My grandmother had dementia. In the decade before she passed away she didn’t know what day it was, where she was in the world, and, after I cut my hair, who I was. She’d circle her way through the same handful of conversational loops, and I’d play a game where I tried to elicit new stories from each repeated opening gambit.

She had her favorite memories, of course. Flirting with pheasant hunters while waitressing in college, and the horrors of sorting through storage potatoes as a kid because they were thick with lizards. When I played guitar, she wanted to hear Red River Valley and Cowboy Jack. Thirty seconds after a rousing round of Cowboy Jack she’d ask, “Do you know Cowboy Jack?” “How about Cowboy Jack?” 

My relationship with my grandmother was sweet and dreamy. I saw her a few days a year and relished this rare relationship that consisted of nothing but the present moment and the distant past. For my mother, it was a wholly different experience. She was her mother’s primary caregiver, and, despite my grandmother’s nearly angelic demeanor, the constant repetition of questions, confusions, slips and hip breaks, and the childlike need to be fed and put to bed exhausted my mother and consumed her life.

According to the CDC, there were an estimated 5 million adults over the age of 65 with dementia in 2014, a number projected to increase to 14 million by 2060. People with dementia have trouble with memory, attention, communication, reasoning, judgment, and problem-solving. They may get lost in familiar places, forget the names of close friends and family members, and struggle to complete tasks independently.

Dementia is not a disease, but a cluster of social and cognitive symptoms that interfere with daily functioning. It’s more common as people grow older, but it is not a normal part of aging.

There are many possible causes of dementia, including Alzheimer’s, stroke and other issues involving blood flow to the brain (diabetes and high blood pressure are risk factors), vitamin deficiency, and thyroid hormone imbalance. Dementia can also arise as a side effect of some medications.

Treatment for dementia depends on its underlying cause. Neurodegenerative dementias like Alzheimer’s have no cure, but medications can be prescribed to protect the brain and manage behavioral changes and symptoms like anxiety (CDC, 2019).

Caring for folks with dementia is a challenge. Caregiver burden, defined as ‘‘a multidimensional response to physical, psychological, emotional, social, and financial stressors associated with the caregiving experience,” correlates with poor outcomes for caregivers, including depression, illness, and decreased quality of life. In the US, family members provide up to 80% of in-home care. The amount of time required for caregiving increases as the severity of dementia worsens (Etters, Goodall, and Harrison, 2008).

Dementia-related costs in 2010 were estimated to be a whopping $159-$215 billion when the value of unpaid caregiving was accounted for (Kasper, et al., 2015).

The burden of caregiving, particularly unpaid caregiving, is disproportionately allocated to women. Over 75% of all caregivers are female, and female caregivers may spend up to 50% more time providing care than male caregivers. Male caregivers are less likely to provide personal care like bathing and dressing, and 40% of male caregivers hire someone else to perform personal care (Family Caregiver Alliance, 2016). The National Partnership for Women and Families reports that in 2020 over 65 million women provided unpaid care in the form of child care, family care, and eldercare. The majority of these women did so while holding full- or part-time jobs, and over half were parents of children under the age of 18 (NPWF, 2021).

There is a clear need to support caregivers of dementia patients, while also addressing the symptoms of dementia itself. A 2021 pilot study published in Aging Clinical and Experimental Research aimed to do just that. Researchers investigated the effect of aromatherapy with lavender and sweet orange essential oil on the behavioral and psychological symptoms of dementia (BPSD), as well as on the psychological distress of caregivers. The outcome? Aromatherapy was found to reduce the severity and frequency of BPSD in patients, and to relieve stress in caregivers (Mascherona et al., 2021).

Aging Clinical and Experimental Research is a multidisciplinary forum that publishes work in the progressing field of gerontology and geriatrics. The journal is indexed in MEDLINE, a highly selective index of biomedical journals currently considered to be the gold standard in databases. In other words, we can trust Aging Clinical and Experimental Research to be a credible source of information (Ossom Williamson, 2019).

The aim of this study was to evaluate the efficacy of aromatherapy as an adjunct to psychotropic drug therapy in managing BPSD, when compared with psychotropic drug treatment alone. Symptoms of BPSD in patients and levels of professional caregiver stress were assessed in both scenarios.

