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 that2 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 suffi￾cient 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 administer￾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]. 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 Uni￾versity. Older persons were recruited from local community elderly centres. The participants were aged 65 or above, members of their community elderly centres, able to under￾stand 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 non￾pharmacological methods - Misconceptions of pharmacological and non￾pharmacological 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 con￾sulted on the content of the aromatherapy programme, which was a tailor-made four-week programme consisting of four centre-based sessions and self-administered home￾based 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 home￾based 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