Use of Aromatherapy in the Care of Patients with Alzheimer’s Disease
Laraine Pounds, RN, MSN, BSN, CMT, Cert AT
Previously published in the International Journal of Professional Holistic Aromatherapy, Vol 6, Issue 1, Summer 2017, pp. 27-33.
Alzheimer’s Disease (AD) is a degenerative brain disease and responsible for an estimated 60-80% of dementia. Dementia is a syndrome consisting of a group of symptoms that can have many causes. Characteristic symptoms include disorientation, poor memory, reduced intellectual functioning impairing judgment, alterations in emotional background and loss of everyday skills. (Alzheimer’s Association, 2017)
This degeneration occurs because the neurons (nerve cells) in the brain responsible for cognitive functioning have been damaged. In later stages of the disease other parts of the brain become damaged or destroyed and basic bodily functions deteriorate. Alzheimer’s disease is fatal with people in the final stages being bed-bound requiring around the clock care. It is estimated that 40 – 60 % of the nation’s nursing home residents suffer from dementia (Alzheimer’s Association, 2017).
Uses of Aromatherapy have been integrated into assisted living and specialized Alzheimer’s programs in the United States since the 1990’s (Carnarius, 1998). I was involved in assisting with the early development of some Aromatherapy programs during this time and later when I had an Aromatherapy mail order company and actively consulted with local long term care facilities and hospices regarding the benefits of essential oils. This article will describe some of my early experiences in integrating various forms of Aromatherapy use in specialized Alzheimer’s environments and discuss some of the challenges in maintaining such programs, once in place.
With guidance, aromatherapy can also be used in the home setting with diffusers, spritzes, inhalers, body lotions and footbaths, to mention a few approaches. Aromatherapy is helpful with all stages of the Alzheimer’s disease process. It is not meant to be a quick fix for underlying pathology that causes emotional and behavioral disturbances such as agitation, pacing, combativeness, delusions, depression and withdrawal.
An aspect of caring for the Alzheimer’s client is to reduce the level of stress as much as possible by providing an environment that the patient understands, reduces confusion and maintains familiarity. Depression frequently accompanies dementia, especially in the early stages. A common symptom that arises in the late phases of dementia is sundowning, when a person becomes confused late in the afternoon and early evening with increased confusion, pacing and wandering behaviors, and agitation. It has been cited that poor nighttime sleeping and end of the day fatigue can contribute to these behaviors. Caregivers need to be flexible with expectations and respond calmly. (Gruetzner, 2001, p41-42)
A common plan of action is to calm the patient with medications with potential side effects. Many Alzheimer’s treatment environments include a space for relaxation with comfortable chairs, adjustable lighting, music and an Aromatherapy diffuser. Generally, diffusers and CD machines are positioned on a shelf that is mounted out of reach of the clients.
Calming essential oils such as Lavender (lavendula angustifolia), Sweet Marjoram (Origanum marjorana), Mandarin (Citrus sinensis), Bergamot (Citrus bergamia) and Petitgrain (Citrus aurantium var. amara) have been found useful in conjunction with room diffusers, personal patches and hand massage. (Buckle, 2015, p244-245)
Individuals with Alzheimer’s disease often experience problems in communicating with others because the brain changes are highly associated with memory and language. Individual Aromatherapy interventions, as well as small group Aromatherapy activities, can promote memory recall and support discussions related to scent memories, such as gardening, cooking and favorite holidays.
Benefits of Aromatherapy for Alzheimer’s Care
- Calming effect for wandering behavior, insomnia, aggression, angry outbursts and anxiety
- Enhances the environment and air purification
- Distraction during periods of confusion, frustration, agitation
- Helps stimulate appetite
- Provides additional sensory stimulation
- Serves as non-verbal communication
- Sleep aide
- Topical applications of Aromatherapy lotion provides tactile reassurance
- Uplifting during times of fatigue and lethargy
- Family and caregiver benefit
Methods of application:
- Lotion application and massage
- Aromatherapy patches, felt stick-on’s, scented cotton balls
- Diffuser – micro-mist, light bulb ring
- Foot soaks
- Room spritz
- Scented shower/bath gel
- Aromatic memory and sensory activities
- Warm, moist scented wash cloths
Sensory stimulation and memory enhancement
Because the effect of aromas relayed to the amygdala in the limbic system of the brain pleasing aromas can affect memory, sleep, appetite and emotions and provide distraction when other attempts have failed. Many AD group activity programs focus on sensory stimulation and memory enhancement (Ward-Smith, 2009). Often these activity groups are arranged in a circle or around a table where aromatic support items can be experienced. Below are examples of Aromatherapy groups that can be facilitated by specially trained activity directors and clinical Aromatherapists.
Small group activities
1) Arrange a group of patients sitting in chairs in a circle, twelve or fewer. Pass around natural aromatic substances from the kitchen such as coffee beans, nutmeg, cloves, small cinnamon sticks in small plastic containers with attached lids. Flowers and herbs from the garden; e.g., peppermint, rosemary, thyme, oregano, geranium, roses can also be passed around. Sliced oranges and grapefruit are nice to include for snacking as well as smelling. Many AD facilities have a secured outdoor courtyard areas with herb and flower gardens. When this is the case, it is convenient to cut samples of basil, thyme, rosemary and other botanical samples from the garden for this activity.