The behavioral and psychological symptoms of dementia, including neuropsychiatric symptoms, “constitute a heterogeneous array of non-cognitive symptoms and behaviors” that can trouble both patients and caregivers. These include:

• Agitation
• Aberrant motor behavior
• Anxiety
• Elation
• Irritability
• Depression
• Apathy
• Disinhibition
• Delusions
• Hallucinations
• Changes in sleep or appetite

The behavioral and psychological symptoms of dementia likely affect up to 90% of those with dementia over the course of their illness. They reduce quality of life, increase the frequency of falls and fractures, contribute to the rapid progression of dementia, and present a challenge for caregivers. It’s a real problem. According to the authors of the study, BPSD can cause severe patient and caregiver distress, and lead to long-term hospitalization or institutionalization, inappropriate medication use, and bloated healthcare costs.

The standard pharmacological approach to BPSD is treatment with psychotropic drugs. These are classified as antipsychotic, antidepressant, anxiolytic, and hypnotic, depending on their primary therapeutic effects. Current guidelines, however, recommend non-pharmacological therapies as first-line interventions due to the fact that psychotropic drugs are limited in their efficacy and may exhibit adverse side-effects. 

Could aromatherapy be the safe and effective non-pharmacological intervention dementia patients need? Let’s get into the nuts and bolts of the article to find out.

This study enrolled 32 patients with an established diagnosis of dementia. These patients were admitted to the Geriatrics Department of the Clinica Luganese Moncucco (CLM) in Lugano, Switzerland for evaluation and treatment of BPSD. (In case you’re curious, the term “monocentric” in the article title refers to the fact that the study was conducted at this single research center).

The subjects were randomly divided into two groups: an experimental group that received aromatherapy in addition to psychotropic therapy, and a control group that received psychotropic therapy alone. Patients in both groups also received Pro Re Nata (PRN), a Latin term meaning “in the circumstances,” which refers to the administration of medication as the situation requires.

Researchers assessed patient symptoms and caregiver distress using the Italian version of the Neuropsychiatric Inventory Nursing Home (NPI-NH) scale. This is a semi-structured interview for professional caregivers (physicians, nurses, and care assistants), that allows them to assess the presence, frequency, and severity of 12 BPSD symptoms. Questions are divided into three categories:

• “Thymic”
  • Depression/dysphoria
  • Anxiety
  • Euphoria/exaltation
  • Apathy/indifference
  • Sleep disorders

• “Psychotic”
  • Delusions
  • Hallucinations

• “Motor Manifestations”
  • Agitation/aggressiveness
  • Disinhibition
  • Irritability/lability
  • Aberrant motor activity

Total scores on the NPI-NH range from 0-144, with anything over 4 considered to be pathological. The NPI-NH was also used to evaluate distress levels in professional caregivers, with a scale of 0 (no distress) to 5 (extreme distress).

Study inclusion criteria mandated that patients be 70+ years old, and admitted to the Acute Geriatrics Department of the Clinica Luganese Moncucco with dementia and associated BPSD. Patients were excluded from the study if they had alcoholic dementia, exhibited only mild cognitive impairments, and had linguistic barriers or a history of aromatherapy use.

In the 48 hours following admission to the ward, patients with BPSD underwent comprehensive clinical and paraclinical assessment to rule out any acute disease that could cause delirium or impact mental status. Patients were assessed using the following measures:

• The four-item Confusion Assessment Method (CAM)
• Mini Mental State Examination (MMSE)
• Frontal Assessment Battery (FAB)
• Clinical Dementia Rating Scale (CDR)
• Tinetti’s Test (measures gait and balance)
• Basic Activities of Daily Living (BADL)
• Instrumental Activities of Daily Living (IADL)
• Cumulative Illness Rating Scale (CIRS)

Patients who scored >2 at the initial CAM screening underwent a full geriatric assessment. Those found to have delirium were admitted to the study after resolution of delirium if they still presented BPSD. This assessment also included a systematic drugs review for psychotropic, anti-dementia, and anticholinergic drugs.

Patients were removed from the study if the patient or a relative/legal guardian withdrew their consent, if the patient did not present BPSD at the first evaluation time point (T1), if a physician determined involvement in the study would negatively impact the patient’s psychological or physical health, or if any pharmacological side effects occurred.

Professional caregivers were interviewed at four different time points (designated T1, T2, T3, and T4) to evaluate the frequency and severity of their patients’ BPSD. Data analysis was performed by a different researcher than the physician who conducted this assessment in order to blind researchers to the patients’ experimental status.

The timing of the study can be a little confusing, so let’s break it down:

T0. Marks the time of enrollment in the study.

T1 (T0 +2 days). First evaluation time point.

T2 (T1 +3 days). The time at which researchers expected the aromatherapy treatment to become effective based on previous research (Tible et al., 2017; Wood et al, 2000).

T3 (T1 +6 days).

T4 (T1 +12 days).

