Yang et al.BMC Complementary and Alternative Medicine (2015)15:93 Page 7 of 8 Figure 1 shows a skew distribution of participants Acknowledgements among three groups that were 56,73,and 57,indicating We would like to thank the staff members at the six care facilities (Taoyuan Veterans'Home,Chih Shan Senior Citizen Home,Chao-Ju Senior Citizen that the aromatherapy group had much more partici- Home,Taipei Veterans'Home,Pingtung Veterans'Home,and Saint Joseph pants than other two groups.This study used stratified Home)for their enthusiastic assistance.Without them,this study could not sampling to enroll the participants,and divided institu- have been completed smoothly. tions into veteran's homes and long-term care facilities. Author details The number of residents with dementia at three vet- 'Department of Nursing,National Yang-Ming University,155,Li-Nong Street eran's homes was 50,56 and 50,respectively,and the Sec 2,Beitou District,Taipei 11221,Taiwan."Institute of Clinical and number was very close.Other three long term care facil- Community Health Nursing,National Yang-Ming University,155,Li-Nong Street Sec 2,Beitou District,Taipei 11221,Taiwan.Institute of Health and ities belonged to large-scale institutions with more than Welfare Policy,National Yang-Ming University,155,Li-Nong Street Sec 2, 300 residents.After the randomization,this study found Beitou District,Taipei 11221,Taiwan."Institute of Traditional Medicine, National Yang-Ming University,155,Li-Nong Street Sec 2,Beitou District, that the number of residents with dementia at the three Taipei 11221,Taiwan.Faculty of Medicine,National Yang-Ming University, facilities was 32,50,and 38,respectively,and the num- 155,Li-Nong Street Sec 2,Beitou District,Taipei 11221,Taiwan.Institute of ber was different.The number of participants random- Traditional Chinese Medicine,China Medical University,91,Hsueh-Shuh ized to aromatherapy group was the largest,so the Road,Taichung 40402,Taiwan. number of participants receiving aromatherapy was Received:18 September 2014 Accepted:13 March 2015 greater than that of other two groups. Published online:29 March 2015 The epidemiology of dementia suggests that there are more female compared with male AD patients [25]. References However,this study recruited a greater number of male 1.Howland RH.Risks and benefits of antipsychotic drugs in elderly patients with dementia.J Psychosoc Nurs Ment Health Serv.2008;46:19-23. AD patients because three of the six chosen institutions 2. Shin BC,Lee MS.Effects of aromatherapy acupressure on hemiplegic for participant recruitment were retirement homes for shoulder pain and motor power in stroke patients:a pilot study.J Altern Complement Med.2007:13:247-52. veterans.Although the demographic data showed no sig- 3. Yip YB,Tse SH.The effectiveness of relaxation acupoint stimulation and nificant difference in sex among the three groups,future acupressure with aromatic lavender essential oil for non-specific low back studies should adopt additional long-term care facilities pain in Hong Kong:a randomised controlled trial.Complement Ther Med 2004:1228-37. to recruit equal numbers of male and female partici- 4.Yip YB,Tse SH An experimental study on the effectiveness of acupressure pants.Another limitation was the experimental study with aromatic lavender essential oil for sub-acute,non-specific neck pain in design,as the participants were aware of the specific Hong Kong.Complement Ther Clin Pract 2006;12:18-26. Gill SS,Bronskill SE,Normand ST,Anderson GM,Sykora K Lam K,et al. group they were assigned to.In future studies,partici- Antipsychotic drug use and mortality in older adults with dementia.Ann pants should be treated with base oil or pressed at false Intem Med.2007.146775-86. acupoints to ensure a double-blind study design. 6 Lin LC,Yang MH,Kao CC,Wu SC,Tang SH,Lin JG.Using acupressure and Montessori-based activities to decrease agitation for residents with dementia:a cross-over trial.J Am Geriatr Soc 200957:1022-9 7. Sutherland JA,Reakes J,Bridges C Foot acupressure and massage for Conclusions patients with Alzheimer's Disease and related dementias.Image J Nurs Sch. This experimental study confirms the beneficial effects of 99931347-8. de Zambotti M,Covassin N,Sarlo M,De Min Tona GD,Trinder J,Stegagno L. non-pharmacological treatments on agitation in patients Nighttime cardiac sympathetic hyper-activation in young primary insomniacs with dementia.In both the aroma-acupressure and aroma- Clin Auton Res.2013:23:49-56. therapy groups,the CMAI scores were significantly lower Patel MB,McKenna JW,Alvarez JM,Sugiura A,Jenkins JM,Guillamondegui OD, et