Hindawi Publishing Corporation BioMed Research International Volume 2014,Article ID 430195,12 pages http:/dk.doi.org/10.1155/2014/430195 Hindawi Research Article Aromatherapy:Does It Help to Relieve Pain,Depression, Anxiety,and Stress in Community-Dwelling Older Persons? Shuk Kwan Tang'and M.Y.Mimi Tse2 Department of OrthopaedicsTraumatology,United Christian Hospital,Kowloon,Hong Kong 2School of Nursing,The Hong Kong Polytechnic University,Kowloon,Hong Kong Correspondence should be addressed to M.Y.Mimi Tse;mimi.tse@polyu.edu.hk Received 11 February 2014;Accepted 10 May 2014;Published 13 July 2014 Academic Editor:Gianluca Coppola Copyright2014 S.K.Tang and M.Y.M.Tse.This is an open access article distributed under the Creative Commons Attribution License,which permits unrestricted use,distribution,and reproduction in any medium,provided the original work is properly cited. To examine the effectiveness of an aromatherapy programme for older persons with chronic pain.The community-dwelling elderly people who participated in this study underwent a four-week aromatherapy programme or were assigned to the control group, which did not receive any interventions.Their levels of pain,depression,anxiety,and stress were collected at the baseline and at the postintervention assessment after the conclusion of the four-week programme.Eighty-two participants took part in the study. Forty-four participants(37 females,7 males)were in the intervention group and 38 participants(30 females,8 males)were in the control group.The pain scores were 4.75(SD 2.32)on a 10-point scale for the intervention group and 5.24(SD 2.14)for the control group before the programme.There was a slight reduction in the pain score of the intervention group.No significant differences were found in the same-group and between-group comparisons for the baseline and postintervention assessments.The depression, anxiety,and stress scores for the intervention group before the programme were 11.18(SD 6.18),9.64(SD 7.05),and 12.91(SD 7.70), respectively.A significant reduction in negative emotions was found in the intervention group(P<0.05).The aromatherapy programme can be an effective tool to reduce pain,depression,anxiety,and stress levels among community-dwelling older adults 1.Introduction Saunders'widely accepted total pain concept [9].This concept helps to guide health professionals to view pain using a Pain is a global and common problem among older persons multidimensional and holistic approach.Pain can cause worldwide.In Hong Kong,the older population is increasing problems to an individual in a single physical,psychological, in proportion to the population as a whole,from 13%in 2011 social,and spiritual aspect,or in two or more interrelated to 30%in 2041 [1].The annual growth rate of older persons aspects.Physical pain leads to psychological distress and from 1991 to 1996 was 5.1%[2].It is anticipated that the burden social interruption,affecting relationships with family,rela- on health services and social welfare will be heavier as a result tives,and friends.It also induces a fear that the condition of of the ageing population in Hong Kong. pain will further deteriorate.Depression,anxiety,stress,and Pain brings many problems to older people,including functional status have been found in different studies to be physical and psychological dysfunctions.The prevalence of associated with chronic pain [10-16].Studies have reported pain in community-dwelling older persons is high,ranging that when older persons have persistent pain,the prevalence from 25%to 50%[3].Older persons have been found to suffer of depression is high and anxiety develops in relation to the from different levels of pain [4-6].Most suffer from pain repetition of pain-inducing activities.Stress was found to originating from the musculoskeletal system [4,5,7,8].The mediate the pain disability of patients with lower back pain pain score rated on a 10-point scale by the older persons was [17].With the presence of pain,the mobility level of older 4.6 to 7.5 and described as moderate to severe [4,5,7]. persons declines,particularly as pain levels increase [ll]. Pain is the total suffering of a person in the physical, Pharmacological and nonpharmacological interventions psychological,social,and spiritual aspects,according to have been effective in managing pain in older persons.Older
Research Article Aromatherapy: Does It Help to Relieve Pain, Depression, Anxiety, and Stress in Community-Dwelling Older Persons? Shuk Kwan Tang1 and M. Y. Mimi Tse2 1 Department of Orthopaedics & Traumatology, United Christian Hospital, Kowloon, Hong Kong 2 School of Nursing, The Hong Kong Polytechnic University, Kowloon, Hong Kong Correspondence should be addressed to M. Y. Mimi Tse; mimi.tse@polyu.edu.hk Received 11 February 2014; Accepted 10 May 2014; Published 13 July 2014 Academic Editor: Gianluca Coppola Copyright © 2014 S. K. Tang and M. Y. M. Tse. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. To examine the effectiveness of an aromatherapy programme for older persons with chronic pain. The community-dwelling elderly people who participated in this study underwent a four-week aromatherapy programme or were assigned to the control group, which did not receive any interventions. Their levels of pain, depression, anxiety, and stress were collected at the baseline and at the postintervention assessment after the conclusion of the four-week programme. Eighty-two participants took part in the study. Forty-four participants (37 females, 7 males) were in the intervention group and 38 participants (30 females, 8 males) were in the control group. The pain scores were 4.75 (SD 2.32) on a 10-point scale for the intervention group and 5.24 (SD 2.14) for the control group before the programme. There was a slight reduction in the pain score of the intervention group. No significant differences were found in the same-group and between-group comparisons for the baseline and postintervention assessments. The depression, anxiety, and stress scores for the intervention group before the programme were 11.18 (SD 6.18), 9.64 (SD 7.05), and 12.91 (SD 7.70), respectively. A significant reduction in negative emotions was found in the intervention group (𝑃 < 0.05). The aromatherapy programme can be an effective tool to reduce pain, depression, anxiety, and stress levels among community-dwelling older adults. 