1IJCA | 2015 | Vol 10 | Issue 1

2015 | Volume 10 | Issue 1 Elderly Care

ISSN 1961-7623

Editor: Rhiannon Lewis Associate Editor: Gabriel Mojay

A unique resource for enhancing clinical practiceWritten by practitioners for practitioners

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INTERNATIONAL JOURNAL OFclinical aromatherapy

Contents

INTERNATIONAL JOURNAL OFclinical aromatherapyEditor: Rhiannon LewisAssociate Editor: Gabriel Mojay

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

2015 | Volume 10 | Issue 1 Elderly Care

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Rédaction/Publication:Essential Oil Resource Consultants EURLChemin des Achaps83840 La MartreFRANCETel/fax: (+33) 483118703Rédactrice/Editor: Rhiannon Harris LewisEmail: editor@ijca.netDepot legal: à parutionISSN: 1961-7623Cover image: copyright © 2015 Pascal Duvetwww.pascal-duvet-photographie.com

DisclaimerThe Publisher cannot accept responsibility for any injury or mishap to persons or property from the use of any methods, products, instructions or ideas referred to within this publication. The views expressed in the IJCA are not necessarily those of the Publisher or members of the Editorial Board.

AdvertisingAdvertising enquiries should be addressed to the Editor.Although all advertising material is expected to conform to ethical standards, and inclusion in this publication does not constitute guarantee or endorsement of the quality or value of such product or of the claims made of it by the manufacturer.The Publisher reserves the right to refuse any advertising that is considered inappropriate.

Copyright © 2015 Essential Oil Resource Consultants EURLNo part of this publication may be reproduced, stored in a retrieval system or transmitted in any form, or by any means, electronic, mechanical, photocopying or otherwise, without prior written permission of the Publisher.

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1IJCA | 2015 | Vol 10 | Issue 1

“An unbending tree breaks in the windthus the rigid and inflexible will surely failwhile 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

Editorial

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 MojayAssociate 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)

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Mapping Aromatherapy Use in Hospitals in USA

Dear IJCA Readers,

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 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 juljones@wakehealth.edu

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.

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.

Letters

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 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.

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 GroupLWeihbrecht@gmail.com

Julie Jones MSN,RN,CHTP,CA

Primary Investigator, Wake Forest Baptist Medical Centerjuljones@wakehealth.edu

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Letter from the Editor

Dear Readers,

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.

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.

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.

Letters

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.

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:

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 Lewiseditor@ijca.net

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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.

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.

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.

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, distillerAarya Aroma, Kathmandu, Nepalkailash@essencenepal.comwww.essencenepal.com

Wintergreen harvest, 2014.

Wintergreen at the distillery, 2014.

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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.

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.

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.

Demolished home, 2014.

Some materials can be salvaged and reused, 2015.

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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

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, Japankurakami@med.tottori-u.ac.jp

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.

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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.

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,

aromatherapy is the result of the vital reaction that occurs through the smell molecule.

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.

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

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).

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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.

FAST3-5 FAST3-5 Total Mean (±SD)age (years)

AD 5 (0/5) 12 (2/10) 17 (2/15) 86.3 ± 6.4VaD 1 (0/1) 2 (0/2) 3 (0/3) 89.7 ± 5.5Others 3 (0/3) 5 (0/5) 8 (0/8) 84.5 ± 8.3Total 9 (0/9) 19 (2/17) 28 (2/26) 86.1 ± 6.9Mean (±SD) age (years) 83 1 6.9 87 1 6.2 86.1 1 6.9

Table 1. Distribution of subjects according to Functional Assessment Staging of Alzheimer’s disease (FAST) assessment

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.

Before 1 1 weekControl period 4 weeksBefore 2 1 weekAromatherapy period 4 weeksAfter 1 1 weekWash out period 4 weeksAfter 2 1 week

Table 2. Study schedule

To evaluate the effects of aromatherapy, tests were performed up to four times throughout the schedule.

