What can Psychology tell us about the effectiveness and popularity of Aromatherapy in the treatment and management of behavioural problems associated with Dementia sufferers? Dementia can broadly be defined as the serious loss of cognitive ability in a previously unimpaired individual, beyond that normally seen in ageing (Fadil et al. , 2009).
The majority of research has focused on the cognitive deficits of the syndrome, however more than 50% of sufferers will also experience behavioural and psychological symptoms which are seen as both distressing for the patients and problematic for the caregivers (Ballard, O’Brien, Reichelt, ; Perry, 2002 ). The most persistent ‘behavioural and psychological symptoms in dementia’ (BPSD) are aggression and restlessness (Ballard et al. , 2002).
Typically treatment of BPSD has been based almost entirely on antipsychotics, however with increasing concerns over the side effects profile of such treatment there has been a particular focus on the development of alternative or complementary approaches. Aromatherapy is one such example of an alternative therapy, and therefore there is a need to consider the effectiveness of its use in decreasing BPSD. The use of antipsychotic treatment has been associated with a variety of side effects, with the most persistent manifestations being movement disorders such as pseudo-parkinsonism and tardive dyskinesia (Nguyen ; Paton, 2008).
The Committee on Safety of Medicines (2004) issued a report warning practitioners of the dangers affiliated with the use of such treatment. The conclusions here were based on both the identified side effects and the plethora of research, which failed to antithesize the efficacy of such treatment from placebo. Unsurprisingly, the popularity of antipsychotic treatments has declined and have almost simultaneously resulted in an increase in the popularity of complementary and alternative medicine; most particularly to dementia, Aromatherapy (Ernst, 2001).
Aromatherapy is a form of alternative medicine that uses plants and/or its materials for the purpose of making a change to an individual’s mood, cognitive function and health (Ericksen, 2000). According to Nguyen (2008) aromatherapists believe that BPSD is a result of imbalances in mental, emotional, and physical processes. Treatment therefore is based on addressing these imbalances via the administration of aromatherapy oils. The exact mechanisms to which aromatherapy work is a subject of debate, however psychological explanations have focused on the link between the aroma and the individual’s perception of it (positive/negative).
Holmes and Ballard (2004) suggested that an individuals past experience with the aroma will determine the outcome of the treatment. The association between the aroma and the response, be it negative/positive, is a result of the emotional significance to which the amygdala attaches to the stimuli (Holmes ; Ballard, 2004). The relevance of this to the reduction of BPSD isn’t clear but Holmes suggested that there might be a pharmacological explanation, which revolves around the active biochemical components of aroma oils, and their involvement in parasympathetic activation.
One of the largest studies to investigate the effectiveness of aromatherapy in reducing BPSD was carried out by Bowles (2002). In this study 72 participants with clinically significant BPSD were randomly assigned to an aromatherapy (N=36) or placebo (N=36) condition. The aromatherapy oil/placebo oil was combined with a base lotion, and applied to the face and arms of the subjects twice a day for a 4-week period. The behavioural and psychological changes (measured via CMAI scale) were then compared. 0% of the active group and 14% of the placebo group experienced a significant reduction in negative symptoms associated with dementia; thus finding aromatherapy an effective treatment for clinically significant BPSD.
Within this study one of the subjects receiving active treatment was unable to complete the trial due to death, whilst another within the same group reported extreme diarrhoea for 2 days. It is unsure if these events relate to the aromatherapy treatment but further research should be conducted to investigate possible idiosyncratic side effects of its use.
In addition whilst the study observed a statistical difference between the two conditions, it is important to note that for both groups concurrent medication was permitted for the duration of the study. This forces us to question the internal validity of the findings; it is quite possible that any reduction in BPSD was actually due to antipsychotic medication, which any of the subjects may have been taking. The study failed to monitor this and therefore any difference observed between the two groups quite simply could be down to the chance that more subjects taking medication ended up in the active treatment condition.
