Iran J Crit Care Nurs. 2015;8(3):125-132 The effects of head and face massage on delirium among elderly women
hospitalized in coronary care units
Maral Makinian1, Tayebeh Mirzaei2*, Ali Ravari2
1. School of Nursing and Midwifery, Rafsanjan University of Medical Sciences, Rafsanjan, Iran
*2. Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan, Iran

Aims: There are few studies in the area of managing delirium by using
complementary therapies. The aim of this study was "to investigate the effects Article type: of face and head massage on delirium among elderly women hospitalized in Original article coronary care units". Methods: This was a clinical trial study. Eighty eight elderly women with
delirium were randomly allocated to either the control or the experimental Article history: groups. Women in the experimental group received fifteen-minute face and Received: 9 May 2015 head massage therapy. Study data were collected and analyzed by using the Revised: 20 Jun 2015 NEECHAM confusion scale and the SPSS18, respectively. Accepted: 26 Sep 2015 Results: Before the study intervention, the means of total delirium score in the
experimental and the control groups were 8.8 and 9.5, respectively. There was no significant difference between the study groups regarding the pretest total Keywords: delirium score. However, after the study intervention, the mean total delirium score in the experimental group was significantly higher than that of the control group (17.6 vs. 16.7; p=0.03). Conclusions: Face and head massage therapy can reduce delirium severity;
therefore, using it in adjacent to pharmacological interventions is
Please cite this paper as:
Makinian M, Mirzaei T, Ravari A. The effects of head and face massage on delirium among elderly women hospitalized in
coronary care units. Iran J Crit Care Nurs. 2015;8(3):125-132.
1. Introduction
The causes of delirium can be infections, drug Delirium is a common problem particularly overdose or withdrawal, acute metabolic among patients hospitalized in critical care disorders, traumas, central nervous system units. It is a short-term, mild-to-severe altered consciousness and cognition which can last for hours to days [5]. It can happen in three forms disorders, poisoning, medications, and heavy metals [3 and 4]. Cardiac patients can also alternative combined delirium [2]. develop delirium secondary to arrhythmias, myocardial *Correspondence author: Tayebeh Mirzaei angiography [6], and coronary artery surgeries Geriatric Care Research Center, Rafsanjan University of Medical Sciences, Rafsanjan Iran. [7]. Delirium is particularly common among TEL: +989133933532 elderly people [8] and hospitalized patients and E mail: 126 Makinian M. et al. The effects of head and face massage on delirium among elderly women hospitalized… it can increase the rates of mortality and enhance the effectiveness of therapeutic hospital-acquired complications [9]. interventions through affecting different body The prevalence of delirium among patients organs and systems [18]. Massage is a generic hospitalized in critical care units in different name and includes a wide range of touch countries is varied and ranges from 11%–89% therapy techniques such as compression, [10]. In our country, Iran, only handful studies friction, and movements [19–20]. Despite the have been conducted so far on delirium. The old history of using massage for maintaining prevalence of delirium in critical care units and promoting health, it was only since 1930s located in Iran has been reported to be 44.5%– that its effects were assessed and proved in 47% [11]. Annually, delirium affects more than animal experiments and human studies [21]. Currently, there are more than 80 types of worldwide and incurs healthcare costs of more massage techniques from which, effleurage and than four billion dollars. Moreover, it increases compression are particularly relaxing, simple, the likelihood of re-hospitalization and the costs and light and hence, all patients including related to rehabilitation and home care [12]. patients with delirium can easily tolerate them The three-month mortality rate among patients [22]. These two types of massage techniques with an acute delirium attack has been reported are parts of the Brown's massage therapy [23]. to be 23%–33% which can increase to 50%. Effleurage includes light, gentle, and rhythmic The mortality rates among hospitalized patients massaging movements in the direction of blood and elderly people who develop delirium are flow towards the heart [24]. 