1. Introduction Pain is a global and common problem among older persons worldwide. In Hong Kong, the older population is increasing in proportion to the population as a whole, from 13% in 2011 to 30% in 2041 [1]. The annual growth rate of older persons from 1991 to 1996 was 5.1% [2]. It is anticipated that the burden on health services and social welfare will be heavier as a result of the ageing population in Hong Kong. Pain brings many problems to older people, including physical and psychological dysfunctions. The prevalence of pain in community-dwelling older persons is high, ranging from 25% to 50% [3]. Older persons have been found to suffer from different levels of pain [4–6]. Most suffer from pain originating from the musculoskeletal system [4, 5, 7, 8]. The pain score rated on a 10-point scale by the older persons was 4.6 to 7.5 and described as moderate to severe [4, 5, 7]. Pain is the total suffering of a person in the physical, psychological, social, and spiritual aspects, according to Saunders’ widely accepted total pain concept [9].This concept helps to guide health professionals to view pain using a multidimensional and holistic approach. Pain can cause problems to an individual in a single physical, psychological, social, and spiritual aspect, or in two or more interrelated aspects. Physical pain leads to psychological distress and social interruption, affecting relationships with family, relatives, and friends. It also induces a fear that the condition of pain will further deteriorate. Depression, anxiety, stress, and functional status have been found in different studies to be associated with chronic pain [10–16]. Studies have reported that when older persons have persistent pain, the prevalence of depression is high and anxiety develops in relation to the repetition of pain-inducing activities. Stress was found to mediate the pain disability of patients with lower back pain [17]. With the presence of pain, the mobility level of older persons declines, particularly as pain levels increase [11]. Pharmacological and nonpharmacological interventions have been effective in managing pain in older persons. Older Hindawi Publishing Corporation BioMed Research International Volume 2014, Article ID 430195, 12 pages http://dx.doi.org/10.1155/2014/430195
2 BioMed Research International persons use analgesics as their pharmacological approach Other factors: [4,18].However,physicians may be reluctant to prescribe Patient factors: Inadequate use of analgesic adequate analgesics because they might not have had suffi- Age Inadequate use of non- -Gender pharmacological methods cient training in this area,and therefore tend to prescribe Health history Misconceptions of medications on an "as needed"(PRN)basis or upon request Education level pharmacological and non- pharmacological pain [19,20].Older persons also tend to wait until the pain cannot Medication use management be tolerated before asking for the PRN analgesics [21].They also fear the adverse effects brought about by analgesics [22]. Older persons without pain education place a lower priority on nonpharmacological interventions for managing pain [4.They tend to administer pain relief strategies by Extraneous factors: themselves [23].Therefore,a pain education programme Aromatherapy Use of analgesics can help older persons to relieve pain-related distress and and Life events improve pain management [8]. empowerment Medical condition Aromatherapy using aromatic plants to treat medical and health problems has a long history in western society [24]. Outcomes: Specifically,aromatherapy involves the use of essential oils to -Pain restore balance and improve well-being.A holistic approach -Depression -Anxiety is applied in aromatherapy,which treats the person as a whole -Stress to strengthen his/her immune system in order to fight against Functional status diseases [25,26].There are different methods of administer- FIGURE 1:Conceptual framework of the present study. ing essential oils,including topical application,inhalation, baths,and compresses.Research using aromatherapy as the intervention has demonstrated its effectiveness in reducing pain in adults and infants [27,28]. the Abbreviated Mental Test and the olfactory test.Older Pain and the olfactory pathways in humans have been persons who were allergic to essential oils or perfumes or found to be related.In a gene study involving the gene had terminal illnesses or a history of diseases affecting the SCN9A,a loss of function of the gene led to a loss of function olfactory senses were excluded. in pain sensation and odour perception [29]. Eighty-two participants were recruited for the present Studies have been conducted using positron emission study.Thirty-eight were assigned to the control group and 44 tomography(PET)to examine the effect of inhaling an odour to the intervention group. on the reduction of pain.The results showed that with the inhalation of a pleasant odour,pain intensity was reduced in 2.2.Intervention human subjects [30-32].Laboratory-and community-based studies produced similar findings,namely,that pain in adults 2.2.1.Centre-Based Sessions.An aromatherapist was con- and older persons can be reduced with the inhalation of sulted on the content of the aromatherapy programme, odours and essential oils [33-37](see Figure 1). which was a tailor-made four-week programme consisting of four centre-based sessions and self-administered home- Aim of the Study.The aim of the present study was to examine based sessions.The centre-based sessions were held once the effectiveness of a four-week aromatherapy programme per week in community elderly centres.Knowledge on pain, for older persons with chronic pain,as well as their levels of pain in older persons,and aromatherapy was introduced depression,anxiety,and stress during the centre-based sessions.In the sessions,lavender and bergamot essential oils were administered by inhalation. 