Article elderly care patients in Finland in english

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2015 | Volume 10 | Issue 1
Elderly Care
ISSN 1961-7623
INTERNATIONAL JOURNAL OF
clinical aromatherapy
Editor: Rhiannon Lewis

Associate Editor: Gabriel Mojay
A unique resource for enhancing clinical practice
Written by practitioners for practitioners
www.ijca.net
IJCA | 2015 | Vol 10 | Issue 1
1
2015 | Volume 10 | Issue 1
Elderly Care
www.ijca.net
Contents
Editorial
Gabriel Mojay
1
Letters
Linda Weihbrecht and Julies Jones; Rhiannon Lewis
2
Developing a community housing project for wintergreen farmers in Nepal
Kailash Dixit
4
Effect of aromatherapy on patients with Alzheimer’s disease
Daiki Jimbo, Yuki Kimura, Miyako Taniguchi, Masashi Inoue and Katsuya Urakami
6
The HEARTS Process and its potential role in elderly care
Ann Carter
14
Reducing anxiety and restlessness in institutionalised elderly care patients in Finland:
A qualitative update on four years of treatment
Ulla-Maija Grace
22
Aromatherapy Service Report: The use of essential oils in the geriatric departments of
Valenciennes Hospital Centre, France
Geraldine Gommez-Mazaingue
30
Towards defining clinical aromatherapy: the essence of
Rhiannon Lewis
35
Care versus Cure: Aromacare for body, mind and spirit in the last stages of dementia
Interview with Madeleine Kerkhof-Knapp Hayes
48
Book reviews
Ann Carter, Pey Colborne, Rhiannon Lewis and Gabriel Mojay
58
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Rédactrice/Editor: Rhiannon Harris Lewis
Email: [email protected]
Depot legal: à parution
ISSN: 1961-7623
Cover image: copyright © 2015 Pascal Duvet
www.pascal-duvet-photographie.com
an
essential oil resource consultants
publication
Disclaimer
The Publisher cannot accept responsibility for any injury or
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Editorial
“An unbending tree breaks in the wind
thus the rigid and inflexible will surely fail
while the soft and flowing will prevail”
From Tao Teh Ching by Lao Tzu (6th century bc)
Integral to the origin of the word ‘clinical’ is the act
of bending or inclining — deriving as it does from
the Ancient Greek klinikós, “pertaining to a bed”,
and from klínein, “to bend, incline”.
Nowhere more does the therapeutically sensitive,
“inclining” aspect of aromatherapy come to the fore
than in its use in the care of the elderly. Practitioners
of aromatic elderly care - such as those who share
their work in this issue - therefore take a ‘clinical’
approach in more than one sense of the word:
first, in terms of their “focus on evidence-based
practice, safety, and methods of evaluating care
effectiveness” (Lewis, pg 36); and secondly, in the
more subtle sense of the gentleness and flexibility
which elderly care calls for. This eminently
professional yet attentively caring core development
of clinical aromatherapy “been largely driven by
nurses or allied health professionals” through whom
aromatic interventions have been “adapted for the
often medicated, frail and vulnerable patient” (pg 36).
I am honoured in this issue of the IJCA - my second
as its Associate Editor - to introduce the work of
those such as Ann Carter, Ulla-Maija Grace and
Madeleine Kerkhof-Knapp Hayes who unite both
the rigour and compassion of clinical aromatherapy,
and who combine firm clinical knowledge with a
sensitive flexibility... characterized by the conviction
that “any form of care to achieve optimal wellbeing
and comfort is appropriate, as long as it is safe,
evidence-based and/or experience-based, and
focuses on the whole patient” (Kerkhof-Knapp
Hayes, pg 49).
In the astute hands of these caring professionals,
essential oils with their capacity to address the wide
range of conditions common in elderly patients
find perhaps their consummate implementation.
With best aromatic wishes,
Gabriel Mojay
Associate Editor
Editorial Advisory Board
Pat Antoniak (Canada)
Ann Carter (UK)
Pam Conrad (USA)
Trish Dunning (Australia)
Jeannie Dyer (UK)
Ann Harman (USA)
Bob Harris (UK)
Wendy Maddocks-Jennings (New Zealand)
Naho Maruyama (Japan)
Mark Moss (UK)
Sandi Nye (South Africa)
Lara Orafidiya (Nigeria)
Laraine Pounds (USA)
Jürgen Reichling (Germany)
Marianne Tavares (Canada)
Sandy van Vuuren (South Africa)
1
Letters
Mapping Aromatherapy Use in Hospitals in USA
Dear IJCA Readers,
The Alliance of International Aromatherapists
would like to serve as a resource center and develop
standards on education, policies, procedures, and
essential oils. The AIA and the Research Committee/
Hospital Working Group of AIA is seeking
information specific to aromatherapy use in acute
care hospitals in the USA to develop a database for
collaboration between the medical community and
aromatherapists.
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The Alliance of International Aromatherapists
(AIA) Hospital Working Group is asking for help
with distributing a survey for a research study
entitled: ‘Mapping Aromatherapy Use in Hospitals in
USA’. This study is being conducted by Wake Forest
Baptist Medical Center, in cooperation with the AIA.
The survey is anonymous and no identifying
information will be collected. Confidentiality will
be protected by collecting only information needed
to assess study outcomes.
The purpose of this research study is to gain an
understanding of the current use of essential oils
in acute care hospitals in the USA or identify the
barriers to the use of essential oils in acute care
hospitals in the USA.
Any acute care hospital can participate in the
survey. All information about essential oil use in
USA acute care hospitals is valuable. Whether a
hospital has a current aromatherapy program, had
an aromatherapy program and disbanded it, or
doesn’t have an aromatherapy program, all acute
care hospitals are invited to take part in this survey.
It is important to know that this letter is not to
tell you to join this study. It is your decision. Your
participation is voluntary. You do not have to
respond if you are not interested in participating in
this study. You are free to ask any questions about
the study or about being a participant by calling
Julie Jones MSN,RN at 336-716-3556 or by email at
[email protected]
Es
For Institutional Review Board (IRB) research
questions, the IRB is a group of people who review
the research to protect your rights. If you have a
question about your rights as a research participant,
or you would like to discuss problems or concerns,
have questions or want to offer input, or you want to
obtain additional information, you should contact
the Chairman of the IRB at 336-716-4542.
If you are interested in participating in this study,
please use the following link to access the informed
consent and survey:
https://www.surveymonkey.com/s/RYR8W3M
Completion of the survey implies your voluntary
consent to participate in this study.
Thank you for your time and consideration.
Sincerely,
Linda Weihbrecht BSN,RN,CCAP,LMT
Chairperson, Alliance of International
Aromatherapists Hospital Working Group
[email protected]
Julie Jones MSN,RN,CHTP,CA
Primary Investigator, Wake Forest Baptist Medical
Center
[email protected]
In addition, please forward this letter to colleagues
in your area (USA only) who work at acute care
hospitals who may also be interested in participating
in this research study.
2
Letters
Letter from the Editor
Dear Readers,
Aromatherapist and author Mollie Jensen, a friend
of Kailash, has employed the popular fund-raising
website Crowdrise to setup a campaign in support
of his project, Help Rebuild a Village in Nepal:
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At botanica2014 participants had the joy of meeting
with Kailash Dixit and his beautiful wife Deepa
of Aarya Aroma (www.essencenepal.com), and
learning of their valuable contributions to the lives
and livelihoods of local and indigenous people
in Nepal. Many of you have also been using their
wonderful quality essential oils.
Kailash is seeking financial support from the
international aromatic community to fund this
project, where all funds donated go directly to
the area of need in a transparent and constructive
fashion. He will personally coordinate, monitor
and supervise the project himself and report to
international contributors through regular reports
shared through emails.
Aarya Aroma are known for their provision of
excellent quality essential oils that meets both local
and international demand. An essential part of their
work is supporting the lives of less privileged farmers
and indigenous people by guaranteeing a market
for collected or cultivated Medicinal and Aromatic
Plants (MAPs). They have done so through forming
a farmer’s cooperative where local and indigenous
people participate in the cultivation and production
of MAPs. The impact of the cooperative on local
communities has been enormous, as it has equipped
local people with the opportunity of employment
and sustainable land use and has significantly raised
their socio-economic status.
The earthquake in April 2015 essentially demolished
much of this far reaching project; homes and
livelihoods of innumerable local people have
effectively been erased.
https://www.crowdrise.com/rebuildavillageinnepal/
fundraiser/MollieJensen
The IJCA is delighted to endorse and promote this
campaign, and we urge to you to kindly donate to it.
All sums, no matter the amount, are welcome, and
will directly support this important project.
I sincerely trust that you will be moved to assist
Kailash secure the necessary funding for this project,
and thank you in advance for your generosity.
Please read further details about the project from
Kailash himself, on the following pages.
Sincerely and aromatically yours,
Rhiannon Lewis
[email protected]
Es
Through Aarya Aroma and in collaboration with
experts in construction and eco-technology, Kailash
has established a project to develop community
housing for local people in Okhaldhunga, a
wintergreen sourcing area in a remote district of
Nepal where 100% of homes were lost. Kailash has
been supporting local people in Okhaldhunga for
the past five years. He recently returned from a visit
to the area to assess the extent of the devastation
and to identify the immediate and long-term needs
of the local communities.
3
Developing a community housing project for Pokali, Okhaldhunga,
a wintergreen sourcing area where earthquake victims live in one
of Nepal’s most remote districts
Kailash Dixit
Producer, harvester, distiller
Aarya Aroma, Kathmandu, Nepal
[email protected]
www.essencenepal.com
Background
Unfortunately, the deadly earthquake that hit Nepal
Nepal on April 25 and April 26 left 17,000 families
homeless in Okhaldhunga-district. According to
the data collected by the District Natural Disaster
Committee, 8084 houses has been completely
destroyed and 9800 houses incurred damage and
are unfit for living. The earthquake victims are
spending their days and nights in the open spaces.
Eighteen people have died after being buried in
their houses and 88 people are injured. Similarly,
five health posts and one area police office have
been completely destroyed. As a result, many of our
farmers have been left with no home, food or water,
or basic services. The government relief work has
not been able to reach there yet, and these farmers
are far from having any stable shelter in the near
future; and with the rainy season coming, they are
likely to endure even more hardship.
Wintergreen harvest, 2014.
Quick Assessment
Recently, we made an assessment of the part of the
districts with the following objectives:
• To assess the devastation in the area where our
farmers make their living.
• To collect indigenous ideas to design a project to
help the farmers rebuild their houses
It was found that in the wintergreen harvesting
area where our farmers reside and cultivate, only
25% have the financial means and have taken
the initiative to rebuild their homes at their own
expense. The remaining residents are extremely
poor and now homeless.
Wintergreen at the distillery, 2014.
Strategy and Plan
Since we cannot reach out to everyone, we envision
supporting the poorest of the poor community who
live on less than US $5.00 per day. With my own
contribution and the contribution from international
community, I propose the following strategy.
4
1.To help plan, and build a model community
low cost housing of 7-8 houses, with a separate
community bathroom and kitchen using local
state of art technology such as solar or peltric set
to produce electrify, biogas to produce necessary
energy needed for domestic use. The idea is to
create a model that attracts other inhabitants,
government and donors to follow the same to
extend the support to other part of and district.
2.
To help rebuild community houses of
approximately 500sq ft, mostly with recycling
debris. These houses will be rebuilt from the reuse
of stone, woods, and corrugated sheets from
debris of damages houses, with utmost attention
to structural safety, as well as reusing salvageable
doors and windows. In my estimation, 50% of
the debris materials are reusable.
Demolished home, 2014.
3. The structure and design of these homes will be
improvised to make it earthquake friendly. The
initial estimated of cost of subsidy to build one
house would be US $6,000 per house. Families
will only be relocated within a radius of 1-1.5 km
to reduce their hardship, keeping them 10-15
minutes walking distance to their farms.
4. The model community housing will be designed
to be as sustainable as possible using their natural
resources. One example is to construct micro
hydropower plants at a cost of US $4-5,000k,
which could provide lighting for 15-20 homes.
5. Bio-gas plants will be built using human waste
and/or cattle dung — an alternative source of
cooking fuel that would alleviate the need to
consume precious trees for fire.
6. The people in this locality are unable to shower
because of extreme cold, so for proactive hygienic
reasons, we would build a common bathing area
for the families. The water will be heated using
solar energy and be partitioned by a common
wall for males and females.
7. In the mountains, there are no playgrounds for
the children. There would be a designated area
built for their playtime and recreation.
Plans are already underway for this project. In order
to establish a sense of ownership and responsibility,
our financial support will be 80%, with the remaining
20% paid by the villagers themselves.
Some materials can be salvaged and reused, 2015.
My appeal to the donor foundations is that it is of
the utmost importance that the appropriate funding
reaches the neediest families. We do not yet have
a local government, and so it is imperative we do
a model job as good citizens. In turn, we will be
teaching by example, and it will increase the capacity
to learn from this catastrophe. We must be equally
transparent on how money is allocated, while being
most economical in all endeavours.
Budgeting and financial plan
I am meeting with of structural engineers, bio-gas
experts, micro-hydro experts, and many more,
for completing the community model housing
planning. I am expecting the project to be completed
rapidly, and welcome your support.
Photos supplied by Kailash Dixit.
5
Effect of aromatherapy on patients with Alzheimer’s
disease
Daiki Jimbo, Yuki Kimura, Miyako Taniguchi, Masashi Inoue and Katsuya Urakami
Section of Environment & Health Science, Department of Biological Regulation, School of Health Science,
Faculty of Medicine & Information Media Center, Tottori University, Yonago, Japan
[email protected]
Objective: Recently, the importance of non-pharmacological therapies for dementia has come
to the fore. In the present study, we examined the curative effects of aromatherapy in dementia
in 28 elderly people, 17 of whom had Alzheimer’s disease (AD).
Methods: After a control period of 28 days, aromatherapy was performed over the following 28
days, with a wash out period of another 28 days. Aromatherapy consisted of the use of rosemary
and lemon essential oils in the morning, and lavender and orange in the evening. To determine
the effects of aromatherapy, patients were evaluated using the Japanese version of the Gottfries,
Brane, Steen scale (GBSS-J), Functional Assessment Staging of Alzheimer’s disease (FAST), a
revised version of Hasegawa’s Dementia Scale (HDS-R), and the Touch Panel-type Dementia
Assessment Scale (TDAS) four times: before the control period, after the control period, after
aromatherapy, and after the washout period.
Results: All patients showed significant improvement in personal orientation related to
cognitive function on both the GBSS-J and TDAS after therapy. In particular, patients with
AD showed significant improvement in total TDAS scores. Result of routine laboratory tests
showed no significant changes, suggesting that there were no side-effects associated with the
use of aromatherapy. Results from Zarit’s score showed no significant changes, suggesting that
caregivers had no effect on the improved patient scores seen in the other tests.
Conclusions: In conclusion, we found aromatherapy an efficacious nonpharmacological therapy
for dementia. Aromatherapy may have some potential for improving cognitive function,
especially in AD patients.
Introduction
Japan, having the highest life expectancy in the
world, has seen a remarkable increase in senile
dementia in recent years. This has become a big social
problem, with Alzheimer’s disease (AD) accounting
for approximately half the number of cases of
dementia (Urakami et al., 1998; Yamada et al., 2001).
Thus, preventive medicine for dementia has
become more important (Urakami, 2007). Recently,
complementary alternative medicine, which, in
addition to using medications, also makes use of
various ‘non-pharmacological’ approaches, has
become an attractive alternative in the treatment
of senile dementia after the introduction of elderly
care insurance. These treatments are performed to
complement the effects of pharmacotherapeutics
and health care services, such as nursing home, day
care etc, for elderly patients. Aromatherapy is one
of the therapies used in complementary alternative
medicine (Ballard et al., 2002; Smallwood et al., 2001).
In recent years, non-pharmacological intervention
has been based on the viewpoint of brain
rehabilitation and the possible prevention of
senile dementia has also been reported and
non-pharmacological treatments other than
aromatherapy, such as memory training, music
therapy, the recollection method, animal-assisted
6
therapy, and optical treatment, have been studied
(Kawamura et al., 2007; Yamamoto-Mitani et
al., 2007; Yamagami et al., 2007). Aromatherapy
experientially classifies the effect of the scent
through the essential oil extracted from the plant,
a traditional treatment used according to its effect,
and is used in many fields. In the present study, the
aromatherapy applied did not include mainstream
aroma massage, aroma baths etc. (including touch
therapy) because physical problems, such as low
temperature burns, may occur in some cases
(Maddocks-Jennings et al., 2004; Lee, 2005; Hur et
al., 2004). The mechanism(s) of action of underlying
the effects of aromatherapy are not known for
certain. In healthy people, essential oils of rosemary
and lavender are commonly used and there is at
least one report showing that these oils influence
feelings about a person’s surroundings (Wheatley,
2005). Moreover, lavender oil has been reported to
improve sleep disorders (Lewith, 2005; Moss, 2003).
It has also been reported that the essential oil of
lemon affects the anti-oxidant action of vitamin E
and improves the state of blood vessels near the skin
(Grassman, 2001). Although there are few reports
on aromatherapy in senile dementia, it has been
suggested that aromatherapy may bring about some
feeling of relief and the ability to act on outside
influences such that the obstacle to action in senile
dementia can be coped with (Lee, 2005). However,
there are no reports of the effects of aromatherapy
on cognitive functional disorder, often seem in
cases of dementia and the central feature of senile
dementia. Disorders of cognitive function pose
considerable problems for both AD patients and
care workers.
aromatherapy is the result of the vital reaction that
occurs through the smell molecule.
The action of aromatherapy begins from a smell
molecule combined with an acceptor peculiar
to each specific odor. The smell molecule passes
along the nasal cavity and adheres to the olfactory
epithelium. The stimulus is transmitted to the
hippocampus or cerebral limbic system and
amygdaloid body through the olfactory nerve system
currently concentrated on the olfactory epithelium.
Although this process is deeply related to cognitive
function, the odor is recognized and the stimulus
sends information to the hypothalamus on which it
was projected by the cerebral limbic system, which
then adjusts the autonomic nervous system and the
internal secretory system, guiding a series of vital
reactions in the hippocampus or amygdaloid body,
such as the discharge of neurotransmitters. In brief,
In total, 28 elderly people (mean age 86.1 ± 6.9
years) were involved in the study. Seventeen
patients had AD (two men, 15 women; mean age
86.3 ± 6.4 years), three had vascular dementia
(VaD; all women; mean age 89.7 ± 5.5 years), and
eight had other diagnoses, including, among others,
a mixed case of AD and cerebrovascular lesions
(CVL; all women; mean age 84.5 ± 8.3 years).
We provided patients and their families with detailed
information regarding the methods and purpose
of the study (Table 1) and informed consent was
obtained. Patients with AD were diagnosed by the
DSM-IV (American Psychiatric Association, 1987)
and NINCDS-ADRDA (McKhann et al., 1984),
whereas patients with CVL were diagnosed using
DSM-IV and NINCDS-AIREN (Roman et al., 1993).
Although some reports have proposed that the
sense of smell is decreased in AD patients, nerve
rebirth through smell is possible (Peters et al.,
2002; Eriksson et al., 1998). We also suspected that
patients’ cognitive function could be improved by
stimulation through the sense of smell.
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The aromatherapy treatment used in the present
study is is physically safer and easier to apply than
mainstream treatments, such as massage and baths,
so the operator feels no limitation because he or she
can work through purely aromatic means.
Initially, the level of congnitive function was
assessed using the Gottfries, Brane, Steen (GBSS-J)
and Touch-panel type Dementia Assessment Scale
(TDAS). Aromatherapy was applied to AD patients
using a combination of a lavender oil–orange oil
solution, which activates the parasympathetic
nervous system, with a rosemary oil–lemon oil
solution used to relieve depression and heighten
concentration. In this preliminary phase of the
investigation, the possibility that the cognitive
function could improve in AD patients following
aromatherapy was discovered and the validity of
using aromatherapy in AD patients was examine
further.
Methods
Patients
7
Table 1. Distribution of subjects according to Functional Assessment Staging of Alzheimer’s disease
(FAST) assessment
FAST3-5
FAST3-5
Total
Mean (±SD)
age (years)
AD
5 (0/5)
12 (2/10)
17 (2/15)
86.3 ± 6.4
VaD
1 (0/1)
2 (0/2)
3 (0/3)
89.7 ± 5.5
Others
3 (0/3)
5 (0/5)
8 (0/8)
84.5 ± 8.3
Total
9 (0/9)
19 (2/17)
28 (2/26)
86.1 ± 6.9
Mean (±SD) age (years)
83 1 6.9
87 1 6.2
86.1 1 6.9
Data show the number of patients in each group, with the number of men/women given in parentheses. FAST3-5, mild
to moderate Alzheimer’s disease (AD); FAST6-7, severe AD; AD, Alzheimer’s disease; VaD, cerebrovascular dementia;
Others, mixed dementia and other dementia.
Methodology
The examine the effect of mixed aromas, a crossover
method was used in the present study. To evaluate
the persistence of any effect of the aromatherapy, a
washout period of 28 days was included after the 28
days of aromatherapy. Furthermore, to examine in
detail how the aromatherapy influenced cognitive
function in dementia patients, the TDAS was
applied as a highly sensitive test with little influence
from the investigator.
After a control period of 28 days, aromatherapy
was performed over the following 28 days, followed
by a 28-day wash out period. During the control
and wash out periods, patients did not receive any
treatment. During the 28 days of aromatherapy,
patients were exposed to the aroma of 0.04 mL
lemon and 0.08 mL rosemary essential oil in the
morning from 0900 to 1100 hours and to 0.08 mL
lavender and 0.04 mL orange essential oils in the
evening from 1930 to 2100 hours. The oils were
placed on a piece of gauze in diffusers with an
electric fan. (All essential oils and diffusers used
in the present study were produced by the Peace
of Mind Company (Tokyo, Japan).) Two diffusers
were set up in each room where patients had been
moved. The essential oils (rosemary and lemon;
lavender and orange) were then mixed as described
above. The lemon and rosemary mix activates
the sympathetic nervous system to strengthen
concentration and memory, whereas the lavender
and orange fragrance activates the parasympathetic
nervous system to calm patients’ nerves.
Table 2. Study schedule
Before 1
1 week
Control period
4 weeks
Before 2
1 week
Aromatherapy period
4 weeks
After 1
1 week
Wash out period
4 weeks
After 2
1 week
To evaluate the effects of aromatherapy, tests were
performed up to four times throughout the schedule.
Table 3. Tests used in the present study
Before 1
Before 2
After 1
After 2
HDS-R
✓
✓
✓
✓
GBS
✓
✓
✓
✓
FAST
✓
✓
✓
✓
CT
✓
x
x
x
Blood Examination
✓
x
✓
x
Biochemical
Examination
✓
x
✓
x
TDAS
✓
✓
✓
✓
Zarit
✓
✓
✓
✓
✓, test performed; x, test not performed; FAST, Functional
Assessment Staging of Alzheimer’s disease; HDS-R, revised
version of Hasegawa’s Dementia Scale; GBSS-J, Japanese version
of the Gottfries, Brane, Steen scale; CT, computed tomography;
TDAS, Touch Panel-type Dementia Assessment Scale.