There were only seven remaining patients in the control group and nine remaining patients in the experimental group by this time point, so the study focuses on comparisons between outcomes at T3 and T1.

Essential oils were administered by geriatric department nurses via a mist diffuser. Six drops of sweet orange essential oil were diffused for 60 minutes three times a day (at 7:00 am, 12:00 pm, and 3:00 pm) in the rooms of patients in the experimental group. At night (10:00 pm), six drops of lavender essential oil were administered for 60 minutes. Patients were in their rooms for the duration of these aromatherapy periods with the doors and windows closed.

Atmospherically-diffused lavender and sweet orange essential oils are considered to be non-toxic, even when administered for extended periods of time. The researchers used certified oils, and confirmed the composition of every batch using spectrophotometry.

To determine a minimum sample size for this pilot study, the researchers looked at a similar study that investigated the efficacy of aromatherapy in managing agitation in severe dementia using the Cohen-Mansfield Agitation Inventory (CMAI). Based on the average and standard deviation values of CMAI scores for the experimental and control groups, the researchers calculated that they would need a minimum sample size of 15 patients per group to establish a statistical power of 80% at the 5% significance level for a two-tailed hypothesis test. 

What does that mean? The function of a two-tailed hypothesis test is to evaluate whether a sample mean is both significantly greater than and significantly less than the mean of a population. Think of the two sides of a bell curve. This test tells us what’s going on on both sides of the bell curve simultaneously. Statistical power refers to the probability of a hypothesis test to detect an effect if there’s an effect to be found. In this case, there’s an 80% chance of finding a p-value of less than 0.05 (a statistically significant effect) in a statistical test.

The researchers assessed differences in sociodemographic characteristics and clinical scores between the experimental and control groups at T1, and determined they had sufficiently overlapping neuropsychological and functional characteristics for the purposes of this pilot study. 

There were, however, three notable differences between the experimental and control groups that should be noted:

1. Higher proportion of women in the experimental group (93%) than the control group (43%) due to random stratification of consecutively enrolled patients.
2. Ratings on the Cumulative Illness Rating Scale (CIRS) were found to be significantly higher in the aromatherapy group than the control group at T1.
3. There were more patients with higher CAM scores and no delirium in the control group due to “random attribution.” It’s not totally clear what “random attribution” means statistically-speaking; I wonder if the authors meant “random attrition,” which refers to subjects randomly dropping out of the study before T4. 

In this study, treatment with aromatherapy was found to reduce NPI-NH scores overall between T1 and T3, and when compared with the control group that received psychotropic therapy alone. In the aromatherapy group, when the NPI-NH values were divided into the three categories (psychotic, thymic, and motor manifestations), a significant reduction was observed in thymic symptoms and motor manifestations between T1 and T3, but there was no change in psychotic symptoms during this same period. It should be noted that there was a low incidence of psychotic symptoms in both experimental and control groups at T1, thus a lack of significant difference in this symptom category is expected. The results were the same for patients that received PRN and those that did not. 

Distress scores among caregivers in the aromatherapy group also decreased significantly from T1 to T3. This effect was more pronounced in nurses and care assistants than physicians, but still significant across all groups. Furthermore, caregiver distress at T3 was lower in the aromatherapy group compared with the control group across all measures. Interestingly, this outcome occurred despite the fact the aromatherapy group displayed higher initial levels of caregiver distress in all three caregiver categories at T1. The reduction of caregiver stress in the aromatherapy group over time, and in comparison with the control group at T3, indicates the efficacy of essential oil therapy in reducing psychological distress in caregivers. 

The authors offer several explanations for the reduction of stress in caregivers in the aromatherapy group:

1. Reduction of the behavioral and psychological symptoms of dementia in patients, as observed in the aromatherapy treatment group, lowers the caregiver burden and reduces caregiver distress.
2. Aromatherapy exerts a direct stress-reduction effect on caregivers.

Reduction of caregiver stress benefits caregivers directly and also improves the treatment of patients and reduces their symptoms. 

No adverse effects of essential oil therapy were observed.

The authors theorize, based on previous studies, that aromatherapy reduced thymic and motor symptoms by modulating GABAergic and serotoninergic pathways (Lange et al., 2004). Lavender essential oil administered via inhalation has been specifically demonstrated to induce anxiolytic and antidepressant effects through activation of these same pathways (Kasper et al., 2014).

In sum, this pilot study demonstrated that a combined intervention of essential oil therapy and psychotropic drugs was more effective in reducing BPSD in patients with dementia and distress in their caregivers than one consisting of psychotropic drugs alone. 