2.Method 2.2.2.Self-Administered Home-Based Aromatherapy.The 2.1.Design and Sample.This was a quasi-experimental self-administered home-based aromatherapy programme pretest and posttest control group study.The size of the was designed to enable the participants to continue practising sample was calculated using Cohen's d table.Based on a aromatherapy at home.Each participant was given a bottle previous study on pain and aromatherapy in Hong Kong,the of aromatic spray to carry out the self-administered home- following parameters were set:effect size 0.8,power 0.9,and based aromatherapy.The content of the aromatic spray 5%alpha [34]. was designed by the aromatherapist to be suitable for use Ethical approval was granted by the Human Subjects by the elderly.The aromatic spray was made with diluted Ethics Subcommittee of the Hong Kong Polytechnic Uni- lavender and bergamot essential oils and lavender hydrolats. versity.Older persons were recruited from local community The ratio of the concentration of the lavender essential elderly centres.The participants were aged 65 or above, oils to the bergamot essential oils to the lavender hydrolats members of their community elderly centres,able to under- was 2:1:2.5,as suggested by the aromatherapist.During stand and communicate in Cantonese and able to follow the centre-based sessions,the participants were shown instructions,and had chronic pain for at least 3 months before how to use the aromatic spray at home.A demonstration the commencement of the study.They were required to pass and a return demonstration were carried out to ensure that
2 BioMed Research International persons use analgesics as their pharmacological approach [4, 18]. However, physicians may be reluctant to prescribe adequate analgesics because they might not have had sufficient training in this area, and therefore tend to prescribe medications on an “as needed” (PRN) basis or upon request [19, 20]. Older persons also tend to wait until the pain cannot be tolerated before asking for the PRN analgesics [21]. They also fear the adverse effects brought about by analgesics [22]. Older persons without pain education place a lower priority on nonpharmacological interventions for managing pain [4]. They tend to administer pain relief strategies by themselves [23]. Therefore, a pain education programme can help older persons to relieve pain-related distress and improve pain management [8]. Aromatherapy using aromatic plants to treat medical and health problems has a long history in western society [24]. Specifically, aromatherapy involves the use of essential oils to restore balance and improve well-being. A holistic approach is applied in aromatherapy, which treats the person as a whole to strengthen his/her immune system in order to fight against diseases [25, 26]. There are different methods of administering essential oils, including topical application, inhalation, baths, and compresses. Research using aromatherapy as the intervention has demonstrated its effectiveness in reducing pain in adults and infants [27, 28]. Pain and the olfactory pathways in humans have been found to be related. In a gene study involving the gene SCN9A, a loss of function of the gene led to a loss of function in pain sensation and odour perception [29]. Studies have been conducted using positron emission tomography (PET) to examine the effect of inhaling an odour on the reduction of pain. The results showed that with the inhalation of a pleasant odour, pain intensity was reduced in human subjects [30–32]. Laboratory- and community-based studies produced similar findings, namely, that pain in adults and older persons can be reduced with the inhalation of odours and essential oils [33–37] (see Figure 1). Aim of the Study. The aim of the present study was to examine the effectiveness of a four-week aromatherapy programme for older persons with chronic pain, as well as their levels of depression, anxiety, and stress. 2. Method 2.1. Design and Sample. This was a quasi-experimental pretest and posttest control group study. The size of the sample was calculated using Cohen’s d table. Based on a previous study on pain and aromatherapy in Hong Kong, the following parameters were set: effect size 0.8, power 0.9, and 5% alpha [34]. Ethical approval was granted by the Human Subjects Ethics Subcommittee of the Hong Kong Polytechnic University. Older persons were recruited from local community elderly centres. The participants were aged 65 or above, members of their community elderly centres, able to understand and communicate in Cantonese and able to follow instructions, and had chronic pain for at least 3 months before the commencement of the study. They were required to pass Outcomes: - Pain - Depression - Anxiety - Stress - Functional status Pain Aromatherapy and empowerment Patient factors: - Age - Gender - Health history - Education level - Medication use Extraneous factors: - Use of analgesics - Life events - Medical condition Other factors: - Inadequate use of analgesics - Inadequate use of nonpharmacological methods - Misconceptions of pharmacological and nonpharmacological pain management Figure 1: Conceptual framework of the present study. the Abbreviated Mental Test and the olfactory test. Older persons who were allergic to essential oils or perfumes or had terminal illnesses or a history of diseases affecting the olfactory senses were excluded. Eighty-two participants were recruited for the present study. Thirty-eight were assigned to the control group and 44 to the intervention group. 