8
Table 4. Test results in dementia patients that did not exhibit significant changes after aromatherapy
Before 1
Before 2
After 1
After 2
P value
FAST
5.64 ± 1.32
5.58 ± 1.37
5.53 ± 1.07
5.76 ± 0.97
0.573
HDS-R
11.06 ± 7.72
10.61 ± 7.49
10.27 ± 7.72
10.56 ± 7.83
0.833
GBSS-J-B
10.65 ± 7.24
9.88 ± 7.05
11.06 ± 8.3
11.35 ± 7.31
0.174
GBSS-J-C
10.29 ± 7.54
9.76 ± 7.05
11.2 ± 7.09
11.65 ± 7.48
0.463
GBSS-J-D
7.24 ± 7.44
8.71 ± 5.97
7.18 ± 4.64
8.47 ± 6.74
0.499
GBSS-J-E
15.65 ± 8.98
15.18 ± 8.91
15.88 ± 9.55
17.59 ± 8.74
0.071
FAST, Functional Assessment Staging of Alzheimer’s disease; HDS-R, revised version of Hasegawa’s Dementia Scale;
GBSS-J, Japanese version of the Gottfries, Brane, Steen scale.
The mixtures used in the mornings and evenings
were changed because this method is known,
through experience, to synchronize the autonomic
nervous system to the circadian rhythm: the
sympathetic nerve system works predominantly
after stimulation by rosemary–lemon oil in the
morning, whereas the parasympathetic nerve
system works predominantly after activation by the
lavender–orange oil at night. Patients were evaluated
at four time points throughout the study: ‘Before 1’,
consisting of 7 days of tests, followed by the 28-day
control period; ‘Before 2’, tests for 7 days, followed
by aromatherapy for the next 28 days; ‘After 1’, tests
for the 7 days, followed by 28 days wash out; and
‘After 2’, tests for 7 days after the 28-day wash out
period (Table 2).
Tests were administered to patients according to
the schedule given in Table 3. The GBSS-J scale (the
Japanese version of the Gottfries, Brane, Steen (GBS)
Scale) (Homma et al., 1991) was used to determine
the effect of medical treatment because this test is
currently used in the evaluation of pateints with
AD. The GBSS-J consists of five items: GBSS-J-A
(cognitive function), GBSSJ-B (spontaneity), GBSSJ-C (feeling function), GBSS-J-D (other moral
condition), and GBSS-J-E (movement function).
The degree of AD was determined in patients using
the Functional Assessment Staging of Alzheimer’s
disease (FAST) (Sclan & Reisberg, 1992). This test
is based on observation of patients with AD and
classifies the level of dementia into seven stages. To
apply the FAST, the evaluator needs to observe the
patient objectively and obtain information from the
nurse or care giver. As a screening tool, the revised
version of Hasegawa’s dementia scale (HDS-R) was
used (Igarashi et al., 1995). Finally, a simple touch
panel was used to identify possible dementia (the
Touch Panel-type Dementia Assessment Scale;
TDAS). One part of the TDAS is a modification of
the Alzheimer disease Assessment Scale (ADAS)
(Rosen, 1984), a method used to evaluate cognitive
function. The TDAS clarifies the level of cognitive
dysfunction by using problems involving word
recognition, vocal orders, figure recognition,
understanding the concept of mail, understanding
knowledge items, money calculation, recall of
names and dates, the use of tools and being able
to tell the time on a clock. An experienced TDAS
investigator can easily inspect these data in
approximately 20 min per subject, but even in the
absence of an experienced investigator, the test
only takes approximately 40 min. In the TDAS,
decreasing scores indicate cognitive improvement.
The four dementia assessment scales (i.e. TDAS,
GBSS-J, FAST, and HDS-R) were applied by nurses
and/or care workers.
In addition, head computed tomography (CT)
scans were performed for all patients. A patient
with a low-density area on the CT scan without
history of stroke was considered as having CVL.
Routine laboratory tests, such as blood analysis and
biochemical examination, were performed before
and after aromatherapy.
Finally, two questions were added to the care
burden evaluation scale (Zarit) (Arai, 1997) for
21 care workers. Originally, the Zarit scale was
9
Figure 1. Changes in scores for item A-13 (abstract
function) of the the Japanese version of the Gottfries,
Brane, Steen scale (GBSS-J) in patients identifed as 3-5
on the Functional Assessment Staging of Alzheimer’s
disease (FAST), before the control period (Before 1),
after the control period (Before 2), after aromatherapy
(After 1), and after the washout period (After 2).
Significant improvement in cognitive function was
observed after aromatherapy. Data are the mena ± SEM.
*P < 0.05 (repeated-measures ANOVA).
Figure 2. Change in Touch Panel-type Dementia
Assessment Scale (TDAS) scores in all subjects ()
and in patients with Alzheimer’s disease (AD;),
before the control period (Before 1), after the control
period (Before 2), after aromatherapy (After 1), and
after the washout period (After 2). All subjects showed
significant improvement in cognitive function after
aromatherapy, as did patients with AD. Data are the
mena ± SEM. *P < 0.05 (repeated-measures ANOVA).
designed to evaluate a family’s care load so, in the
present study, the questions ‘Do you think the
patient’s excreta is unpleasant?’ and ‘Do you think
that you unknowingly present an unpleasant face to
the patient?’ were added to help judge the nursing
staff ’s care load more appropriately. In total, this
questionnaire consists of 24 items about a care
worker’s mental and economic burden.
Figure 3. Change in Touch Panel-type Dementia
Assessment Scale (TDAS; concept understanding)
scores before the control period (Before 1), after the
control period (Before 2), after aromatherapy (After
1), and after the washout period (After 2). Significant
improvement in ideational praxis function after
aromatherapy was observed. Data are the mena ± SEM.
*P < 0.05 (repeated-measures ANOVA).
Figure 4. Change in Zarit’s score before the control
period (Before 1), after the control period (Before 2),
after aromatherapy (After 1), and after the washout
period (After 2). There was no significant change in
Zarit’s score after aromatherapy.
All results were compared by repeated-measures
ANOVA and Scheffé’s post hoc test using the
Statview software for analysis.
Results
There were no significant differences between
patients with dementia for most items, except for
those evaluating actual function, such as GBSS-J-B
(spontaneity), GBSS-J-C (feeling function), and
GBSS-J-D (other psychotic manifestations), before
and after aromatherapy (Table 4). However, a
significant improvement was seen in GBSS-J-A-13
10
(abstract function) in the FAST3-5 AD (mild
moderate AD) group (P < 0.05; Fig. 1)
There was no significant difference in HDS-R, in
the transition of the FAST score or in the results of
routine laboratory tests.
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Although there were no significant changes on the
TDAS for each of the individual items described
above (i.e. word recognition, vocal orders etc.),
some improvement was seen in the overall score
for the TDAS in all patient groups (P < 0.05; Fig.
2). Some significant improvement was noted in
concept understanding (P < 0.05; Fig. 3). The overall
total points for TDAS in the AD patient group were
improved after aromatherapy (P < 0.01; Fig. 2).
Finally, there were no significant differences
differences in any items on the Zarit scale before
and after aromatherapy (Fig. 4).
Discussion
The TDAS results suggest an improvement in
recognition after aromatherapy. Nevertheless, total
scores for abstract thinking and motor function on
the GBSS-J remained the same. During preliminary
investigations, we noted some improvement in the
total score for GBSS-J-A (cognitive function) and
GBSS-J-B (spontaneity) with less aromatherapy
oil than that used in the present study. Moreover,
based on results of our preliminary investigations,
the effects observed depend on the amount of
aromatherapy oil used. Thus, a stronger effect
may be obtained by increasing the amount of the
oil used. Conversely, although we did not see any
significant effect on HDS-R, this doesn’t mean
that aromatherapy is not effective. The HDS-R is
simply a scale used for screening test for patients
with dementia and, perhaps, we were not able to
demonstrate any any cognitive improvement on
screening because the HDS-R is a screening test
with low sensitivity.
Es
In the present study, aromatherapy was performed
on dementia patients and was found to improve
the ability to form abstract ideas. In addition, some
improvement in movement was noted. Furthermore,
using the TDAS, improvements in cognitive
function were noted for the entire group, with
some improvement in conceptual understanding.
Although no significant differences were seen in
other disease groups, slight improvement in cognitive
function was found in patients with moderate
AD. Consequently, we believe that aromatherapy
effectively improves cognitive function and may
be particularly effective for patients with moderate
AD. We did not observe any significant changes on
the HDS-R after aromatherapy.
Some studies of the effects of aromatherapy have
used scales evaluating behavioral and psychological
symptoms of dementia (BPSD) (Kawamura et al.,
2007; Yamamoto-Mitani et al., 2007; Yamagami et
al., 2007). However, on the basis of the results of the
present study, our view is that the most important
effect of aromatherapy in dementia is on cognitive
function. Thus, the main aim of the present study
was to determine whether aromatherapy can
improve cognitive disorders.
One of the limitations of the present study is the low
patient numbers. In future studies, a greater number
of patients may need to be evaluated to clearly
demonstrate the effect of aromatherapy in
cognitive disorders. Stimulation of the sense of
smell is projected to the cerebral limbic system.
Very important areas, such as the hippocampus
and the amygdaloid body, are part of the cerebral
limbic system. These are strongly related to the
cognitive impairment that is the central symptom
of dementia. Moreover, neurofibrillary tangles
(NFT) are observed in the early stages of AD in the
entorhinal cortex, hippocampus, amygdaloid body,
and thalamus, which receive stimulation from the
cerebral limbic system (Braak & Braak, 1991; Gold
et al., 2000). On the basis of these observations, it
has been suggested that the olfactory area is closely
related to AD and the development of dysosmia in
early AD may support this hypothesis. Neuropoiesis
in the human hippocampal dentate gyrus and
subventricular zone is controlled by various
environmental agents, but continues throughout life
(Bruel-Jungerman et, 2005). One hypothesis states
that stimulation by smell promotes neuropoiesis in
the human hippocampal dentate (Eriksson et al.,
2005). There is also a report that indicates a positive
effect of pleasant surroundings on levels of senile
plaques (Lazarov et al., 2005).
11
In brief, it is thought that neuropoesis, reinforced
by stimulation from smell projected to the cerebral
limbic system, plays an important role in improving
cognitive function. However, aromatherapy has
positive effects on care givers in addition to the
possibility of improving a patient’s actual function.
To investigate these factors, we evaluated Zarit’s
score to determine the care load level. However,
there appeared to be no significant change in Zarit’s
score after aromatherapy; thus, the nursing load
did not change and could not have impacted on
the improvements in cognitive function seen or on
general results of patient evaluation.
Acknowledgements
Complementary alternative medicines need to be
safe. To confirm the safety of the aromatherapy used
in the present study, we performed routine
laboratory tests, such as blood analysis and
biochemical examinations, before and after the
treatment. There were no significant differences
in any of the parameters evaluated, indicating no
deleterious side effects from the aromatherapy.
Based on these results, we believe that cognitive
dysfunction, the central symptom of AD, improves
after aromatherapy. As far as we know, the present
study is the first to investigate the possibility of
improved cognitive function with simulatneous
improvemenmts in other symptoms of AD using
aromatherapy. We confirmed that aromatherapy
using pure aromas is safe. Anyone can understand
how easy it is to perform this type of treatment,
which appears to be an effective complement to
conventional therapy. Moreover, aromatherapy can
be used not only a treatment, but also as a preventive
measure because it influences neuropoiesis. Now
that adult day care, brain rehabilitation, and
dementia syndrome prevention classrooms are
becoming more and more necessary, it is thought
that aromatherapy may be very profitable as one type
of program in the near future. It will be necessary to
verify the effect of this treatment, as well as the
underlying mechanism of action, from both a clinical
and biological perspective in order to establish a
clear methodology for the use of aromatherapy in
the future. We are currently examining these issues
by investigating the effects of aromatherapy on cell
differentiation.
American Psychiatric Association (1987). Diagnostic
and Statistical Manual of Mental Disorders (DMS-IV).
Washington, DC: America Psychiatric Association.
The authors thank Professor Hiroyuki Arai, Dr
Takae Ebihara, and Dr Satoru Ebihara (Department
of Geriatrcs and Gerontology, Center for Asian
Traditional Medicine) for their advice in the writing
of this article. In addition, the authors thank Rieko
Hosoda, Aki Yonehara, Junko Hasegawa, Norie
Kojima, Yuriko Shimizu, Yasuko Morimoto,
Takao Yorita, and Ryouhei Ojima (Yonago Chukai
Hospital and Nursing Home, Awashima) for their
cooperation with this study.
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Editor’s Acknowledgement
This article originally appeared in Psychogeriatrics
(John Wiley and Sons):
Jimbo D, Kimura Y, Taniguchi M, Inoue M, Urakami
K (2009). Effect of aromatherapy on patients with
Alzheimer’s disease. Psychogeriatrics, 9: 173-179.
It is reproduced here with kind permission from
John Wiley and Sons. License agreement number:
3443060206605; license date: Aug 6, 2014.
13
The HEARTS Process and its potential role in elderly care
Ann Carter
Aromatherapist, educator, complementary therapist specialising in cancer care, life coach and author
[email protected]
The HEARTS process is a multisensory combination of relaxation techniques used as a
complement to care. It can be used by practitioners, carers and family members to provide
support for the fragile patient or elderly person. Developed in a UK cancer care setting in the
mid 1990’s, this technique has been taught in different countries and is practised in a range of
care settings. In this article, the originator of this process explores the role of HEARTS with
particular reference to its potential in elderly care environments and the various ways that
aromas can contribute to relaxation and positive psychological and emotional support.
Introduction
‘…But O! For the touch of a vanish’d hand
And the sound of a voice that is still!’
From Break! Break! Break! by Alfred, Lord Tennyson
This article will explore the potential role for the
HEARTS process to support the care of elderly
persons. HEARTS was initially developed for use
in a cancer care setting and the process involves an
approach that makes it ideally suited for use with
the elderly. The different components of HEARTS
will be described and their relevance to care of
the elderly will be explained, along with specific
discussion on the aromatic element of the process.
The HEARTS Process: background and
context
HEARTS is a therapeutic approach which draws
on the most relaxing components adapted from
several complementary therapies. It was developed
in the mid 1990’s at a cancer care day centre situated
on a large hospital site in Manchester (UK). Here,
patients and their primary carers could attend the
day centre for support on a self-referral basis, or
via referral through a health care professional. On
attending the centre for the first time, the patient/
carer had an initial consultation with a key worker
to find out his/her reasons for accessing the services
and to establish some key goals. One of the services
that could be accessed after a care plan had been
established was the complementary therapies
service.
At the time, the therapies that were offered were
aromatherapy, massage, reflexology and Reiki. I
was working at the centre as an aromatherapist
and facilitator for a relaxation and massage group
for patients and I also worked with patients for
aromatherapy on an individual basis.
It wasn’t long before myself and a complementary
therapy colleague realised that the standard
treatments we had learned in our original trainings
and assessments did not meet the needs of all of
our patients. For example, some were recovering
from treatments for a primary cancer whilst others
had very complex needs that were bordering on
the need for more advanced palliative care than we
could offer.
Difficulties we encountered included the length of
time for which some patients could comfortably
receive a standard aromatherapy treatment. At the
centre, the aromatherapy session lasted one hour;
for patients who were very ill or frail, this was
14
too long a duration. There were also challenges
of positioning a vulnerable patient on a massage
couch as well as working with some patients who
were reluctant to remove clothing due to issues
concerning body image. Additionally there was a
degree of scepticism about the value of massage and
reflexology with some patients believing that these
therapies might spread their cancer.
Empathy
We felt it was important to acknowledge empathy
as an essential component of physical hands-on
work. In this case, empathy refers to the way in
which the hands were used. We found that the set
sequences we had learned in our original therapy
trainings were a limiting factor in therapeutic work;
often, the hands had a wisdom of their own if we
simply let them communicate with good intent.
The hands-on work was thus delivered from a state
of benevolence, loving-kindness and empathy –
sometimes called metta (the Pali term for lovingkindness) in Thai massage.
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After much discussion, attending a range of
complementary therapy courses, reading and
observing the outcomes of several therapies and
a considerable amount of tailoring practice to
suit individual patients, the following points were
agreed:
Shiatsu and CranioSacralTM Therapy as to receive
these therapies, a patient didn’t have to remove any
clothing. Only very basic techniques were chosen:
palming from Shiatsu and Thai massage; holding
techniques from CranioSacral work and so on. We
also adapted effleurage techniques from Swedish
massage, although this was developed into stroking
movements. Other additions were made to form
a ‘library of strokes’ and these could be varied by
changes in speed, rhythm and pressure.
•Where touch was involved, there was always
potential for a relaxed state to be achieved.
•Even in noisy environments, where empathic
touch was involved, a patient could still achieve a
state of relaxation.
• Most patients were able to respond to the sound
of the human voice during relaxation/ guided
imagery sessions.
• It wasn’t necessary to do anything complicated to
promote relaxation.
• Sometimes a patient couldn’t relax with a touch
therapy or a spoken therapy alone. However,
when the two were used together there seemed
to be a synergistic effect where both body and
mind were engaged, thereby enabling a patient to
‘switch off ’ and achieve a state of relaxation.
Es
Over a period of two years, patients were reporting
back to their key workers about what they liked at
the centre and what the perceived benefits were.
This included all the complementary therapies
and the adaptations to techniques that were being
made. The key workers wanted to refer patients
specifically for ‘groups of techniques’ but as there
was no name for them, they asked us to provide a
title. So, one afternoon, my colleague and I devised
the mnemonic HEARTS.
Aromas
Originally, Aromatherapy was the term included
in the HEARTS mnemonic. This was subsequently
changed to Aromas. The aromas from essential oils
were a very popular addition to the techniques. This
aspect of the process will be explored more fully
later in the text.
Relaxation
Relaxation is the main goal for HEARTS. Anything
else is a bonus. If patients are able to relax, even
if just for a few minutes, there are a wide range of
benefits to be realised, even if they don’t achieve a
full ‘trance’ state of deep relaxation.
The components of HEARTS
Textures
Hands-on
All HEARTS treatments are given through a fabric
covering; a lubricant in terms of base oil or cream
is not required. The rationale for this was drawn
principally from the eastern approaches of Shiatsu
This essential component includes physical contact.
Techniques were adapted from Thai massage,
15
and Thai massage where a patient is often covered
for the treatment or s/he wears loose comfortable
clothing. The therapist can just as easily work
through fabric such as towels, sheets, bed covers,
duvets, clothes, blankets, dressing gowns…
whatever is available or appropriate at the time.
Every time the texture is changed, the individual’s
sensory experience will vary. A colleague described
HEARTS thus:
Sound
Relevance of HEARTS to elderly care
At the time when HEARTS was being developed,
most of our patients were over 60 years of age. Some
were coping well with a cancer diagnosis and some
were very frail, with a full range of physical, mental
and emotional conditions in between. Although
our patients had cancer, their problems had much
in common with the regular difficulties faced by
elderly persons, especially those connected with
social isolation, anxiety and fear, insomnia, altered
body image, and stress.
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‘The skin and the covers are like a sensory canvas on
which we paint our art, and our hands are like the
paint brushes’.
Feedback from therapists confirms that the HEARTS
process can also be useful to promote relaxation at
any stage of a conventional complementary therapy
treatment. HEARTS can be used at the beginning,
the middle or the end of a conventional treatment,
or, it can be can be used to provide a coping strategy
in difficult circumstances, such as changing of
wound dressings and some stress-provoking
medical procedures.
Patients often reported that it felt ‘lovely’ to relax with
a touch therapy, as well as with progressive muscle
relaxation or guided imagery. However, sometimes
an individual would find it difficult to ‘get into’ the
relaxation as their thoughts were ‘working overtime’.
By combining Hands-on with the simplest of voiceled relaxations, this approach seemed to occupy
both body and mind, thus enabling easier access to
the relaxed state. Although personally, I prefer the
use of the human voice, some therapists, nurses or
care assistants can find this challenging, and prefer
instead to use relaxing music for this component of
HEARTS.
If someone receives a HEARTS treatment
what can s/he expect?
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• A HEARTS treatment usually takes from around
5-20 minutes if used on its own.
• The treatment will always include Hands-on, and
Empathy with the hands, and Textures.
• The therapist will be aiming for the patient to feel
relaxed at the end of the treatment; most patients
enter a trance state of relaxation quickly and
easily.
• The patient will always be covered with the giver
working though a fabric which is placed over
the patient, or with his/her permission through
clothes e.g. someone’s dressing gown.
• The use of the voice/the sound of music and the
use of aromas are optional but enriching elements.
Currently, in the UK alone, there are already nearly
20,000 care homes (Carehomes UK, 2015). Age UK
(2015) state that 10 million people in the UK are
over 65 years of age. The number of people aged 65
or more is projected to rise by nearly 50% (48.7%) to
16 million in the next 17 years. Finding simple costeffective strategies to help meet the psychosocial
needs of our elders will be an increasing challenge
in the years ahead. Relaxation-inducing strategies
such as HEARTS are easy to learn, apply and receive
and can positively impact wellbeing and quality of
life for this sector of society.
HEARTS can be readily taught to caregivers in
residential homes/elderly care settings and can
be an adjunct to activities of daily living, such as
washing, getting dressed, after combing hair or
before bed time. For example, following bathing,
the person can be wrapped in warm soft towels
followed by body stroking of areas of the body
which are acceptable to the individual.
Advantages of HEARTS
A big advantage of using HEARTS is that the
individual does not have to remain still for very long
for HEARTS to be effective. Additionally, parts of
the body which are accessible can be worked on,
16
and the person is always covered. The hands, feet
and face are particularly well supplied with sensory
receptors; skilful empathetic touch to these small
surface areas can be rapidly calming. In the context
of HEARTS, it has also been found to be beneficial
to work on the upper back, shoulders and the arms
and hands. Some or all of these parts of the body are
easily accessible, especially when a person is seated.
Generally, most people seem to perceive that these
areas of the body are acceptable to receive touch.
Aromatherapists may query why HEARTS does
not include the use of aromas with every treatment.
When the mnemonic was first devised, some
non-aromatherapists wished to use the approach.
Similarly, health care professionals and caregivers
can be taught the basics of HEARTS in a one day
workshop, but it is not possible to teach professional
aromatherapy to non-aromatherapists in such a
short space of time.
There is no doubt that there are far reaching benefits
for the elderly with using aromatherapy. After a
systematic review of complementary and alternative
medicine in cancer care, Ernst (2009) supports the
use of aromatherapy and massage for improving
wellbeing. He suggests that the main benefits
tend to be in the areas of psychological/emotional
support. Some of the emotional challenges which
may be associated with aging (and cancer) include
low self esteem, loneliness, body image problems
due to physical changes, stress, tension and anxiety,
loss of family and friends, loss of role and loss of life
purpose.
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Two therapists can work on an individual at the
same time and the approach is very easy to teach
to friends and relatives. An example of how this
approach was used to help a patient and his wife is
outlined in the following case history.
Why Aromas are an optional component
of HEARTS
Case history 1
A couple in their late 60s had received bad news
early one morning, and a nurse suggested that they
might like some complementary therapy. The man,
John, who had advanced cancer, was ashen and
very subdued. The therapist asked how she could
help and his wife (Mary) said that they would like to
learn something that they could do for each other.
