Buddy was a lively, gregarious, openhearted, 84-year-old man.
He lived alone in a small apartment in a big city in the Northeast. Over the last year, his friends and family gradually noticed some changes—his grooming became haphazard, his normally perfect clothes were often stained, his shaving was sporadic, he began substituting words, and he had some rapid shifts in mood and temperament. But these deviations were pretty subtle. Nothing was specifically alarming. He lived by himself, his children were far away, and no one was close enough to him to connect all the dots.
Every Saturday, Buddy met his friends for breakfast at the local diner. One winter day, he came to the gathering as usual, but was met with stunned silence. Buddy showed up on time and eager for his scrambled eggs—it’s just that he forgot to get dressed.
In the aftermath of this event, my siblings and I discovered that my father, Buddy—who we all thought was a bit frail but quite capable of being independent—had descended into Alzheimer’s disease with a terrifying rapidity. His apartment was in ruins, and it was only good luck that prevented a much more serious problem than showing up at a restaurant in his pajamas—he could easily have caused a
fire or worse.
We moved Buddy to a facility specially designed for physically healthy people with dementia. He took it hard—he was taken away from all his friends and the city he’d lived in all his life. He had lots of visits from family, but it was never the same. He lived there for two years—disoriented, disconnected, diminished—until he succumbed to pneumonia in 2008.
I miss you, Buddy.
It is likely that many readers of this column have their own stories of Alzheimer’s disease or other forms of dementia to tell. These conditions affect about 8 percent of people over age 60—close to 6 million people in the United States, and as our population ages, that number is expected to climb.

What is Dementia?
Dementia—literally, loss of mental capacity—is not a disease in itself; it is a symptom of some problem in the brain. It is not a part of normal aging. It goes beyond the occasional forgetfulness that is common in old age; it is a sign of substantial neurocognitive decline and a leading cause of disability among senior adults. It is progressive and irreversible.
Some people assume that dementia and Alzheimer’s disease are synonymous, but this is not the case. Alzheimer’s disease is the most common form of dementia, but not the only form. Let’s take a look at the three most common dementing diseases, with a special focus on Alzheimer’s disease.

What is Alzheimer’s Disease?
Alzheimer’s disease is a progressive degenerative disease of the brain. It involves memory loss, personality changes, and, eventually, organ failure and death.
Although Alzheimer’s disease is mostly seen in older adults, one version affects younger people. In the United States, we think about 200,000 people under the age of 65 may be affected. And, because this population is less likely to have other age-related disorders, they tend to live with the disease for a much longer time.
About 70 percent of all cases of dementia are probably related to Alzheimer’s disease.
Hallmarks of Alzheimer’s Disease: Plaques and Tangles
In 1906, a German doctor named Alois Alzheimer first documented observable aspects of the disease that now bears his name. The two features he found—plaques and tangles—are still the main identifying lesions associated with this condition.

Plaques
Plaques are the development of deposits of a sticky cellular protein called beta amyloid. This material is found in many places, but in the brains of people with Alzheimer’s disease it causes problems when it stimulates an inflammatory response—this can damage the plaque-covered cells, but also nearby healthy cells.  
It is unclear whether plaques cause the signs and symptoms of Alzheimer’s disease, or whether Alzheimer’s-related changes in the brain lead to the accumulation of beta amyloid plaques. However, the discovery that these plaques appear to stimulate an inflammatory response is important. It puts Alzheimer’s disease in the same category as other diseases related to chronic, long-term, low-grade inflammation like heart disease and some forms of cancer; and it opens the door to some treatment options that had previously not been considered.

Tangles
Neurofibrillary tangles are a different signature lesion associated with Alzheimer’s disease. The neurons in our brain must be in the right spatial relationship to each other for their synapses to function. These cells are held up with an internal scaffolding made partly of a protein called tau. For reasons that are not clear, the tau proteins degenerate in Alzheimer’s disease patients. This causes the neurons to collapse. Long fibers become snarled and twisted together: these are the neurofibrillary tangles.
Both plaques and tangles interfere with functioning synapses. The consequences of this are complex and serious: not only do important signals get lost, but those postsynaptic neurons are no longer stimulated by neurotransmitters from the damaged presynaptic neurons. Unstimulated neurons degenerate, healthy levels of neurotransmitters decline, and the problem progresses throughout the brain.
In particular, we see that Alzheimer’s disease leads to shrinking and reduced function at the hippocampus—the part of the brain that processes and stores new information and short-term memory.
Over time, all the brain tissue shrinks, and function is lost—first with memory, but then with other aspects of cognition as well. In the long run, even the most basic autonomic functions of the brain are interrupted. Most patients with Alzheimer’s disease succumb to other causes of death before this happens, however.

Other Forms of Dementia
Dementia and memory loss are the leading indicators in early Alzheimer’s disease, but other conditions involve dementia as well. It can be important to identify the cause of mental changes, because treatment options vary. That said, it is possible for a person to have multiple, or mixed, causes of dementia; of course, this makes treatment much more challenging.

Vascular Dementia
Vascular dementia is a collection of conditions that comprise this second most common form of dementia in the United States, accounting for up to 20 percent of all dementia cases. As we might surmise from its name, it has to do with blood vessels and is strongly correlated to a history of hypertension, cardiovascular disease, high cholesterol, and strokes.  
A typical pattern seen in vascular dementia patients is that they experience a specific neurological event followed by progressive cognitive impairment. Their function tends to decline in a stepwise pattern: it stabilizes at a certain level, then suddenly declines and re-stabilizes at a lower level, and then declines again, and so on. This reflects new sites of brain damage from vascular disease.
Treatment for vascular dementia can slow or halt its progression, so it is important to distinguish between this condition and other forms of dementia as early as possible.