The study was conducted on a double blind design, in an attempt at reducing the potential for demand characteristics and expectation bias’. However, the ability to blind subjects in aromatherapy studies is very difficult as the smells of active treatments are usually very strong and therefore detectable(Nguyen ; Paton, 2008). Similar results for the effectiveness of aromatherapy, however, were obtained in several other studies. For instance Burleigh (1997) conducted a longitudinal investigation on 7 subjects with severe BPSD.
The investigation period was divided into four phases; phase one and three were characterised by active aromatherapy treatment, whilst phases two and four subjects remained free of treatment. In this instance behavioural and psychological symptoms were assessed using the ‘Behaviour assessment scale of later life (BASOLL). BPSD was significantly reduced in 5/7 subjects, and further observations showed that 6/7 subjects post treatment needed less assistance with activities in daily living. This again, promotes the efficacy of aromatherapy in reducing BPSD.
Critically evaluating the findings of Burleigh (1997) exposed points, which are important to consider. The study reported that some subjects whom received the treatment experienced allergic reactions despite skin tests being performed beforehand. It is not shown how many or the extent to which subjects were affected; an aspect that should be considered in effectiveness. Also, the study failed to apply any statistical tests for significance, which arguably is very import for such a small sample group. Small samples also increases the risk of both type 1 error and a publication bias.
All commitments to medication within subjects was neglected. Again, without taking this into consideration the results obtained could be a result of antipsychotics rather than the aromatherapy. Furthermore, the cogency of the findings is questionable as untrained staff members carried out all the data collection. One could to attribute the changes in BPSD to inconsistent behavioural reporting made by the varying care staff. It is also unclear whether blinding of the patients/staff took place in this study, which also leaves the study vulnerable to expectation biases.
Future research that investigates effectiveness has to focus on adhering to a main principle of aromatherapy: the individualisation of treatment. Henry (2004) proposed that the effectiveness of an oil is entirely based on the how matched it is to an individuals characteristics and experiences. Nguyen and Paton (2008) conducted a review of the recent literature on the subject and found that of 11 studies, only one has adopted this principle whilst the others used a single or a blend of oils.
BPSD incorporates a variety of behaviours and therefore it is important to establish which oils are best suited in treating particular symptoms. For instance studies have rationalised the use of Lavender oil in subjects characterised by high levels of aggression (Ballard, O’Brien, Reichelt, & Perry, 2002 ). However, this assertion is for the most part unsubstantiated, as there is very little research that supports the efficacy of lavender oil specifically to the treatment of aggression in BPSD.
The way in which we administer aromatherapy oils is also an avenue that should be explored. Kayne (2009) points out that that the most common modes of treatment have been application to the skin via lotion/massage oils and via scents and smells. Research should focus on the significance of the method of application: for instance, some individuals with dementia experience bouts of anosmia (loss of the sense of smell) and therefore treating BPSD in this way will not always be effective (Snow, Havanec, & Brandt, 2004).
Nguyen (2008) found that in only 1/11 recent studies, were subjects tested on olfactory functioning whilst 5/11 administered the treatment via scent/smell. Research is needed to establish the mechanism that mediates the reduction is BPSD so that the most appropriate mode of application can be matched with the most appropriate dementia characteristics. In addition to this, aromatherapy may be combined with other complementary treatments, like massage therapy and acupuncture.
Viggo & Jorgensen (2006) suggested that other forms of pressure and touch may aid the return of cognitive ability, and thus open up the potential to further reductions in BPSD. To conclude, there is some evidence to support the use of aromatherapy in the reduction and management of BPSD, however the evidence is extremely scarce and filled with extensive concerns. Research is a long way from fully understanding the aetiolgical principles that mediate effectiveness, and little is know about the chronic side effects of its usage.
Psychological research makes an attempt at inferring efficacy of CAM, however it struggles to fully understand both the benefits and limitations of its usage. Due to the prematurity of the research it would be inadvisable to recommend the use of CAM, and most particular aromatherapy without caution(Nguyen & Paton, 2008). Psychology, whilst taking the necessary measures to understanding CAM still needs progress further otherwise any decisions to implement its usage may result in the replacement of antipsychotics with an alternative, but nonetheless, equally damaging treatment.