The therapist suggested that John, who was sitting
in a chair, returned to bed where he could be more
comfortable. He was then propped up with pillows
so he was almost in a seated position and covered by
bed clothes. The therapist covered John’s right arm
with a towel and repeatedly stroked over the towel
from John’s shoulder to his hands. At the same time
she suggesting verbally that, “All you need to do, is to
follow the sensation in your arms as my hands travel
down your arm, from the top of your shoulder to the
ends of your finger tips”.
Es
After approximately three minutes, the colour
started to come back into John’s cheeks, and he
said, “Do you know, I don’t feel sick any more.” The
therapist suggested to Mary that she might like to
join in, stroking John’s left arm at the same time
as the therapist. Mary mirrored the movements of
the therapist and was pleased to have something
to do that could help. After around ten minutes,
both husband and wife were more comfortable and
some ‘normality’ had returned to the situation. The
therapist went on to share more HEARTS techniques
and the couple were pleased to have something that
was easy to do and that they could share.
The biggest difficulty in using essential oils
in the context of HEARTS is having qualified
aromatherapists readily available to accurately
and safely assess, select and dispense essential
oils and to monitor the effects they have on the
patient or care home resident. Whilst aromatherapy
is well established in many hospice and cancer
care settings, with complementary therapy teams
providing service provision, in elderly care settings,
aromatherapy provision is less structured and most
hands-on care is delivered by care staff and family
rather than therapists. This raises the question as
to how aromatherapy can be safely and effectively
implemented.
How aromas can be used in the context of
HEARTS
Having explained the goals and processes of
HEARTS, no doubt qualified aromatherapists
reading this article in the International Journal
17
of Clinical Aromatherapy will have already have
some ideas and opinions based on their personal
aromatherapy practice. An important point to
emphasise is that in HEARTS, the Aroma element
of the process can involve the sense of smell alone;
essential oils are not necessarily applied directly to
the skin.
Below, I make a few suggestions to guide practice
and to provide ideas.
Firstly, the patient and therapist can explore together
key fragrance preferences and agree on a pleasing
aroma. One or two drops of the corresponding
essential oil can be placed on the fabric cover,
especially if it is a towel or blanket as the person’s
body heat will then facilitate the evaporation of
the oils. Other well-used methods include using
the essential oil/s on a tissue, cloth strip or a ball
of cotton wool and placed near the face, so that
the person becomes aware of the aroma during
treatment. Above all, the most important factor
is that the person likes the aroma. Bear in mind
that olfactory stimuli that are most easily liked
and recalled are those that are simple, familiar and
identifiable.
Since HEARTS was developed, the use of
personalised aroma inhaler devices/ aromasticks
has become a very popular patient-controlled
coping strategy. Providing the individual is
cognitively and physically able, these same devices
could effectively form part of a HEARTS treatment.
Over recent years there have been a number of
publications on aromastick / aroma inhaler use
in clinical care settings (Maycock et al., 2014;
Hackman et al., 2012; Carter et al., 2011; Stringer
& Donald, 2011; Dyer et al., 2010; Dyer et al.,
2008), clearly demonstrating their effectiveness
for managing common challenges such as anxiety,
nausea, sleep disturbance, for promoting relaxation
as well as for anchoring aroma to other techniques
such as massage. Results suggest that the effects
of aromastcks may be directly proportional to the
frequency of their use (Stringer & Donald, 2011).
To date, the use of aromasticks in elderly care has
not yet been reported in the literature.
Figure 1. Aromastick components
Other inhalation appliances that are currently
attracting interest in elderly care settings include
the Bioesse patented inhalation patch (Bioesse
Technologies LLC, USA), with an advantage that
these may be used with individuals who are less
cognitively or physically able to control aroma
inhalation. They also hold potential for passively
providing the Aroma part of the HEARTS process
during a session. This inhalation patch adheres
directly to the patient’s skin or clothing, releasing
vapours for inhalation for a period up to five hours
following application. These single use patches
are available already ‘pre-charged’ with blends of
essential oils or with familiar and pleasant oils such
as Lavandula officinalis (lavender), Mentha spicata
(spearmint) or Citrus reticulata (mandarin) or as
neutral/ blank patches which the carer/therapist
can personalise with a chosen oil/ blend/ fragrance.
Figure 2. Bioesse Inhalation Patch.
18
• Chamomile - ‘the countryside after rain’
• Clove - ‘Christmas punch’
• Lilac - ‘my aunt’s garden’
Once the individual has identified the aroma that
triggers an odour memory, the scenario can usually
be recalled in terms of sensory language fairly
easily. This includes the details of what the person
could see, what s/he could hear, how s/he felt, the
temperature of the scenario as well as the associated
aromas and possibly the taste. This approach can be
illustrated in the following case history.
Case history 2
Figure 3. Bioesse Inhalation Patch in situ.
Odour memory as a powerful therapeutic
tool
If no aromatherapist is present in the care setting,
how can aromas be incorporated into the Handson work of HEARTS? In the context of HEARTS,
I am working on the concept that everyone has a
unique smell memory related to a context/event
that makes that person feel good or brings back
pleasant memories, even if that very same aroma is
not physically present. I am also assuming that the
person receiving the treatment is cognitively able to
participate with the process.
When asked about a positive memory which can be
triggered by smell, responses from patients over the
years have included:
• Rose - ‘reminds me of my mother’
• Orange - ‘tangerines at Christmas’
• Lemon - ‘that holiday we had in Spain’
• Lavender - ‘my grandmother’s garden’
• Eucalyptus - ‘my son’s muscle rub’
Elsie was in her late 70s. She was asked if there was
an aroma from a time in her life that was particularly
memorable. Without hesitation, Elsie replied that
she could always remember the smell of wood
smoke as bonfire night was a particularly happy and
memorable occasion. The therapist asked Elsie what
she could smell, and immediately she described the
smell of the bonfire, the fireworks, and the smell
that was hanging in the air the next morning. With
prompting from the therapist, Elsie travelled back
in time and described what she could see, what she
could hear, if there were any tastes and how she felt
when she accessed these memories. Needless to say,
at the end of the conversation, Elsie was in a more
relaxed state; she was more alert and looked brighter.
The therapist then offered to do some gentle Handson work and to repeat back some of the elements of
the scenario which Elsie had described in the form
of a story
This approach can bring a great deal of pleasure to
an older person, especially if touch is involved at the
same time. For the therapist to relay the scenario
back to the person acts as reinforcement of the
aromatic recall. This is very helpful method where
a caregiver wants to do something extra, but s/he is
not an aromatherapist. As we have seen, once this
sensory association has been cognitively made, just
imagining the aroma during the HEARTS process
can elicit positive responses, even when it might
not be possible to use the corresponding fragrance
during the session. It is also a useful approach when
an aromatherapist finds him/herself involved in an
opportunistic HEARTS treatment, where having to
leave and find essential oils would break the rapport
that had been established.
19
Even if a care giver is not an aromatherapist, there
may still be opportunities to use the sense of smell
with the HEARTS process and it may be possible
here to involve the family. For example, vanilla has
a familiar aroma which has been associated with
pleasurable and calming situations; if an individual
likes the aroma, either a vanilla perfume or fragrance
extract could be used on a tissue to facilitate
recall or relaxation. Suggestions of other aromas
which may be useful could include, chocolate,
coffee, tea, clove, orange, lemon, nutmeg, flower
fragrances such as lilac or linden, herbs, cosmetics,
perfume, aftershave… the list is endless and often
inexpensive. Perhaps an ‘aroma toolbox’ could be
compiled; containing typically familiar fragrances
(not necessarily essential oils, and destined only to
be inhaled - not applied to the skin) which could be
used in triggering odour memories specially to be
used with kind well-intentioned touch.
Es
Conclusion
Some comments from a wide range of patients/
older people include:
• “I felt safe and secure and not alone.”
• “I’ve waited 80 years for this!”
• “After a short session of HEARTS, I was amazed to
find I didn’t have any more nightmares.”
• “I am very relaxed after HEARTS – and it was nice
to be covered up – I felt very snug.”
• “Bringing in my niece to help resulted in a lot of fun
as well as relaxation.”
• “I felt very emotional when the treatment started
but at the end, I was at peace.”
• “I was surprised that I could feel so ‘content’ after
only 15 minutes of complementary therapy.”
• “Bloody marvellous – I’ve never had anything like
that in my whole life.”
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Although the actual aroma may not present, this
above-mentioned approach of recreating an aroma
in the imagination can still have tangible benefits.
Levy et al. (1999) found that in the absence or
reduction of a sense of smell, providing the person
has an established odour memory, they can still
elicit neurological responses (albeit reduced) to
fragrance via their imagination. Furthermore,
where the aroma is present, Herz (2009) argues that
an aroma can adopt the properties of an associated
emotion and then can evoke the full emotional
experience along with its cognitive, physiological
and behavioural effects upon re-exposure to the
same fragrance.
Over the last 20 years some 1000 therapists/health
care workers and more latterly staff in care homes
have been trained to use HEARTS, mainly through
attending workshops where the process is taught.
Increasingly, care homes are becoming interested
in HEARTS as an approach which may to help
improve the quality of life for older residents which
can be easily integrated with daily care.
HEARTS has been accepted as a useful therapeutic
approach by therapists, health care professionals
and care staff. It has been used in a wide range
of supportive and palliative care settings, as a
therapeutic approach as well as an adaptation for
use with other complementary therapies.
At the end of a two day course, I offer a HEARTS
Practitioner Certificate. This is based on the
satisfactory submission written case histories and
focuses on an individual’s practice. Some quotations
from course participants are:
• “At last, I have found something that will help my
most resistant patients to relax.”
• “I was so pleased to find there was something that
B. could do for her father that was pleasant for
both of them.”
• “I have never seen my care home client so relaxed. I
left her with a smile on her face thinking of playing
with her grand children on the beach.”
• “Through HEARTS, I have learned how to give
treatments by working with a client, rather than
feeling I have to be ‘doing’ something all the time.”
• “Using this approach, I am surprised in the degree
of trust which develops between the patient and
myself.”
It has been a pleasure and a privilege to be involved
in developing HEARTS and to learn of its benefits
over time. Its potential for making a difference is
largely undiscovered and I hope that more people
will be able to realise its benefits in the future.
20
References
Campbell L, Pollard A, Roeton C (2001). The development
of clinical practice guidelines for the use of aromatherapy
in a cancer setting. Aust J Hol Nurs, 8 (1):14-22.
Dyer J, McNeil S, Ragsdale-Lowe M, Tratt, L (2008). A
snapshot survey of current practice: the use of aromasticks
for symptom management. Int J Aromather, 5 (2):17-21.
Dyer J, Ragsdale-Lowe M, Cardoso M, McNeill S, Cleary
L (2010). The use of aromasticks for nausea in a cancer
hospital. IJCA, 7 (2):3-6
Fitzgerald M, Culbert T, Finkelstein M, Green M, Johnson
A, Chen S (2007). The effect of gender and ethnicity on
children’s attitudes and preferences for essential oils: a pilot
study. Explore-NY, 3(4):378-385.
Hackman E, Mackereth P, Maycock P, Orrett L, Stringer J
(2012). Expanding the use of aromasticks for surgical and
day care patients. IJCA, 8 (1&2):10-15.
Kemper KJ, Vohra S, Walls R (2008). Task Force on
Complementary and Alternative Medicine, the Provisional
Section on Complementary, Holistic, and Integrative Medicine,
American Academy of Paediatrics. The use of complementary
and alternative medicine in paediatrics. Paediatrics, 122(6):
1374-1386. DOI: 10.1542/peds.2008-2173.
Langler A, Mansky PJ, Seifert G (2012) Integrative
Paediatric Oncology. Berlin: Springer-Verlag.
National Cancer Institute. Aromatherapy and Essential Oils
PDQ®. Health Professional Version. National Institutes
of Health, last modified 10/16/2012. Web. 14 Jan 2014.
<http://w w w.cancer.gov/cancer topics/p dq/cam/
aromatherapy/healthprofessional/>
Ndao DH, Ladas EJ, Cheng B, Sands SA, Snyder KY, Garvin
JH, Kelly KM (2012) Inhalation aromatherapy in children
and adolescents undergoing stem cell infusion: results of
a placebo-controlled double-blind trial. Psycho-Oncol,
21(3):247-254. First published online in Wiley Online Library
(wileyonlinelibrary.com) 2010 DOI: 10.1002/pon.1898.
Post-White J (2006) Complementary and alternative medicine
in paediatric oncology. J Ped Onc Nurs, 23(5): 244-253.
Post-White J, Nichols W (2007) Randomized trial testing
of QueaseEase™ essential oil for motion sickness. Int J
Essential Oil Ther, 1(4):158-166.
Ragsdale-Lowe M (2009) Supporting a young girl through
radiotherapy following resection of a brain tumour: case
study. IJCA, 6(1): 23-25
Stringer J, Donald G (2011) Aromasticks in cancer care:
an innovation not to be sniffed at. Complement Ther Clin
Prac, 17:116-121.
21
Reducing anxiety and restlessness in institutionalised
elderly care patients in Finland: A qualitative update on
four years of treatment
Ulla-Maija Grace
Aromatica Wellness, Aromatica Oy, Turku, Finland
[email protected]
http://www.aromatica.fi/
This paper is a report of aromatherapy treatments delivered in several different institutions
caring for persons with dementia between 2010 and 2014. It draws on implementation and
evaluation of aromatherapy treatments delivered by nursing and care staff to residents in
hospital and care settings in Finland between these dates as well as care implemented in Japan
in 2014. The same methods described can also be extended to home care situations where most
of the work in the future is likely to be conducted.
The study questions were:
1. Do aromatherapy treatments reduce the restlessness and anxiety of the patients ?
2. Do aromatherapy treatments affect the working atmosphere of the staff ?
3. Do aromatherapy treatments reduce the need for sedative /pain relief medications ?
Evaluation of care detailing 429 aromatherapy treatments (up to December 2014) suggests
that aromatherapy clearly achieves the first study question and offers insights into the value of
aromatherapy delivery in elderly care as well as its potential benefits to care staff and family.
Introduction
The numbers of ageing population in most countries
is forecast to increase for the next 25 to 30 years, but
carer resources are not predicted to keep pace. There
is thus a need to find ways to compensate for this
imbalance. We have a effective and relatively simple
way with essential oils to keep people naturally
healthier and more able cope with the basics of life
such as eating, moving and communicating in later
life.
Aromatherapy is also economical (in this
atmosphere of world financial gloom). Hospital and
residential home care is much more expensive than
carers visiting the ageing person at home.
We believe that easy, down-to-earth methods of
care can benefit from the addition of essential
oils to reduce anxiety and lift persons from their
melancholy, activate their interest and ease their
discomfort. With these small changes to the routines
of the elderly, handicapped or palliative care patient,
the carer, nurse, therapist or family member will
themselves also benefit from the health-enhancing
effects of aromatherapy.
The phases of dementia: the effect of
fading memory on personality
Dementia is invariably linked to significant
memory impairment and thus it is worth reminding
ourselves of the impact this has on the individual as
the therapist is likely to encounter individuals at all
stages of the disease. The advancement of memory
loss is usually described in four stages.
22
1.The disorientation phase is when the person is
still connected to reality and tries to maintain
control over his/her life. Self confidence weakens,
the person notices their memory lapses and tries
to hide them. There is a resistance to change and
a frequent need to seek for words. The person
searches to feel secure (can manifest as thieving)
and is afraid of being deserted (can bring about
feelings of jealousy).
In Ann-Mari’s words:
“Some long term patients can be with us for ten
years. They suffer from many illnesses and memory
impairment, no longer communicate and are seldom
visited by their relatives. Basic nursing and care
cannot substitute the closeness and love of relatives.
I felt that by using aromatherapy, we could help to
calm the patients, offer comfort, experience gentle
touch and have the undivided attention of the nurse.
I was hoping to be able to bring something better into
their dull daily lives with these kinds of treatments.”
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2.In the second phase, time and place become
indistinct and the person withdraws into
emotional
memories.
By
withdrawing
momentarily into past memories, self control
and inhibitions disappear and speech can be
very direct and even rude. The person can still
recognise insincerity. False or pretentious conduct
towards the patient can lead to uncooperative
behaviour. He/she will spend time doing familiar
things, wants to be useful and loved and needs
to have his/her basic feelings and needs to be
recognised.
Slow, steady and persistent work over the years then
brought about a new phase with the initiation of a
pilot study in 2010 at the Long Term Geriatric Care
Unit 3C, Kaskenlinna Hospital for the Elderly, Turku,
Finland. The permission for the pilot was given
by the Head Doctor Tapio Rajala of Kaskenlinna
Hospital. Nurse Ann-Mari Lindgren took the
responsibility for the running of the project.
3.In the third phase, the repetitive movements
phase, speech is largely replaced by movement.
The person is no longer fully aware of himself /
herself as a person, nor of his or her surrounding
space. Waiting for anything becomes difficult
and he / she longs for the smile and touch of the
nurse/ carer. Feelings are expressed by making
noises, crying, knocking, wandering around,
with repetitive actions and by using force. Speech
becomes unclear.
Es
4. In the fourth phase, the foetal or turning inwards
phase, the external world is shut out. The person
shuts the external world out and withdraws into
their own emotions and feelings by lying or
sitting with closed unmoving eyes. They still are
able to sense the touch of others and react with
eye movements or smiling.
History and evolution of the aromatherapy projects
Approximately 12 years ago Kaarinakoti, an elderly
care home in Finland, contacted our company,
Aromatica to have their staff trained in our elderly
care treatments using essential oils. The goal was to
benefit their patients suffering from various types
of dementia.
The experience gained from the initial pilot
study conducted in 2010 was encouraging and
Kaskenlinna Hospital then funded the training of
more staff as well as the costs of the essential oils
used for the treatments to enable the continuation
of further data collection for better validity. This
extended study was continued with the same format
as the pilot.
We also then went on to train staff at other elderly
care centres to be able to give treatments and collect
the data in the same way as at Kaskenlinna. To date,
we have more than doubled the number of total
treatments given from when we first presented
our work at the First International Aromatherapy
Congress run by the Japan Aromatherapy
Association in September 2012, up to December
2014. This article reports on the total number of
treatments given over the entire time period.
Study questions
1.
Do aromatherapy treatments reduce the
restlessness and anxiety of the patients ?
2. Do aromatherapy treatments affect the working
atmosphere of the staff ?
3. Do aromatherapy treatments reduce the need for
sedative /pain relief medications ?
23
Materials and Methods
Patients treated:
78 patients, men and women between the ages of
65-95.
The total number of treatments given:
429 with the average number of treatments given
per patient being 5.5 sessions.
General health concerns of the patients:
These included:
• Heart and circulatory problems (diminished
function, high blood pressure), reduced kidney
function, diabetes, arthritis, constipation, poor
sleeping.
•Mental health and memory deficiencies:
Alzheimers, problems related to stroke, epilepsy,
schizophrenia, dementia…
•Medications: these vary depending on the
philosophy of each institution. Some reduce
medications to the very minimum required
for wellbeing with each incoming patient. This
enables the patients to be more alert, active and
mobile. The main medications that are prescribed
are for reducing pain, controlling blood pressure,
diabetes, sedation and antipsychotic effect.
Treatment method:
The aromatherapy treatments were delivered by
nurses and care staff after attending in-house
training. The treatment given was a 10 to 15 minute
hand and lower arm massage (light stroking) using
one of two ready-blended products containing
essential oils. The quantity of the blend used in
each treatment was between one and one and a
half millilitres. These blends were developed by
the author and have been used in spa and clinic
treatments and therapies in Finland, Estonia and
Japan for over ten years.
The most popular blend used for the massages was
called ‘Harmony and Delight’. The formulation is
detailed in Table 1. The aim of this blend is to calm
the mind, to soothe fluctuating emotions, to refresh
and uplift the spirit. The essential oils were blended
to a 1 % dilution in a base of Sesamum indicum
(sesame seed) and Vitis vinifera (grapeseed)
vegetable oils.
Data collection sheet:
Staff observations were recorded immediately
before and after treatment on a data collection
sheet (see Figure 1). The collected data was based
on the observations and experiences of the nurses
and care staff that delivered the treatment as many
of the patients were not able to communicate. Staff
were briefed on how to most accurately complete
the data. For example:
• On arrival to the patient, the nurse/carer observes
the mood/ facial expression of the patient and
records it on the sheet and makes a note of any
verbal greeting or comment from the patient.
• During the treatment, any changes in expression;
words, singing, facial expressions etc are also
observed and noted.
•After the treatment, any behavioural changes
are recorded and also the final facial expression
marked on the data collection sheet.
Table 1. Essential oil Blend 1 ‘Harmony and Delight’ (concentration 1% in vegetable oil base).
Botanical name
Common name
Principal components with approximate %
Citrus paradisi
grapefruit peel
Limonene 94% beta myrcene 2%
Picea mariana
black spruce
Alpha pinene 15%, camphene 20%, bornyl acetate 27%
Cymbopogon martinii
palmarosa
Geraniol 82%, geranyl acetate 6%
Melissa officinalis
lemon balm
Geranial, neral and citronellal up to 70%
Citrus aurantium
petitgrain
Linalol 23%, linalyl acetate 48%
Lavandula angustifolia
lavender
Linalool 42%, linalyl acetate 31%
Rosa damascena
rose
Citronellol 24%, nerol 10%, geraniol 22%
24
Figure 1. Data collection sheet (orange text: before treatment; green text: after treatment)
The main evaluation that enabled a numerical
presentation of the study was gained by recording
the changes in the mood that was visibly expressed
in the patient’s face immediately before and after
treatment. We also collected data on any verbal
communication during treatment as well as any the
occasional extra feedback from staff later on the
same day of the treatment. Continuous follow up of
the treatments after the nurse/carer had finished her
shift was not possible on a ward with changing staff.
The data collected are from the pilot study conducted
in 2010 plus the data collected from autumn 2011 to
the end of 2014 at the Long Term Geriatric Care Units
3C and 3D Kaskenlinna Hospital plus three elderly
care homes in Finland and one in Japan. One set of
treatments has also been given in patients’ homes in
Heinola, where the local government buys services
from health care entrepreneurs for home care.
By the end of December 2014, where the number
of total treatments was almost 2.5 times that of
the pilot study, the same trend in mood shift from
apathetic or negative state towards a positive state
was maintained (see Table 2).
Spontaneous comments by patients:
‘I am glad that I found you’
‘Why am I given such luxurious treatment?’
‘This makes me always so calm’
Fig 2. The effects of treatments (pilot study results)
(yellow = very happy; orange = cheerful; neutral = apathetic;
purple = low mood; grey = sad or depressed)
Results
Data collection sheet:
The graphics in Figure 2 which reflect the results
of the initial pilot study show a systematic mood
change from the gray “sad” faces towards the yellow
“very happy” face. Before treatment, the mood of
neutral colour/ apathy has the highest peak and after
the treatment the highest peak was at the orange/
cheerful mood indicating a positive mood shift.
The data in the data collection sheets show that the
improvement and expression of mood, which could
imply a state of relaxation, is clearly noticeable during
and after message.
25
Table 2. Mood shifts from before to after treatment across all studies until Dec 2014 (Total 429 treatments)
Before treatment
After treatment
Difference
very happy
31
162
+131
cheerful
134
171
+37
apathetic
192
88
-104
low mood
60
8
-52
sad or depressed
12
0
-12
“I can use my hands again”… singing during the
treatment
“Now my hands are stiff, they need treatment”…
asking for treatment
“This Miss has now amazingly fine hands”… “that
the substance all goes in!”
“Will you come again? Will you find me?”