20%–75% and 22%–76%, respectively. First- When using the effleurage technique, an and six-month mortality rates of delirium after increasing pressure is applied by using the hospital discharge are 15% and 25%, whole plantar surface of the hand and the respectively [14]. fingers [24]. The positive effects of effleurage Delirium is transient and reversible provided include improved blood flow to the massaged that the underlying cause is treated [14]. area, nerve stimulation, decreased muscular Accordingly, delirium management is of tension, relaxation of muscular fibers, and skin paramount importance. Besides managing the clearance [25]. Effleurage is associated with no underlying cause and starting medication pain or discomfort and can be easily applied by therapy, delirium management also includes amateur individuals even on points where physical, environmental, and sensory support as massaging is contraindicated [26]. On the other well as complementary therapies. Medications which are used for treating delirium are includes applying rhythmic pressures on the chlorpromazine, diphenhydramine, haloperidol, muscles which causes deep tissue hyperemia olanzapine, perphenazine, quetiapine, and and relaxation. This technique is mainly used at the beginning of a massage therapy session in complementary therapies are also used for order to warm and prepare muscles for subsequent specialized massages [24]. Complementary therapies include relaxation Studies conducted in the last decades have exercises, aromatherapy, acupressure, physical demonstrated the positive effects of massage activity, music therapy, reflexology, herbal therapy on problems such as sinusitis [27], back medicine, mind-body techniques, hypnosis, touch therapy, and massage [16]. musculoskeletal pains [30], anxiety [31], and One of the complementary techniques is sleep quality [32]. massage therapy which has been used for Massage can also be applied on the face and the alleviating and managing ailments since remote head. Face massage became prevalent since the past [17]. The aim of massage therapy is to early 20th century [18]. Face and head massage Iran J Crit Care Nurs. 2015;8(3):125-132 The effects of head and face massage on delirium among elderly women hospitalized… Makinian M. et al. 127 is particularly easy and satisfying because visual or hearing problem, history of cognitive patient's body is not to be exposed and it can be or psychiatric disorders, history of receiving applied even in public places such as hospital psycho-affective drugs, and skin lesions or ward while the intended patients lies on bed in tender area in the face and the head. supine position. Patients with delirium are The following sample size calculation formula restless and irritable and hence, exposing their showed that a sample 88 patients is necessary body can hinder their recovery. The head and for the study, n=(z1+z2)2 the face are normally exposed and no more was conducted over a four-month period. exposure is needed for applying massaging Patients were ascribed with numbers 1–88 techniques. Moreover, face and head massage is while those receiving odd and even numbers among the most effective techniques for fast were allocated to the experimental and the access to relaxation and rapid reduction of control groups, respectively. mental and physical fatigue [33]. It can relax facial and ocular muscles, alleviate tension NEECHAM confusion scale were used for data headaches, enhance concentration, reduce collection. The items of the demographic fatigue, relieve nervous tensions and stress, questionnaire encompassed age, the underlying improve mood, enhance blood flow, and condition, and the length of hospital stay. stimulate the nerves [39]. Demographic data were collected through Given the positive effects of face and head referring to patients' medical records and massage and the negative effects of delirium on asking their family members. individuals' physical and social functionality The NEECHAM scale consisted of three main [16], investigating the effects of delirium on the subscales including processing (with the three outcomes of patients with delirium looks items of attention, command obedience, and useful. Moreover, delirium has been showed to orientation), behaviors (with the three items of be correlated with pain, anxiety, and sleep appearance, motor, and verbal behavior), and problems [40]. On the other hand, massage physiological parameters (with the three items therapy is useful in alleviating pain and anxiety of vital functions stability, oxygen saturation and promoting sleep [34 and 35]. However, to stability, and urinary continence control). The the best of our knowledge, there are few studies total scores of these three subscales are in the area of managing delirium by using respectively 0–14, 0–10, and 0–6, yielding a complementary therapies. The aim of this study total NEECHAM score of 0–30. Scores of 27– was to investigate the effects of face and head 30, 25–26, 20–24, and 0–19 are interpreted as massage on delirium among elderly women healthy condition, mild confusion without hospitalized in coronary care units (CCU). delirium, mild delirium, and moderate to severe delirium, respectively. 2. Methods
The required time for completing the This was a clinical trial study. The study NEECHAM scale is 8–10 minutes. This scale population comprised all elderly women has been developed based on nurses' 24-hour hospitalized in CCUs of Kashani, Al-Zahra, and care-related activities and observations [36]. Chamran teaching hospitals, Isfahan, Iran. The NEECHAM confusion scale is a reliable Patients were considered eligible if they were scale for delirium assessment by nurses in female, had an age of 60 years or older, were general hospital wards and has been recently hospitalized in coronary care units, had used for assessing delirium among non- received a diagnosis of delirium, were not intubated patients hospitalized in critical care dependent on drug or alcohol, were not receiving mechanical ventilation at the time of Sohrabi et al. (2010) reported a Cronbach's the study, and also if they did not have any alpha, a sensitivity, and a specificity of Iran J Crit Care Nurs. 2015;8(3):125-132 128 Makinian M. et al. The effects of head and face massage on delirium among elderly women hospitalized… respectively 0.96, 87%, and 95% for the scale 3. Results
