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THE EFFECTS OF SLOW-STROKE BACK MASSAGE ON THE SLEEP OF PERSONS WITH DEMENTIA IN

THE NURSING HOME: A PILOT STUDY

dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Philosophy

By

MELODEE HARRIS

B.S.N., Excelsior College, 2001 M.S.N., Concordia University of Wisconsin, 2003

2009 The University of Arkansas for Medical Sciences

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UMI Number: 3357546

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This dissertation is approved for recommendation to the Graduate Council

Major Professor

s\ A

Dissertation Committee

Robert Kenned^, PhD IS

Donna Middaugh, PhD, RN

aWR/ID Jeffery Rai

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Abstract of dissertation submitted in partial fulfillment of the requirements for the degree of Doctor of Nursing Philosophy

By

MELODEE HARRIS

B.S.N., Excelsior College, 2001 M.S.N., Concordia University of Wisconsin, 2003

2009 The University of Arkansas for Medical Sciences

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Abstract

In spite of the wide-spread use of sedative hypnotic medications,

disturbed sleep is a common problem in persons with dementia in the nursing

home. Studies report marginal benefits and numerous side effects associated

with pharmacological interventions for sleep in persons with dementia.

Although evidence for its effectiveness is sparse, slow-stroke back

massage is a non-pharmacological intervention that has been used since the

time of Florence Nightingale to relieve physiological and psychological stressors

and promote restorative sleep.

This pilot randomized controlled trial examined the effects of a 3-minute

SSBM on minutes of nighttime sleep in persons with dementia (n = 40) in the

nursing home

The hypothesis was: participants receiving slow-stroke back massage will

have increased minutes of nighttime sleep compared to participants receiving a

usual care/control condition.

The primary aim of this study was to compare the effects of slow-stroke

back massage to a usual care/control condition on minutes of nighttime sleep.

Secondary aims were to explore the effects of slow-stroke back massage

compared to a usual care/control condition on minutes of nighttime sleep latency,

sleep efficiency, wake after sleep onset, daytime sleep, and the day/night sleep

ratio.

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Participants were randomized to an intervention group (n = 20) who

received the 3-minute SSBM intervention or a control group (n = 20) who

received usual bedtime care. Actigraphy was used to record data on sleep

variables at baseline and post intervention. Descriptive statistics showed a 36

minute increase on minutes of nighttime sleep in the SSBM intervention group

(46.1 minutes) compared with the control group (10.32 minutes). ANCOVA did

not reveal any statistically significant differences between the intervention and

control groups on minutes of nighttime sleep [F(1, 37) = 1.90, p = 0.18, effect =

0.05)] or on exploratory sleep variables. Long hours in bed, poor sleep hygiene

practices and environmental factors contributed to poor sleep patterns. Findings

from this pilot study suggest that SSBM may be an effective nursing intervention

to promote sleep in persons with dementia in the nursing home, but further

testing is needed to provide definitive results.

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This research was made possible through generous support and scholarships from:

The John A. Hartford Foundation Building Geriatric Nursing Capacity (BAGNC) Predoctoral Scholarship Program

National Gerontological Nurses Association Mary Wolanin Graduate Scholarship Award

Sigma Theta Tau Gamma XI Research Award

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Table of Contents

Chapter Page

I. Background

Introduction 1

Background and Significance 5

Purpose 7

Specific Aims and Hypothesis 7

Conceptual Framework 8

Transactionalism 9

Individual Interpretations and Response to Stress 10

Slow-Stroke Back Massage as a Mediating Process 12 for Restorative Sleep

Summary 13

Figure 1 14

II. Literature Review

Introduction 15

Sleep Disturbance in Persons with Dementia 16 In the Nursing Home

Physiological and Psychological Stress, Individual Interpretations 20 of the Environment, and Pre-Sleep Hyperarousals in Persons with Dementia