“This is how you should massage!”… and then
actually massages the care staff ’s hands
“Hands are warm, hands feel less stiff ”… a patient with
Parkinson’s disease, who wants treatments more often.
Additional observations from care staff:
• A fearful, aggressive, big male patient, who does not
like being touched commenting after successive
treatments: “did not feel bad”... “felt good”... “feels
as good every time”... “hands feel healthier now
when they are warm under the blanket”.
• A patient with dementia talks about how good
it feels in the hands and the whole body (suffers
with a lot of pain).
• A patient with depression and many illnesses and
in a lot of pain tells what she has done with these
hands, she sings, her breathing calms…
Comments by staff on the day of treatment:
“K. (after the 1st treatment) was so calm. He did not
follow behind anybody asking questions the whole
evening after the treatment” (given about 2.30pm).
“L. ate his meal without being assisted” (normally
needs to be fed).
“M. massaged her own hands for a long time after
the treatment and wondered about the softness of her
hands”.
“H. sat still quite calmly for a long time after the
treatment” (normally walks around all day looking
worried and talking).
Other general effects commonly observed after
treatments:
• in general the overall effect is a satisfied, happy
mood
•according to patients the treatments appear to
ease pain
• the patients recognize the sensation of warming
of their hands
• many want the treatment to continue
• their breathing eases
• talk becomes coherent
• hands relax
• massaging their own hands
• massaging the hands of the therapist
• showing the therapist how to massage
• eating without assistance
• remembering the treatment given yesterday.
Staff experiences:
The staff themselves found giving the treatments to
be rewarding and beneficial and therefore enhanced
their experience of the value of their work. One
comment by the nurse in charge of the study in
Kaskenlinna:
“Systematically the treatments are effective. They
calm restlessness and lift anxiety. For restlessness,
anxiety, hallucinations it always helps”.
Discussion
This study shows that aromatherapy can be offered
as an excellent supportive treatment to patients
with dementia. It shows that the calming effect of
the treatments is immediate for anxious, restless
patients.
26
The patients that we meet in institutions are
usually at the levels three and four of the memory
impairment stages mentioned earlier and it is at
those stages that we witness the greatest benefits.
Naturally the treatments also work on persons
in better health, but the changes do not appear to
differ quite so much from the norm.
How the treatments work
1. The ready-blended oils that were used answered
to a fairly wide range of the needs of the patient
group in question. Only brief training was
needed in their use. The blends themselves had
already been tried and tested in professional
practice over a number of years.
2. The massage technique itself was simple enough
to be taught in two short sessions during the
working day to the staff.
3. The massage treatment duration was short
enough to be delivered and incorporated into the
normal working day routine.
4. The data recording document was fast and easy to
use and easily explained to the staff.
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The whole treatment has at least four separate
elements to be considered:
1. The massage with essential oils - touch will be
noticed and it brings pleasure. The aroma linked
with touch will eventually awaken the anticipation
of the treatment even before touch occurs.
2. The effect of the aroma - as the aroma is linked
with the feeling of pleasure and of reducing
pain, at some stage of the treatment programme
the scent alone may evoke the memory of the
treatment. This in itself will be beneficial.
3. Triggering memories - a familiar aromatic note in
the treatment blend can trigger old memories and
create the desire to verbalize them to the carer.
4. The interaction between the patient and the
therapist - the undivided attention and respectful
approach at all levels of treatment is a vital part
of care. In particular I feel that this is important
at the very first phase of memory loss as it can
boost the person’s self confidence. With repeated
treatments, it may help to overcome the shame
felt and hopefully start working to delay the
memory impairment process.
major question that needed to be resolved. We tried
to accomplish this with the following strategies.
Reducing therapist bias
Es
In a treatment with such close contact between two
people, the personality and the mood and emotions
of the carer/therapist is likely have an effect on the
treatment and could have impacted the results of
the study. In our study, because there was more
than one carer giving treatments to each patient,
this reduced the possibility of the personality of the
therapist having a direct influence on the overall
result.
Key elements of successful integration
In planning the study, the practicality of putting it
into the practice to suit working conditions was a
The place of readymade blends
As therapists, we are all familiar with aromatherapy
treatment routines; creating the client record card
and filling it in before and after each treatment,
choosing the appropriate oils for each treatment and
making up the blend before actually delivering care.
This is aromatherapy at its best and is wonderful
when you can do it. Aromatherapy training is a long
process and the treatments are by their very nature
very personalized for each client. The therapist can
and has to give time for each individual client and
work with him/ her to find the best oils for each
treatment and also give guidance in self-care.
In the first part of this presentation I reported
on reducing anxiety and restlessness in memory
impaired patients. For the original study we
used two different blends of essential oils. The
reason for readymade blends rather than single or
individualised oils was simple:
• The staff are not trained aromatherapists.
• In a ward of 20 to 30 patients it is not possible
for the staff to break from their daily routines to
spend a long time in treating one individual.
•The needs and aroma histories are different
among so many people. This makes choosing an
individual oil that would suit everyone almost
impossible.
•A single essential oil would not cover all the
aspects and needs of a group of patients.
27
In this way, more people can benefit from essential
oils as healthcare professionals who may not be
interested training as professional aromatherapists
can safely and effectively offer Aromatica Wellness
treatments to their clients. This is also an easier way
to be able to introduce the use of essential oils into
the general health care setting.
to enhance memory recall. For this, the carer will
have to talk to person’s relatives/ friends to find out
the patient’s history to be able to choose appropriate
scents. These might not always be found from
natural essential oils.
Creating a blend with a common purpose needs
even more work from the outset before it is then
used in practice. One needs to consider the general
needs of the group and the goal/s for the treatments,
choosing the appropriate essential oils and finally
creating the blend that has an aroma acceptable to all
and effects that are noticeable by all. The blends that
I have created over the past 20 years for professional
use started from the need for aromatic treatments
in the Finnish spas. Now they have found their way
from the spas, to masseurs, physiotherapists, self
care, hospital, elderly and handicapped care as well
as palliative care.
Music therapy has a well established place in elderly
care. We may be able to expand this with associating
music with familiar names of aromatic items coupled
with the corresponding aromas. Singing along with
the music brings back words and the aroma ties the
words again into the memory that can then be reevoked at a later stage.
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Music therapy and aroma
Enhancing other methods of care with the
use of essential oils
Aromatherapy offers many potential benefits
to enhancing care of the elderly person. Some
examples follow.
Looking to the past
Es
Reviving memory with photos or personal items
In every country there are different environmental
aromas that are held in the collective communal
memory. Photographs often are taken outdoors and
aromas related to the natural environment may help
to bring old memories to the surface. In Finland, it
might be the silver birch or acacia; in Japan: hinoki;
Canada: pine tree; France: lavender; England: rose…
and so on. We can use these familiar fragrances to
stimulate and revive memory as well as enhance
mood.
The life story told by the patient.
As we journey through life, we make powerful
connections with aromas linked to specific contexts.
We are therefore able to use aromas from the past
Living environment and wellbeing
Boosting appetite
Appetite and weight loss is a common challenge
in dementia care. Citrus limonum (lemon peel) oil,
will for most people increase salivation. For elders,
this will make chewing/eating easier and saliva will
bring the all important enzymes into the food to
ease digestion. As a result, in some cases, there is an
increase in weight gain.
Cleansing / refreshing the room air
Particularly in the mornings when the staff first
goes into the patient rooms, it is useful to have a
cotton ball or hankerchief in the pocket with a fresh
smell of one oil such as Citrus paradisi (grapefuit
peel) or another refreshing aroma that is universally
pleasing.
Lifting mood and getting ready for activity
The morning routine of using the same refreshing
aroma in the carer’s pocket will, in time, help the
patients to associate the same aroma with morning
time and the associated morning routines such as
getting up, having breakfast etc.
Another aroma could be used for giving information
for the afternoon or evening activities, just as
using food-related aromas can signal meals and
refreshment times.
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Personal care
For personal care, with our student group, we
have recently discovered the delights of aroma
inhalers. During their training, students have to use
essential oils with different methods of application
for targeted purposes. One student who works in
a psychiatric hospital in Switzerland reported her
success using Citrus bergamia (bergamot) oil in
aroma inhalers for both staff and patients for lifting
the mood and calming agitation.
Conclusion
•Treatments can be included in the daily ward
routines.
• The nurses and care staff find the giving of the
treatments a positive experience.
• The treatments were economical, using only one
to one and a half millilitres of oil per treatment.
This indicated a potential cost saving compared to
the expense of medications that we could explore
further in future work.
•Treatments have now been included in the
official ward treatment protocol at Kaskenlinna
Geriatric Hospital. This positive development
has in fact affected our continuing evaluation
of aromatherapy at this location as the nurses
now record the information for each treatment
directly onto the hospital computer database.
The database does not facilitate the original data
collecting sheets and thus the data collection
from there cannot be used to add information
to this work in the future. The great achievement
here is that the treatments now are available for
the patients as needed in the future.
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The aroma inhaler is an effective way of using
essential oils in situations where there may be
other people sharing the same space such as in
institutionalised care, who may not like or who are
allergic to scents.
Other valuable findings of our work include:
Es
Elderly care is increasingly under scrutiny with much
discussion concerning the quality and cost of care.
With people living longer and medical treatments
being more effective and more expensive, caring for
elders in their latter years is an urgent subject that
has social, economic and political aspects. In recent
years, due to the escalating demand for health care
resources, in many countries, the focus has been
shifting towards community based care for the
elderly, with responsibilities falling on the wider
society (families, neighbourhoods, communities…)
to help support the elder in their home environment.
In the future, it may well be that hospitalisation or
care home facilities are going to be able to offer
places only to those who really cannot cope at all on
their own at home. ‘Independent living’ has become
the latest buzz phrase. A key question remains: how
can we support our elders and improve quality of
life in their latter years?
In terms of our study goals, the most important
target (first question) was achieved:
1.
Do aromatherapy treatments reduce
restlessness and anxiety of the patients ?
the
The results concerning reducing anxiety and
restlessness immediately after the treatment is clear.
Our work at Kaskenlinna Hospital and the three
elderly care homes in Finland continues. We also
now have the Lahti City Hospital, palliative and
terminal care unit beginning treatments during
this summer 2015 to collect data for our project
and of course benefit the patients. Aromatherapy is
now an integral and established part of elderly care
provision and we anticipate that as focus shifts in
the future to delivering more care in people’s homes
that aromatherapy provision will continue to extend
into the community.
“Then…when I do not remember my name
Then, when today has blended with yesterday.
Then, when my adult children
have grown small again in my memories.
Then, when I no longer am a productive individual.
Even then…treat me as a human being
Care for me, give me love, touch me gently.
The clock slows down and one day
it will stop completely.
But there is still time before that.
Let me grow old honourably.”
Anonymous
29
Aromatherapy Service Report: The use of essential oils in the
geriatric departments of Valenciennes Hospital Centre, France;
integration within the rigours of hospital practice and protocols
Geraldine Gommez-Mazaingue
Hospital doctor, Geriatrician, short stay geriatrics, Valenciennes Hospital Centre, France
[email protected]
In France there is increasing integration of aromatherapy in clinical settings, often instigated
or overseen by medical practitioners themselves and meeting the stringent rigours of hospital
care and protocols. Contrary to many other countries, aromatherapy in French hospitals is
often integrated ‘from the top down’ via doctors and pharmacists, along with trained care staff
delivering care under their prescription and approval with robust protocols for patient safety,
care and assessment in place. This service report is one such example where aromatherapy care
provision is delivered under medical prescription.
Under the supervision of Dr Geraldine Gommez-Mazaingue, a geriatrician with 10 years
experience working in acute geriatric medicine in charge of the division for pain management
and palliative care, aromatherapy has been part of the non-pharmacological service provision
in geriatric care since 2008. To date, 18 aromatherapy protocols have been implemented within
her hospital; the service is fully streamlined with conventional care and has since extended into
all hospital departments such as obstetrics and surgery. In this service report she presents an
overview of her service in geriatrics.
Introduction
Valenciennes Hospital Centre is a 2000-bedded
hospital situated to the south of Lille in the north
of France of which half the beds are destined for
acute care across all medical, surgical and obstetric
specialties (with the exception of cardiac surgery
and severe burns). It is the reference hospital for
the south of the department ahead of the University
Hospital (CHRU) of Lille, covering a population
of 800,000 inhabitants. It is the second biggest
establishment in the Region of Nord Pas-de-Calais
and one of the 30 biggest hospitals in France.
A complete chain of geriatric care has been developed
with acute medical geriatric care beds (health sector:
45 beds in short stay geriatrics plus a day hospital),
residential beds (medico-psycho-social sector:
retirement home, long stay geriatrics, day care for
Alzheimer patients, etc) and town-hospital and
hospital-hospital interface beds (geriatric sector).
This chain of care generally welcomes patients over
the age of 75, with multiple pathologies, with loss
of physical or cognitive independence and who
meet the criteria of being vulnerable and with high
dependency on a physical, mental and/or social level.
Non-pharmacological interventions have long
been part of general geriatric care irrespective
of the health or medico-psycho-social structure
(touch-relaxation, Snoezelen®, Humanitude, odour
memories, etc) and the use of essential oils is a
natural step to further enrich this palette of care
provision, whilst always remaining complementary
to the pharmacological interventions provided.
30
One difficulty of integrating this type of care in the
hospital environment is the rigour that is imposed
and demanded in terms of prescription, paperwork
and protocols, traceability of care and efficacy as well
as quality and transparency regarding the purchase
of essential oils, materials used and training of staff
that meets specific criteria.
This scientific aromatherapy approach in geriatrics
was initiated at our hospital in 2008 starting with
symptoms that were identified to be the most
challenging for our patients and which were not
effectively relieved with the usual recommended
treatments. These included: pain, anxiety,
behavioural issues, insomnia, skin lesions, airborne
deodorisation, bruising as well as use in association
with other wellbeing interventions to enhance their
effect (touch-relaxation, relaxing baths, etc).
Training programs for care staff were therefore
initiated and are repeated annually, combining
theory (physicochemical knowledge of essential
oils, etc) with practice (use of essential oils and/or
blends with elderly patients).
In parallel, we developed a number of aromatherapy
protocols based on the same protocol models
for medicines (the exact composition to
ensure reproducibility, dose, indications and
contraindications, a defined duration of care
and compulsory re-evaluation of efficacy based
on traceability and according to the targeted
symptom). Additional elements of our care
provision include compulsory medical prescription,
patient consent, olfactory and skin testing as well as
qualitative assessment based on patient satisfaction
questionnaires.
The essential oil protocols that we developed are
primarily concerned with skin application (direct
application/ touch-relaxation/ massage or relaxing
bath) and airborne diffusion. From this we have
developed 18 aromatherapy protocols for skin
application and/or for diffusion. For example we
have:
• An acute or inflammatory pain procotol composed
of wintergreen, lemon scented eucalyptus and
katafray essential oils (see Table 1).
• A bruise protocol based on arnica infused oil and
helichrysum essential oils
•A melissa protocol used in palliative care in
the case of ‘letting go’ (essential oils of melissa,
lavender and sweet orange)
•An antifungal skin protocol with a blend of
vegetable, oil, tea tree, lavender, etc.
Table 1 illustrates a typical protocol (in this case,
our acute or inflammatory pain protocol) that was
developed and validated; it is reviewed on a regular
basis. As one can see, this protocol guides the user
in the indications, contraindications, dose, duration
and application of the protocol along with clear
instructions on the preparation of the blend itself.
The details of the protocol in French are translated
below.
Acute pain blend
• 1 volume lemon-scented eucalyptus essential
oil (Eucalyptus citriodora)
• 1 volume wintergreen essential oil
(Gaultheria procumbens)
• 1 volume katrafay essential oil (Cedrelopsis
grevei)
Indications:
• Acute pain
• Inflammatory pain
•Bruising
Examples: arthritis, gout, cartilage calcifications,
acute sciatica, polyarthritis.
Contraindications:
None if the dose is respected.
Dose:
Direct undiluted skin application:
• 1 to 2 painful areas = 1 drop to each zone three
times per 24-hr period
• 3 painful areas = 1 drop to each zone twice per
24-hr period
• More than 4 painful areas = 1 drop to each zone
once per 24-hr period
In dilution in a vegetable oil:
Diluted to 10 percent in a vegetable oil (example:
1ml essential oil for 9mls vegetable oil):
• for larger areas = 1ml of the diluted blend three
times per 24h period
• for massage (delivered by the physiotherapist).
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Table 1. Aromatherapy protocol for acute pain
32
Treatment over a period of 5 days maximum,
with possibility of renewing following medical reevaluation.
Preparation of Blend 1:
In a 10ml bottle:
3mls lemon eucalyptus essential oil
3mls wintergreen essential oil
3mls katrafay essential oil
In a 30ml bottle:
10mls lemon eucalyptus essential oil
10mls wintergreen essential oil
10mls katrafay essential oil
Dilution table for blend at 10% in a vegetable oil:
•In a 10 ml bottle: 1ml essential oil blend and
9ml vegetable oil
•In a 30ml bottle: 3ml essential oil blend and
27ml vegetable oil
• In a 100ml bottle: 10ml essential oil blend and
90ml vegetable oil
Computerised medical prescriptions for
aromatherapy
With patient consent, each care intervention is
preceded by a medical prescription that then
permits the care to be integrated within the official
hospital care plan at the same level as medical and
pharmacological care, to which aromatherapy
is most often used as a complement. This data is
entered into the hospital’s computerised care system
(see Table 2) along with all the patients care needs.
As with medicines, a review of efficacy of an
aromatherapy blend is made as well as care
traceability entered in a separate and specific
aromatherapy care plan that is recorded on the
computer, giving details of the blend used, the
emotional state of the patient, the results of the
olfactory and cutaneous tests, the indication and
timing of treatment, the degree of relief obtained
and identity of the care staff who delivered the care.
Table 2. Computerised medical prescription for aromatherapy
La prescription se met
The
aromatic prescription
au niveau des soins et
is in the care section and
est intégré au plan de soin
is integrated into the care
du patient au même titre
planque
at the
same level as
prescriptions
medications.
médicamenteuses
33
Feedback
Since the service started, aromatherapy care has
been unanimously welcomed by our elderly patients
who appreciate this care approach (results obtained
from our patient satisfaction questionnaires). It also
allows the care staff to ‘take care’ differently from
the usual recourse to medication and to develop
more of a relationship with our elderly patients who
are weakened by life and diseases.
This same group is also working on clinical
research projects concerning our service in order to
scientifically validate this type of care measure. Some
studies have already been conducted in a number of
geriatric settings concerning behavioural problems
and constipation but at Valenciennes Hospital
Centre, we currently lack a statistical support
structure to help us with the implementation of
scientific studies that would permit us to underpin
the benefits of aromatic care provision. This
challenge is currently under discussion; it would be
also interesting to be able to conduct joint studies
with other French hospital centres and to exchange/
share our findings.
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This type of care takes on a particular relevance with
regards our patients who have memory loss with or
without associated behavioural changes but equally
in end of life care where the emotions and senses
are highly enhanced.
tender with established criteria in the form of core
knowledge across all sectors combined with specific
information according to specialty: psychiatry,
obstetrics, surgery, paediatrics, geriatrics, etc).
We have also noticed that more and more patients
are using essential oils themselves in home care,
giving us the chance to further connections and
exchange experiences.
Lastly, our patient population being in part
composed of individuals with memory problems,
we cannot omit mentioning the evocation of odour
memory that can often soothe and bring comfort.
The proposed oil is often a vector of communication
or an emotional trigger for patients who are
otherwise not able to communicate.
The development of aromatherapy in our services
has therefore naturally evolved to enrich our project
of complementary non pharmacological care, all the
time respecting the obligations and the necessary
safety issues for hospital practice both in acute or
residential care settings.
Es
The current situation
Currently, aromatherapy is integrated within
the entirety of hospital services and has led to
formation of a special focus group that works on
protocols, the purchase of essential oils via tender
(according to established criteria that correspond
specifically to service provision requirements) and
the quality of training for carers (once again via
Future perspectives
Future perspectives underway include the continued
development of aromatherapy protocol via our
institutional focus group in different care settings,
ensure the continued place of aromatic care via
prescription and traceability, and the possibility of
finding further training that is adapted to hospital
care and meeting our specific requirements. An
additional big challenge is also to be able to develop
clinical research that integrates essential oil use
which unfortunately is not yet a priority in hospital
research structures.
Nevertheless, since 2008 the aromatic journey
we have undertaken in our institutions is not
negligible, and the use of essential oils that were
initially disparaged have become part of, and have
been combined with, other well established forms
of care, clearly demonstrating that it is possible
to successfully integrate essential oils via safe
prescribing, quality materials and quality education.
Postscript
Article translated from French by Rhiannon Lewis.
34
Towards defining clinical aromatherapy: the essence
of
Rhiannon Lewis
Aromatherapist, educator, editor, director of Essential Oil Resource Consultants, organiser of botanica2016
www.botanica2016.com • www.essentialorc.com • [email protected]
Melanie Lahuerte
Freelance research assistant
Clinical aromatherapy as a profession is beginning to establish a clearer identity worldwide.
Despite no universal agreement to date of what actually constitutes clinical aromatherapy,
and how a clinical aromatherapist is distinguished from the traditional holistic or medical
aromatherapist, this title - over the past decade - is increasingly chosen and used by practitioners.
This report is based on participant surveys conducted at botanica2012 and botanica2014 — two
international aromatherapy conferences that were held at Trinity College Dublin. Both were
educational events that specifically promoted clinical aromatherapy and attracted participants
from around the world who identified with both conferences’ theme of ‘celebrating clinical
aromatherapy and plant therapeutics’. The results of these two surveys enable us to begin
building an international profile of the typical clinical aromatherapist and furthermore, to
identify their specific interests and educational needs.
The results of these surveys also suggest that the clinical aromatherapy profession itself may be
moving towards establishing a clearer identity that is separate from that of holistic aromatherapy.
As a result, it is perhaps now time to establish clearer guidelines/ definitions for this facet of
aromatherapy provision, to distinguish it from other aromatherapy styles and to identify any
eventual different/ additional education requirements.
Background
mainland Europe (Harris, 2003; Bensouilah 2005).
In some European countries such as France, Belgium
and Germany, aromatherapy is allied to herbal
medicine/ phytotherapy, whereas in the United
Kingdom, these two professions have evolved
somewhat separately with little direct dialogue or
collaboration between them. This may be in part to
the historical origins of UK aromatherapy; being
birthed mainly through the aesthetic profession
rather than evolving via the medical profession as
is the case in France and some other countries on
This Anglo-Saxon style of holistic aromatherapy has
since been ‘exported’ to other countries and is the
main form of aromatherapy practiced worldwide
(Harris, 2003).
Associated with holistic principles and often
including metaphysical concepts, the holistic
aromatherapy style has struggled at times to establish
a secure and valued place within the medical sector
where academic and clinical rigour along with a
robust evidence base is usually demanded.
35
Figure 1. Different styles of aromatherapy
Public perception of holistic aromatherapy as a ‘feel
good’ therapy, being useful predominantly for stress,
relaxation, as a ‘pick me up’ or for general aches
and pains may have contributed to the continued
perception of traditional holistic aromatherapy as a
nice but not integral complement to medical care
(Emslie et al., 2002; Furnham, 2000).