Before 1 Before 2 After 1 After 2HDS-R ✓ ✓ ✓ ✓GBS ✓ ✓ ✓ ✓FAST ✓ ✓ ✓ ✓CT ✓ x x xBlood Examination ✓ x ✓ x

Biochemical Examination ✓ x ✓ x

TDAS ✓ ✓ ✓ ✓Zarit ✓ ✓ ✓ ✓

Table 3. Tests used in the present study

✓, 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.

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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), GBSS-J-C (feeling function), GBSS-J-D (other moral condition), and GBSS-J-E (movement function).

The degree of AD was determined in patients usingthe 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

Before 1 Before 2 After 1 After 2 P valueFAST 5.64 ± 1.32 5.58 ± 1.37 5.53 ± 1.07 5.76 ± 0.97 0.573HDS-R 11.06 ± 7.72 10.61 ± 7.49 10.27 ± 7.72 10.56 ± 7.83 0.833GBSS-J-B 10.65 ± 7.24 9.88 ± 7.05 11.06 ± 8.3 11.35 ± 7.31 0.174GBSS-J-C 10.29 ± 7.54 9.76 ± 7.05 11.2 ± 7.09 11.65 ± 7.48 0.463GBSS-J-D 7.24 ± 7.44 8.71 ± 5.97 7.18 ± 4.64 8.47 ± 6.74 0.499GBSS-J-E 15.65 ± 8.98 15.18 ± 8.91 15.88 ± 9.55 17.59 ± 8.74 0.071

Table 4. Test results in dementia patients that did not exhibit significant changes after aromatherapy

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.

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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.

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

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 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 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).

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.

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(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 ofroutine laboratory tests.

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

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.

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 preliminaryinvestigations, 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.

One of the limitations of the present study is the lowpatient numbers. In future studies, a greater numberof 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).

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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.

Complementary alternative medicines need to be safe. To confirm the safety of the aromatherapy usedin 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 toverify 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.

Acknowledgements

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.

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Introduction

‘…But O! For the touch of a vanish’d handAnd 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

The HEARTS Process and its potential role in elderly care

Ann Carter

Aromatherapist, educator, complementary therapist specialising in cancer care, life coach and author coffeecups@tiscali.co.uk

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.

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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.

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:

• 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.

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.

The components of HEARTS

Hands-on

This essential component includes physical contact. Techniques were adapted from Thai massage,

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.

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 loving-kindness) in Thai massage.

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.

Textures

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

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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:

‘The skin and the covers are like a sensory canvas on which we paint our art, and our hands are like the paint brushes’.

Sound

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 voice-led 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?

• 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.

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.

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.

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 cost-effective 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,

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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.

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.

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”.

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.

Why Aromas are an optional component of HEARTS

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.

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

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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.

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 1. Aromastick components

Figure 2. Bioesse Inhalation Patch.

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Odour memory as a powerful therapeutic tool

If no aromatherapist is present in the care setting, how can aromas be incorporated into the Hands-on 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’

• 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

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 Hands-on 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.

Figure 3. Bioesse Inhalation Patch in situ.

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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.

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.

Conclusion

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.

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.”

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.

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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://www.cancer.gov/cancertopics/pdq/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.

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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.

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, Finlandulla-maija.grace@aromatica.fihttp://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.

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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).

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.

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.

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 projectsApproximately 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.

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.

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.”

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 ?

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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.

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%

Table 1. Essential oil Blend 1 ‘Harmony and Delight’ (concentration 1% in vegetable oil base).

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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.

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.

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’

Figure 1. Data collection sheet (orange text: before treatment; green text: after treatment)

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.

Fig 2. The effects of treatments (pilot study results)(yellow = very happy; orange = cheerful; neutral = apathetic; purple = low mood; grey = sad or depressed)

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“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.