Despite the positive results of this study, there are a few limitations to consider. First, the small sample size. There were only 16 subjects in each group, and not all subjects remained for the duration of the experiment (At T4 there were nine subjects in the aromatherapy group, and seven in the control group). Secondly, observation times were short due to patient stays of less than two weeks. A third potential issue is that there were significant sex differences in the composition of the two test groups. The authors conclude that their findings are promising, but must be validated “in a larger sample of patients over the long-term.”

Finally, let’s consider the unique benefits of using aromatherapy to support dementia patients and their caregivers.

Aromatherapy is a fast-acting remedy. Indeed, the behavioral and psychological symptoms of dementia and caregiver distress were already significantly reduced after only three days of treatment in the aromatherapy group.

Importantly, essential oil therapy via mist diffusion is simple to administer. Patients with dementia and high levels of BPSD are often agitated and/or aggressive, which can be a major obstacle to treatment. For example, physicians often prescribe parenteral psychotropic drugs to avoid uncooperative and non-compliant patients refusing oral administration. “Parenteral” refers to methods of administration that occur elsewhere in the body than the mouth and alimentary canal; injections, for example. Parental drug administration is, however, invasive and can exacerbate patient agitation and aggression. A further problem is that most modern neuroleptics (antipsychotic medications) and antidepressants are only available in oral form. Atmospherically diffused essential oils, on the other hand, offer the benefit of “regular, prolonged, non-invasive, and non-traumatic therapy administration” (Mascherona et al., 2021).

Overall, this study serves as promising proof of concept. Aromatherapy appears to be uniquely suited to support dementia patients and their caregivers, and warrants further research.

References

Caregiver statistics: Demographics. (2016). Family Caregiver Alliance. https://www.caregiver.org/resource/caregiver-statistics-demographics/

Etters, L., Goodall, D., & Harrison, B. E. (2008). Caregiver burden among dementia patient caregivers: A review of the literature. Journal of the American Academy of Nurse Practitioners, 20(8), 423–428. https://doi.org/10.1111/j.1745-7599.2008.00342.x

Kasper, J. D., Freedman, V. A., Spillman, B. C., & Wolff, J. L. (2015). The disproportionate impact of dementia on family and unpaid caregiving to older adults. Health Affairs, 34(10), 1642–1649. https://doi.org/10.1377/hlthaff.2015.0536

Kasper, S., Gastpar, M., Müller, W. E., Volz, H.-P., Möller, H.-J., Schläfke, S., & Dienel, A. (2014). Lavender oil preparation Silexan is effective in generalized anxiety disorder – a randomized, double-blind comparison to placebo and paroxetine. The International Journal of Neuropsychopharmacology, 17(06), 859–869. https://doi.org/10.1017/S1461145714000017

Lange, R. T., Hopp, G. A., & Kang, N. (2004). Psychometric properties and factor structure of the Neuropsychiatric Inventory Nursing Home version in an elderly neuropsychiatric population. International Journal of Geriatric Psychiatry, 19(5), 440–448. https://doi.org/10.1002/gps.1108

Mascherona, I., Ferretti, M., Soldini, E., Biggiogero, M., Maggioli, C., & Fontana, P. E. (2021). Essential oil therapy for the short-term treatment of behavioral and psychological symptoms of dementia: A monocentric randomized pilot study. Aging Clinical and Experimental Research, 33(8), 2251–2259. https://doi.org/10.1007/s40520-020-01754-2

Ossom Williamson, P., & Minter, C. I. J. (2019). Exploring PubMed as a reliable resource for scholarly communications services. Journal of the Medical Library Association : JMLA, 107(1), 16–29. https://doi.org/10.5195/jmla.2019.433

Tible, O. P., Riese, F., Savaskan, E., & von Gunten, A. (2017). Best practice in the management of behavioural and psychological symptoms of dementia. Therapeutic Advances in Neurological Disorders, 10(8), 297–309. https://doi.org/10.1177/1756285617712979

What is dementia? (2019, December 19). Centers for Disease Control and Prevention (CDC). https://www.cdc.gov/aging/dementia/index.html

Women Carried the Burden of Unpaid Caregiving in 2020. (2021, May). National Partnership for Women & Families. https://www.nationalpartnership.org/our-work/resources/economic-justice/women-carried-the-burden-of-unpaid-caregiving-in-2020.pdf

Wood, S., Cummings, J. L., Hsu, M.-A., Barclay, T., Wheatley, M. V., Yarema, K. T., & Schnelle, J. F. (2000). The use of the neuropsychiatric inventory in nursing home residents: Characterization and measurement. The American Journal of Geriatric Psychiatry, 8(1), 75–83. https://doi.org/10.1097/00019442-200002000-00010