Confusion about what aromatherapy means is
further apparent in the following statement by
Dunning in her book Essential Oils in Therapeutic
Care (2007; pg 6) — a text that focuses on the
integration of aromatherapy in clinical settings:
“Aromatherapy is a confusing term that may not
adequately convey the complexity or therapeutic
benefits of essential oils… In fact, overuse of the term
‘aromatherapy’ for commercial reasons may have
obscured its therapeutic applications, which makes it
more difficult for sceptical conventional practitioners
to take aromatherapy seriously”.
As a result, and largely driven by nurses or allied
health professionals working within the clinical/
medical setting, aromatherapy that is practiced in
these environments (and therefore adapted for the
often medicated, frail and vulnerable patient) often
differs from the traditional holistic style in its scope,
style and training requirements and has additional
focus on evidence-based practice, safety, and
methods of evaluating care effectiveness. Over the
years, the increasing adoption of the title ‘clinical
aromatherapist’ may have stemmed in part from
an attempt to differentiate between these styles.
However, to date, there exists little agreement
between institutions and educators as to what
actually constitutes clinical aromatherapy compared
to holistic aromatherapy.
Botanica2012 and botanica2014 surveys
At the initiative of Rhiannon Lewis, in September
2012, the first international conference of clinical
aromatherapy and plant therapeutics in the English
language was held at Trinity College Dublin,
welcoming 243 participants from 29 countries.
The goals of the inaugural conference -botanica2012
- were to bring together practitioners of clinical
aromatherapy and herbal medicine to share and
demonstrate common ground and learn from
international experts in their respective fields.
Building on its success two years later, another event
- botanica2014 - was held at the same location; this
time welcoming 270 participants from 39 countries.
Both events were based around three days of
international conferences, professional trade show
and one day of professional workshops.
Following both events, participants were asked to
complete a basic survey that included questions
concerning their level of satisfaction with the event
as well as questions concerning the demographic
characteristics of each participant. The second
survey conducted at botanica2014 was further
adjusted and expanded to include more questions
about the participants’ experience of other aspects
36
of the event such as the trade show and workshops,
and provided the opportunity for them to express
their educational desires and needs for future
educational events (botanica2016 is scheduled
for 2-5th September 2016 at Sussex University,
Brighton, UK).
The surveys comprised a series of open-ended
questions as well as checklists concerning the
person’s background (gender, age, training etc) and
took approximately 5 minutes to complete.
The basic data of the 2012 survey (n=168; 69%
response rate) were collected by the conference
organisers and presented at a subsequent
international
aromatherapy
conference
in
Kumamoto, Japan in 2013, organised by the
Japanese Society of Aromatherapy. The data of
the 2014 survey (n=199; 74% response rate) were
collected and recorded by a non-aromatherapist
research assistant, Melanie Lahuerte (France).
Due to these high response rates from participants
at both events as well as the significant number
of countries represented (29 countries for
botanica2012 and 39 for botanica2014), we suggest
that these demographic characteristics are likely
to be representative of all botanica conference
participants and, especially, may provide an insight
into building the profile of a clinical aromatherapist.
Demographic characteristics of botanica
conference participants
Countries represented
Whilst aromatherapy appears to be well established
in main countries such as the United Kingdom,
United States, Canada, Japan and Australasia, it is
rare for practitioners to have the opportunity to
network face-to-face with their peers outside of
their respective countries and member associations.
Most educational events are organised on a yearly
or biennial basis and are hosted by their respective
aromatherapy organisations in their own country,
some of which are listed in Table 1.
Main goals of the botanica conference series are to
bring together and facilitate educational exchanges
between students, practitioners, researchers,
producers and retailers of essential oils, herbs
and related products from around the world via
an educational event that is independent of any
professional association or member group. Prior to
botanica2012, the last independent English speaking
aromatherapy event in Europe was Aroma97, hosted
and organised by Robert Tisserand at Warwick
University in 1997.
In 2012, participants (including conference
attendees, speakers and Trade show exhibitors)
came from 29 different countries. In 2014, the
Table 1. Main aromatherapy associations representing aromatherapists and their headquarters
UK
USA
CANADA
International
Federation of
Professional
Aromatherapists
(IFPA)
Alliance of
International
Aromatherapy
(AIA)
Canadian
Federation of
Aromatherapists
(CFA)
International
Federation of
Aromatherapists
(IFA)
National
Association
of Holistic
Aromatherapy
(NAHA)
British Columbia
Association
of Practicing
Aromatherapists
(BCAPA)
JAPAN
AUSTRALIA
Japanese Society
of Aromatherapy
(JSA)
International
Aromatherapy
and Aromatic
Medicine
Association
(IAAMA)
37
Table 2. Top six countries represented at botanica2012 and 2014
Top six countries represented at botanica2012
(n=135)
Top six countries represented at botanica2014
(n=129)
Ireland32%
United Kingdom 22%
United Kingdom
25%
Ireland 20%
United States
11%
United States 11%
Canada5%
France 4%
France3%
Brazil 3%
Australia4%
Australia 3%
diversity of countries represented at the event
significantly increased to 39. Table 2 shows the top
six countries for each event, representing 80% of
participants at botanica2012 and 65% of participants
at botanica2014.
The total numbers of countries represented at both
events are shown in Figure 2 . In many cases, countries
were represented by just one or two participants.
These include Hungary, The Netherlands, Qatar,
Ecuador, Iceland, Greece, Madagascar, Italy, India,
Jamaica, Portugal, and Finland amongst others,
where aromatherapy organisations relating to those
countries are not yet in place or are in their infancy.
The dominance of the main attending countries
may be due in part to geographical location and
accessibility of the conference events themselves
(held in Dublin, Ireland) and the presence of
‘botanica ambassadors’ who worked actively with the
main organiser to promote the event. Additionally,
with aromatherapy use in clinical settings as well
as aromatherapy education being well-established
in these countries, it is not surprising to see their
increased participation.
It is difficult to argue, however, that the countries
represented at botanica are fully representative
of clinical aromatherapy provision worldwide.
This is due to language barriers; for example,
in countries such as France, Japan and Germany,
where one would have expected more participant
representation given that clinical aromatherapy is
relatively well-established in these domains. Having
an English language-only event definitely excluded
a number of participants from these countries,
despite having an active promotional presence in
each of them via the ‘botanica ambassador’ scheme.
Another observation is that the overall numbers of
participants from West Coast USA and Canada fell
significantly in botanica2014 compared to the event
in 2012. This was found to be due to a USA-based
aromatherapy association conference that ran on
the West Coast within the same time period as
botanica2014. Feedback at the time from potential
participants was that most could not afford to attend
both events and several chose to support and attend
the event in their own region.
Gender
Both events were attended predominantly by
women (n=150; 89% in 2012; n=169; 85% in 2014).
This is in keeping with other reports such as the
paper published by Carter et al in 2009, reporting
on the demographics of participants of a one-day
clinical aromatherapy conference held at a leading
cancer hospital in the Manchester, England. In their
survey, 96% of participants were women. Similarly,
in a general survey of aromatherapists who were
members of an aromatherapy association in the UK
(Osborn et al., 2001), it was found that women were
the predominant therapy providers (95%).
38
Figure 2.
Age
The findings that the majority of botanica
participants were mature professionals over the age
of 40 (Table 3: n= 129; 77% in 2012 and n=165; 83%
in 2014) is also in keeping with the findings of the
UK survey in 2009 (Carter et al.), which found that
93% of their conference participants were over 40
years of age. In the survey by Osborn et al., (2001)
concerning traditional holistic aromatherapists
in the UK, the mean age was found to be 42.9
years. This age is lower than our findings and may
reflect the observation that many complementary
therapists working in clinical care may be on a
second or third career path, or embark on their
career once their children have reached a sufficiently
independent age. Additionally, aromatherapy in
clinical environments may also attract a more
mature therapist, as they benefit from further life
experience and life skills to adapt to and cope with
sick and vulnerable patients who are living with
life-limiting illness and/or facing specific clinical
challenges.
Table 3. Age of botanica participants
AGE
Botanica2012
(n=168)
Botanica2014
(n=199)
Under 21
-
-
21-30
5%
4%
31-40
18%
11%
41-50
37%
36%
51-60
32%
31%
Over 60
8%
16%
No answer
-
2%
39
Profession
When it comes to identifying the participants’
respective professions, despite botanica2012 and
2014 including a strong herbal medicine theme and
educational element throughout the conference,
it was evident that aromatherapy was the most
represented in terms of conference participants
(Table 4.). This is without doubt related to the
organiser’s own profession and the direction of most
promotional information. The data collected from
botanica2012 concerning participants’ professions
was incomplete and therefore has not been included
here for comparison.
Another observation is that 52% (n=104)
of respondents in the 2014 survey were
multidisciplinary, having other roles as healthcare
professionals. In the survey, they were asked to
specify any other roles. Those listed most often
included (in descending order):
•Nurses
• Teachers/ trainers
• Massage therapists
•Reflexologists
• Pharmacist/ doctor
8.6%
6.0%
6.0%
6.0%
4.0%
Table 4. Profession
PROFESSION *
Botanica2014
(n=199)
Herbalist
12%
Aromatherapist
76%
Herbal/essential oil
retail
15%
Retired
1%
Other health care
professional
52%
No answer
3%
* Some respondents gave more than one answer. Data
only available from botanica2014.
There were also a wide range of other professions
listed including: acupuncturist, naturopath, mental
health awareness consultant, lactation consultant,
holistic therapist, energy medicine practitioner,
aromatic medicine practitioner, vibration (spiritual)
healer, kinesiologist, student, product manufacturer
and educational consultant.
Level of professional training
The results concerning participants’ level of
training are shown in Table 5. What is interesting
is the modest fall in private college education and
the rise in online education from 2012 to 2014. The
data from the survey planned for botanica2016 will
go some way to establishing if this is an emerging
trend for aromatherapy education.
For those who responded ‘other’, they were asked to
specify what training they received. Responses were
varied, with the majority of this group expressing
they had received from multiple sources such as
via variety of classes with different educators and
educational establishments as well as self-taught via
Table 5. Level of professional training
TRAINING *
Botanica2012
(n=168)
Botanica2014
(n=199)
Currently a
student
70%
59%
Less than a
year
11%
3%
1-5 years
12%
10%
6-10 years
none
4%
11-20 years
7%
13%
More than 20
years
Not asked
6%
No answer
-
5%
* Some respondents gave more than one answer.
40
books and apprenticeship. Respondents in this group
also had a tendency to mention specific educational
programs. These included: Neals Yard Remedies;
Jane Buckle Clinical Aromatherapy; Shirley Price;
Robert Tisserand; Penny Price Academy; Mary
Grant; American College of Healthcare Sciences;
Aromahead Institute; Essential Oil Resource
Consultants; Primavera Academy; Pranarom and
Michael Scholes.
Length of time in practice
This question sought to establish the degree of
professional experience of botanica participants.
Table 6 clearly shows that the majority of participants
(n=121; 72% and n=129; 65% of botanica2012
and 2014 respectively) had 6 or more years of
professional experience, and that few were students
or just starting out in their careers.
The length of time in practice for attendees of
botanica differs from that of the survey of traditional
holistic aromatherapists in 2001 (Osborn et al.)
where the mean number of years in practice was 4.2.
This reflects once again that the botanica events
Table 6. Years in practice
YEARS IN
PRACTICE
Botanica2012
(n=168)
Botanica2014
(n=199)
Currently a
student
4%
8%
Less than a
year
3%
2%
1-5 years
23%
20%
6-10 years
20%
19%
11-20 years
40%
26%
More than 20
years
12%
20%
No answer
-
5%
attracted more mature and experienced therapists,
an observation also found by Carter et al. (2009) in
their survey of participants at their smaller clinical
aromatherapy event. Here, they found that 73% of
participants had been practising aromatherapy for
more than 6 years.
Membership of professional therapy associations
This question in 2014 was worded as such: “Are
you a member of a professional therapy association?
If yes, please specify”. 23% (n=46) replied specifically
to this question in the negative and 12% (n=24) did
not reply at all.
Due to the wording of the question, we thus have to
assume therefore that a total of 35% of participants
are not members of a professional association.
Due to the large number of countries represented
at the events, this might be in part due to the lack
of an organised membership structure within the
participant’s own country.
For the remaining responders (we are assuming
65%) who replied as being members of a professional
therapy association, it was typical for there to be
membership of more than one association.
• 30% were members of the International Federation
of Professional Aromatherapists (IFPA)
• 11% were members of the Alliance of International
Aromatherapists (AIA)
• 6% were members of the National Association of
Holistic Aromatherapy (NAHA)
• 4% were members of the International Federation
of Aromatherapy (IFA)
• 4% were members of the International Aroma-therapy & Aromatic Medicine Association
(IIAMA)
•3% were members of the National Institute of
Medical Herbalists (NIMH)
Other associations mentioned (1% and below)
included member associations from different
countries (Canada, South Africa, Australia, Ireland,
USA).
41
Place of work
To obtain a glimpse of where participants were
working, the survey included a question concerning
their place of work (Table 7). The results here
demonstrate that private practice remains the
major place of work for most practitioners, and that
at least 20% provide domiciliary visits.
The large difference between 2012 and 2014 with
regards the question concerning working in
hospital/ hospice/ aged care facility may be in part
due to the sharp decline since 2012 in financial
support for therapists from their Health Service
employer. In 2012, a number of UK- and Irelandbased therapists attended botanica2012 as a result of
obtaining sponsorship/ funding from their place of
work, covering the costs of them attending the event.
Table 7. Years in practice
In 2014, very few participants attended via this
system, as economic constraints within their
respective places of work led to a withdrawal of
funding for education. As many therapists within
the clinical environment work on a voluntary rather
than paid basis, this may have negatively influenced
their decision to attend.
The theme of the conference may also have
influenced participant’s attendance. In 2012 there
was a significant emphasis on cancer and palliative
care; this may also explain the increased numbers in
2012 of therapists working in hospital/ hospice care
compared to 2014.
There was a significant rise in the number of
educators from 9% in 2012 to 22% in 2014.
Feedback to the organiser from a number of
participants was that the positive reporting
of botanica2012 in professional publications
encouraged more attendance from aromatherapy
educators in 2014 as the event was now viewed to
be an important professional platform for leaders
in the aromatherapy field.
YEARS IN
PRACTICE *
Botanica2012
(n=168)
Botanica2014
(n=199)
Own practice
43%
48%
Multi-disciplinary
practice
17%
5%
Home visiting
25%
20%
In the ‘other’ group (n=22; 11% of responders in
2014), most answers were of a business/ commercial
nature. These included: running my own school;
running my own business; product development
and sales; luxury spa; publishing company; set up
aromatherapy service in hospice; online company;
medical devices business; consultant to healthcare
institutions; consultant to beauty/ wellness sector, etc.
Hospital/
hospice/ aged
care facility
23%
3%
Part two of the survey: logistical details
concerning botanica2014
Educational
establishment
9%
22%
Charitable
organisation
Not asked
5%
In a
laboratory
8%
9%
I don’t work
-
5%
Other
-
11%
* Some respondents gave more than one answer.
Participant satisfaction
In the second part of the survey of botanica2014,
participants were asked to rate their levels of
satisfaction with regards the event itself, general
organisational aspects, the conferences, the trade
show, the social program and the workshops.
Overall, satisfaction levels were extremely high with
all bar 3 participants stating they would consider
attending the next botanica event in 2016. For the
3 participants who said they did not know if they
would attend a future event, geographical location
and financial constraints were cited as the reasons
why attendance might not be possible should the
event move outside of Ireland.
42
Trade Show diversity and feedback
• Aromatherapy supplies (1 stand)
• Education (2 stands)
• Essential oil retailers (11 stands)
• Herbal products (3 stands)
• Hydrosol supplier (1 stand)
• Natural perfumery (1 stand)
• Publications (2 stands)
•the opportunity to buy directly from distillers
and producers
• stands selling books
• stands selling herbal/aromatherapy tool supplies
such as bottles, diffusers, essential oil carrier boxes
• stands selling perfumery and clothing
• suppliers of herbs and herbal teas.
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At botanica2012 there were 21 trade show stands,
representing companies from eight countries. Trade
stand diversity included:
Participants were also asked what companies or
product would they like to have seen at the event.
In addition to naming individual companies they
hoped to see at botanica2016, there were other
specific requests including:
At botanica2014, the number of trade stands was
increased to 24, representing 10 different countries.
Trade stand diversity was also increased and
included:
• Aromapatch devices (1 stand)
• Aromatherapy jewellery (1 stand)
• Distillers (3 stands)
• Education (3 stands)
• Educational online aromatherapy tool (1 stand)
• Essential oil retailers (8 stands)
• Flower essences (1 stand)
• Herbal suppliers (2 stands)
• Natural candles (1 stand)
• Professional association (1 stand)
• Publications (1 stand)
Es
Comments from the 2014 survey were that all
stands were well-visited, there was sufficient
diversity (81% said great or good diversity) and 83%
of responders said they had bought products from
the stands at the event. The amount of monies spent
ranged from 10 to 2100 euros. The average amount
of monies spent by those who completed this part
of the questionnaire was 219.14 euros per person.
This amount equates to 161.25 pounds sterling or
240.86 USD at the currency exchange rate at time
of writing.
6% of responders who said they were displeased
with the diversity of stands stated they wanted a
greater number of stands; that there were “too many
selling essential oils” and that even more diversity
was needed with more wholesalers rather than
retailers.
All these points are useful for future trade show
planning.
Looking ahead: Topics for future
conferences
Participants of botanica2014 were also asked to
suggest topics they would like covered at future
conferences. The diversity of suggestions reflects the
numerous settings where clinical aromatherapy has
a role as well as the need for further expanding the
evidence base for clinical practice in these settings.
The prevailing request was for more clinical
research presentations along with more examples of
integration into hospital practice and clinical uses
including case presentations. Other requests were
to retain the same broad diversity of presentations
as had been offered in both botanica2012 and
botanica2014 and to maintain the rich international
focus. Another theme that evolved was the desire
to connect with more distillers/ herb producers and
to learn more about the art and craft of distillation
itself.
Concerning requests for specific clinical
aromatherapy settings/ topics, requests were made
for presentations on a wide range of subject areas
including:
• Women’s health, menopause
• Working with children, teenagers, young adults
• Working in mental health
• Combining herbs and essential oils in therapy
• Novel uses of essential oils
•Self-care
43
For example, other questions/ topics that will be
added in 2016 will include:
What is the degree of liaising/ referral between
health professionals?
What the participant understands by the term
clinical aromatherapy/ clinical aromatherapist
Whether aromatherapy is their primary source of
revenue
Which routes of administration do practitioners
routinely use
The main publications/ resources that participants
access to inform their practice
The average number of hours of training undertaken
by clinical aromatherapists.
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• Different plant extracts (including CO2 extracts,
absolutes, etc)
• Natural perfumery
•
Traditional medical systems (Ayurveda,
Traditional Chinese Medicine, Native American
Traditions, etc)
• Plant medicine as a business
• Skin care
• Autoimmune disease
• Mental/ emotional/ spiritual uses of essential oils
•Olfactotherapy
•Gemmotherapy
• Essential oil chemistry
• Aromatic medicine
• Essential oil and herbal safety
• Legislative issues, different courses and training
standards
Survey limitations
The two botanica surveys were primarily conducted
to track participant feedback and level of satisfaction
with a goal to using this information to inform future
events and to best meet the needs of participants.
They were not designed for in-depth analysis but
nevertheless may be valuable in building a profile
of practitioners who have an interest in clinical
aromatherapy and are seeking extending their
knowledge and skills.
Another limitation is that the survey only concerns
participants who elected to attend the event,
who were attracted by the specific content and
programme, and who had the financial means to
participate.
Es
Additionally, as previously discussed, a global
impression of the clinical aromatherapists profile
as expanded in this article can only be seen to be
as relevant to therapists for whom English is the
primary language. In other countries such as China,
Japan, Germany, France, Russia and so on, the
profile of a clinical aromatherapist may well differ
from our findings.
For botanica2016, the survey design of the upcoming
botanica2016 event will be further revised and
expanded to continue establishing a more clear
profile of the clinical aromatherapist.
Discussion: Towards a clearer
understanding of clinical aromatherapy
As can be seen from the above, there now appears
to be sufficient momentum and interest worldwide
concerning clinical aromatherapy to warrant
constructive debate and reflection as to what
constitutes this emerging clinical aromatherapy style
and how to best meet the needs of aromatherapists
who identify more with this descriptor of their work
than the title of ‘holistic aromatherapist’.
With increasing numbers of practitioners identifying
with the title of ‘clinical aromatherapist’, in order to
present a clear message to the public and facilitate
their access to an appropriate aromatherapy
practitioner (holistic, aesthetic, clinical, medical or
other) we believe there is a need to establish common
ground as practitioners, associations and educators
in the very basic definitions of all of these styles.
It appears that for many educators, the definition of
holistic aromatherapy is relatively well-established.
Battaglia (2003) states “holistic aromatherapy
utilises the pharmacological, psychotherapeutic and
metaphysical properties of essential oils” and that
it focuses “on the development of wellbeing and
enjoyment of life in a system of self-responsibility”
rather than being focused on symptoms experienced
by the patient.
When talking of the holistic approach, Price and
Price (2012) state that “the aromatherapist looks at
the whole person to ascertain the cause of the illness,
44
and the treatment that follows aims to strengthen the
body’s natural defense system to cope with attacks by
pathogens. The weakness is then considered in relation
to the body as a whole and studied in the context of
the living environment, then the aromatherapist
chooses the essential oils for healing”.
However, this view is not common to all educators
and the term ‘clinical aromatherapist’ appears to
remain confused or, at the very least, ambiguous
and open to personal interpretation. In one
aromatherapy school blog on the subject of “What is
clinical aromatherapy”, the school director suggests
that holistic aromatherapy and clinical aromatherapy
are basically different terms to describe essentially
the same practice saying… “My guess would be
that there is very little difference between those who
call themselves Holistic Aromatherapist (my term of
preference) or Clinical Aromatherapist. And my guess
too is that as long as you gain your education from a
respected school or individual that your knowledge
base will be very similar regardless of what the
program was called or what you call yourself.”
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The same authors differentiate holistic aromatherapy
from ‘aromatic medicine’ (which in the context of this
paper, could also be termed ‘clinical aromatherapy’)
with a number of distinctive elements that include
further training at a more advanced level, to permit
the practitioner to practice clinical aromatherapy
safely, confidently and effectively, using doses and
methodologies that are more intensive and evidencebased than the holistic aromatherapy style.
Buckle’s definition of clinical aromatherapy is closely
allied with that of this paper’s main author (Lewis).
In Fundamentals of Complementary and Alternative
Medicine (editor: Micozzi, 2011; chapter 23; pg 334)
Lewis states “when essential oils are integrated into
medical environments to address particular patient
challenges alongside mainstream medical care,
the practice is often termed clinical aromatherapy.
It effectively represents a merging of both holistic and
medical styles that are adapted to the individual”.
Massage is also seen to be an essential and
inseparable feature of traditional holistic
aromatherapy treatments, with aroma-alone
treatment strategies being the exception rather
than the norm. Indeed, Price and Price (2012) state:
“It would prevent misunderstanding of the word
aromatherapy if the qualification of massage were
totally separate from that of essential oil knowledge”
(cited in Aromatherapy for Health Professionals, 4th
edition, pg 166).