Both the demographic questionnaire and the hypertension, and thyroid disorders among NEECHAM confusion scale were completed patients in the experimental group was 65.9%, for eligible patients at the time of their 72.72%, and 6.81%, respectively while these admission to CCU. Once the NEECHAM scale values in the control group were respectively was completed and a diagnosis of delirium was 54.54%, 72.72%, and 25%. The means of established, patients in the control and the participants' age in the experimental and the experimental groups received a single dose of control groups were 77.06 and 71.16 years haloperidol prescribed by attending physicians. while the means of hospital stay in these two re-administration groups were 4.11 and 4.6 days, respectively . haloperidol during the study intervention, they The paired-samples t test showed that after the were excluded from the study. intervention, the mean of total delirium score as Then, we provided massage therapy to the well as the mean scores of the processing, patients in the experimental group while the behaviour, and physiological control subscales patients in the control group solely received in both the experimental and the control groups routine delirium management therapies. increased significantly (p≤0.01; Table 1). On The massage therapy intervention consisted of the other hand, the independent-samples t test thirteen combined techniques selected from the revealed that before the intervention, there was Brown's massage therapy approach (23). no significant difference between the study These techniques were developed by combining groups regarding the total delirium score and the compression and the effleurage techniques. the scores of the NEECHAM subscales Massage therapy was administered by a trained (p>0.05; Table 2). person twice a day (10:00 and 18:00) in two The means of post-test total delirium score in subsequent days—four sessions in total. The the control and the experimental groups were face and head massage therapy which was used 16.7±8.5 and 17.6±8.9, respectively (Table 2). in the current study had been developed and The results of the ANCOVA test with the tested by Bahraini (2014) on 35 women adjustment of the minor non-significant suffering from sinusitis headache [27]. difference between the study groups regarding For administrating massage therapy, the the pre-test readings of the total delirium scale intended patient was positioned in supine indicated that after the intervention, the total position and the massage therapist stood at the delirium mean score and the mean score of the head of patient's bed. Each movement was processing subscale in the experimental group repeated five times. Massage therapy sessions were significantly higher than the control group lasted for fifteen minutes. (p<0.05) . However, the difference between the At the end of the fourth massage therapy study groups regarding the post-test mean session, another trained person assessed scores of the behaviour and the physiological delirium severity by using the NEECHAM scale. Finally, the severity of delirium in the significant (p>0.05; Table 3). two groups and across the two measurement Before the study intervention, the total time-points were compared by conducting the NEECHAM score of all patients was less than independent- and the paired samples t as well as 24. However, after the study intervention, the analysis of covariance (ANCOVA) tests. 15.9%, 15.9%, 22.7%, and 45.5% of patients in Data analysis was performed via SPSS18 the experimental group acquired a total NEECHAM score of respectively 27–30, 25– 26, 20–24, and 0–19. In the control group, these values were 9.1%, 9.1%, 31.8%, and 50%, Iran J Crit Care Nurs. 2015;8(3):125-132 The effects of head and face massage on delirium among elderly women hospitalized… Makinian M. et al. 129 respectively (Table 4). organ and hence, it plays a significant role in establishing interpersonal communications [39]. 4. Discussion
The results of a study conducted in Miami The findings of this study showed the positive University also showed that short-term fifteen- effects of massage therapy on delirium. We minute massage therapy alleviates anxiety and could not retrieve any study in the area of promotes career output so much so that after massage therapy and delirium. However, massage therapy, workers were more alert and studies have shown the effectiveness of solved mathematical problems faster and with massage in improving patients' functions [39]. more precision [41]. Human skin is the largest observable sensory Given the proximity of the scalp with the Table 1: Within-groups comparison of the total NEECHAM and its subscales scores Before intervention After intervention Paired-samples t Total delirium score Processing subscale Behavior subscale Physiological control subscale Total delirium score Processing subscale Behavior subscale Physiological