Slow-Stroke Back Massage 24

Slow-Stroke Back Massage and Relaxation 27

Summary 40

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Methodology

Introduction 41

Study Purpose, Specific Aims, and Hypothesis 41

Design 42

Setting 42

Sample 42

Human Subjects Protection 45

Baseline Data Collection 46

Randomization 47

Instruments 48

Slow-Stroke Back Massage Protocol 51

Training 52

Timeline 53

Data Collection Protocol 53

Tab le t 55

Data Security 55

Data Management 55

Data Analysis 56

Limitations 57

Summary 59

References

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Appendices

Appendix A: Data Collection Form 68

Appendix B: Actigraphy Data Collection Form 69

Appendix C: Informed Consent for Research Study 70

Appendix D: Qualification Form 80

Appendix E: Sample Interview: Adapted from the MacCAT-CR 81

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Chapter 1

Background

Introduction

Disturbed sleep occurs in up to 44% of community dwelling persons with

dementia (McCurry et al., 1999; McCurry, Gibbons, Logsdon, Vitiello, & Terri,

2005). Disturbed sleep is even more common in institutionalized persons with

dementia (Ancoli-lsrael & Kripke, 1989; Martin et al., 2006). In spite of the wide

spread use of sedative hypnotics, two-thirds of persons in the nursing home

experience sleep disturbances (National Institute of Health Consensus Group,

1990). According to data from the Office of Inspector General (2001), sedative

hypnotic drug use remained at 5% in the nursing home from 1995-1999, but the

use of potentially sedating psychotropic medications rose from 16% in 1995 to

19.4% in 1999. Adverse side effects of sedating medications result in falls,

decreased cognition, daytime drowsiness, respiratory depression, and injury

(Holbrook, Crowther, Lotter, Cheng, & King, 2000; Glass, Lanctot, Herrmann,

Sproule, & Busto, 2005). The marginal benefit associated with long term use of

psychotropic drugs for sleep disturbances does not justify the risk for adverse

drug reactions (National Institutes of Health, 2005; Holbrook et al., 2000).

The consequences of disturbed sleep are severe for persons with

dementia in the nursing home. Untreated sleep disturbances are associated with

limited social interaction, caregiver stress, and increased morbidity and mortality

(Martin et al., 2006; Foley, Ancoli-lsrael, Britz, & Walsh, 2004; Pollak, Perlick,

Linser, Wenston, & Hsieh, 1990; Ancoli-lsrael & Ayalon, 2006; Vitiello & Borson,

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2001). Increased nighttime arousals are patterns of sleep disturbances that

result in daytime napping and drowsiness in persons with dementia and may

further deteriorate their cognitive and functional abilities (Ohayon & Vecchierini,

2002). Poor health and reduced quality of life is the overall result of sleep

disturbances in persons with dementia (Kuhn, Edelman, & Fulton, 2005).

The Centers for Medicare and Medicaid Services guidelines (2006) in the

State Operations Manual, Section F329 recommend aggressive reductions in

psychotropic medications and the implementation of non-pharmacological

therapies as first-line interventions for sleep in persons with dementia in the

nursing home. Cognitive behavioral therapy, lifestyle changes, and guided

imagery are non-pharmacological therapies that improve sleep in non-cognitively

impaired older adults. However, these interventions may not be appropriate for

most nursing home residents with dementia due to their cognitive impairment.

Researchers are making progress in the treatment of sleep disturbances in

persons with dementia in the nursing home. Bright light therapy (McCurry et al.,

2005) and social activities (Richards, Beck, O'Sullivan, & Shue, 2005) have

shown benefit. The evidence base remains limited and more research is needed

to identify effective non-pharmacological interventions that will improve sleep in

persons with dementia in the nursing home.

The cause of disturbed sleep in persons with dementia is multi-factorial.

The severity of neurodegenerative changes in the brain are thought to have a

close relationship with increased sleep disturbances (Bliwise, 2005).

Pathological aging in dementia may cause abnormal circadian rhythm and sleep

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fragmentation due to damage in the suprachiasmatic nucleus located in the

hypothalamus (Bliwise, 2005; Harper et al., 2001). Poor sleep is associated with

multiple chronic psychological and physiological illnesses such as pain from

osteoarthritis, chronic low back pain, depression, and anxiety (Ancoli-lsrael,

2006). Studies show that 26% of persons with dementia have osteoarthritis

(National Academy on an Aging Society, 2000) and higher rates of diagnosed

depression in nursing home residents (Payne et al., 2002; Rovner et al., 1991).

Physiological and psychological stress from pain, depression, and anxiety

correlate with sleep disturbances and result in Cortisol secretion from the

hypothalamic-pituitary-adrenal axis (Vgontzas et al., 2001). The consequences

from the increased stress response include cognitive and somatic pre-sleep

hyperarousals that lead to sleep disturbances (Morin, Rodrigue, & Ivers, 2003).