Es
With regards clinical aromatherapy, a global
definition is clearly lacking. Dr Jane Buckle, pioneer,
educator and driver of clinical aromatherapy
especially within the USA (Buckle, 2003) has a
precise view, defining clinical aromatherapy as
“about targeting a specific clinical symptom (eg.
nausea) and measuring the outcome” (cited in
Clinical Aromatherapy: Essential oils in Healthcare,
2015, page 13).
Similarly, in the preface to the latest edition of her
clinical aromatherapy text she states “aromatherapy
is a multifaceted therapy, so it is not surprising
that many people do not know what it really is...
from the very beginning, the term ‘aromatherapy’
was associated with healthcare… my focus has
always been on the clinical aspects of aromatherapy.
By calling it clinical, I strive to put aromatherapy
back where I feel it belongs – in healthcare”.
The same author then goes further to suggest that
“I fear that in some instances those calling themselves
clinical aromatherapists may be forgetting their
holistic roots in a blind desire to be accepted by a
system of medicine that will never truly be holistic”
(Shutes, 2011).
This latter comment is not at all reflected in the
emerging clinical aromatherapist profile from
the botanica surveys; in our findings, clinical
aromatherapy practitioners are experienced,
mature, educated individuals that are seeking to
combine evidence-based information in clinical
care whilst retaining interest in holistic principles.
At the member association level, the ambiguity
about clinical aromatherapy continues, with
two prominment international aromatherapy
associations (IFPA; AIA) having levels of clinical
aromatherapy membership with a number of
association-accredited colleges offering clinical
aromatherapy training. However, neither association
45
has an established definition for the title of clinical
aromatherapy/ clinical aromatherapist as compared
to holistic aromatherapy/holistic aromatherapist.
Finally, in order to move closer to defining clinical
aromatherapy/ the clinical aromatherapist, key
questions remain. They include:
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In their recently amended standards of practice
document (http://www.alliance-aromatherapists.
org/aromatherapy/standards-of-practice) the AIA
acknowledges that “For the clinical aromatherapy
community to grow as a profession and take its
place with more-established complementary care
modalities, it has the obligation to identify and establish
standards of care and practice. Professional standards
of practice reflect the current knowledge base and
practice in any given field and imply accountability.”
However, to date there is no actual agreed definition
for the title ‘clinical aromatherapist’.
If one accepts that there are subtle but key differences
between holistic and clinical aromatherapy practice
(with of course their inevitable and necessary
overlap), then further questions arise concerning
the educational needs of the clinical aromatherapist,
especially if they are working in specialist
environments such as cancer care or hospice care
(Carter et al., 2010; Mackereth et al., 2009). The
development of specific courses on adapting skills
and knowledge coupled with clinical supervision
and practitioner support are areas that are already
starting to be addressed in some specialist areas.
In Standard I: Theory and Practice, the AIA go
on to describe the clinical aromatherapist thus:
“The qualified aromatherapist understands and
applies appropriate, scientifically sound theory as
a basis for essential oil use. The art and science of
Aromatherapy is characterized by the application
of relevant information that provides the basis for a
skilled use of essential oils and subsequent evaluation
of the outcomes.”
Es
In their UK-based clinical aromatherapy
survey, Carter et al (2009) defined the clinical
aromatherapist as “a skilled and knowledgeable
practitioner, who assesses, prescribes, applies and
reviews the use of essential oils with patients”.
Here, rather than defining the place of practice, the
term ‘clinical aromatherapist’ denotes more a certain
level of practice (such as symptom management).
This definition is more encompassing than
that of Buckle and Lewis in that it includes the
aromatherapist in private practice who may also
be working clinically with their clients. This view
is clearly reinforced by the botanica surveys where
most practitioners reported being in private practice
rather than working in clinical environments.
Indeed, they may have more scope and freedom
to practice the full range of clinical aromatherapy
interventions in private practice than in a clinical
setting where essential oil selection, dose and
routes of administration may be limited by policies,
protocols and budget constraints.
• Is clinical aromatherapy defined by the location as
to where it is practiced (ie. is it limited to clinical/
medical environments)?
• Is clinical aromatherapy defined by the type of
aromatherapy interventions provided (symptomfocussed using application methods and doses
that are not necessarily massage-orientated/
holistic aromatherapy orientated…)?
• Can clinical aromatherapy be defined by the type
and level of training the therapist receives?
•Does a holistic aromatherapist have the
competence and skills to work in a clinical setting
without a further level of training?
Conclusion
Based on the results of participant surveys
conducted following two international clinical
aromatherapy conference and reinforced by the
findings of an earlier survey (Carter et al., 2009),
we can suggest the following apply to the majority
of English-speaking clinical aromatherapists who
attended the botanica conference events:
Most clinical aromatherapists are mature women who
have six or more years of aromatherapy experience.
Most are multidisciplinary, having other roles as
health professionals, many of which are holistic
modalities. Most, but not all, are members of a
professional association and continue to further their
46
knowledge and skills through attending educational
events outside of their member organizations.
Some, but not all, have current or prior medical
training in disciplines such as nursing, medicine
and pharmacy. Most have attended training run
by private colleges, and many have education to a
higher level. Online education may be an emerging
trend for aromatherapy training. The majority of
practitioners have their own practice and/or provide
domiciliary visits. Aside from providing treatments,
many have an associated commercial interest in
aromatherapy (products, consultancy, school, etc).
Most are seeking evidence-based information to
inform their practice and are seeking guidance in
how to integrate aromatherapy with mainstream
medical care.
Finally, as conference organizers, these surveys have
served to identify the needs and specific interests of
clinical aromatherapists and have been extremely
useful in assessing the level of satisfaction of
participants to assist us with planning future events.
References
Battaglia SB (2003). The Complete Guide to Aromatherapy,
2nd ed. International Centre of Holistic Aromatherapy:
Australia.
Bensouilah J (2005). The history and development of modern
British aromatherapy. Int J Aromather, 15(2):134-140.
Buckle J (2015). Clinical Aromatherapy: Essential oils in
Healthcare. Elsevier.
NOW in its
20
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year of
publication
written by
aromatherapists for
aromatherapists,
herbal medicine
practitioners, herbalists
and other health care
professionals
Buckle J (2003). Aromatherapy in the USA. Int J Aromather,
31(1):42-46.
Carter A, Mackereth P, Stringer J (2010). Aromatherapy
in Cancer Care; do aromatherapists in cancer care need
specific training to do this work? In Essence, 9:20-22.
Carter A, Mackereth P, Tavares M, Donald G (2009) Take
me to a clinical aromatherapist: An exploratory survey of
delegates to the first Clinical Aromatherapy Conference,
Manchester UK. IJCA, 6(1):3-8.
Emslie MJ, Campbell MK, Walker KA (2002). Changes in
public awareness of, attitudes to, and use of complementary
therapy in North East Scotland: Surveys in 1993 and 1999.
Comp Ther Med, 10(3):148-153.
Furnham A (2000). How the public classify complementary
medicine: a factor analytic study. Comp Ther Med, 8(2):82-87.
Harris R (2003). Anglo-Saxon aromatherapy: its evolution
and current situation. Int J Aromather, 13(1):9-17.
Mackereth P, Carter A, Parkin S, Stringer J, Caress A, Todd
C, Long A, Roberts D (2009). Complementary Therapist’s
training and cancer care: a multi-site survey. Eur J Oncol
Nurs, 13:330-335.
Micozzi MS (2011). Fundamentals of Complementary and
Alternative Medicine, 4th ed. Saunders; Elsevier.
Osborn C E, Barlas P, Baxter G D, Barlow J H. (2001).
Aromatherapy: survey of common practice in the
management of rheumatic disease symptoms. Comp Ther
Med, 9:62-67.
Price S, Price L (2012). Aromatherapy for Health
Practitioners, 4 ed. Churchill Livingstone; Elsevier.
Shutes J (2011). What is clinical aromatherapy? http://
theida.com/aromatherapy-education/what-is-clinicalaromatherapy. Accessed May 15th, 2015.
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47
Care versus Cure: Aromacare for body, mind and spirit in
the last stages of dementia
Interview with Madeleine Kerkhof-Knapp Hayes
Owner of De Levensboom, Centre for Complementary Care,
The Netherlands
Chairperson of Kicozo, the Knowledge Institute of
Complementary Nursing, The Netherlands
[email protected]
www.levensboom.com
www.kicozo.nl
Introduction
Whilst palliative care is well established in many
countries for persons suffering with cancer and
a wide range of other diseases, nursing home
residents dying with advanced dementia rarely
access optimal end of life care that addresses their
physical, emotional and spiritual needs. Although a
leading cause of death in countries such as the USA,
there has been a widespread lack of recognition of
dementia as a terminal condition in the fullest sense
of the word, affecting the body, mind and spirit
(Elton, 2009; Mitchell et al., 2004). This often results
in inappropriate and rather aggressive care in the last
phase of life when a palliative approach focused on
comfort and wellbeing would be more appropriate.
Madeleine Kerkhof-Knapp Hayes has been an
aromatherapy expert and educator based in The
Netherlands for over 18 years. Over the past ten years
she has led the way for the integration of aromatherapy
and other complementary interventions into
hospitals, care homes and palliative care centres in
her home country and beyond.
Although Madeleine’s main focus lies in palliative
care for cancer patients and patients with other life
threatening illnesses, one of her passions is making
a difference in end stage dementia; improving
comfort and quality of life and dying using essential
oils, related products such as carbon dioxide (CO2)
extracts, vegetable oils and lotions via a range of
application methods. Her rigorous work in training
nurse practitioners and care staff in implementation
of simple, safe, effective and cost-effective aromatic
treatment strategies had led to an improvement
in quality of life for many persons in their final
days. Here she discusses her work and offers clear
guidance based on her experience.
Madeleine, can you please start by sharing with
us your aromatic journey that led to your current
work?
Some thirty years ago I started training to be a
nurse. The main reason to leave the hospital setting
was that in this setting, all focus went into the
diagnosis, rather than to the person behind the
diagnosis. I wanted to care for patients in a more
holistic way, especially for the most fragile patients
and the terminally ill.
After I left nursing, I gained a wealth of experience
and expertise in natural health care. I am largely a
self-made woman and visiting Varna at the Black
Sea coast, I was greatly inspired by some of the large
spa and health clinics – working with all elements
of mainstream medicine, combined with herbal
medicine, hydrotherapy and aromatherapy. After
six years I returned to The Netherlands, where
I continued to study and practise as a herbalist,
nutritionist, hydrotherapist and aromatherapist. I
also graduated as a Kneipp Hydrotherapist.
I started De Levensboom in 1998, initially to treat
patients with serious and life threatening illnesses.
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Patients were offered a range of possible treatments,
from nutrition to herbs, massage and aromatherapy,
but always complementary to the treatment
and care they already received in mainstream
healthcare. I learned how more wellbeing-directed
complementary care could be offered to terminally
ill patients. Palliative and terminal care captured
my special interest and expertise. I am passionate
about the integration of complementary care in
modern nursing (or other professional) care and
mainstream healthcare.
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With time, my expertise and experience was
acknowledged by nurses and other caregivers
from hospitals, hospices and nursing homes and
I was increasingly asked for talks and on-the-job
training sessions. In the following years, interest
from professionals increased and I started to teach
to larger groups of professionals in my own training
institute. I am a member of various professional
associations and I am involved in activities of
several palliative and integrative networks.
I do admit however to frequently crossing the often
vague line where ‘care’ ends and so called ‘therapy’
begins. If using lavender helps to avoid the use or
increase of sleep medication, or if we can postpone the
use of sedatives by diffusing anxiolytic and calming
essential oils, or by massaging the patient with
gentle massage, one could call these interventions
‘therapy’. When we help heal a decubitus ulcer by
applying an ointment with sea buckthorn, sweet
marjoram, lavender and helichrysum oils, one
could call that ‘therapy’ as well. We need to be
aware that there are many more options to promote
wellbeing than with pharmacological interventions.
I believe that any form of care to achieve optimal
wellbeing and comfort is appropriate, as long as it is
safe, evidence-based and/or experience-based and
focuses on the whole patient.
In 2010, I founded Kicozo, the Knowledge Institute
of Complementary Nursing, now responsible for all
my educational activities. De Levensboom with its
own range of essential oils and aromatic products
has become an important source of products for
Dutch health care facilities and home care.
Furthermore I am the chairperson of De
Levensboom Foundation, a registered charity in
palliative care that supports patients in palliative
stages in small projects, such as a long wished
weekend away, donating equipment or supporting
hospices with products etc.
Es
You prefer to use the word aromacare rather
aromatherapy to describe the work you do. Can you
please explain why?
One of the reasons why I started using the term
aromacare instead of aromatherapy in care settings
is that it expresses more accurately what we actually
want to achieve by using aromatic and plant-derived
materials from nature. Nurses and other caregivers
usually come from a classical care background and
are very rarely trained aromatherapists. They don’t
necessarily want to engage in therapy / cure, nor do
they have the time for that, but instead they wish to
promote the wellbeing of patients by offering care
integrated within their standard care.
We all deserve the best care possible when we are
sick, disabled or dying. I truly believe that aromacare,
with its many possible applications and its profound
influence on body, mind and spirit is one of the most
promising ways to complement classical medicine
and care. My mission is to enhance the quality of life
and dying of all, but especially the most vulnerable
people amongst them.
You feel strongly that more can be done at the end of
life for persons with dementia. Why is this?
There is a common and widespread misconception
that dementia is a mental ailment that simply
accompanies older age. Of course, memory loss is
an early and significant sign of dementia, but it is
much more than this. It could more accurately be
described as fatal brain failure; a terminal disease
that ultimately becomes responsible for the person’s
death. As the brain controls the whole body,
eventually all systems are affected by dementia.
We also know that many people with dementia,
some 40%, according to one American study
(Mitchell et al., 2009) experience a burdensome
intervention (for example are sent to the emergency
room, hospitalized, tube-fed or given IV nutrition)
during the last three months of life. This can
cause distress and pain while providing, at best,
questionable benefit and minimal prolongation of
life. In my opinion, when a person with dementia is
in the terminal stage of the disease, the focus should
be on quality of life and wellbeing, rather than on
49
lengthening life and giving treatment. Palliative or
hospice care focuses on the whole person’s needs physical, social, emotional and spiritual but not all
persons with dementia are recognised as needing
palliative care. It is in this area of care provision
that complementary interventions can integrate
perfectly to ensure as much wellbeing as possible
for the person in their final life journey.
How many nurses have you trained in aromacare
to date?
How many care centres use aromatherapy in The
Netherlands?
A new study has just been published on
complementary care in Dutch health care centres
(Busch et al., 2015). 380 Professionals from 180
care settings such as hospitals, psychiatry, nursing
homes, home care and hospice care responded to
a questionnaire asking them about complementary
care activities in their place of work. According to
this study, aromacare is offered in 13.5% of hospitals
and 60.8% of nursing homes. Massage is performed
in 25.8% of hospitals and 54.9% of nursing homes.
Hospice care has not been evaluated separately, but
my estimate is that approximately 85% of hospices
offer complementary interventions including
aromacare. In 80% of hospices, complementary care
is embedded to such an extent in general hospice
care that it is coordinated by a specially appointed
person.
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I have trained thousands of nurses and other care
professionals over the last 10 years, on the job, in
my training institute as well as at conferences and in
clinical lessons. In my tuition, I show students how
effective aromacare can be in different interventions
to add extra special individualised care for all levels
of wellbeing. As a down-to-earth former nurse, I pay
much attention to efficacy, safety, and practicalities.
Any given intervention must be fairly easy to
execute and implement alongside normal care
procedures. Rather than train nurses in classical
aromatherapy using a wide range of essential oils,
I prefer to teach them to add a limited number of
well-known and well-founded essential oils and
bases to their general care, for which research has
been conducted on efficacy and safety. They must
be easy to obtain and relatively affordable to ensure
that aromacare finds its place within mainstream
healthcare without too many difficulties / barriers.
In this way, I strive to help integrate complementary
interventions in mainstream care.
5. Complementary Care for Baby & Mum around
Birth
6. The Diploma Year training Aromacare in
Healthcare.
Es
In 2008, the Society of Nurses initiated the
foundation of the Quality Register of Nursing,
a body that ensures the quality of education to
nurses and other care professionals in mainstream
healthcare. My school was accredited right from the
start.
Kicozo offers (apart from lectures and madeto-measure in-house education for health care
facilities) six different training programs:
1. Complementary Care in End of Life Care
2. In-depth Training Program Complementary
Palliative Care
3. Complementary Care in Care for the Elderly
and People with Dementia
4. Complementary Care in End Stage Dementia
The study also shows that initiatives and projects
are often fragmented throughout a facility and there
is a greater need for more scientific foundations,
improved budgeting, education, support from
management as well as clear guidelines on
interventions and their implementation. Kicozo is
one of only three educators for nurses and other
professionals in Dutch mainstream health care - all
in our own fields of expertise with some overlap but
working closely together. A lot remains to be done.
Your book, “Complementary Nursing in End of Life
Care, Integrative Care in Palliative Care” that was first
published in Dutch in 2013 has now been translated
into English. Who is this book destined for?
My book is especially written for nurses and
other care workers around the patient with a
life-threatening or life-shortening illness from a
classical medical background. My aim is to make
aromatherapy in palliative care as accessible as
possible to professional carers.
I have incorporated a chapter on basic knowledge
on aromacare, as well as a brief explanation on
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supervision where we discuss individual patients
and the results that carers report. This is very helpful
for both the team, myself and of course patients and
their families.
In hospices, where people with dementia are very
rarely admitted, due to the complexity of the needed
care, we frequently evaluate results in general and
individual cases. Some of these cases are discussed
in my book.
Thanks to my continuing efforts to bring more
complementary care into mainstream healthcare,
I have now teamed up with Academic Hospice
Demeter in De Bilt; a teaching hospice connected
to the University Medical Center Utrecht. I have
recently trained staff members in abdominal
washing: a form of aquacare that has given excellent
results in combating constipation. This simple, yet
very effective technique, which only takes a minute
to execute by a trained caregiver, will be evaluated
in a pilot study in the coming months. After that,
my partners and I hope to prove in a larger study
that this form of abdominal washing is one of the
most effective non-pharmacological interventions
for constipation. Although many patients have
already experienced the benefits of this method, it
will be useful to be able to evolve from experiencebased to evidence-based aquacare and pave the way
for inclusion in the guidelines for palliative care and
care for the elderly and people with dementia.
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the chemistry and absorption of essential oils.
I focus on efficacy and safety, without elaborating
too much on technical data. I chose to detail ten
essential oils as the main basic tool. These include
bergamot, ginger and lavender. They are chosen
for their efficacy, for the fact that they are (more or
less) studied, relatively easy to use with little or no
complications, affordable and easy to obtain from
quality sources around the world. I complement
these ten oils with some 20 or so others, from
eucalyptus and petitgrain to ylang ylang, to give
extra special care, comfort and healing for specific
symptoms. These oils offer a variety of possibilities
to add extra effect to the ‘Top Ten’.
To a professional and experienced aromatherapist, it
may seem that there too few essential oils to choose
from, and other choices might be beneficial, but
for a nurse or other professional with limited basic
knowledge who also has certain and financial and
logistical constraints, this is in my opinion a good
choice for palliative nursing in Europe and across
the world. Every chapter also offers insights into
general palliative care. This can be of great value to
aromatherapists who would like to work more with
patients in their last stages of life. I also included a
chapter on how to promote the implementation of
complementary nursing in mainstream healthcare.
What in your opinion are the biggest contributions
of essential oils and related products in end stage
dementia?
Es
In my opinion, the biggest contributions of essential
oils and related products are in care for emotional
and spiritual needs. They also have great value in
skin care, mouth care, respiratory problems and
pain. We do not necessarily want to cure any illness,
but instead give special care to symptoms that can
have such a detrimental effect on quality of life and
dying.
In The Netherlands, complementary care for end
stage dementia is still in its infancy. I do not have
much direct contact with patients or their families;
I teach and coach their carers. Nurses report good
results in the aforementioned symptoms, but it
is sometimes difficult to get an overview of this.
However, with teams of carers in some nursing
homes, we regularly get together for clinical
Following your training to nurses and care staff,
what steps ensure effective care delivery?
To help implement complementary care and ensure
maximum compliance, I advise students to form
a complementary workgroup of at least two or
three people per ward. They will be responsible
for initiating and integrating complementary
interventions alongside standard care. Team leaders
of wards and ultimately the location manager and
treating physician are responsible for the care
provided. Other staff members can consult with
the work group for backup and instruction of
interventions. In my training, I recommend simple
blends that can be prepared easily – for which the
work group is responsible. I also offer a range of
ready-made blends to make it easier to start using
aromacare in every day practise without difficulty.
51
or for pain relief. Popular oils for sensory activities
include aniseed, ginger CO2, chamomile CO2,
lemon, lavender, lemongrass, peppermint, rosemary,
sweet fennel, sweet orange and frankincense.
In the last stages of dementia, where verbal or
even non-verbal communication can be almost
impossible, for relaxation and creating a sense of
nurturing attention I often choose low doses of oils
with fine fragrances, such as mountain lavender,
rosewood, mandarin, rose, rose attar, frankincense,
myrrh, neroli, benzoin, clary sage, sweet marjoram
CO2, spikenard, Atlas cedar or sandalwood.
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Cost is always a factor to consider. In The Netherlands
we have seen many cutbacks in healthcare in recent
years. Unfortunately complementary care is often
sacrificed when decisions have to be made, but
in the case of caring for people with dementia,
relatives often pay towards individually-used
products such as essential oil blends, massage oils
or creams. One of the key elements in my training
and post-training support is to show that many
complementary interventions can be cost effective.
The more evidence, examples of best practice and
case studies we can gather, the more likely it will be
that insurers will finally start recognising the great
value of complementary care, in terms of wellbeing
and costs.
Have you noticed a trend in the oils/ extracts most
commonly used in dementia care?
Of course lavender remains at the top of most
carers’ favourite essential oils. And yes, lavender
is often a good choice and many patients like the
scent. This oil is precious for nervous, agitated and
restless patients, in cases of sleeplessness and pain.
However, not all care recipients like the fragrance,
and if this is the case, it could potentially increase
unrest and agitation. Lavender is also often an oil
choice of convenience because some carers do not
have any or enough experience with other essential
oils or lack confidence using them. That is one of
the reasons I only discuss a limited selection of
essential oils in my training courses. In this way,
students learn to really work with these oils and feel
more confident about blending and using them.
Es
Bergamot, sweet orange and mandarin are amongst
the most popular citrus oils. Ginger CO2 extract
has become popular for feelings of inner and outer
cold, nausea, abdominal, muscular and joint pains
and constipation. Scots pine and myrtle are great in
cases of airway congestion and chest rattling and I
have very good results with frankincense, mountain
lavender, helichrysum and spike lavender in patients
suffering from dyspnoea.
Of course, the choice of oils also depends on the
stage of the individual’s dementia. In early stages,
where we can expect a certain level of verbal
communication, fragrances can be used as sensory
stimulants, in activities such as reminiscence
sessions, or in massages or foot baths for relaxation
Of course it is important to avoid any discomfort by
having a clear view of possible contra-indications or
interactions with medications. For example, we take
care with clary sage and spikenard that have shown
to have potential interactions with haloperidol (Seol
et al., 2010; Rasheed, 2010) which is a drug that is
frequently given to patients with dementia as well
as other dopaminergic medications.
What routes of administration are most widely used
in dementia care?