al Decreasing adrenergic or sympathetic hyperactivity after severe traumatic over time.Aroma-acupressure was better able to inhibit brain injury using propranolol and clonidine (DASH after TBI study):study the sympathetic nervous system and increase the activity protocol for a randomized controlled trial.Trials.2012:13:177-86 of the parasympathetic nervous system compared with 10.Lee MS,Shin BC,Ernst E.Acupuncture for Alzheimer's disease:a systematic review.Int J Clin Pract 2009;63:874-9. aromatherapy.Our findings support the efficacy of non- 11.Cook N,Lynch J.Aromatherapy:reviewing evidence for its mechanisms of pharmacological treatments in decreasing agitation.These action and CNS effects.Br J Neurosci Nurs.20084:595-601. non-pharmacological protocols should be more fully ex- 12 Holmes C,Hopkins V,Hensford C MacLaughlin V,Wilkinson D,Rosenvinge H.Lavender oil as a treatment for agitated behaviour in severe dementia: plored and refined in future studies. a placebo controlled study.Int J Geriatr Psychiatry.2002:17:305-8. 13.Ballard CG,O'Brien JT,Reichelt K.Perry E.Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: Competing interests the results of a double-blind,placebo-controlled trial with Melissa.J Clin The authors declare that they have no competing interests. Psychiatry.2002:6:553-8. 14.Nguyen QA,Paton C The use of aromatherapy to treat behavioural problems in dementia.Int J Geriatr Psychiatry.2008:23:337-46. Authors'contributions 15.Yang MH,Wu SC,Lin JG,Lin LC The efficacy of acupressure for decreasing All authors read and approved the final manuscript.MY and LL drafted and agitated behaviour in dementia a pilot study.J Clin Nurs.2007;16:308-15. revised the manuscript.SW participated in data analysis.JL,JC,and PW 16 Cohen-Mansfield J,Billig N.Agitated behaviors in the elderly:I.A conducted the use of instruments and reviewed the study procedure.All conceptual review.J Am Geriatr Soc.198634:711-21. authors participated in the development of the study protocol and design 17.Lin LC,Kao CC,Tzeng YU,Lin YJ.Equivalence of Chinese version of of the study.All authors read and approved the final manuscript. Cohen-Mansfield Agitation Inventory.J Adv Nurs.2007,59:178-85.Figure 1 shows a skew distribution of participants among three groups that were 56, 73, and 57, indicating that the aromatherapy group had much more partici￾pants than other two groups. This study used stratified sampling to enroll the participants, and divided institu￾tions into veteran’s homes and long-term care facilities. The number of residents with dementia at three vet￾eran’s homes was 50, 56 and 50, respectively, and the number was very close. Other three long term care facil￾ities belonged to large-scale institutions with more than 300 residents. After the randomization, this study found that the number of residents with dementia at the three facilities was 32, 50, and 38, respectively, and the num￾ber was different. The number of participants random￾ized to aromatherapy group was the largest, so the number of participants receiving aromatherapy was greater than that of other two groups. The epidemiology of dementia suggests that there are more female compared with male AD patients [25]. However, this study recruited a greater number of male AD patients because three of the six chosen institutions for participant recruitment were retirement homes for veterans. Although the demographic data showed no sig￾nificant difference in sex among the three groups, future studies should adopt additional long-term care facilities to recruit equal numbers of male and female partici￾pants. Another limitation was the experimental study design, as the participants were aware of the specific group they were assigned to. In future studies, partici￾pants should be treated with base oil or pressed at false acupoints to ensure a double-blind study design. Conclusions This experimental study confirms the beneficial effects of non-pharmacological treatments on agitation in patients with dementia. In both the aroma-acupressure and aroma￾therapy groups, the CMAI scores were significantly lower over time. Aroma-acupressure was better able to inhibit the sympathetic nervous system and increase the activity of the parasympathetic nervous system compared with aromatherapy. Our findings support the efficacy of non￾pharmacological treatments in decreasing agitation. These non-pharmacological protocols should be more fully ex￾plored and refined in future studies. Competing interests The authors declare that they have no competing interests. Authors’ contributions All authors read and approved the final manuscript. MY and