| In a consensus statement recently published by the | | | | masks infused with fragrance or nose clips to wear |
| British Association for Psychopharmacology,1 the use | | | | when assessing participants, infusing the environment |
| of aromatherapy as an adjunct to the pharmacological | | | | with control fragrances and masking the aroma of the |
| treatment of dementia is supported by one of the | | | | essential oil with air fresheners. |
| highest level of scientific evidence - evidence from | | | | In addition, as large placebo responses have been |
| randomized controlled trials. | | | | observed in many studies investigating the treatment |
| A number of recent, controlled studies have shown | | | | of behavioural or psychiatric symptoms in people with |
| that aromatherapy (the therapeutic use of pure plant | | | | dementia, it is important, in studies investigating the |
| essential oils) can be useful in the management of | | | | effects of essential oils, that the control and |
| patients with dementia: lavender (Lavandula angustifolia | | | | aromatherapy interventions involve similar amounts of |
| or Lavandula officinalis) and lemon balm (Melissa | | | | time and touch with each participant. |
| officinalis) are two essential oils of particular interest in | | | | Conclusions |
| this area. The aim of the article by Holmes & | | | | Holmes & Ballard2 conclude that although there is |
| Ballard,2 summarized here, was to review published | | | | much case-based evidence suggesting the efficacy of |
| reports of the efficacy of aromatherapy for the | | | | aromatherapy in improving sleep, agitated behaviours |
| treatment of behavioural problems in people with | | | | and resistance to care in dementia, there is a marked |
| dementia. | | | | lack of adequately sized, placebo-controlled, |
| The results of these studies are interesting as their | | | | randomized studies in this area. Although one |
| findings cannot be dismissed as merely resulting from | | | | placebo-controlled study has shown evidence that |
| the placebo effect of a pleasant-smelling fragrance: as | | | | aromatherapy may be effective as adjunct to existing |
| the authors note, most people with severe dementia | | | | therapy in the management of patients with dementia, |
| will have lost any meaningful sense of smell because | | | | this study had a number of methodological flaws. |
| of the early loss of olfactory neurons.3 Indeed, the | | | | The authors identify a number of important issues that |
| pharmacological mechanism by which aromatherapy | | | | need to be addressed in researching the efficacy of |
| produces its effects is not thought to involve any | | | | aromatherapy in patients with dementia, including: |
| perception of odour. Instead, the active compounds are | | | | - Patients with different forms of dementia respond |
| thought to enter the body (by absorption through the | | | | differently to pharmacological agents; whether the |
| lungs or olfactory mucosa) and be delivered to the | | | | same is true regarding their response to aromatherapy |
| brain via the bloodstream, where they elicit direct | | | | remains to be determined. |
| actions. | | | | - Essential oils are administered by massage in various |
| Aromatherapy studies in patients with dementia A | | | | 'carriers' (e.g. skin creams, massage oils), and therefore |
| large number of small, uncontrolled case studies have | | | | involve the 'additional therapy' of physical contact with |
| demonstrated the efficacy of inhaled and/or topical | | | | carers. Clearly, this additional therapy needs to be |
| lavender oil in this setting. In summary, these studies | | | | minimised or controlled for before direct inferences can |
| have shown lavender oil to improve sleep patterns,4-7 | | | | be made about the effects of aromatherapy alone. |
| and to improve behaviour.8,9 | | | | - If it is accepted that there are active neurochemical |
| Although only a few controlled studies have | | | | differences between essential oils, then research |
| investigated the potential use of aromatherapy for the | | | | should investigate not only the oils from different |
| management of behavioural problems in people with | | | | genuses but should also compare those from related |
| dementia, the results have been positive. A single-blind, | | | | species (e.g. Lavandula angustifolia and Lavandula |
| case-controlled study investigated the effects of | | | | officinalis). |
| lavender essential oil on disordered behaviour in | | | | - Properly conducted, well-designed, randomized, |
| patients with severe dementia.10,11 Patients (n=21) | | | | controlled trials are required before firm conclusions |
| were randomized to receive massage only, lavender | | | | regarding the efficacy and safety of essential oils can |
| essential oil administered as massage or lavender oil | | | | be drawn. |
| administered via inhalation plus conversation. Of the | | | | References |
| three patient groups, those receiving the essential oil in | | | | |
| a massage showed a significantly greater reduction in | | | | 1. Burns A, O'Brien J; BAP Dementia Consensus group. |
| the frequency of excessive motor behaviour. | | | | Clinical practice with anti-dementia drugs: a consensus |
| In a small (n=15) double-blind, placebo-controlled, | | | | statement from British Association for |