Aromacare uses essential oils and CO2 extracts in a
variety of ways. For example, we can:
• Vaporise fragrant oils in a diffuser, such as an
electric aroma lamp or an Aroma-Stream. This
method has many benefits. The right choice of
oils can enhance wellbeing of the patient and
loved ones, purify the air in both physical and
emotional sense, promote a certain ambiance, and
support a sense of safety using familiar fragrances
from positive life experiences.
• Use them in direct inhalation. This is especially
useful in case of respiratory problems or nausea,
to influence pain perception or to promote
emotional and spiritual wellbeing. Aroma inhalers
are not very useful for patients with dementia,
especially in the last stages. We can instead work
with a simple tissue to drop essential oils on and
lay near the patient. A recent innovation is the
AromapatchTM for which I have developed three
effective blends for nausea, for dyspnoea and for
promoting deep rest. This latter blend contains
Damask rose, mandarin, frankincense, vetiver
and some other highly relaxing essential oils.
52
We have already had wonderful results with this
blend. In one case, this AromapatchTM was used
for a lady who was very restless in her last few
hours. It helped her come to peace and gently slip
into the next world. The family of this lady were
deeply grateful for the assistance of this fragrance
and even left the AromapatchTM on her chest
during the wake before the funeral.
• Add them to vegetable oils and other bases to be
massaged/ topically applied. For example, in the
final stages of dementia, I use massage oils to very
gently massage the patient to promote relaxation,
for pain relief, or to keep the skin supple and
hydrated. I prepare creams or lotions for skin care
and to relieve symptoms such as itch; an often
underestimated symptom in dementia care that
can severely decrease quality of life and dying.
• Add to aloe vera gel for mouth care. Here we use
essential oils and CO2 extracts and hydrosols.
Here, my blends have been effective for oral
mucositis, mouth ulcers, oral pain, dry mouth
and halitosis.
• Use them in compresses, footbaths, washing and
other aquacare techniques (see below).
One of the unique aspects of your work is that you
often combine hydrotherapy/ aquacare principles with
aromatherapy to further improve treatment efficacy…
Depending on the stage of dementia and the
Figure 1. AromapatchTM
individual condition of the patient, working with
aquacare techniques, combined with aromatherapy,
can be highly effective for stress and anxiety, pain or
constipation. The warmth of a full bath envelopes
and soothes, improves circulation, relieves cramp
and pain and supports freer movement. Taking
a bath can also confer emotional and spiritual
benefits. People with severe dementia (according
to their physical condition and taking all safety
measures into account) can be helped to deeply
relax in this way. Choosing the right fragrant oil can
further enhance the feeling of being comforted and
safe, surrounded by the warmth akin to being back
in the mother’s womb.
Footbaths can be extremely helpful for people that
are fatigued, unsettled and worried. It will help them
relax and descend from their heads into their heart
and body. It can be a challenge to offer a footbath to
patients, and of course we do not burden patients
in the last stages of dementia with this technique.
However this soothing intervention can be offered
to family member, or professional carer. We add
a nourishing bath oil to the water oils such as
lavender, neroli, petitgrain or blue chamomile CO2
extract. We also use hydrosols such as rose, orange
flower, chamomile or lavender waters. These can be
added directly to the bathing water. Helichrysum
hydrosol is wonderful too, especially in traumatised
people with many bruises on their soul.
Figure 2. Foot bath
53
Figure 3. Hot compress
Another relaxing treat can be given by applying a hot
compress, for instance on the neck and shoulders.
Many patients, loved ones and carers alike benefit
from the warmth that deeply penetrates the muscles
and tendons as well as touching their mind and
soul. Usually for compresses, I don’t advise adding
essential oil to the water itself. This is because
much of the oil will be discarded or will remain in
the compress cloth. Instead, I advise to prepare a
massage oil, rub it gently onto the area and then
lay the hot compress on top. In this way, there is no
loss of oil, the intervention is more effective and the
addition of gentle touch is always an added bonus.
How do you respond to those who argue that
aromatherapy has a limited place in dementia due
to the poor sense of smell that is a key feature?
Many patients with dementia do have a poor
sense of smell. One American study showed that
from people aged 53 to 97, the mean prevalence of
impaired olfaction was 24.5%. Prevalence increased
with age; 62.5% of 80 to 97 year olds had olfactory
impairment (Murphy et al., 2002). The gradual loss
of smell can be an early sign of dementia (Hawkes &
Doty, 2009; Velayudhan & Lovestone 2009; Graves
et al., 1999). There is also one form of dementia
(semantic dementia) where patients are no longer
able to place a fragrance in its right context. For
example, they do not remember what lavender
scent is, or link its smell to the wrong association.
However, a large number of older people retain a
fair olfactory sense well and can thus benefit from
aromacare. And even if they are unable to smell,
aromatherapy still works. After all, the volatile
molecules of essential oils and CO2 extracts are
not just sensory elements. They can absorbed by
the mucous membranes and the skin and perform
their action within the body. Although partial
or complete loss of smell might make the use of
fragrance for emotional and spiritual wellbeing
challenging, when it comes to diffusing or
inhalation, aromatherapy remains of great value for
other challenges such as pain, respiratory problems,
skin disorders and problems of the digestive tract.
When smell is impaired, we can also refer to a
combination of fragrance and gentle touch, or
envelop care recipients with the warmth of a hot
compress or bath.
What do you suggest for providing emotional
support to loved ones of the patient with dementia?
Dementia as an illness can often bring feelings of
sorrow, uncertainty, helplessness, anger, grief and
spiritual problems from an early stage. This can
affect both the patient and his or her loved ones.
Grieving is usually associated with death, but the
people around the patient can suffer from deep
feelings of loss in the different stages of the disease
and long before the patient actually dies.
We often see personality changes, restlessness,
agitation, aggression or apathy, and loss of decorum
in patients. This can make the care for people with
dementia very stressful for family members and
professionals alike. It is of high importance that
loved ones are helped with their questions, sorrow
and fears.
In the final stages of dementia the patient is hardly
recognisable from the person he once was. He
is almost like he was at the beginning of his life,
much like a new-born baby. A mother is not a
mother anymore, but her daughter’s child instead.
A husband can no longer have an equal relationship
to his wife…and so on. All this can be very difficult
to live with. Additionally, although relatives find
it hard to witness the suffering of their loved
one and would like to see that end, it can still be
extremely hard to let go. Children and husbands or
wives may experience a great sense of loneliness.
54
They also often experience feelings of guilt,
helplessness and inadequacy. It is important to
recognise these emotions and be supportive. Being
well informed usually helps to accept the changes
and deal with witnessing symptoms.
What suggestions do you have for offering relief of
stressful symptoms in the dying phase?
The dying phase is defined as the phase immediately
preceding death, the days in which death is
inevitable. At this point, all aspects of palliative care
come together. While there are different symptoms
and problems over the course of each illness, the
course of the dying phase consists of a ‘final common
pathway’ with corresponding characteristics.
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The waiting period for the patient to pass can be
long and hard to cope with. Most people close to
the patient will be happy to help with simple tasks
in the day-to-day care and can be asked to perform
gentle slow massages of the hands or feet, help with
mouth care, with changing clothes or bed linen
and so on. This can help them contribute to care
which will also aid them in the grieving process.
They can be invited to read a story to the patient,
pray, sing or hum a favourite song or hymn. Even
when the patient seems unaware, this can be a great
consolation to both the patient and the family.
In case of tension in the room (sometimes relatives
do not get along and it even happens that years of
latent tensions are fought out in the presence of the
patient), apart from taking measures to ensure more
peace around the bed by offering separate visiting
hours to each party, essential oils can help to calm
the atmosphere. Here we think of oils such as lemon,
neroli, Scots pine, petitgrain and peppermint, to
name just a few. Diffused into the room, they create
a sense of space for everyone to breathe and relax.
Complementary care can offer relief to relatives
too. A footbath will relieve stress and anxiety and
help family members to unwind. For example,
lavender (preferably high altitude) is often added for
relaxation. Lavender is very helpful when a person
is easily overwhelmed by circumstances. Dependent
on the level of anxiety we also use citrus oils such as
neroli or mandarin, as well as German chamomile
CO2 extract or frankincense. I love the fragrance
and the effects of frankincense. It enables one to let
go when there is no time or possibility to go through
everything once again, which is indeed impossible in
case of dementia in the last stages. This oil is thought
to help break connections with earthly things, whilst
providing support when searching for connections
in the larger whole. It is also an oil which is known
in many cultures and religions and can therefore
also provide a level of spiritual support.
Es
A blend which I often use with people surrounding
the dying person consists of frankincense, neroli,
mandarin, sweet orange, vanilla and the exquisite
Bulgarian rose. Such blends can be put into an aroma
inhaler to be used whenever needed, or diffused
subtly in the room (making sure of course that the
fragrance does not disturb the dying person). The
blend can also be added to a neutral base oil to be
massaged into hands or feet and family members can
be invited to massage each other’s hands and really
connect with one another, not only on a physical
level, but also on emotional and spiritual levels.
The start of the dying phase, if the process follows
its natural course, is accompanied by important
signals. The signals that indicate the dying stage are
often noticed first by caregivers who have intensive
contact with the patient, although in case of people
with dementia the signals are not always easy to
distinguish from signs of the illness. These signals
include:
• no or minimal food or fluid intake
• severe weakness and fatigue
• decreased urine output
• rapid, weak pulse
• limbs cold to the touch, occasionally blue toes or
fingers, lividity
• pointed nose
• reduced and later absent consciousness
•increasing disorientation, sometimes terminal
unrest (terminal delirium)
• audible respiration, chest rattling
•irregular, disrupted breathing (Cheyne-Stokes
respiration).
If these signals are missed, the dying phase and
the mourning process of relatives and other people
involved may be disrupted, either because treatable
symptoms cannot be adequately treated or that
relatives have been insufficiently informed about the
meaning of the signals. Some signals, such as chest
55
rattling, are very stressful for relatives, while the
patient himself may seem to be much less burdened
by them. The entire course of events surrounding
death and thereafter leaves an indelible impression
on relatives and has implications for the grieving
process and the way in which people look at their
own future deathbed.
Especially in the dying stage, where we even more
focus on care rather than cure, there is a need for
extra attention to reducing disturbing factors on a
physical, emotional and spiritual level.
Persons with dementia form a special group. It is
believed that in their final life stage, they probably
suffer longer from debilitating symptoms such
as pain than people with cancer. Patients with
dementia may express their pain in ways that are
quite different from those of elderly people without
dementia (Herr & Decker, 2004). Particularly in the
more advanced stages of dementia, the complexity
and consequent inadequacy of pain assessment
can lead to under-treatment of pain. Several
observational studies indicate that pain is undertreated among cognitively impaired elderly people.
Fewer analgesics are prescribed for the oldest
category of cancer patients (> 75 years) than for
younger patients, and low cognitive performance
was one of the independent predictors of this finding
(Morrison & Siu, 2000; Bernabei et al., 1998; Ferrell
et al., 1995; Semla et al., 1993).
My biggest passion is to help make complementary
care available to the weakest and most vulnerable
patients, especially in the last phase of their lives
across the world. I am so excited that many years
of hard work has led to the publication of my book
in English. This year I will start to offer my training
program for English speaking professionals. A first
group of international students travelled to my
training centre with its medicinal garden for four
days of training on specific symptoms in palliative
care. I feel honoured and humbled by the fact that
via professionals from around the globe, I can
contribute to the quality of life and death of even
more people.
The already complex care for people with dementia
becomes even more so in advanced stages, as they
cognitively and physically deteriorate, as a result
of which it becomes more and more difficult to
communicate, verbally or otherwise. The decrease
in ‘storage capacity’ for memories and relations also
plays an inhibitory role. For example, the patient
may experience chronic pain as a new and therefore
acute pain every time he becomes aware of it.
Patients with dementia are often no longer able to
properly indicate what their needs are. The difficult
communication mostly stands in the way of the
essential principle of good palliative care that the
patient is central to all that is done.
References
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And finally, how do you feel about your work
extending to English speaking therapists?
The dying phase is a crucial phase during which,
in preparation for the passing, certain final
adjustments can be made. A comfortable and
dignified environment can be created, depending
on the desires and traditions of the patient and his
relatives. One can think of providing the necessary
privacy, proper lighting, music or silence, ambient
fragrance, burning of candles and so on.
Thank you Rhiannon, for allowing me to express
my expertise, experience, thoughts and passions to
the readers of the IJCA.
Bernabei R, Gambassi G, Lapane K, Landi F, Gatsoni C,
Dunlop R, et al. (1998). Management of pain in elderly
patients with cancer. JAMA, 279: 1877-1882.
Busch MA, Jong M, Baars E (2015). Complementaire zorg in
ziekenhuizen, verpleeghuizen en GGZ‐instellingen. Eerste
Nederlandse inventarisatie, Januari 2015. (Complementary
care in hospitals, nursing homes and psychiatry, First Dutch
inventorial study, January 2015) Louis Bolk Instituut.
http://www.louisbolk.org/downloads/2960.pdf
Elton C (2009). Redefining Dementia as a Terminal Illness.
Time Magazine http://content.time.com/time/health/
article/0,8599,1930278,00.html
Ferrell BA, Ferrell BR, Rivera L (1995). Pain in cognitively
impaired nursing home patients. J Pain Symptom
Management, 10: 591-598.
Graves AB, Bowen JD, Rajaram L, McCormick WC,
McCurry SM et al (1999). Impaired olfaction as a marker
for cognitive decline: interaction with apolipoprotein E
epsilon4 status. Neurology, 53: 1480-1487.
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Hawkes CH, Doty RL (2009). In: The Neurology of Olfaction.
Cambridge University Press, Cambridge, UK, 159.Herr K,
Decker S (2004). Assessment of pain in older adults with
severe cognitive impairment. Ann Long Term Care, 12: 46-52.

  

Kerkhof-Knapp Hayes M (2013). Complementary Nursing
in End of Life Care, Integrative Care in Palliative Care
(Dutch version, published by Kicozo), expected in English
in June 2015. www.kicozo.nl
Complementary Nursing in
End of Life Care
Integrative Care in Palliative Care
by Madeleine Kerkhof - Knapp Hayes
Mitchell SL, Kiely DK, Hamel MB (2004). Dying with
advanced dementia in the nursing home. Arch Intern Med,
164 (3): 321-326. doi:10.1001/archinte.164.3.321.
Aromacare
Massage
Aquacare
Mitchell SL, Teno JM, Kiely DK et al (2009). The Clinical
Course of Advanced Dementia. N Engl J Med, 361 (16):
1529-1538.
Relaxation
Murphy C, Schubert CR, Cruickshanks KJ, Klein BEK,
Klein R, Nondahl, DM (2002). Prevalence of Olfactory
Impairment in Older Adults. JAMA, 288 (18): 2307-2312.
doi:10.1001/jama.288.18.2307.
Morrison RS, Siu AL (2000). A comparison of pain and
its treatment in advanced dementia and cognitively intact
patients with a hip fracture. J Pain Symptom Management,
19: 240-248.
Rasheed AS, Venkataraman S, Jayaveera KN, Fazil
AM, Yasodha KJ, Aleem MA, Mohammed M, Khaja Z,
Ushasri B, Pradeep HA, Ibrahim M (2010). Evaluation of
toxicological and antioxidant potential of Nardostachys
jatamansi in reversing haloperidol-induced catalepsy in
rats. Int J Gen Med, 26(3): 127-136.
Semla TP, Cohen D, Paveza G, Eisdorfer C, Gorelick P,
Luchins D, et al (1993). Drug use patterns of persons with
Alzheimer’s disease and related disorders living in the
community. J Am Geriatr Soc, 41: 408-413.
Seol GH, Shim HS, Kim PJ, Moon HK, Lee KH, Shim I,
Suh SH, Min SS (2010). Antidepressant-like effect of Salvia
sclarea is explained by modulation of dopamine activities
in rats. J Ethnopharmacol, 130(1): 187-190. doi: 10.1016/j.
jep.2010.04.035. Epub 2010 May 2.
Velayudhan L, Lovestone S (2009). Smell identification test
as a treatment response marker in patients with Alzheimer
disease receiving donepezil. J Clin Psychopharmacol, 29:
387-90.
Highly recommended by Rhiannon Harris Lewis,
Eliane Zimmermann and Gayle MacDonald



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57
Book reviews
Ann Carter
Pey Colborne
Rhiannon Lewis
Gabriel Mojay
Comforting Touch in Dementia and End of Life Care: Take My Hand
Authors:
Publisher:
Formats:
Barbara Goldschmidt and Niamh van Meines
Jessica Kingsley Publishers; Singing Dragon, 2011
paperback, 208pp; ISBN: 978-184810733 (£15.99)
eBook, 208pp; eISBN: 978-0857010483
This book is written for all ‘care givers’. The term
‘care giver’ includes families and friends, as well
as professional care givers. The content focuses on
the needs of people who find themselves in care
environments such as residential homes, hospitals
and palliative care settings.
The aim of the book is to offer inspiration and an
approach for care givers who wish to share touch
to provide comfort for a loved one or friend (or a
patient). Complementary therapists, nurses, nursing
assistants and other health care professionals who
use touch as part of their work are likely to find the
book a useful resource.
The content of the book is divided into three
sections and consists of a total of 12 chapters. The
three sections are entitled ‘A Sense of Connection’,
‘Focusing Your Touch’ and ‘The Reality of Practicing.’
The text is focused uniquely on massaging the
hands, and doesn’t cover other parts of the body.
The theoretical aspects are well supported by case
histories and at the end of the book, there is a
comprehensive reference list which adds credibility
to the content.
This is an in depth book about the skillful use of
touch approached from several perspectives. The
authors have covered many issues relating to touch
from spiritual, emotional and physical perspectives.
The hand massage, which incorporates stroking
movements and the meridian points, is described
in detail in Chapter 8. One of the most useful
aspects is that the hand treatment is given from
both the perception of the giver and the receiver.
The sequence is timed to last a maximum of 20-30
minutes, and I was pleased to notice that it could be
adapted to ‘accommodate the receiver’.
The book is presented in an easy to read format and
the text is supported by diagrams in the form of line
drawings and case histories, which play a useful role
in helping to bring the text alive. The content is very
easy to access through a user friendly text.
This book has an interesting approach, in that it was
originally intended for relatives and friends who
may not have any knowledge of massage at all. Its
relevance to health care professionals is also featured
in the text. One of the goals of the authors is to
combine eastern and western approaches, hence the
inclusion of Meridian points. These are explained as
clearly as possible using diagrams and text.
58
Some newcomers to massage and meridian points
could feel a little daunted at first by the detail in the
book. However, with a little practice, the sequence
can be easily learned and the explanatory diagrams
are very clear. Perhaps the stroking movements
could be practised first and, when confident, the
meridian points could then be added.
This book would be a useful edition to any therapist’s
library. It is well referenced and complementary
therapists will find the reference list at the end
of the book a useful resource. This book does not
have any direct link with essential oils. It is a book
about the skillful use of touch, particularly relating
to the hands and arms for people with a variety of
illnesses. However, aromatherapy could easily be
incorporated into the treatment described.
Complementary Therapies for Older People in Care
Author:
Publisher:
Formats:
Sharon Tay
eBook, 216pp; eISBN: 978-0857011411
The aim of this book is to support beauticians and
complementary therapists in using their skills in care
home environments and other care facilities for the
aged. The book covers many aspects of working with
older people in these environments. These include
the assessment of older clients for appropriate
treatments, effective communication, adapting
treatments for specific health conditions, hygiene and
ethical considerations, working around beds, wheel
chairs, walking frames and medical equipment,
guidance on using specific complementary
therapies (reflexology, aromatherapy and massage),
and dealing with common pitfalls and difficulties
practitioners may encounter.
The topics are covered in 9 chapters and the layout
of the book encourages easy reading. The text is
well spaced, both in terms of line spacing and its
positioning on the page. There is a comprehensive
contents list at the front of the book and a detailed
index at the back. As the headings on all the pages
are very clear, it makes the topics very easy to access.
The book is illustrated with grey tone photographs
and diagrams which add to its interest. Where the
author wishes to emphasise or develop important
points, the font is changed, thus making the text
even more pertinent to the reader.
On the back cover, the publishers state “this book
offers helpful information and practical advice on
issues that are often overlooked in training”. The
range of topics (outlined above) vary in the detail
in which they are covered. Some, such as colour
therapy and creative visualization, only have half a
page dedicated to them. It is always difficult to know
what to leave out in a book of this nature, especially
when the author is well practised and experienced.
However, I did wonder where topics have been
included, and then given little page space, that it may
have been better to have omitted them altogether.
For beauticians who are interested in working with
this target group, this book will probably be a useful
resource, especially the chapters on working in care
home environments and working with older people
who have more complex needs.
Aromatherapists will likely be seeking information
59
in more detail and scope; the use of aromasticks
and hydrolats weren’t mentioned, and neither was
the importance of stimulating smell memory. When
working with older people, I have found this to
be an important therapeutic part of the process.
I was puzzled that the main base vegetable oil
recommended was sweet almond oil, even where
“...clients who have allergies to nuts can cope with a mild
application of sweet almond oil” (page 152). It would
be helpful to understand what a ‘mild application’
of sweet almond oil is; grapeseed oil could have
been mentioned as a useful alternative. On page
155, where the author describes two aromatherapy
blends, I found it difficult to understand what was
meant by ‘½ drop’ of an essential oil and how such a
small quantity could be measured accurately.
Overall, the book achieves its goals in offering helpful
information and practical advice on using beauty
treatment and complementary therapies to support
older people. The author is clearly a committed
and experienced practitioner with a compassionate
interest in improving the quality of life for this often
‘forgotten group’ of people.
Clinical Aromatherapy: Essential Oils in Healthcare
Author: Jane Buckle
Publisher: Churchill Livingstone, an imprint of Elsevier, 2014
Formats: paperback, 432pp; ISBN: 978-0702054402 (US$66.95)
This is the third edition of a text originally published
in 1997 under the title Clinical Aromatherapy in
Nursing, followed by a second edition, Clinical
Aromatherapy: Essential oils in Practice, published
in 2003. As with most successive editions, one might
expect a format or text similar to the original, with
revisions and updated information, but this third
edition, published more than ten years later, reads
like a new text altogether.
As a leader in the clinical aromatherapy field, Dr Jane
Buckle has been influential in the largely nurse-driven
integration of essential oils into a range of hospital
settings, particularly in the USA where thousands
of nurses and health care professionals have been
introduced to aromatherapy through the author’s
pioneering and acclaimed education programs.
Coupled with a glowing foreword from the celebrity
figure Dr Mehmet Oz, cardiac surgeon and host of
the TV program The Dr Oz Show, a certain American
influence reigns throughout the text.
This new and revised edition largely revolves
around the collection and collation of research
from around the world; especially data that has
arisen from dissertations and small-scale pilot
studies conducted by students of the author’s
clinical aromatherapy educational programs, which
span almost two decades. This wealth of experience
and data is shared within this text, representing
a significant contribution to the ways in which
aromatherapy can be and is practised in medical
settings.
The author’s stated main goal of the book is to
present an overview of what essential oils can do
in professional healthcare,‚ rather than as a ‘how to’
substitute for training. The book also emphasises its
clinical relevance for the healthcare professional in
that it is peer-reviewed, evidence-based (containing
more than twice the references featured in previous
editions) and written by a PhD nurse with postdoctoral training.