2.2. Intervention 2.2.1. Centre-Based Sessions. An aromatherapist was consulted on the content of the aromatherapy programme, which was a tailor-made four-week programme consisting of four centre-based sessions and self-administered homebased sessions. The centre-based sessions were held once per week in community elderly centres. Knowledge on pain, pain in older persons, and aromatherapy was introduced during the centre-based sessions. In the sessions, lavender and bergamot essential oils were administered by inhalation. 2.2.2. Self-Administered Home-Based Aromatherapy. The self-administered home-based aromatherapy programme was designed to enable the participants to continue practising aromatherapy at home. Each participant was given a bottle of aromatic spray to carry out the self-administered homebased aromatherapy. The content of the aromatic spray was designed by the aromatherapist to be suitable for use by the elderly. The aromatic spray was made with diluted lavender and bergamot essential oils and lavender hydrolats. The ratio of the concentration of the lavender essential oils to the bergamot essential oils to the lavender hydrolats was 2 : 1 : 2.5, as suggested by the aromatherapist. During the centre-based sessions, the participants were shown how to use the aromatic spray at home. A demonstration and a return demonstration were carried out to ensure that
BioMed Research International TABLE 1:Interventions of the aromatherapy programme. Week Teaching content(40 minutes) Activity (20 minutes) Self-administered aromatherapy (i)Introduction to pain: mechanism,assessment,effects of pain on physical and psychological health, pharmacological and Practical session on deep nonpharmacological approaches breathing exercises and (ii)Aromatherapy:introduction, aromatherapy history,and indications (iii)Deep breathing exercises: introduction and theory (i)Carried out at home by older persons Introducing different types of Practical session on deep 2 (ii)Aromatic spray given with essential oils and uses, breathing exercises and education on use and precautions indications for usage aromatherapy (i)Odour testing game Demonstration of how to make (ii)Practical session on deep an aromatherapy toolbox breathing exercises and aromatherapy (i)Practical session on deep Making an aroma decoration-a breathing exercises and towel rabbit aromatherapy (ii)Drinking of fruit tea the participants knew how to use the aromatic spray correctly. for the dependent variables when comparing the control and The aromatic spray was used externally,by inhalation (see intervention groups. Table 1). 3.Result 2.3.Procedure.The study took place at community elderly There were 44 participants in the intervention group (37 centres in a local area.The community elderly centres were females and 7 males)and 38 in the control group (30 females similar.A baseline assessment before the intervention was and 8 males),for a total of 82 participants in the study. conducted using a questionnaire to collect data on the demographics of the participants and their pain,depression, anxiety,and stress levels.The Geriatric Pain Assessment was 3.1.Demographic Data:Intervention Group versus Control adopted for assessing pain [38].The questionnaire included Group.Of the participants,27.3%and 34.2%were aged over 76 to 80 in the intervention and control groups,respectively. questions on pain measured using a 10-point scale,factors There was no significant difference in gender,age,marital that might alleviate and exacerbate the pain,and any activities that needed to be avoided in relation to the pain.The status,education level,personal health history,living status, Depression,Anxiety,and Stress Scale (DASS-21)was used financial status,and previous occupation (P 0.05)(see Table 2). to measure the negative emotional status of depression, anxiety,and stress [39].A total of 21 items were included in the questionnaire,with seven items in each subscale of 3.2.Pain Scores and Pain Sites:Baseline and Post-Intervention depression,anxiety,and stress.The negative emotional status Assessments.All of the participants from both groups had of depression,anxiety,and stress were graded as follows: had chronic pain for more than 3 months.They had different normal,mild,moderate,severe,and very severe.A postin- patterns and frequency of pain.No significant difference was tervention assessment was conducted after the conclusion of found when comparing the pain situations of the two older the four-week aromatherapy programme. groups at the baseline and postintervention assessments (P 0.05)(see Table 3). At the baseline,the pain score of the intervention group 2.4.Data Analysis.The Statistical Package for Social Science, was 4.75(SD 2.32)and that of the control group was 5.24(SD SPSS for Windows version 17.0,was used for the quantitative 2.14).After the aromatherapy programme,the pain score of data analysis.P<0.05 was considered the level of statistical the intervention group had decreased to 4.66(SD 2.56).In significance.The Chi-square test was used to measure the the control group,the pain score was 4.79(SD 2.19)at the demographic data of the control and intervention groups. postintervention assessment.No significant difference was The dependent variables were pain,depression,anxiety,and found in the between-group and within-group comparisons stress.The Wilcoxon's signed ranks test was used to examine (see Table 4). the dependent variables and compare the baseline data to the The most common sites of pain for the older persons at postintervention data.The Mann-Whitney U Test was used the baseline and postintervention assessments were the knees