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

Table 2. Mood shifts from before to after treatment across all studies until Dec 2014 (Total 429 treatments)

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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

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.

Reducing therapist bias

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

major question that needed to be resolved. We tried to accomplish this with the following strategies.

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.

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.

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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.

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.

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

Reviving memory with photos or personal itemsIn 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

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.

Music therapy and aroma

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 re-evoked at a later stage.

Living environment and wellbeing

Boosting appetiteAppetite 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 airParticularly 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 activityThe 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 careFor 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.

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.

Conclusion

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 the restlessness and anxiety of the patients ?

The results concerning reducing anxiety and restlessness immediately after the treatment is clear.

Other valuable findings of our work include:

• 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.

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 nameThen, 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 beingCare 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

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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.

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 gommez-g@ch-valenciennes.fr

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.

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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

Indications:• Acute pain• Inflammatory pain• BruisingExamples: 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).

• 1 volume lemon-scented eucalyptus essential oil (Eucalyptus citriodora)

• 1 volume wintergreen essential oil (Gaultheria procumbens)

• 1 volume katrafay essential oil (Cedrelopsis grevei)

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Table 1. Aromatherapy protocol for acute pain

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Treatment over a period of 5 days maximum, with possibility of renewing following medical re-evaluation.

Preparation of Blend 1:In a 10ml bottle:

3mls lemon eucalyptus essential oil3mls wintergreen essential oil3mls katrafay essential oil

In a 30ml bottle:10mls lemon eucalyptus essential oil10mls wintergreen essential oil10mls 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 au niveau des soins et

est intégré au plan de soin du patient au même titre

que prescriptionsmédicamenteuses

The aromatic prescription is in the care section and is integrated into the care plan at the same level as medications.

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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 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.

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.

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

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). 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.

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.

PostscriptArticle translated from French by Rhiannon Lewis.

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Background

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

mainland Europe (Harris, 2003; Bensouilah 2005).

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.

Rhiannon Lewis

Aromatherapist, educator, editor, director of Essential Oil Resource Consultants, organiser of botanica2016www.botanica2016.com • www.essentialorc.com • essentialorc@club-internet.fr

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.

Towards defining clinical aromatherapy: the essenceof

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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

Figure 1. Different styles of aromatherapy

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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

UK USA CANADA JAPAN AUSTRALIA

International Federation of Professional

Aromatherapists(IFPA)

Alliance of International

Aromatherapy(AIA)

Canadian Federation of

Aromatherapists(CFA)

Japanese Society of Aromatherapy

(JSA)

International Aromatherapy and Aromatic

Medicine Association (IAAMA)

International Federation of

Aromatherapists(IFA)

National Association of Holistic

Aromatherapy(NAHA)

British Columbia Association of Practicing

Aromatherapists(BCAPA)

Table 1. Main aromatherapy associations representing aromatherapists and their headquarters

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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%).

Top six countries represented at botanica2012 (n=135)

Top six countries represented at botanica2014 (n=129)

Ireland 32% United Kingdom 22%

United Kingdom 25% Ireland 20%

United States 11% United States 11%

Canada 5% France 4%

France 3% Brazil 3%

Australia 4% Australia 3%

Table 2. Top six countries represented at botanica2012 and 2014

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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.

Figure 2.

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%

Table 3. Age of botanica participants

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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 8.6% • Teachers/ trainers 6.0%• Massage therapists 6.0%• Reflexologists 6.0%• Pharmacist/ doctor 4.0%

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

PROFESSION * Botanica2014(n=199)

Herbalist 12%

Aromatherapist 76%

Herbal/essential oil retail 15%

Retired 1%

Other health care professional 52%

No answer 3%

Table 4. Profession

* Some respondents gave more than one answer. Data only available from botanica2014.

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%

Table 5. Level of professional training

* Some respondents gave more than one answer.

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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

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).

