The softer side of therapy: Therapeutic benefits without the "work". (Feature Article).

While traditional therapies are the backbone of rehabilitative/restorative care, some residents might be resistant to participating in a program that requires them to "work." Others might become bored or frustrated with what they perceive as a lack of progress. Alternative therapies provide a break from the more regimented programs and are success based. To the resident, alternative therapies provide sensory and mental stimulation, along with therapeutic benefit--without the drudgery and frustration of being urged to "walk two more steps." Instead, alternative therapies, such as puttering in the garden, enjoying the tactile stimulation of a massage or just sitting and absorbing sights, smells and sounds, can relieve resident ennui. These therapies encourage many of the same goals as traditional therapies, by having the resident perform the same exercises without their being perceived as "work." For example, residents (including those with Alzheimer's and dementia-related diseases) can still retain hand functions by squeezing the soil instead of a rubber ball.

Horticultural, massage and Snoezelen (R)(*) are three types of therapies that provide their own particular physical and emotional benefits for the long-term care population. They are not intended to replace, but to enhance, traditional therapies.

Let's Get Growing!

Beverly Agard, a registered horticultural therapist employed at Ralston House and member of the American Horticultural Therapy Association (AHTA), has "greened up" the facilities in NewCourtland, Inc.'s (Philadelphia) long-term care network as part of the Eden Alternative. "NewCourtland wanted to address the three major plagues of nursing home life: loneliness, helplessness and boredom," remarks Agard. NewCourtland considers its facilities as habitats and wanted to create caring places rather than places of long-term care.

Outside gardens with rolling pots and indoor gardens with tabletop workstations accommodate the physical limitations of the residents. A staff member does the heavy work such as turning the soil and moving any cumbersome containers and heavy gardening materials.

"All mobile residents are welcome and encouraged to participate," Agard explains. Seniors gain physical, emotional, spiritual, sensory and intellectual benefits from experiencing natural, living things. Prior to preparing their garden, these resident gardeners discuss what flowers and vegetable they want to plant. Agard finds that they prefer flowers such as the pansies and geraniums they used to grow in their home gardens. Tomatoes are a great favorite in the vegetable area of the garden.

Preparing the beds and potting plants, residents practice their hand-eye coordination by using a trowel to dig or scoop. They manipulate their fingers when making a hole in the soil to plant a seed. Feeling the textures of the soil and plant materials, while experiencing the sights, sounds and smells of the garden, stimulates all five senses: sight, sound, touch, smell--and even taste, when they sample an herb or vegetable they have grown.

"Spiritually," Agard states, "the residents feel reunited with a part of the healthy, living world around them. They are empowered because they are useful." The residents, she says, love to go outside and pick the garden-fresh tomatoes they've grown. "One resident likes to pass them out to the nurses to score brownie points," Agard laughs.

Socially, they receive the benefits of group interaction through sharing a commonality of purpose and enjoyment. In winter months, the groups dry the flowers they have grown and, using deep detergent caps, spend an afternoon creating dried-flower arrangements. Other cold-weather projects include painting gourds and cooking--for instance, preparing a snack of crackers and cream cheese blended with herbs from the garden. This spring, Agard is planning a May Day party. She'll have the residents make garlands for their hair and serve punch and light snacks--pesto is a favorite.

To accommodate residents with Alzheimer's or dementia-related illness, Agard brings in plants that have a nice fragrance, such as scented geraniums, and helps them create potpourri bags. "Sometimes I'll simply pass around plants and flowers, such as lavender, so residents' senses can reconnect their minds to the pleasurable aromas and feel of these living things." She cautions that the therapists and staff must be very watchful to keep residents with dementia safe and prevent harmful or inappropriate behaviors, such as ingesting soil.

As a testament to what guidance and talent can accomplish, residents at two of NewCourtland's facilities won recognition in Philadelphia's City Gardens Contest last year. Tucker House placed third in the Community Flower/Sitting Garden category and, in the same category, Germantown Village received an honorable mention.

Horticultural therapists work in many areas of healthcare, including hospitals, assisted living, nursing homes and other long-term care facilities. To find an experienced horticultural therapist, AHTA maintains a directory available on its Web site at www.ahta.org.

A Compassionate Touch

One of the most basic human needs beginning at infancy is to experience comforting, caring touch. Unfortunately, most of the touching experienced by residents is task oriented (cleaning, brushing, wiping, applying lotion, injecting and eating). Massage therapy introduces an aspect of touch that is more caring and homelike.

Steve Olson, immediate past president of the American Massage Therapy Association (AMTA) and professional massage therapist for 17 years, began his career at a nursing home in Fargo, North Dakota, on a grant to provide massage therapy specifically for residents with dementia. "At that time there weren't many massage therapists employed in the healthcare field," Olson recalls. "I worked within the activities department but had full access to all records and, when appropriate, was allowed to chart. Although my focus was on those with dementia, I worked with any and all the residents through staff referrals. At times I would be called to intervene when a resident was seized by agitation or anxiety," he says.

Massage therapy is unique in that it spans a full range of services: relaxation, wellness and clinical. In general, the same benefits a younger person receives from wellness and relaxation massage are available to the elderly. For an active person, massage helps to maintain range of motion and diminish the injury process; that is, people who receive massage have fewer strains, aches and pains. For nursing home residents, massage helps to maintain the muscle tone needed to stabilize their physical status and discourage further muscular deterioration.