BioMed Research International 3 Table 1: Interventions of the aromatherapy programme. Week Teaching content (40 minutes) Activity (20 minutes) Self-administered aromatherapy 1 (i) Introduction to pain: mechanism, assessment, effects of pain on physical and psychological health, pharmacological and nonpharmacological approaches (ii) Aromatherapy: introduction, history, and indications (iii) Deep breathing exercises: introduction and theory Practical session on deep breathing exercises and aromatherapy (i) Carried out at home by older persons (ii) Aromatic spray given with education on use and precautions 2 Introducing different types of essential oils and uses, indications for usage Practical session on deep breathing exercises and aromatherapy 3 Demonstration of how to make an aromatherapy toolbox (i) Odour testing game (ii) Practical session on deep breathing exercises and aromatherapy 4 Making an aroma decoration—a towel rabbit (i) Practical session on deep breathing exercises and aromatherapy (ii) Drinking of fruit tea the participants knew how to use the aromatic spray correctly. The aromatic spray was used externally, by inhalation (see Table 1). 2.3. Procedure. The study took place at community elderly centres in a local area. The community elderly centres were similar. A baseline assessment before the intervention was conducted using a questionnaire to collect data on the demographics of the participants and their pain, depression, anxiety, and stress levels. The Geriatric Pain Assessment was adopted for assessing pain [38]. The questionnaire included questions on pain measured using a 10-point scale, factors that might alleviate and exacerbate the pain, and any activities that needed to be avoided in relation to the pain. The Depression, Anxiety, and Stress Scale (DASS-21) was used to measure the negative emotional status of depression, anxiety, and stress [39]. A total of 21 items were included in the questionnaire, with seven items in each subscale of depression, anxiety, and stress. The negative emotional status of depression, anxiety, and stress were graded as follows: normal, mild, moderate, severe, and very severe. A postintervention assessment was conducted after the conclusion of the four-week aromatherapy programme. 2.4. Data Analysis. The Statistical Package for Social Science, SPSS for Windows version 17.0, was used for the quantitative data analysis. 𝑃 0.05) (see Table 2). 3.2. Pain Scores and Pain Sites: Baseline and Post-Intervention Assessments. All of the participants from both groups had had chronic pain for more than 3 months. They had different patterns and frequency of pain. No significant difference was found when comparing the pain situations of the two older groups at the baseline and postintervention assessments (𝑃 > 0.05) (see Table 3). At the baseline, the pain score of the intervention group was 4.75 (SD 2.32) and that of the control group was 5.24 (SD 2.14). After the aromatherapy programme, the pain score of the intervention group had decreased to 4.66 (SD 2.56). In the control group, the pain score was 4.79 (SD 2.19) at the postintervention assessment. No significant difference was found in the between-group and within-group comparisons (see Table 4). The most common sites of pain for the older persons at the baseline and postintervention assessments were the knees
BioMed Research International TABLE 2:Demographic data of the intervention and control groups. Intervention group Control group (n=44) Group difference (1=38) n(%) n(%) P value Mean±SD Mean±SD Gender 0.627 Male 7(15.9) 8(2L.1) Female 37(64.1) 30(78.9) Age 0.074 65-70 9(20.5) 6(15.8) 71-75 8(18.2) 7(18.4) 76-80 12(27.3) 13(34.2) Over 80 15(34.1) 12(31.6) Marital status Single 3(6.8) 2(5.3) Married 18(40.9) 17(44.7) Divorced 1(2.3) 0(0) Widowed 22(50) 19(50) Education Level No formal education 16(36.4) 19(50) Primary level 23(52.3) 13(34.2) Secondarylevel 5(1.4) 5(13.2) Tertiary level 0(0) 1(2.6) Personal health history(multiple answers can be chosen) No chronic illnesses 6(13.6) 3(7.9) 0.536 Hypertension 31(70.5) 26(68.4) 0.130 Diabetes mellitus 10(22.7) 13(34.2) 0.825 Heartdiseases 4(9.1) 6(15.8) 0.593 Stroke 5(1.4) 1(2.6) 0.693 Gout 6(13.6) 12(31.6) 0.392 Respiratory diseases 4(9.1) 6(15.8) 0.435 Arthritis 8(18.2) 13(34.2) 0.145 Cataract 13(29.5) 11(28.9) 0.715 Others 11(25) 11(28.9) 0.932 Living Status 0.485 Alone 16(36.4) 23(60.5) With spouse 9(20.5) 3(7.9) With spouse and children 10(22.7) 6(15.8) With children 8(18.2) 5(13.2) With relatives or friends 1(2.3) 1(2.6) Financial status 0.881 Very poor 0(0) 0(0) Poor 4(9.1) 5(13.2) Average 31(70.5) 21(55.3) Good 9(20.5) 12(31.6) Very good 0(0) 0(0) Previous occupation 0.729 Worker 19(42.2) 20(52.6) Clerk 1(2.3) 1(2.6)
4 BioMed Research International Table 2: Demographic data of the intervention and control groups. Intervention group (𝑛 = 44) Control group (𝑛 = 38) Group difference 𝑛 (%) Mean ± SD 𝑛 (%) Mean ± SD 𝑃 value# Gender 0.627 Male 7 (15.9) 8 (21.1) Female 37 (64.1) 30 (78.9) Age 0.074 65–70 9 (20.5) 6 (15.8) 71–75 8 (18.2) 7 (18.4) 76–80 12 (27.3) 13 (34.2) Over 80 15 (34.1) 12 (31.6) Marital status 0.298 Single 3 (6.8) 2 (5.3) Married 18 (40.9) 17 (44.7) Divorced 1 (2.3) 0 (0) Widowed 22 (50) 19 (50) Education Level 0.559 No formal education 16 (36.4) 19 (50) Primary level 23 (52.3) 13 (34.2) Secondary level 5 (11.4) 5 (13.2) Tertiary level 0 (0) 1 (2.6) Personal health history (multiple answers can be chosen) No chronic illnesses 6 (13.6) 3 (7.9) 0.536 Hypertension 31 (70.5) 26 (68.4) 0.130 Diabetes mellitus 10 (22.7) 13 (34.2) 0.825 Heart diseases 4 (9.1) 6 (15.8) 0.593 Stroke 5 (11.4) 1 (2.6) 0.693 Gout 6 (13.6) 12 (31.6) 0.392 Respiratory diseases 4 (9.1) 6 (15.8) 0.435 Arthritis 8 (18.2) 13 (34.2) 0.145 Cataract 13 (29.5) 11 (28.9) 0.715 Others 11 (25) 11 (28.9) 0.932 Living Status 0.485 Alone 16 (36.4) 23 (60.5) With spouse 9 (20.5) 3 (7.9) With spouse and children 10 (22.7) 6 (15.8) With children 8 (18.2) 5 (13.2) With relatives or friends 1 (2.3) 1 (2.6) Financial status 0.881 Very poor 0 (0) 0 (0) Poor 4 (9.1) 5 (13.2) Average 31 (70.5) 21 (55.3) Good 9 (20.5) 12 (31.6) Very good 0 (0) 0 (0) Previous occupation 0.729 Worker 19 (42.2) 20 (52.6) Clerk 1 (2.3) 1 (2.6)