LL drafted and revised the manuscript. SW participated in data analysis. JL, JC, and PW conducted the use of instruments and reviewed the study procedure. All authors participated in the development of the study protocol and design of the study. All authors read and approved the final manuscript. Acknowledgements We would like to thank the staff members at the six care facilities (Taoyuan Veterans’ Home, Chih Shan Senior Citizen Home, Chao-Ju Senior Citizen Home, Taipei Veterans’ Home, Pingtung Veterans’ Home, and Saint Joseph Home) for their enthusiastic assistance. Without them, this study could not have been completed smoothly. Author details 1 Department of Nursing, National Yang-Ming University, 155, Li-Nong Street Sec 2, Beitou District, Taipei 11221, Taiwan. 2 Institute of Clinical and Community Health Nursing, National Yang-Ming University, 155, Li-Nong Street Sec 2, Beitou District, Taipei 11221, Taiwan. 3 Institute of Health and Welfare Policy, National Yang-Ming University, 155, Li-Nong Street Sec 2, Beitou District, Taipei 11221, Taiwan. 4 Institute of Traditional Medicine, National Yang-Ming University, 155, Li-Nong Street Sec 2, Beitou District, Taipei 11221, Taiwan. 5 Faculty of Medicine, National Yang-Ming University, 155, Li-Nong Street Sec 2, Beitou District, Taipei 11221, Taiwan. 6 Institute of Traditional Chinese Medicine, China Medical University, 91, Hsueh-Shuh Road, Taichung 40402, Taiwan. Received: 18 September 2014 Accepted: 13 March 2015 References 1. Howland RH. Risks and benefits of antipsychotic drugs in elderly patients with dementia. J Psychosoc Nurs Ment Health Serv. 2008;46:19–23. 2. Shin BC, Lee MS. Effects of aromatherapy acupressure on hemiplegic shoulder pain and motor power in stroke patients: a pilot study. J Altern Complement Med. 2007;13:247–52. 3. Yip YB, Tse SH. The effectiveness of relaxation acupoint stimulation and acupressure with aromatic lavender essential oil for non-specific low back pain in Hong Kong: a randomised controlled trial. Complement Ther Med. 2004;12:28–37. 4. Yip YB, Tse SH. An experimental study on the effectiveness of acupressure with aromatic lavender essential oil for sub-acute, non-specific neck pain in Hong Kong. Complement Ther Clin Pract. 2006;12:18–26. 5. Gill SS, Bronskill SE, Normand ST, Anderson GM, Sykora K, Lam K, et al. Antipsychotic drug use and mortality in older adults with dementia. Ann Intern Med. 2007;146:775–86. 6. Lin LC, Yang MH, Kao CC, Wu SC, Tang SH, Lin JG. Using acupressure and Montessori-based activities to decrease agitation for residents with dementia: a cross-over trial. J Am Geriatr Soc. 2009;57:1022–9. 7. Sutherland JA, Reakes J, Bridges C. Foot acupressure and massage for patients with Alzheimer’s Disease and related dementias. Image J Nurs Sch. 1999;31:347–8. 8. de Zambotti M, Covassin N, Sarlo M, De Min Tona GD, Trinder J, Stegagno L. Nighttime cardiac sympathetic hyper-activation in young primary insomniacs. Clin Auton Res. 2013;23:49–56. 9. Patel MB, McKenna JW, Alvarez JM, Sugiura A, Jenkins JM, Guillamondegui OD, et al. Decreasing adrenergic or sympathetic hyperactivity after severe traumatic brain injury using propranolol and clonidine (DASH after TBI study): study protocol for a randomized controlled trial. Trials. 2012;13:177–86. 10. Lee MS, Shin BC, Ernst E. Acupuncture for Alzheimer’s disease: a systematic review. Int J Clin Pract. 2009;63:874–9. 11. Cook N, Lynch J. Aromatherapy: reviewing evidence for its mechanisms of action and CNS effects. Br J Neurosci Nurs. 2008;4:595–601. 12. Holmes C, Hopkins V, Hensford C, MacLaughlin V, Wilkinson D, Rosenvinge H. Lavender oil as a treatment for agitated behaviour in severe dementia: a placebo controlled study. Int J Geriatr Psychiatry. 2002;17:305–8. 13. Ballard CG, O’Brien JT, Reichelt K, Perry E. Aromatherapy as a safe and effective treatment for the management of agitation in severe dementia: the results of a double-blind, placebo-controlled trial with Melissa. J Clin Psychiatry. 2002;6:553–8. 14. Nguyen QA, Paton C. The use of aromatherapy to treat behavioural problems in dementia. Int J Geriatr Psychiatry. 2008;23:337–46. 15. Yang MH, Wu SC, Lin JG, Lin LC. The efficacy of acupressure for decreasing agitated behaviour in dementia: a pilot study. J Clin Nurs. 2007;16:308–15. 16. Cohen-Mansfield J, Billig N. Agitated behaviors in the elderly: I. A conceptual review. J Am Geriatr Soc. 1986;34:711–21. 17. Lin LC, Kao CC, Tzeng YU, Lin YJ. Equivalence of Chinese version of Cohen-Mansfield Agitation Inventory. J Adv Nurs. 2007;59:178–85. Yang et al. BMC Complementary and Alternative Medicine (2015) 15:93 Page 7 of 8