| crossover trial in patients with severe dementia on an | | | | Psychopharmacology. Journal of Psychopharmacology |
| NHS care ward,11,12 2% lavender oil was administered | | | | 2006;20:732-55. |
| in an aroma diffuser on the ward for a 2-hour period, | | | | 2. Holmes C, Ballard C. Aromatherapy in dementia. |
| alternated with placebo (water) every other day, for a | | | | Advances in Psychiatric Treatment 2004;10:296-300. |
| total of ten treatment sessions. According to the group | | | | 3. Vance D. Considering olfactory stimulation for adults |
| median Pittsburgh Agitation Scale score, treatment | | | | with age-related dementia. Perceptual and Motor Skills |
| with lavender aromatherapy reduced agitated | | | | 1999;88:398-400. |
| behaviour significantly (p=0.016) in patients with severe | | | | 4. Henry J, Rusius CW, Davies M et al. Lavender for |
| dementia compared with placebo, with 60% of | | | | night sedation of people with dementia. International |
| patients experiencing some benefit. No adverse | | | | Journal of Aromatherapy 1994;5:28-30. |
| events were reported and compliance with therapy | | | | 5. West BJM, Brockman SJ. The calming power of |
| was 100%. | | | | aromatherapy. Journal of Dementia Care 1994;2:20-2. |
| In a crossover study,13 56 elderly patients with | | | | 6. Hardy M, Kirk-Smith M, Stretch D. Replacement of |
| moderate to severe dementia were massaged with a | | | | drug treatment for insomnia by ambient odour. Lancet |
| cream containing a blend of four essential oils | | | | 1995;346:701. |
| (lavender, sweet marjoram, patchouli and vetiver) or | | | | 7. Wolfe N, Herzberg J. Can aromatherapy oils |
| cream alone five times a day for 8 weeks. | | | | promote sleep in severely demented patients? |
| Behavioural problems and resistance to care were | | | | International Journal of Geriatric Psychiatry |
| significantly lower in patients who received the cream | | | | 1996;11:926-7. |
| containing the essential oils compared with those who | | | | 8. Brooker DJR, Snale M, Johnson E et al. Single case |
| received the cream alone. | | | | evaluation of the effects of aromatherapy and |
| In the largest double-blind, placebo-controlled study | | | | massage on disturbed behaviour in severe dementia. |
| published at the time this review was written,11,14 72 | | | | British Journal of Clinical Psychology 1997;36:287-96. |
| patients with severe dementia in NHS continuing care | | | | 9. MacMahon S, Kermode S. A clinical trial of the |
| were randomized to receive either lemon balm | | | | effects of aromatherapy on motivational behaviour in |
| essential oil (n=36) or sunflower oil (n=36) applied | | | | a dementia care setting using a single subject design. |
| topically as a cream twice a day, in addition to patients' | | | | Australian Journal of Holistic Nursing 1998;52:47-9. |
| existing psychotropic medication. Clinically significant | | | | 10. Smallwood J, Brown R, Coulter F et al. |
| changes in agitation (as assessed using the | | | | Aromatherapy and behaviour disturbances in dementia: |
| Cohen-Mansfield Agitation Inventory [CMAI]) and quality | | | | a randomized controlled trial. International Journal of |
| of life indices were compared between the two | | | | Geriatric Psychiatry 2001;16:1010-13. |
| groups over a 4-week period of treatment. A 30% | | | | 11. Burns A, Byrne J, Ballard C et al. Sensory stimulation |
| reduction in CMAI score was seen in 60% of the | | | | in dementia. BMJ 2002;325:1312-15. |
| active treatment group and 14% of the control group. | | | | 12. Holmes C, Hopkins V, Hensford C et al. Lavender oil |
| The overall improvement in agitation (mean reduction in | | | | as a treatment for agitated behaviour in severe |
| CMAI score) was 35% in patients treated with lemon | | | | dementia. International Journal of Psychogeriatric |
| balm compared with 11% in those receiving placebo | | | | Psychiatry 2001;17:305-8. |
| (pMethodological issues | | | | 13. Bowles EJ, Griffiths DM, Quirk L et al. Effects of |
| In their article, Holmes & Ballard2 draw attention to | | | | essential oils and touch on resistance to nursing care |
| a number of methodological issues that need to be | | | | procedures and other dementia related behaviours in a |
| considered in the design of future studies investigating | | | | residential care facility. International Journal of |
| the potential role of aromatherapy in the clinical | | | | Aromatherapy 2002;12:22-9. |
| treatment of behavioural and psychiatric symptoms in | | | | 14. Ballard CG, O'Brien JT, Reichelt K et al. |
| people with dementia. | | | | Aromatherapy as a safe and effective treatment for |
| Although most people with severe dementia have little | | | | the management of agitation in severe dementia: the |
| sense of smell, the researchers assessing the study | | | | results of a double-blind, placebo-controlled trial with |
| may be able to identify the essential oil being tested, | | | | Melissa. Journal of Clinical Psychiatry 2002;63:553-8. |
| which could compromise a double-blind study. This | | | | 15. Thorgrimsen L, Spector A, Wiles A, Orrell M. Aroma |
| problem can be overcome in various ways, such as | | | | therapy for dementia. Cochrane Database of |
| using observational measures as the primary | | | | Systematic Reviews 2003;(3):CD003150. |
| outcomes of the study, supplying researchers with | | | | |