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%

Table 6. Years in practice

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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 Ireland-based therapists attended botanica2012 as a result of obtaining sponsorship/ funding from their place of work, covering the costs of them attending the event.

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.

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.

Part two of the survey: logistical details concerning botanica2014

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.

YEARS IN PRACTICE *

Botanica2012(n=168)

Botanica2014(n=199)

Own practice 43% 48%

Multi--disciplinary

practice17% 5%

Home visiting 25% 20%

Hospital/ hospice/ aged care facility

23% 3%

Educationalestablishment 9% 22%

Charitable organisation Not asked 5%

In a laboratory 8% 9%

I don’t work - 5%

Other - 11%

Table 7. Years in practice

* Some respondents gave more than one answer.

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Trade Show diversity and feedback

At botanica2012 there were 21 trade show stands, representing companies from eight countries. Trade stand diversity included:

• 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)

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)

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.

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:

• 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.

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

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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.

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.

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 aromatherapistWhether aromatherapy is their primary source of revenueWhich routes of administration do practitioners routinely useThe main publications/ resources that participants access to inform their practiceThe average number of hours of training undertaken by clinical aromatherapists.

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,

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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”.

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 evidence-based than the holistic aromatherapy style.

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).

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”.

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”.

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.”

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

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has an established definition for the title of clinical aromatherapy/ clinical aromatherapist as compared to holistic aromatherapy/holistic aromatherapist.

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’.

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.”

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.

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.

Finally, in order to move closer to defining clinical aromatherapy/ the clinical aromatherapist, key questions remain. They include:

• 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 (symptom-focussed 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

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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.

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-clinical-aromatherapy. Accessed May 15th, 2015.

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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.

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 NetherlandsChairperson of Kicozo, the Knowledge Institute of Complementary Nursing, The Netherlandsmadeleine@levensboom.comwww.levensboom.comwww.kicozo.nl

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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.

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.

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.

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.

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.

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

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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?

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.

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 made-to-measure in-house education for health care facilities) six different training programs:

1. Complementary Care in End of Life Care2. In-depth Training Program Complementary

Palliative Care3. Complementary Care in Care for the Elderly

and People with Dementia4. Complementary Care in End Stage Dementia

5. Complementary Care for Baby & Mum around Birth

6. The Diploma Year training Aromacare in Healthcare.

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.

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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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?

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

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 experience-based 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.

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.

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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.

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

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.

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.

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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

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 1. AromapatchTM Figure 2. Foot bath

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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.

Figure 3. Hot compress

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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.

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.

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.

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.

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.

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.

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

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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.

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 under-treated 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).

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.

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.

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.

And finally, how do you feel about your work extending to English speaking therapists?

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.

Thank you Rhiannon, for allowing me to express my expertise, experience, thoughts and passions to the readers of the IJCA.

References

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

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.

Mitchell SL, Teno JM, Kiely DK et al (2009). The Clinical Course of Advanced Dementia. N Engl J Med, 361 (16): 1529-1538.

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.

Complementary Nursing in End of Life Care

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Book reviews

Ann CarterPey ColborneRhiannon LewisGabriel Mojay

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.

Comforting Touch in Dementia and End of Life Care: Take My Hand

Authors: Barbara Goldschmidt and Niamh van MeinesPublisher: Jessica Kingsley Publishers; Singing Dragon, 2011Formats: paperback, 208pp; ISBN: 978-184810733 (£15.99) eBook, 208pp; eISBN: 978-0857010483

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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.

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

Complementary Therapies for Older People in Care

Author: Sharon TayPublisher: Jessica Kingsley Publishers; Singing Dragon, 2013Formats: paperback, 216pp; ISBN: 978-1848191785 (£14.99) eBook, 216pp; eISBN: 978-0857011411

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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.

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 post-doctoral training.