BioMed Research International 5 TABLE 2:Continued. Intervention group Control group Group difference (n=44) (n=38) n(%) n(%) P value Mean±SD Mean±SD Specialized 17(38.8) 15(39.5) Housework 7(15.9) 2(5.3) Percentages may not add up to 100%because of rounding. "The Chi-square test was used. *A P value of <0.05 was considered statistically significant. TABLE 3:Geriatric pain assessment of the intervention and control groups. Intervention group (n=44) Control group (n 38) Group difference Baseline Postintervention P value* Baseline Postintervention Pvalue Baseline Postintervention n(%) n(%) 1(%) n(%) P value" P value Pain more than 3 months Yes 44(100) 44(100) 38(100) 38(100) No 0(0) 0(0) 0(0) 0(0) Pattern of pain 0.086 0.180 0.299 0.575 Occasional 24(54.5) 28(63.6) 18(47.4) 21(55.3) Persistent 20(45.5) 16(36.4) 20(52.6) 17(44.7) Frequency(per day) 0.059 0.070 0.384 0.667 1 3(6.8) 7(15.9) 3(7.9) 3(79) 2 5(11.4) 11(25) 3(7.9) 7(18.4) 3 11(25) 3(6.8) 5(13.2) 6(15.8) 4 3(6.8) 1(2.3) 6(15.8) 1(2.6) 1(2.3) 2(4.5) 2(5.3) 2(5.3) More than 5 21(47.7) 20(45.5) 19(50) 19(50) Percentages may not add up to 100%because of rounding. The Chi-square test was used. "A P value of <0.05 was considered statistically significant. and back.Figure 2 shows the percentage of participants who of nonpharmacological interventions in both groups after suffered from pain in each particular body part. the aromatherapy programme.In the intervention group, the percentage of participants using nonpharmacological 3.3.The Use of Pharmacological Interventions:Baseline and interventions increased from 84.1%to 100%.As shown in Postintervention Assessments.Significant differences in the Table 5,no participants in the intervention group reported use of analgesics were found in both groups when comparing that they had any reason for not using or knowing about the baseline and postintervention assessments within the nonpharmacological interventions after the aromatherapy same group (P 0.05).There was no significant difference programme.Analgesic balm or oils,massage,and hot pads between the groups (P 0.05).There was an increase were the top three choices of nonpharmacological interven- in the use of analgesics in the intervention group after the tions adopted by both groups at the baseline and postinter- aromatherapy programme,while in the control group there vention assessments.A significant difference in the partici- was a decrease in use. pants'perceptions of the effectiveness of nonpharmacological Panadol was the analgesic most commonly used by interventions was shown in the intervention group(P<0.05) participants in the intervention and control groups.There (see Table 5). was a significant difference in the types of analgesics used in the intervention group when comparing the baseline and 3.5.Depression,Anxiety,and Stress Level:Baseline and Postin- postintervention assessments (P 0.05).A significant tervention Assessments.The baseline and postintervention difference in frequency(prescription of PRN)was also found assessment results for depression,anxiety,and stress in the in the within-group comparison,but not in the between- intervention group are shown in Table 6.When the base- group comparison. line and postintervention assessments were compared,the intervention group showed decreased scores for depression, 3.4.The Use of Nonpharmacological Interventions:Baseline anxiety,and stress.Significant differences in the depression, and Postintervention Assessments.There was increased use anxiety,and stress scores were found at the postintervention
BioMed Research International 5 Table 2: Continued. Intervention group (𝑛 = 44) Control group (𝑛 = 38) Group difference 𝑛 (%) Mean ± SD 𝑛 (%) Mean ± SD 𝑃 value# Specialized 17 (38.8) 15 (39.5) Housework 7 (15.9) 2 (5.3) Percentages may not add up to 100% because of rounding. # The Chi-square test was used. ∗A 𝑃 value of 0.05). There was an increase in the use of analgesics in the intervention group after the aromatherapy programme, while in the control group there was a decrease in use. Panadol was the analgesic most commonly used by participants in the intervention and control groups. There was a significant difference in the types of analgesics used in the intervention group when comparing the baseline and postintervention assessments (𝑃 < 0.05). A significant difference in frequency (prescription of PRN) was also found in the within-group comparison, but not in the betweengroup comparison. 3.4. The Use of Nonpharmacological Interventions: Baseline and Postintervention Assessments. There was increased use of nonpharmacological interventions in both groups after the aromatherapy programme. In the intervention group, the percentage of participants using nonpharmacological interventions increased from 84.1% to 100%. As shown in Table 5, no participants in the intervention group reported that they had any reason for not using or knowing about nonpharmacological interventions after the aromatherapy programme. Analgesic balm or oils, massage, and hot pads were the top three choices of nonpharmacological interventions adopted by both groups at the baseline and postintervention assessments. A significant difference in the participants’ perceptions of the effectiveness of nonpharmacological interventions was shown in the intervention group (𝑃 < 0.05) (see Table 5). 3.5. Depression, Anxiety, and Stress Level: Baseline and Postintervention Assessments. The baseline and postintervention assessment results for depression, anxiety, and stress in the intervention group are shown in Table 6. When the baseline and postintervention assessments were compared, the intervention group showed decreased scores for depression, anxiety, and stress. Significant differences in the depression, anxiety, and stress scores were found at the postintervention
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6 BioMed Research International Table 4: Pain scores of the intervention and control groups. Intervention group (𝑛 = 44) Control group (𝑛 = 38) Group difference Baseline Postintervention 𝑍a 𝑃 valuea Baseline Postintervention 𝑍a 𝑃 valuea Baseline Postintervention Mean ± SD Mean ± SD Mean ± SD Mean ± SD 𝑈b P valueb 𝑈b 𝑃 valueb Pain score 4.75 ± 2.32 4.66 ± 2.56 0.22 0.830 5.24 ± 2.14 4.79 ± 2.19 1.16 0.247 721 0.274 789 0.654 aThe Wilcoxon signed ranks test was used to compare the baseline data to the postintervention data of the control and intervention groups. bThe Mann-Whitney U Test was used to compare the control and intervention groups. ∗A 𝑃 value of <0.05 was considered statistically significant