Although evidence for its effectiveness is sparse, slow-stroke back

massage is a non-pharmacological intervention that has been used since the

time of Florence Nightingale to relieve physiological and psychological stressors

and promote sleep. Slow-stroke back massage is characterized by long, slow,

gliding, repetitive strokes from the sacral to cervical regions of the spine (Labyak

& Metzger, 1997; Richards, 1998). The technical term for slow-stroke back

massage is effleurage (Labyak & Metzger, 1997). However, the practice of

massage has been lost as nurses adapted to the convenience of pharmacology

for conditions such as sleep that were once treated with massage (Ouslander et

al., 2006).

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Relaxation is the proposed mechanism of slow-stroke back massage for

reducing physiological and psychological stressors in older adults. Studies on

the vital signs of institutionalized older adults showed statistically significant

decreases in blood pressure, pulse, and respirations after slow-stroke back

massage (Meek, 1993; Fakouri & Jones, 1987; Mok & Woo, 2004; Fraser & Kerr,

1993; Holland & Pokorny, 2001). Data from a study in hospitalized elders

showed that slow-stroke back massage reduced anxiety and was effective for

pain relief (Mok & Woo, 2004). Studies in institutionalized older adults show

statistically significant reductions in stress and anxiety after slow-stroke back

massage (Fakouri & Jones, 1987; Fraser & Kerr, 1993). The investigators from

studies in hospitalized and institutionalized older adults concluded there is a

relationship between slow-stroke back massage and the relaxation response

(Meek, 1993; Fakouri & Jones, 1987; Mok & Woo, 2004; Fraser & Kerr, 1993;

Holland & Pokorny, 2001).

Slow-stroke back massage was found to improve relaxation and sleep of

older adults in a study that used polysomnography as an objective measure for

sleep (Richards, 1998). One study documented numerous anecdotal reports that

slow-stroke back massage improved sleep in older adults, but the data collection

instruments lacked reliability and validity (Madison, 1973). The results from

polysomnography and subjective data suggest the need for further research to

investigate the effects of slow-stroke back massage on sleep disturbances in

persons with dementia in the nursing home (Richards, 1998).

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There are significant gaps in research for slow-stroke back massage.

There are no studies that used objective measures to investigate the effects of

slow-stroke back massage on sleep in persons with dementia in the nursing

home (Cuellar, Rigers, & Hisghman, 2007). This pilot study tested the effects of

slow-stroke back massage on the sleep of persons with dementia in the nursing

home.

Background and Significance

Persons with dementia in the nursing home may experience greater

severity of sleep disturbances than other geriatric populations (Martin et al.,

2006). A study of institutionalized and non-institutionalized elders (n=160)

revealed that institutionalized elders experienced more advanced phase

sleep/wake patterns (p<0.05), more time spent in bed during 24 hours (p<0.05)

and more sedative hypnotic use (p<0.05) than non-institutionalized elders

(Middelkoop, Kerkhof, Smilde-van den Doel, & Kamphuisen, 1994). A secondary

analysis of 492 nursing home participants from a non-pharmacological trial

showed daytime sleepiness (69%), nighttime sleep behaviors (60%) and

abnormal circadian rhythms (97%) were characteristic of persons with dementia

(Martin et al., 2006). Another study of actigraph data in 20 persons with

moderate to severe dementia in the nursing home identified that sleep

fragmentation was a problem for all subjects. Only three participants

experienced more than one hour of consolidated sleep and no participants had

two or more consecutive hours of consolidated sleep during 24 hours (Jacobs,

Ancoli-lsrael, Parker, & Kripke, 1989).

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Institutionalization and mortality are major consequences of sleep

disturbances for persons with dementia. In a study using logistic regression,

nighttime awakenings was the most distressing behavior for caregivers of

persons with dementia in the community (McCurry et al., 1999). In a longitudinal

study using a Cox proportional regression model of 1855 community dwelling

elders (Pollak et al., 1990), data revealed that insomnia was a statistically

significant predictor for mortality and institutionalization in older men.

Pharmacological therapy provides only marginal benefit and numerous

side effects for the treatment of sleep disturbances in persons with dementia.

The economic cost of institutionalization, pharmacological therapy, and side

effects of medications associated with sleep disturbances in persons with

dementia is staggering. Results from a cost effective analysis on direct costs

from health care services for nursing home care for insomnia (data based on The

National Commission of Sleep Disorders Research) estimated that 20.4% of

nursing home admissions could be attributed to sleep disturbances (Martin,

Aikens, & Chervin, 2004).