control subscale Table 2: Between-groups comparison of the total NEECHAM and its subscales scores before the intervention Experimental group Independent-samples t Total delirium score Processing subscale Behavior subscale Physiological control subscale Table 3: Between-groups comparison of the total NEECHAM and its subscales scores after the intervention Experimental group Analysis of covariance Total delirium score Processing subscale Behavior subscale Physiological control subscale Table 4: The frequency distribution of post-intervention delirium severity in both study groups Experimental group Delirium severity 27–30 (no delirium) 25–26 mild confusion 20–24 (mild delirium) 0–19 (moderate to severe delirium) Iran J Crit Care Nurs. 2015;8(3):125-132 130 Makinian M. et al. The effects of head and face massage on delirium among elderly women hospitalized… forehead, temple, and occiput, fatigue of the body image[50], self-confidence [51], thoughts scalp muscles can deteriorate blood flow to the [52], mood [52], sleep pattern and quality [49], adjacent areas and cause vague and even stress hormones [51], sinusitis headaches [27], migraine headaches [42]. Consequently, head and blood pressure, heart rate [54]., and massage is among the most effective strategies respiratory rate [55]. Consequently, given the for reducing mental and physical fatigue and direct correlation of delirium and massage regaining calm. It is particularly useful for therapy with anxiety, emotions, stress, pain, managing stress-related problems. It even can sleep disorders, vital signs, and physiological boost physical energy and reduce fatigue in parameters, massage therapy can be potentially other body organs to some extent [43]. Among effective in alleviating delirium. Moreover, it the other benefits of face and head massage are seems that face and head massage can warm the relaxation of facial and ocular muscles, tissues in these areas and increase cerebral alleviation of tension headaches, facial pains, blood flow and hence, promote the function of and toothache, improvement of concentration, the brain. Further studies are needed for reduction of mental fatigue, nervous distress, verifying the accuracy of this theory. and stressors, and prevention of hearing Delirium is highly prevalent among elderly problems [42]. Gentle massage helps patients people and causes them different physical, articulate their feelings more conveniently, mental, and psychosocial problems. On the gives positive feelings to patients who suffer other hand, it is refractory to medication from physical and psychosocial pains, and facilitates the process of communicating with Therefore, conducting further studies for them [44 and 45]. On the other hand, exposing patient's body, which can aggravate delirium, is therapies (including massaging) on patients not necessary for applying face and head with delirium seems pretty crucial. Moreover, given the scarcity of studies on the effects of Bahraini (2014) investigated the effect of face complementary therapies on delirium, robust and head massage therapy on sinusitis large-scale studies are needed for providing headaches among 35 female students in Isfahan, conclusive evidence regarding the effectiveness Iran, and reported that effleurage and of these therapies in alleviating delirium. significantly decreased headache severity [27]. 5. Conclusions
Face and head massage is a safe, simple, cost- Hosseinabadi et al. (2008), and Shafiei et al. (2014) also conducted studies on respectively 60 post-menopausal women [29], 107 patients delirium. Accordingly, using it in adjacent to with chronic back pain [46], 30 elderly people pharmacological interventions is recommended [47], and 72 patients undergoing coronary for delirium management. Nurses can both use artery bypass graft surgery [48] and reported it personally or educate patients' family that massage therapy has positive effects on members to use it for alleviating the somatic menopausal symptoms, sleep quality, manifestations of delirium. and physical pain. The results of a meta- analysis conducted by Jane et al. (2011) also 6. Acknowledgments
showed that massage therapy is an appropriate We hereby thank all the participating patients complementary therapy for alleviating chronic and their family members. Moreover, we are non-malignant pains [49]. Other studies also grateful to the administrators of the Geriatric have reported the positive effects of massage Research Center and the Research Council of therapy on emotions, anxiety, mental stress, Rafsanjan University of Medical Sciences, Iran J Crit Care Nurs. 2015;8(3):125-132 The effects of head and face massage on delirium among elderly women hospitalized… Makinian M. et al. 131 Rafsanjan, Iran, which financially supported 15. Seyediyan N. Neurology and psychiatry Kaplan this study. The help and the support of the Medical Review Amynf. 1999. [Persian] 16. Zolriasatain F, Bahriani S. Effects of massage administrators of Kashani, Al-Zahra, and therapy: a literature review. J Shahid Beheshti School of Nursing & Midwifery. 2011;20(71):2321. [Persian] 17. Barnes PM, Powell-Griner E, McFann K, Nahin RL, editors. Complementary and alternative medicine use References
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