Lewy Body Dementia
Lewy bodies are protein deposits that accumulate inside certain cells in the brain. They are a part of the pathophysiology of Parkinson’s disease, and they are the main feature in the cognitive disorder called Lewy body dementia (LBD).
This condition is still not well understood, but it appears to be related to a disruption in the flow of neuron signals between the frontal lobe (where we make decisions) and a section of the basal ganglia (where voluntary movement is initiated).
LBD looks a little different from Alzheimer’s disease because the dementia it causes seems to fluctuate: sometimes people can seem fine, and at other times they are definitely not. And because it affects movement centers, it can also affect voluntary muscle control: myoclonus, or a sudden involuntary jerking contraction of skeletal muscles is an early symptom. In addition, LBD can involve a decline in motor/spatial skills, hallucinations, and delusions. Memory loss can occur, but this tends to happen in late-stage disease, which is different from the typical Alzheimer’s disease pattern.
LBD, like Alzheimer’s disease, is progressive and ultimately fatal.  

Treatment
Alzheimer’s disease and other dementing diseases are difficult to treat, and no single approach works well for the majority of people who are affected by them. Treatment must be customized to the individual, of course.
Some patients find that drugs that increase the availability of acetylcholine in the brain—called cholinesterase inhibitors—seem to slow the progression of these diseases.
These drugs are not appropriate for vascular dementia, however, which is treated with antiplatelet drugs and other strategies to improve vascular health.
Nonsteroidal anti-inflammatory drugs, not including aspirin and acetaminophen, may help to limit the inflammation associated with plaque formation. Some people with dementia experience great agitation and paranoia; they could benefit from tranquilizers or antipsychotic drugs.
Depression is almost an inevitable part of any progressive degenerative disorder. It tends to be especially severe with LBD. Addressing this problem may make other interventions more successful.

Implications for Massage
Massage therapy has some benefits for people with dementia, but this has to be offered with some very specific cautions.
Many practitioners working with elders who have frail health find that doing massage in a seated position at the person’s home or care facility may be more practical than trying to do full-body table massage.
It is also important to remember that diseases and conditions don’t happen just one at a time. An older person with Alzheimer’s disease or other dementing diseases may have any number of other age-related conditions that require some adjustments. These could include a history of stroke, diabetes, or osteoporosis—each of these requires special accommodations for massage, and that’s just the short list.
Another important thing to remember when we are working with someone who has limited means of communication is that we need to be watchful and sensitive about nonverbal signals. Our client may begin the session feeling safe and secure, but we don’t know what triggers might lead to a change in that status. It is our responsibility to make sure our work is perceived as safe and welcomed every minute.
Massage is unlikely to rebuild someone’s lost memories or to restore lost function, but it may help with mood, pain, and anxiety. If we can add just a little improvement to the life of someone who lives with these conditions, then we are having a positive impact not just on the client, but also on their loved ones and caregivers.
There’s only a limited amount of research on massage therapy for patients with dementia, but what has been done suggests that those who receive massage are less combative, less restless, and better oriented after their sessions. This alone makes massage therapy look like a helpful intervention for this population.
Progressive, degenerative, dementing diseases are not pleasant to think about. Often, when we think about massage in this context, it’s as a comfort measure, not as a strategy toward getting better. But let’s not minimize the value of comfort measures. Offering temporary well-being through healthy, welcomed touch is a noble calling, and we can be proud to be a part of that tradition.

Signs and Symptoms
The Alzheimer’s Association lists these 10 early signs of the disease:
• Challenges in planning or solving problems.
• Changes in mood and personality.
• Confusion with time or place.
• Decreased or poor judgment.
• Difficulty in completing familiar tasks.
• Memory loss that disrupts daily life.
• Misplacing things and losing the ability to retrace steps.
• New problems with words in speaking or writing.
• Trouble understanding visual images and spatial relationships.
• Withdrawal from work or social activities.
The Alzheimer’s Association offers advice about living with dementia at www.alz.org/livewell.

Resources
Alzheimer’s Association. “10 Early Signs and Symptoms of Alzheimer’s.” Accessed March 2017. www.alz.org/10-signs-symptoms-alzheimers-dementia.asp.
National Institute on Aging. “Lewy Body Dementia: Information for Patients, Families, and Professionals.” Last updated July 29, 2016. Accessed March 2017.
www.nia.nih.gov/alzheimers/publication/lewy-body-dementia/basics-lewy-body-dementia.
WebMD. Alagiakrishnan, K. “Vascular Dementia.” Accessed March 2017.
http://emedicine.medscape.com/article/292105-overview.
WebMD. Crystal, H. “Dementia with Lewy Bodies.” Accessed March 2017.
http://emedicine.medscape.com/article/1135041-overview.
World Health Organization. “Dementia Fact Sheet.” Accessed March 2017.
www.who.int/mediacentre/factsheets/fs362/en/.

Ruth Werner, BCTMB, is a former massage therapist, a writer, and an NCBTMB-approved provider of continuing education. She wrote A Massage Therapist’s Guide to Pathology (Lippincott Williams & Wilkins, 2016), now in its sixth edition, which is used in massage schools worldwide. Werner is available at www.ruthwerner.com.