BioMed Research International 7 Left shoulder Right shoulder L:25%→22.7% 1上34.1%→20.5% C:31.5%→31.6% C:21.1%→28.9% Left elbow Back 上13.6%→6.8% 1:38.6%→34.1% Right elbow C:5.3%→10.5% C:57.9%→34.2% 上13.6%→6.8% C:5.3%→10.5% Right hip 1:18.2%→6.8% C:13.2%→7.9% Right knee Left knee Left hip 159.1%→52.3% L59.1%→47.7% 上11.4%→4.5% C:65.8%+57.9% C13.2%→5.3% C:65.2%→63.2% Right ankle Left ankle 1:9.1%→6.8% 上6.8%→6.8% C:7.9%→5.3% C:10.5%→7.9% I:Intervention group C:Control group Multiple answers can be chosen FIGURE 2:Location of pain in intervention and control groups. assessment when comparing the intervention and control the use of PET [31,32].The reduction in pain scores in groups (P 0.05).Significant differences were noted in the present study was minimal.Pain scores ranging from the depression,anxiety,and stress scores in the intervention four to five were found in both groups,indicating mild to group when comparing the baseline and postintervention moderate pain.The pain in older persons originated in the assessment results (P<0.05)(see Table 6). musculoskeletal system,while in laboratory-based studies the pain was induced by thermodes,hot water,or cold water. 4.Discussion The nature of the pain was different.In the laboratory- based studies,the essential oils were inhaled rather than The present study shows that the aromatherapy programme topically applied to pain sites as in the community-based was effective in reducing the pain,depression,anxiety,and studies [34,35].The method of administering the essential stress levels of older persons in the intervention group. oils and the duration of the aromatherapy were factors Under the total pain concept,a person not only suffers from affecting the impact of the aromatherapy programme in pain physical pain but also from psychological distress [9].The fact management that pain can induce psychological distress in older persons Lavender and bergamot essential oils are antidepressants is consistent with the total pain concept.As illustrated and relaxants [25,40].Essential oils can be absorbed by by Saunders [9],psychological distress can be related to inhalation into the olfactory pathway and from there to progressive pain.Although in the present study a decrease the brain [41].The scores on depression,anxiety,and stress in pain scores was noted in both groups,psychological decreased in the intervention group after the aromatherapy distress increased to a greater degree in the control group programme,but there was increased psychological distress than in the intervention group.This can be related to the in the control group.The results were consistent with those effect of the aromatherapy programme,which provided the of previous studies,namely,that aromatherapy was able to intervention group with adequate information on pain and relieve negative emotional symptoms [25,40,42]. pain management.Older persons in the control group did not Pleasant odours can induce a positive mood in a person receive this information and were still uncertain as to their 25].Essential oils administered in the centre-based sessions pain and pain management,resulting in an increased level and aromatic spray used in the self-administered home-based of psychological distress.The findings were consistent with sessions exposed the older persons to pleasant aromas.Their those of previous studies,namely,that the inadequate pain mood was lifted after inhaling the essential oils and aromatic management of older persons results in decreased enjoyment spray,resulting in decreased depression,anxiety,and stress of life,and pain management programmes can decrease pain- scores. related distress [4,8. Aromatherapy has been used to treat diseases for decades Laboratory-based studies have proven that the inhalation in western countries [24].Using aromatherapy as a method of odours or essential oils is effective at reducing pain under of managing pain was a new concept to the older Chinese
BioMed Research International 7 I: 34.1% → 20.5% C: 21.1% → 28.9% Right shoulder I: 13.6% → 6.8% C: 5.3% → 10.5% Right elbow I: 59.1% → 52.3% C: 65.8% → 57.9% Right knee I: 9.1% → 6.8% C: 7.9% → 5.3% Right ankle I: 25% → 22.7% C: 31.5% → 31.6% Left shoulder I: 13.6% → 6.8% C: 5.3% → 10.5% Left elbow I: 18.2% → 6.8% C: 13.2% → 7.9% Right hip I: 11.4% → 4.5% C: 13.2% → 5.3% Left hip I: 38.6% → 34.1% C: 57.9% → 34.2% Back I: 59.1% → 47.7% C: 65.2% → 63.2% Left knee I: 6.8% → 6.8% C: 10.5% → 7.9% Left ankle I: Intervention group C: Control group Multiple answers can be chosen Figure 2: Location of pain in intervention and control groups. assessment when comparing the intervention and control groups (𝑃 < 0.05). Significant differences were noted in the depression, anxiety, and stress scores in the intervention group when comparing the baseline and postintervention assessment results (𝑃 < 0.05) (see Table 6). 4. Discussion The present study shows that the aromatherapy programme was effective in reducing the pain, depression, anxiety, and stress levels of older persons in the intervention group. Under the total pain concept, a person not only suffers from physical pain but also from psychological distress [9].The fact that pain can induce psychological distress in older persons is consistent with the total pain concept. As illustrated by Saunders [9], psychological distress can be related to progressive pain. Although in the present study a decrease in pain scores was noted in both groups, psychological distress increased to a greater degree in the control group than in the intervention group. This can be related to the effect of the aromatherapy programme, which provided the intervention group with adequate information on pain and pain management. Older persons in the control group did not receive this information and were still uncertain as to their pain and pain management, resulting in an increased level of