At its most basic level, Olson explains, massage is direct skin-to-skin communication. "With a person with dementia who has difficulty communicating, a comforting, caring touch transmits a message to the resident that he is being cared for and cared about. We know this is true with infants, and it holds true throughout life." To illustrate the bonds created through touch communication, Olson relates: "Our nursing home had an annual fundraiser at a local historic theater. Grace, a resident with severe dementia, was taken from her normal environment and brought to this social event. When I walked into the lobby, she waved to me from the other side, came over and said, 'It's you,' which demonstrates that physical contact can create a bond with a person with dementia."

According to Olson, 29 states and the District of Columbia currently regulate massage therapy, while in other jurisdictions individual cities or municipalities regulate the profession. "It is imperative that a long-term care facility be aware of these regulations when seeking massage therapists as consultants, providers or staff. They must know local regulations, such as licensing, and make sure that their therapist meets or exceeds those requirements," he advises.

In providing this caring touch, Olson emphasizes the importance of using a clinically skilled massage therapist, because the technique for the elderly differs from the mainstream approach. "Often with the aging process, the skin becomes very delicate, and the therapist cannot use the same techniques as he would on a 21-year-old athlete. Generally, the approach in the nursing home situation would be gentler in favor of safety. Also, the aging vascular system is more brittle, which increases the potential for bruising," advises Olson. He adds, "A massage therapist must be aware of illnesses and health issues specific to the aging population and be knowledgeable about the contraindications for massage in residents taking certain drugs."

When working on a person with arthritis, the massage therapist must be careful of joints and joint replacements, Olson cautions. "It is not wise to work on inflamed or deformed joints when inflammation is present. It is possible to work around the areas of inflammation, and the benefits will radiate to the inflamed area. For arthritis sufferers, any relief is a blessing."

AMTA provides a locator service that requires massage therapists to meet the association's special qualifications before they are listed on its Web site at www.amtamassage.org.

ReLaxing the Snoezelen Way

Snoezelen [R] is an interactive, success-oriented therapy, originally developed for autistic children more than 20 years ago, which uses touch, smell, hearing and sight to engage residents in purposeful activity that accentuates their strengths, not their weaknesses. A thoughtfully designed Snoezelen room presents a safe, loving, warm and comforting environment that separates the residents from the institutional distractions of facility life.

Guylaine Mazure, activities director at Ramapo Ridge Psychiatric Hospital of Southgate Behavioral Management Unit, a division of Christian Health Care Center, which also owns The Courtyard at Longview Assisted Living Residence in Wychoff, New Jersey, introduced the Snoezelen concept five years ago. It is now used throughout the Christian Health Care Center system in its behavioral and long-term care facilities.

"At Southgate," Mazure says, "the main lounge is divided into two areas and fitted with two major Snoezelen items that we purchased from FlagHouse, Inc.: a colorful fiberoptic spray and a bubble board that are permanently attached to the walls for residents to touch and watch." (A bubble board is a flat, wide device that "bubbles" when air is pumped through it to display changing colors.) The sound of the compressor, much like the filter on a fish tank, is very relaxing, too, according to Mazure.

A typical Snoezelen room is also supported with other accessories, such as lava lamps; a mirrored disco ball that reflects light on the floor, walls and ceiling of the room; a rotating projector that shows images on the walls; and other comforting items, such as stuffed animals and music boxes that promote contentment and a sense of well-being. The calming effects of these items make the Snoezelen room an ideal place for family visits.

The rooms at Southgate and Longview are also furnished with recliners, so that the resident can lean back to watch the movement of light around the room or contemplate interesting articles, such as colorful hangingyarns, positioned higher on the walls.

"Everything incorporated in the room must be safe," Mazure explains. "For that reason, the residents are attended by staff while in the room." Because of its behavioral population, the Southgate Unit runs the program anywhere from 2 to 3 hours a day, whereas The Courtyard at Longview Assisted Living Residence has a 24-hour dedicated room where residents can go to relax and calm down. Residents are encouraged to handle the props, which helps them reminisce and redirect their thoughts.

Staff must be trained not only on the props and their use, but also on what music to select and use the use of aromatherapy. Families also need to be educated so that when visiting they, too, along with helping their loved one, can relax. "Often," Mazure observes, "I see staff come in and use the room to regroup their own thoughts."

Mazure states that Snoezelen has achieved good results in all their facilities. Psychiatric patients who suffer from hallucinations can go in the room, relax, refocus on reality and not hear voices. At Southgate, there is a meditation room for residents who need private one-on-one time that incorporates a mini-Snoezelen room. If someone is very upset or displaying severe behavior problems, he can enter the room to relax and come out feeling better. "After residents attend our Snoezelen program," Mazure states, "they go to lunch. Participating in this Snoezelen program has enabled them to be more calm and focused for meals."

Mazure cautions that this program does take time to institute. "Not only do staff and family have to be trained, but the residents also require some training, because this is something different for them," she explains. "It takes a while for staff and residents to catch on so be patient and don't give up."

Initiating alternative therapies can open up a world of opportunity, growth and satisfaction for long-term care residents. Along with horticultural, massage and Snoezelen therapy, the alternative therapies roster includes pet therapy, aromatherapy, hydrotherapy and more--and keeps growing.

For more information on Horticultural Therapy--Pam Mammarella, New-Courtland, Inc.: phone [phone], fax [phone] [e-mail]; Massage Therapy--AMTA: phone [phone], fax [phone] or visit amtamassage.org; SnoezeLen Therapy--Guylaine Mazure, Southgate Behavioral Management Unit: phone [phone] or fax [phone].

(*) The word Snoezelen is derived from the Dutch words for "to snooze" and "to sniff." FlagHouse, Inc., is the exclusive North American distributor of the SNOEZELEN concept and equipment.