Clinical Aromatherapy: Essential Oils in Healthcare

Author: Jane BucklePublisher: Churchill Livingstone, an imprint of Elsevier, 2014Formats: paperback, 432pp; ISBN: 978-0702054402 (US$66.95)

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The text is divided into three sections:

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 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.

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.

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.

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.

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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!

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, well-referenced 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

Fragrance and Wellbeing: Plant Aromatics and Their Influence on the Psyche

Author: Jennifer Peace RhindPublisher: Jessica Kingsley Publishers; Singing Dragon, 2013Formats: paperback, 448pp; ISBN: 978-1848190900 (£28.00) eBook, 448pp; eISBN: 978-0857010735

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of aromatics divided into chapters including woody, resinous, balsamic and coniferous scents; spices; herbaceous, green, camphoraceous, cineolic and agrestic scented botanicals; flower; citrus, lemon-scented 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 easy-to-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!

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.

Essential Oil Basics: A Simple Guide To Greater Health With Essential Oils

Authors: Jennifer Eden ClarkPublisher: www.learnessentialoils.comFormats: paperback, 58pp; ISBN: 978-0988997202 ($6.25) Kindle, 219 Kb; ASIN: B00W2SH592 ($3.05)

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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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Pain/Osteoarthritis

65IJCA | 2015 | Vol 10 | Issue 1

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

Harvest to Hydrosol: Distill your own exquisite hydrosols at home

Author: Ann HarmanPublisher: IAG Botanics LLC dba BotANNicals, 2014Formats: paperback, 243pp; ISBN: 978-09913859 (US$44.95)

66IJCA | 2015 | Vol 10 | Issue 1

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.

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We 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.

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68IJCA | 2015 | Vol 10 | Issue 1

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

Guidelines for authors

INTERNATIONAL JOURNAL OFclinical aromatherapy

Editor: Rhiannon LewisAssociate Editor: Gabriel Mojay

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.

Submission

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 Word-compatible 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:

IJCARhiannon Lewis, EditorChemin des Achaps83840 La MartreFRANCE

editor@ijca.net

Content

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

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.

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).

70IJCA | 2015 | Vol 10 | Issue 1

• 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.

Advertising rates 2015

INTERNATIONAL JOURNAL OFclinical aromatherapy

Editor: Rhiannon LewisAssociate Editor: Gabriel Mojay

Ad size Dimensions (width x height) Rate (excl VAT)

Full page 210 mm x 297 mm €600

Half page horizontal 185 mm x 130 mm €300

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Quarter page horizontal 185 mm x 65 mm €200

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Eighth page 90 mm x 65 mm €130

All rates are payable in Euros.Payment by bank transfer, Visa and Mastercard are accepted.

Please note that we are only able to insert advertisements on a pre-paid basis.

Advertisers outside the European Union are not subject to VAT.Advertisers within the European Union who do not provide an international

VAT number prior to payment will be charged the VAT-inclusive rate.

Please supply artwork at 300 dpi in PDF or JPEG formats or as an Adobe InDesign document.

Essential Oil Resource Consultants EURLChemin des Achaps

83840 La MartreFRANCE

Tel/fax: (+33) 483118703

info@ijca.net • www.ijca.net

anessential oil resource consultantspublication

Aromatherapy Study Day at Kew GardensRediscovering aromatic plants and their essential oilswith plant scientist & aromatherapist Dr Viv AnthonySat, June 6, 2015 at Royal Botanic Kew Gdns, London

The Institute ofTraditional Herbal Medicineand Aromatherapy (established 1987)

Gabriel Mojay, PrincipalTel: +44 (0)20 7193 7383

info@aromatherapy-studies.comwww.aromatherapy-studies.comITHMA

Professional training courses for 2015-2016

Aromatherapy Product BlendingEssential product development

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Oct 31-Nov 1, 2015 at Regent’s University London

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Oct 17-18, 2015 at the Atlantic Institute of Aromatherapy, Tampa, Florida

Nov 21-22, 2015 at Regent’s University London

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