60
The text is divided into three sections:
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1.Overview: including chapters giving basic
information such as aromatherapy definitions,
taxonomy, chemistry, toxicity, contraindications,
aromatherapy and integrative healthcare, and so
on — with a special chapter on the author’s own
hands-on technique, the ‘M’ Technique® which
has been used in healthcare settings (with or
without essential oils) for over 20 years.
2. Clinical uses of aromatherapy: with five chapters
spanning main symptom areas including:
infection; insomnia; nausea and vomiting; pain
and inflammation; stress and wellbeing.
3.Aromatherapy in clinical specialties: with nine
very short chapters spanning aromatherapy
across a range of clinical settings including:
elderly care; critical care/ ICU; dermatology;
mental health; oncology; palliative, hospice and
end of life care; paediatrics; respiratory care and
women’s health.
The limitations of the book are few; and the positive
assets of the book outweigh the comments that
follow. In terms of readability and user-friendliness,
the layout can be confusing, with information not
always being confined to the subject headers, and
a fair amount of run-on text with few subheadings.
At times, there appeared to be random groupings of
information; for example, in the chapter on elderly
care, one very short paragraph addresses both
arthritis and haemorrhoids, while in the chapter on
women’s health, at the end of a section concerning
cracked nipples, the last few lines talk of using
peppermint oil for nausea post-caesarean section.
The book’s assets are numerous. Its main value lies in
a presenting a snapshot synopsis of aromatherapy’s
potential in healthcare, at times reading like a
literature review of specific topics, citing as many
studies as possible for the given subject area. This
is useful and meets the author’s goal of providing
an overview of what is possible in healthcare. It
is also inspiring to reflect just how far clinical
aromatherapy has come in the past 20 years or so,
and leaves the reader hopeful about the future of
clinical aromatherapy within mainstream medical
care. For the reader looking for greater detail, they
are able for the most part to refer to the extensive
reference trail that is included for each chapter.
Es
Another significant contribution of the book is the
extensive reporting of small scale pilot studies and
dissertations conducted by the author’s own clinical
aromatherapy students. Whilst it is admirable and
encouraging to read about the sheer scale of positive
reporting by nurse-aromatherapists that illustrate
all aspects of this book, very few of these important
contributions have reached publication — so the
reader is unable to access further details on many
of the studies that are cited. However, the value of
them being included in this resource is undeniable.
Whilst clearly not written as a ‘how to’ text, the
author does include several suggestions for use
which are unsupported and open to question. For
example, in the oncology chapter in Section Three,
there is a suggestion of preparing the skin prior to
radiotherapy with undiluted niaouli (Melaleuca
viridiflora) essential oil, with the comment that
doing so ‘seems to toughen the skin’ (page 310).
Additionally, some of the safety data and the
instructions for the preparation and use of
aromasticks (personal inhalers) are not consistent
with other respected tutors.
The mix of writing styles was engaging but at times
confusing. As a clinical text directed at healthcare
professionals, the style is generally appropriate for
the level of knowledge of medical terminology and
pathology that one would expect of such readers.
At other times, however, the language used is more
conversational, with broad statements that can
on occasion leave one in doubt about the target
readership. Whilst a colloquial approach certainly
conveys the author’s passion, personal experience
and involvement in aromatic healthcare, the style in
some areas was distracting. For example, there are
a number of overly-simplistic statements such as:
“some essential oils are thought to have emmenagogic
actions, meaning they cause tiny uterine contractions
and can bring on a menstrual period early’ (page
378); and ‘while antidepressants work by making
the neurotransmitter serotonin linger in the gaps
between brain cells, essential oils are thought to work
as serotonin agonists, which can push the serotonin
system into overdrive” (page 299). For me, such
explanations detracted from the clinical rigour of
other aspects of the book.
61
In summary, this book is a key resource for all
aromatherapists working within clinical settings. If
you already possess previous editions of the book, I
recommend that you purchase this text as well; it is
sufficiently different to warrant its contribution as
an important complement to the previous editions.
It is also a testament to the sheer potential of essential
oils to make a difference in clinical settings.
Clinical Aromatherapy: Essential oils in Healthcare
is an rich resource that (more than the previous
editions) clearly demonstrates the author’s
enormous contribution to the aromatherapy field as
well as giving a precious insight into her personal
passion and dedication to making a human and
aromatic difference at the bedside. Restoring
humanity to healthcare via the ‘M’ Technique® and
clinical aromatherapy: what a great contribution!
Fragrance and Wellbeing: Plant Aromatics and Their Influence
on the Psyche
Author:
Publisher:
Formats:
Jennifer Peace Rhind
eBook, 448pp; eISBN: 978-0857010735
The author in her Preface observes that “there
are many excellent books about the sense of smell,
aromatherapy, incense, essential oils, perfumery and
the fragrance industry, and there is a considerable
body of research too, on many aspects of odours…
Here, I have made every attempt to draw together
the many disparate strands and compose a work on
fragrance that I hope will be of interest to a wide
range of readers... It has been challenging to bring
together subjects such as biology, neuroscience,
behavioural science, psychology, social science,
theology, anthropology, ethnobotany, natural product
chemistry, psychotherapy, aromatherapy, ancient
Greek philosophy, mythology, history, folk traditions,
healing practices, essential oils, hallucinogens, fine
perfumery, meditation, spirituality and wellbeing.
However, in order to do fragrance justice, this was
necessary, because fragrance reaches and permeates
all these realms.”
Fragrance and Wellbeing does indeed explore aroma
from a wide range of perspectives. It provides the
reader with a truly multidimensional survey of
fragrance and fragrance materials that include
aromatic extracts, essential oils and perfumes.
The breadth of its focus is such that its appeal is
inherently broad — of interest to anyone working
with or studying fragrant materials, and whether in
a therapeutic, academic or product manufacturing
context. The fact that the author is a PhD biologist
and previous university lecturer ensures that the
book is sufficiently academic in tone and depth to
serve as near-encyclopaedic source of sound, wellreferenced information.
The book divided into two main parts. Part I, Scent:
A Pan Dimensional Perspective, features chapters
that deal with topics including the biological
significance of olfaction; the psychodynamic odour
effect mechanisms proposed by perfumer Stephan
Jellinek; concepts of wellbeing;
incense and
ritual; aromatic smoke and shamanism; the role of
entheogens (psychoactive substances that ‘generate
the divine within’); the evolution of perfumery from
ancient Eygpt to modern times; and the psychology
and sociology of fragrance.
Part II, A Natural Palette of Aromatics, comprises
a chapter on the language of fragrance and its
classifications, followed by profiles on a wide range
62
of aromatics divided into chapters including woody,
resinous, balsamic and coniferous scents; spices;
herbaceous, green, camphoraceous, cineolic and
agrestic scented botanicals; flower; citrus, lemonscented botanicals and fruity fragrances. Part II
concludes with an interesting chapter by Jeannie
Fatimeh Graham on Attars and the Role of Fragrance
in Unani Tibb Medicine.
The profiles can perhaps be considered the heart of
the book, and comparable to those that form part of
Jennifer Peace Rhind’s excellent 2002 publication,
Essential Oils: A Handbook for Aromatherapy Practice.
In contrast, Fragrance and Wellbeing provides a more
indepth historical and olfactory discussion of each
aromatic — though peppered in many instances with
important facts surrounding its chemical composition
and therapeutic uses. Coupled with the book’s easyto-read page design - a hallmark of Singing Dragon
publications - each profile’s globetrotting excursion of
historical and aromatic facts makes for an enjoyable
and satisfying read.
All in all, the sumptuous breadth and delicious
depth of this book, both as a reliable reference and
entertaining read, make it well worth having in one’s
aromatic library. It’s achievement, however, lies
more in the scope of its survey than in developing
a specifc theme that would otherwise fulfill an
expectation engendered by the title: that is, a more
systematic discussion of the link between fragrance
and wellbeing. For example, while a concluding
section comes back to themes such as reflective
awareness, meditative trance and noetic insight,
they are subsumed within a chapter primarily
concerned with Cultivating the Olfactory Palate.
Such an observation is not to detract from the work
at all, but to suggest that it highlights the fact that
the theme of wellbeing is not the consistent focus
— something which is also evident in many of the
aromatic profiles.
‘Wellbeing’ as a term is, of course, sufficiently
generalized to embrace many facets of fragrance
without arguing the point. And if the therapeutics
of fragrance had indeed been the main focus of
Fragrance and Wellbeing, it is highly likely that we
would not have such an exhaustive treasure trove of
information that the book so fruitfully delivers. A
vertiable feast for the aromatic mind!
Essential Oil Basics: A Simple Guide To Greater Health With
Essential Oils
Authors: Jennifer Eden Clark
Publisher:www.learnessentialoils.com
Formats: paperback, 58pp; ISBN: 978-0988997202 ($6.25)
Kindle, 219 Kb; ASIN: B00W2SH592 ($3.05)
This is a small and compact booklet with a clean
attractive cover. Its style is conversational and
approachable, almost like a blog. The author
strives genuinely to explain accurately to the public
how to use essential oils and how to negotiate an
increasingly confusing market. The author asserts
from the beginning how accurate she is being, and
how this book will answer all the reader’s questions.
I think the questions she chooses to address in her
book are valid and topically current. The book goes
hand in hand with the author’s website, which at
the moment is like an advertorial for the book, and
quotes a few sources for further reading.
She succeeds in covering a lot of ground gracefully
but as a reader, I wanted to know more about who I
was reading, along with their background to provide
some context. I felt that there was much explanation
of many points of view, and admirably the author had
tried very hard to neutrally venture into opinionated
territory. All we are told in ‘Why This Guide?’ is that
it is written by a Registered Aromatherapist. This
would not really inform the ‘aroma novice’ - for
whom the book is written - in very much depth
about her experience, which would be a positive
thing.
63
At first glance, the layout covers what a reader may
find on most essential oil supplier websites, with
headings which begin: Why, What, How, Who,
When and Where. It begins with what essential oils
are and then ranges from a discussion about dilution
and safety, to recognising adverse effects. The
information is very comprehensive and I think it
gets this huge subject communicated very concisely.
However, it does advocate that the aroma novice
begin ingesting oils with no formal training. I would
feel more comfortable if there was some advice to the
novice to learn as much as possible about essential
oil safety, and to receive further aromatherapy
education before trying essential oils internally or
even topically. I feel it would have more authority
if the sources of information were listed at the end
of this book, rather than simply a sentence which
refers the reader to the website. Although there is
good discussion and some warning, it is not enough
for a very basic book for beginners.
There is a list of oils and section on using essential
oils in blends and for cooking and cleaning. The
list of oils does not include any discussion of their
properties. Perhaps Cinnamomum cassia is more in
use in the United States, but I found it an odd choice
as there are other safer oils ones which could be used
in a beginner’s book.
The recipes are appealing and chatty. It’s lovely to
find references to her family here. However, I can’t
kick my prejudice as a practising aromatherapist
to find the suggestion of mixing up these blends
and then using them for a variety of situations a
little forced, but I understand the necessity and
convenience of being able to explain the uses in a
very quick way. I had to keep referring back to what
these blends were when reading about the uses. I
wanted more explanation as to why a blend works
and worry about an even vaguer suggestion: “If they
don’t produce the results you desire, try other essential
oils and blends until you find the ones that work for
you”. This sounds a little too much like trial and
error to me.
The next half of the book continues to discuss issues
of dilution and methods of application, cost, storage
and quality standards, with an engaging list of myths
and misconceptions before a personal conclusion. It
is during the listing of quality standards and testing
where the book tips over the neutrality border for
me, as on page 47 there is a special area in grey text
not found in any other formatting of the book. Here
the author explains a trademarked term owned by
a ‘particular company’. In her own words, “Not only
does it claim the oil in the bottle to be ‘Pure Therapeutic
Grade’, it is certified to be so.” It is unmistakable
to me that this is a long running explanation to
detractors of this particular ‘use model’. At this
point of the book I felt the author could have been
clearer about this affiliation from the beginning if
she felt compelled to include this paragraph. So in
conclusion, I suggest taking the author’s own advice:
Buyer Be Aware.
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64
Harvest to Hydrosol: Distill your own exquisite hydrosols at home
Author: Ann Harman
Publisher: IAG Botanics LLC dba BotANNicals, 2014
Formats: paperback, 243pp; ISBN: 978-09913859 (US$44.95)
With almost two decades of experience, organic
farmer and distiller Ann Harman presents this
ground-breaking book on home distillation for
hydrosol/ hydrolat production. In her own words, this
text provides a “road map” for the distillation journey,
offering information, encouragement, guidance, tips,
wisdom and experience along the way.
In her introduction, the author’s first quote
essentially sets the scene for the book’s direction:
“The ACT of distillation is simple; the ART of
distillation is a journey”. The author then goes on
to successfully weave together years of in-depth
research with passion and personal expertise,
generously presenting it all in an accessible and
user-friendly way.
Written essentially for the home distiller, Harvest to
Hydrosol is divided into two key sections:
Section one: The act of distilling
Here the author explores essential information
concerning distillation history, methods, and
techniques, illustrated with examples, tips
and images. Even though the technicalities of
distillation are presented here, the author manages
to distil complex concepts into clear and easily
understandable sections that empower the reader
to grasp the essentials of distillation without
feeling overwhelmed by detail. The beautiful visual
presentation of the text and its illustrations puts the
reader at ease, and from the outset makes the book
personal and practical: talking distiller-to-distiller
whilst at the same time presenting information
that is solid, well-researched and validated through
experience and years of testing.
Section two: The art of distilling
Here the author delves further into the magical art
of distillation; exploring its nuances in more detail,
such as the importance of personal attention during
the distillation process along with issues such as
subtle but essential concepts about water itself, the
freshness and identity of botanical material, still
design and construction materials, and of course
the impact of the distiller/alchemist him/herself
on the final product. An essential theme that runs
throughout the book concerns the personal journey
of the distiller, summarised thus: “Keep in mind that
you, the distiller, are an alchemist and there remains
a part of you in every one of your distillations.
You make the difference between a mere product and
an exquisite product.”
The final chapter of this section entitled ‘The still
room’ details a range of plants (excluding resins
and roots) along with details of their identification,
cultivation, harvest time, plant parts for distillation,
likely chemical components and general therapeutic
actions, and examples of hydrosol use.
A comprehensive appendix follows that details
the analytical information for over 20 hydrosols,
provided by the Circle H Institute; the research arm
of the author’s activities.
In terms of practicality, the comprehensive contents
pages provide easy access to key areas of the book,
and the extensive bibliography encourages further
research and journeying in the world of distillation.
The beautiful colour illustrations and images along
with practical sidebars of tables, tip boxes and
summaries make this book a practical, beautiful
65
and joyful resource that reflects the author’s love of
nature and of these sublime living waters.
In my opinion this book achieves and surpasses
its objectives and target audience; I believe the
readership should extend beyond potential
home distillers to commercial growers, distillers,
researchers and all those who need reminding of the
need to remain humble and personally connected
to nature and to the plants they use in extractions
such as distillation. Aromatherapists who use these
healing waters should also read this text as it will
serve to emphasise the value and importance of
selecting hydrosols that have been distilled as the
primary product rather than some of the waters on
the market that bear little resemblance to hydrosols
that have been carefully and consciously distilled
from fresh plant material.
In her preface to Harvest to Hydrosol, Jeanne Rose,
executive director of the innovative Aromatic Plant
Project in the USA concludes “Ann sets the stage
for a collaboration between you and your still, an
intimate reality for the practitioners and researchers
of plant-based medicine and skin care – to improve
your wellbeing, your health, and the quality of life
through the magic of this alchemy of plant to water
through steam”. In a nutshell, this book is an essential
resource.
66
www.aromatherapytoday.com
W e are delighted to launch LabAroma into the wonderful world of Aromatherapy. LabAroma is a chemistry based,
aromatherapy focused, software tool that formulates the chemistry behind essential oil blending. The aim of
LabAroma is to enhance aromatherapists formulating skills while creating brilliant blends. LabAroma was created
to aid reliability and accurateness to formulating essential oil blends and to make producing these blends
productive and precise.
What the aromatherapy community is saying about LabAroma…
I am so impressed with LabAroma! It solves a significant challenge in
formulating, as the math is often the difficult part for Aromatherapists.
LabAroma is both beautiful and user friendly. I am excited to use it and
share it.
Andrea Butje, Aromahead Institute
I think this is what’s
what missing in the industry; Technology! This is a tool
to enhance our work, not replace it.
Lisa Archey, Essential oil Formulator
Tested and Trusted by Experts
www.labaroma.com
Fostering the education and practice of the professional holistic aromatherapist
Available in print!
 Peer-reviewed articles
 Practitioner case studies
 In-depth essential oil and chemical profiles
 Well-referenced
 Information and resources for the professional
 Current research
 Integrative practices
 Practical techniques
Subscribe online at
www.ijpha.com
68
Guidelines for authors
The International Journal of Clinical Aromatherapy
(IJCA) welcomes submissions for publication. This
includes research studies, articles, case studies
and letters. Please find below some guidelines to
assist with writing for this practitioner-orientated
and research-based journal. Submissions that do
not follow these guidelines will be returned to the
author.
Content
Submission
Each submission must be accompanied by an
abstract of no more than 200 words. If this abstract
is accompanying clinical or basic research, standard
abstract formatting providing a summary of
information on all aspects of the study must be
used. Non-research based articles can have a less
structured abstract.
Please make your submission by electronic means
only, sending text, references, tables and any
illustrations as separate files.
Please submit all work as a Microsoft Wordcompatible document in Times font 12 point, and
double spaced. Do not send your submission as
JPEG or PDF.
Please ensure that the submission is accompanied by
the author’s full contact details, including an email
address. The author’s photograph and biography are
not required; however, the author should indicate
their current occupation or position.
If the submission is from more than one author,
please list the principal author first together with
one email address for correspondence.
Submissions may be made to the Editor:
IJCA
Rhiannon Lewis, Editor
Chemin des Achaps
83840 La Martre
FRANCE
[email protected]
As the IJCA is a thematic journal, we reserve the
right to publish submissions that are relevant to
specific topics chosen by the editors. The list of
topics evolves as the journal progresses; for details
of future topics, visit: www.ijca.net
Abstract
Length of article
Generally, articles are no longer than 5000 words,
with articles of 1500-3000 words being the norm.
Case studies may be of a shorter length; specific
guidelines for these are provided below.
Essential oil nomenclature
For clarity, list all botanical names in italics followed
by the common name of all essential oils used in
brackets; eg. Lavandula latifolia (spike lavender).
Stipulate the part of plant used, method of
extraction, and chemotype, subspecies or variation,
where relevant.
References
It is the author’s responsibility to ensure that the
following referencing style is adhered to:
• References within the text should be cited with
the author’s name and the year of publication; eg:
(Halflinger, 2003).
• Where there are two authors, cite both names
and the year; eg:
(Halflinger and Burns, 2003).
• If there are more than two authors then cite the
first name plus et al.; eg:
(Halflinger et al., 2003).
•At the end of the article, references should be
listed in alphabetical order by the primary author’s
name, ensuring that all authors are listed; eg:
Halflinger P, Betsworth AA (2003). Pain
modulation: a multifaceted approach. Int J Pain
Res, 21(3):27-35.
• Please note that journal titles are abbreviated; eg:
The International Journal of Pain Research
becomes Int J Pain Res.
•References from books should be styled with
the author, year, title, place of publication and
publisher mentioned; eg:
Holloway, P (1999). Pain and its pathology.
London: Parsons Press.
Please note that we are not able to accept articles
that employ the Numeric Style of referencing.
Figures and tables
Figures and tables should be submitted separately
to the text. If figures are included, these should be
submitted in a large or high resolution format. A
concise description should accompany each figure
and table, and they should be cited within the text.
Please ensure that their position within the text is
clear; eg. Insert Table 1 here.
Copyright and permission
As author, you retain the copyright for your work.
You also retain responsibility that the work is your
own, and not copied from other sources. If you
plan to use illustrations from previously published
sources, you require permission from both its
author and publisher, and should cite the source as
well as the permission in your work.
On publication of your work, you will receive a PDF
of your original article as well as PDF of the full
issue in which it is featured.
Where another journal approaches the IJCA for
permission to reprint your work, we will first
contact you for your permission before granting
authorisation to republish it.
Case studies
If submitting a case study for publication, in
addition to the aforementioned information, the
following points may serve as guidelines:
• Obtain consent for publication from your client.
• Provide an overview of the client’s condition.
•
Provide
some
background
information
concerning your client’s condition and any
diagnosed pathology.
• State clearly the reasons for treatment.
•Outline the aromatic care you planned and
instigated.
• Include details on the essential oils chosen, their
relative dosages, and any other products used.
•Wherever possible, provide a precise rationale,
with references, as to why the essential oils and
your treatment intervention were selected.
•Include details of any physical interventions
used; eg. 10 minute foot soak followed by 5
minutes massage per foot using light effleurage
movements.
•Include details of any self help/ home care
measures used by the client.
• Note the client’s ongoing responses and progress.
A successful outcome is not always needed for a
case study; negative reactions also provide useful
points for discussion and reflection.
•Provide commentary on the client’s ongoing
progress, if relevant.
•Reflect critically on the treatment given and
progress made, and state any difficulties you
encountered or any ‘with hindsight’ reflections that
may improve your future aromatic interventions.
Assistance
Should you require assistance or advice regarding
your submission, please contact the editor.
70
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Essential Oil Resource Consultants EURL
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an
publication
ITHMA
The Institute of
Traditional Herbal Medicine
and Aromatherapy (established 1987)
Gabriel Mojay, Principal
Tel: +44 (0)20 7193 7383
[email protected]
www.aromatherapy-studies.com
Professional training courses for 2015-2016
Heart
Soul
Will
Mind
Vital
Spirit
Harmonizing the Spirit: Five Element
Aromatherapy & Essential Oil Acupoint Massage
for Psychological Conditions
Aromatic Medicine: Advanced Essential Oil
Formulating for Common Clinical Conditions
with world-class instructor-clinician Mark Webb (Aus),
author of the classic text on Australian oils, Bush Sense
Oct 10-11, 2015 & March 17-20, 2016
at the Heal Center Atlanta, Georgia
Jan 9-12 & March 31-April 3, 2016 at Regent’s Univ
Aromatherapy Diploma Course
On-year Professional qualification course in
Aromatherapy, Essential Oil Therapeutics,
Therapeutic Massage and Anatomy & Physiology
Starting Sept 19, 2015 at Regent’s University London
Aromatherapy Product Blending
Essential product development
from creation to regulation
with aromatic blending expert Alan Stuart
Oct 31-Nov 1, 2015 at Regent’s University London
Aromatic Blending for Organic Skin Care
Create unique skincare blends from raw materials
with clinical aromatherapist Tanya Moulding
Nov 28-29, 2015 at Regent’s Univ, London
Aromatherapy Study Day at Kew Gardens
Rediscovering aromatic plants and their essential oils
with plant scientist & aromatherapist Dr Viv Anthony
Sat, June 6, 2015 at Royal Botanic Kew Gdns, London
with aromatherapist & acupuncturist Gabriel Mojay
Oct 17-18, 2015 at the Atlantic Institute of
Aromatherapy, Tampa, Florida
Nov 21-22, 2015 at Regent’s University London
Director: Rhiannon Lewis
FIFPA
Providers of research, education and
information in the field of essential oils
•Custom built study programs
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Advanced Clinical Aromatherapy
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