psychological distress. The findings were consistent with those of previous studies, namely, that the inadequate pain management of older persons results in decreased enjoyment of life, and pain management programmes can decrease painrelated distress [4, 8]. Laboratory-based studies have proven that the inhalation of odours or essential oils is effective at reducing pain under the use of PET [31, 32]. The reduction in pain scores in the present study was minimal. Pain scores ranging from four to five were found in both groups, indicating mild to moderate pain. The pain in older persons originated in the musculoskeletal system, while in laboratory-based studies the pain was induced by thermodes, hot water, or cold water. The nature of the pain was different. In the laboratorybased studies, the essential oils were inhaled rather than topically applied to pain sites as in the community-based studies [34, 35]. The method of administering the essential oils and the duration of the aromatherapy were factors affecting the impact of the aromatherapy programme in pain management. Lavender and bergamot essential oils are antidepressants and relaxants [25, 40]. Essential oils can be absorbed by inhalation into the olfactory pathway and from there to the brain [41]. The scores on depression, anxiety, and stress decreased in the intervention group after the aromatherapy programme, but there was increased psychological distress in the control group. The results were consistent with those of previous studies, namely, that aromatherapy was able to relieve negative emotional symptoms [25, 40, 42]. Pleasant odours can induce a positive mood in a person [25]. Essential oils administered in the centre-based sessions and aromatic spray used in the self-administered home-based sessions exposed the older persons to pleasant aromas. Their mood was lifted after inhaling the essential oils and aromatic spray, resulting in decreased depression, anxiety, and stress scores. Aromatherapy has been used to treat diseases for decades in western countries [24]. Using aromatherapy as a method of managing pain was a new concept to the older Chinese
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8 BioMed Research International Table 5: Use of pharmacological and nonpharmacological interventions by the intervention and control groups. Intervention group (𝑛 = 44) Control group (𝑛 = 38) Group difference Baseline Postintervention 𝑃 value# Baseline Postintervention 𝑃 value# Baseline Postintervention 𝑛 (%) 𝑛 (%) 𝑛 (%) 𝑛 (%) 𝑃 value# 𝑃 value# Use of analgesics 16 (36.4) 17 (38.6) 0.000∗ 19 (50) 18 (47.4) 0.001∗ 0.087 0.272 Types of analgesics used (multiple answers can be chosen) 0.513 0.714 Panadol 13 (29.5) 14 (31.8) 0.000∗ 12 (31.6) 15 (39.5) 0.088 Tramadol 1 (2.3) 3 (6.8) 2 (5.3) 1 (2.6) Others 2 (4.5) 0 (0) 5 (13.2) 2 (5.3) Frequency (prescription on PRN) 0.000∗ 0.010∗ 0.629 0.767 Once daily 3 (6.8) 5 (11.4) 7 (18.4) 7 (18.4) Twice daily 4 (9.1) 6 (13.6) 5 (13.2) 4 (10.5) TDS 4 (9.1) 3 (6.8) 5 (13.2) 2 (5.3) QID 5 (11.4) 2 (4.5) 0 (0) 5 (13.2) Q4H 0 (0) 0 (0) 1 (2.6) 0 (0) Q6H 1 (2.3) 0 (0) 1 (2.6) 0 (0) Use of nonpharmacological interventions 37 (84.1) 44 (100) — 28 (73.7) 37 (97.4) 0.090 0.731 — Reasons for not using nonpharmacological interventions (multiple answers can be chosen) Do not know enough about nonpharmacological interventions 4 (9.1) 0 (0) — 6 (15.8) 0 (0) — — — No medical/nursing staff have introduced such interventions 2 (4.5) 0 (0) — 3 (7.9) 1 (2.6) — — — Do not believe this is an effective method of pain relief 2 (4.5) 0 (0) — 2 (5.3) 0 (0) — — — No nursing staff to carry out the interventions 1 (2.3) 0 (0) — 1 (2.6) 0 (0) — — — No facilities to carry out the interventions 1 (2.3) 0 (0) — 1 (2.6) 0 (0) — — — Types of nonpharmacological interventions used (multiple answers can be chosen) Aromatherapy 0 (0) 37 (84.1) — 0 (0) 0 (0) — — — Analgesic balm/oil 31 (70.5) 34 (77.3) — 24 (63.2) 32 (84.2) — — — Massage 14 (31.8) 17 (38.6) — 7 (18.4) 9 (23.7) — — — Hot pad 2 (4.5) 0 (0) — 11 (28.9) 0 (0) — — — Resting in bed 2 (4.5) 0 (0) — 7 (18.4) 2 (5.3) — — — Watching television 2 (4.5) 0 (0) — 6 (15.8) 0 (0) — — — Cold pad 1 (2.3) 0 (0) — 3 (7.9) 0 (0) — — — Chatting 1 (2.3) 0 (0) — 2 (5.3) 0 (0) — — — Listening to music 0 (0) 1 (2.3) — 1 (2.6) 0 (0) — — — Mediation 0 (0) 0 (0) — 0 (0) 0 (0) — — — Deep breathing 0 (0) 0 (0) — 0 (0) 0 (0) — — — Others 14 (31.8) 0 (0) — 4 (10.5) 6 (15.8) — — —
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BioMed Research International 9 Table 5: Continued. Intervention group (𝑛 = 44) Control group (𝑛 = 38) Group difference Baseline Postintervention 𝑃 value# Baseline Postintervention 𝑃 value# Baseline Postintervention 𝑛 (%) 𝑛 (%) 𝑛 (%) 𝑛 (%) 𝑃 value# 𝑃 value# Participants’ perceptions of the effectiveness of nonpharmacological interventions 28 (63.6) 38 (86.4) 0.008∗ 22 (57.9) 35 (92.1) 0.296 0.380 0.168 Percentages may not add up to 100% because of rounding. #The Chi-square test was used. ∗A 𝑃 value of <0.05 was considered statistically significant
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10 BioMed Research International Table 6: Depression Anxiety and Stress Scales of the intervention and control groups. Intervention group (𝑛 = 44) Control group (𝑛 = 38) Group difference Baseline Postintervention 𝑍a 𝑃 valuea Baseline Postintervention 𝑍a 𝑃 valuea Baseline Postintervention Mean ± SD Mean ± SD Mean ± SD Mean ± SD 𝑈b 𝑃 valueb 𝑈b 𝑃 valueb Depression 11.18 ±6.18 7.05 ± 5.11 3.43 0.001∗ 12.11 ± 7.32 12.89 ± 6.70 1.14 0.256 834 0.985 404 0.000∗ Anxiety 9.64 ± 7.05 5.64 ± 3.72 3.49 0.000∗ 8.26 ± 5.94 10.05 ± 5.47 1.87 0.062 745 0.395 423 0.000∗ Stress 12.91 ± 7.70 7.55 ± 6.37 3.38 0.001∗ 11.37 ± 7.07 11.74 ± 7.63 0.31 0.761 709 0.233 574 0.014∗ aThe Wilcoxon signed ranks test was used to compare the baseline data to the postintervention data of the control and intervention groups. bThe Mann-Whitney 𝑈 Test was used to compare the control and intervention groups. ∗A 𝑃 value of <0.05 was considered statistically significant
