthesis MASSAGE THERAPY FOR AGITATION 6 Despite non-pharmacological interventions being recommended as first line therapy, literature indicates that there is a continued trend in prescription of antipsychotic drugs to adults with dementia to control BPSD, specifically agitation. Kongpakwattana et al. (2018) classified risperidone, an antipsychotic, and serotonin reuptake inhibitors as two pharmacological treatments that demonstrated evidence of usefulness for agitation in dementia. Although medications can decrease agitation and other BPSD, there are many associated adverse effects such as cardiac side effects, increase in cognitive decline, and increased risk of mortality (Livingston et al., 2014). Dyer, Harrison, Laver, Whitehead, and Crotty (2018) found that pharmacological interventions are effective; however, they also found that functional analysisbased interventions should be used first due to the lack of adverse effects. Functional analysisbased interventions are individualized
interventions aimed at identifying unmet needs. This literature supports that medications are effective in decreasing agitation symptoms, but this should not be first line treatment due to the associated adverse effects. Through a continued literature review, it was clear that person-centered care was a common trend that was found to be effective in treating agitation. Dementia care should be tailored to the individual and ultimately requires a multidisciplinary approach. Chenoweth et al. (2009) found a significant decrease in agitation with person-centered care compared to standard care practices. Individualizing care can be time consuming; therefore, it is important to have a team caring for those with dementia who values individualized care. Watt et al. (2019) also found that multidisciplinary assessment and care was clinically effective as it addresses underlying patient needs. Person-centered care is just one approach that can reduce BPSD. In addition, the outcome of non-pharmacological interventions on agitation have been studied. Intervention methods and size of studies varied across many articles and systematic MASSAGE THERAPY FOR AGITATION 7 reviews found in a literature search. Massage therapy is one of the interventions that has shown effectiveness in reducing agitation. Wu, Wang, and Wang (2017) conducted a systematic review and meta-analysis on the effectiveness of massage and touch on BPSD. The results of the metaanalysis showed the massage intervention has a statistically significant effect on the total score of BPSD. Margenfeld, Klocke, and Joos (2019) also conducted a systematic review and metaanalysis of randomized control trials on manual massage for people with dementia. This review also identified how massage improved BPSD. Majority of the studies included in these systematic reviews used the Cohen-Mansfield Agitation Inventory to measure behavioral symptoms such as agitation. Massage intervention varied in frequency and duration amongst many of the studies, and there are currently no specific protocols on how to implement massage. According to the evidence, the frequency ranged from 5 times to 14 times per week, and suggests the frequency of the intervention should be increased by healthcare professional depending on the individual’s response (Leng, Zhao, & Wang, 2019, p. 5). Overall, there is evidence that supports the effectiveness of massage therapy in decreasing agitation; however, many of the studies had small sample sizes and there is a need for further consistent protocols. 3. Project Stakeholders The management of dementia requires a multidisciplinary team. Project stakeholders for this benchmark study include management and leaders at Sunrise senior living. Management support is necessary for the success of this change project. The key stakeholders for intervention include doctors, nurses, nurse practitioners, caregivers, massage therapist, health educators, patients, and families of patients in the long-term care facility. In addition to the stakeholders onsite, the local Alzheimer’s Association Dallas chapter offers support, education, and training for caregivers. MASSAGE THERAPY FOR AGITATION 8 Evidence suggests that collaborative practices ultimately improve patient outcomes (Malloch & Porter-O’Grady, 2015, p.363). 4. Implementation Plan There are many non-pharmacological interventions that have shown evidence in decreasing agitation in dementia. Massage therapy is one non-pharmacological intervention that can decrease agitation outbursts. First, residents in a dementia care facility who struggle with agitation will be identified. Healthcare providers will be educated to target the use of nonpharmacological interventions, specifically massage therapy. Stakeholders will be educated on both the benefits and risks of this therapy. If the provider chooses to use a pharmacological intervention, they will be required to identify and document why a non-pharmacological intervention was not implemented. The plan will be to apply therapeutic touch to the back, shoulders, neck, hands, and feet by a qualified massage therapist (Scales, Zimmerman, & Miller, 2018, p. S91). The therapist will individualize therapy location and technique. Massage technique will use slow or large strokes, rubbing, or kneading (Scales et al., 2018, p. S93). Amongst many of the systematic reviews appraised, massage intervention varied in frequency and duration, and there are currently no specific protocols on how to implement massage. According to the evidence, the frequency ranged from 5 times to 14 times per week, and suggests the frequency of the intervention should be increased by healthcare professional depending on the individual’s response (Leng et al., 2019, p. 5). Therefore, frequency will be individualized based on the provider ordering the intervention, but each individual will have a massage at least 5 times per week. On average, the evidence suggests massage should last 15-20 minutes (Rodríguez-Mansilla et al., 2015). The Cohen Mansfield Agitation Inventory (CMAI) will be used to measure effectiveness of therapy. Ideally the goal of implementing massage therapy is to MASSAGE THERAPY FOR AGITATION 9 provide person-centered care for the individual to feel comforted, improve the individual’s quality of life, and decrease agitation outbursts