There is evidence in the nursing literature that slow-stroke back massage

modifies stressors associated with chronic physiological and psychological

illnesses in persons with dementia in the nursing home. Studies document the

physiological and psychological effects of massage on relaxation in

institutionalized persons (Ersser et al., 1999; Corley, Ferriter, Zeh, & Gifford,

1995; Fraser & Kerr, 1993). Although slow-stroke back massage is

contraindicated in skin ulcers, burns, severe osteoporosis, fractures, and severe

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agitation that may indicate an acute condition, this technique can be

administered safely by trained nursing staff (DAYBREAK Geriatric Massage

Institute, 2006; Rowe & Alfred, 1999; Watson & Watson, 1997). In comparison

with falls, decreased cognition, over sedation, and other adverse effects from

pharmacological therapy, slow-stroke back massage may provide a safe

alternative for the treatment of sleep disturbances in persons with dementia.

However, there are no studies that investigated the effects of slow-stroke back

massage on the sleep of persons with dementia in the nursing home. The

findings from this study suggest that slow-stroke back massage is a nursing

intervention that may be used to improve sleep and the quality of life for persons

with dementia in the nursing home.

Purpose

The purpose of this study was to test the effects of slow-stroke back

massage on the sleep of persons with dementia in the nursing home.

Specific Aims and Hypothesis

The primary aim of this study was to compare the effects of slow-stroke

back massage with a usual care/control condition on minutes of nighttime sleep.

Secondary aims were to explore the effects of slow-stroke back massage

compared to a usual care/control condition on minutes of nighttime sleep latency,

sleep efficiency, wake after sleep onset, daytime sleep, and the day/night sleep

ratio.

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The hypothesis was: participants receiving slow-stroke back massage will

have increased minutes of nighttime sleep compared with participants receiving a

usual care/control condition.

Conceptual Framework

The conceptual framework for this study was based on Florence

Nightingale's Environmental Adaptation Theory. Concepts from Morin, Rodrigue,

and Ivers (2003) Path Analysis Model of the Impact of Coping on Stress,

Presleep Arousal, and Sleep and Lazarus and Folkman's (1984) Transactional

Model are adapted to illustrate the sleep of persons with dementia. Little work

has been done on a conceptual model to explain nursing interventions for the

sleep of persons with dementia. The underlying explanation of the conceptual

framework represents responses to an intervention as an organized process

involving a series of transactions or connections that take place between the

person and the environment.

The environment may be the external environment outside the person or

the internal environment. This process is pivotal to the physiological,

psychological, and spiritual aspects of human beings. Research studies on The

Path Analysis Model of the Impact of Coping on Stress, Presleep Arousal, and

Sleep revealed significant correlations between stress, pre-sleep arousal, and

sleep (Morin et al., 2003). Figure 1 depicts the relationships between constructs

in the conceptual model. The model explains the relationship between

alterations in the external and internal environments modified by the massage

intervention that results in individual coping and interpretation of physiological

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and psychological stressors that influence sleep. The effects of slow-stroke back

massage on sleep are a network of causal antecedents, processes, and

outcomes that can be systematically analyzed at multiple levels (Lazarus &

Folkman, 1984).

Transactionalism

Lazarus and Folkman (1984) define transactionalism as a process

oriented model that implies a transformation in which the person and the

environment (internal or external environment) are joined together to form

relationships between multiple variables. Transactionalism is used to define

stress as a culmination of many variables. In this intervention study, massage is

not a linear method, but a mediating process to promote relaxation and

restorative sleep.

Stress researchers credit Bandura with the concept of transactionalism

(Lazarus & Folkman, 1984). However, The Transactional Model closely parallels

the 19th century Environmental Adaptation Theory by Florence Nightingale.

Nightingale based her theory on the concept that non-pharmacological nursing

interventions such as massage could alter the environment of human beings

(Selanders, 1998). Nightingale believed nurses created the best possible

internal and external environment that would allow natural laws to improve the

healing process (Dossey, Selanders, Beck, & Attewell, 2005). In Notes on

Nursing, Nightingale said, "If a patient sleeps two or three hours early in the night

and then does not sleep again at all, ten to one it is not a narcotic he wants, but

food or stimulus or perhaps only warmth," (1902, p. 108). Although she never

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