Invite the participants to speak to any memories that come to mind, including likes and aversions. Scents related to the kitchen and cooking bring back long-term memories for women especially. Some end-stage patients are non-verbal, depressed, and need encouragement to hold or pass an herbal sample. Expectations for cross-talk are low and comments are expressed awkwardly and sound nonsensical, with pleasant memories expressed, as possible. Periodically, there will be an impulse to put the items in the mouth, so use plant material and spices that are harmless if eaten and have a second staff person present to observe attempts to ingest something they shouldn’t.
It can be nice to have an activity group centered on a fruit, such as grapefruit or orange, where the activity can include eating the fruit, serving the juice and providing an Aromatherapy lotion for hand and arm application made with the thematic essential oil.
2) For another enjoyable group activity, prepare warm scented washcloths in a crockpot prior to the group or ask the kitchen to prepare in a steamer pan. Saturate as many wash clothes as you need in warm water, ring out to dampness, apply several drops of essential oils on each washcloth, roll up and keep warm until the group is ready. Typical essential oils used include Lavender (Lavendula angustifolia), Rosemary (Rosmarinous officinalis), Geranium (Pelargonium graveolens), and Orange (Citrus sinensis). Invite the participants to smell the aromatic cloth, and wipe their hands, and faces, being careful to avoid the eyes. Ask for any memory associations. This activity can be useful before a mealtime to stimulate appetite or in late afternoon when Sundowner’s behaviors, such wandering, increased confusion and restlessness can occur. If there is staff available, this is an opportunity to offer an aromatic hand massage, or provide some scented lotion for the residents to apply to hands and face.
3) In one memorable group Aromatherapy activity for an Alzheimer’s facility, a group of twelve mid to late stage AD residents were arranged facing each other around joined six-foot tables. I had not met the participants before and after all were seated, the Aide left the room to take a break or catch up with charting. I prefer a staff representative to stay in the room in case I need assistance and also to watch how the group was arranged and the activity progressed. I recommend this expectation be pre-arranged.
I pre-selected essential oils for them to smell from scent strips and as I passed them around, asked if they could identify the scents, made notes of aromatic preferences, and encouraged conversation relating to scent memories, such as gardening, favorite baking memories, past travels. One memorable account was a resident describing “tapping” for maple syrup in the spring where she grew up.
With my notes in hand, I assisted the residents in creating a one ounce scented lotion using approximately ten drops of essential oils. I don’t remember the oils I chose that day, but generally bring a variety and select five or six in the moment, generally a citrus; such as Orange (Citrus aurantium), flower such as Lavender (Lavandula angustifolia) or Geranium (Pelargonium graveolens)(Lin, PW) (2007), a tree oil such as Fir (Abies siberica), Juniper (Juniperus communis) berry and spice such as Black Pepper (Piper nigrum) oils.
When the nursing assistant returned to the room she was amazed the patients were engaged in conversation, talking across the table or to their fellow resident next to them. “They never talk to each other. What did you do?” Actually, most of the conversation was unintelligible but they nodded away in agreement with each other, smiled and seemed to generally enjoy this time together. To me, in the moment, it seemed as though their cross-talk was a common occurrence.
Micro-mist diffusers and spritzing
Diffused essential oils can be especially useful in a common area in the morning for uplifting purposes and in the hallway leading to the dining room. There can be diminished appetite or loss of interest in eating in later stages of Alzheimer’s, and the smells of citrus and spice oils, such as Orange, Grapefruit (Citrus paradis) and Clove (Syzygium aromaticum) or Nutmeg (Myristica fragrans) can be useful to encourage appetite.
A Japanese study was conducted to assess the efficacy of aromatherapy diffusion with 28 elderly patients with dementia, 17 of whom had Alzheimer’s disease (AD). Rosemary and Lemon essential oils were diffused in the morning for two hours with Lavender and Orange diffused in the evening for two hours. Pre and post assessments reflected “significant improvement in personal orientation related to cognitive function”. (Jimbo et al, 2009) In conclusion, the study found aromatherapy to be an efficacious non-pharmaceutical therapy for dementia.
It can take some time to determine the best placement for diffusers for reasons of safety and air circulation. Generally diffusers are placed in a high or hidden location where patients can’t handle them. Glass nebulizer diffusers do not hold up well for institutional use and it is generally preferable to use a sturdy plastic diffuser with a timer and flow setting for intermittent diffusion. This makes diffuser use less labor intensive for staff and allows the aroma in the room to clear at intervals.
It is not necessary to produce a strong aroma to have an effect in the environment. Be aware if some clients with AD or their families, or the treatment staff, have smell sensitivities or aversions and be prepared to shut off diffusers as needed. Do not use essential oils in a carrier oil with micro-mist diffusers. It is recommended that the Aromatherapy policy statement clarifies that Aromatherapy uses are not for odor management.
Spritzing essential oils in water can be a wonderful intervention for potentially escalating behaviors and skillful distraction. A variety of spritzers can be prepared for calming and uplifting outcomes and general environmental benefit. These can be on the medicine cart or left in areas readily accessible for staff to use at their discretion. One Alzheimer’s facility coded energizing and calming Aromatherapy spritzes with colored stickers, to make them easily available on the unit for all staff to access on an as-needed basis (Carnarius, 2017).
You can ask a patient’s permission to mist them directly. A recommended technique is to spritz above the head or around the resident with a light-hearted attitude. Some AD patients have an aversion to water and bathing. To mist the shower area with a calming synergy can promote relaxation and improve cooperation. Adding music and dimming the lights to create a spa ambiance can sometimes be useful.
Topical applications of Aromatherapy
Aromatherapy massage for comfort, relaxation and tactile reassurance have long been an entry point for introducing Aromatherapy for AD (Canarius,1998). With essential oils added to massage lotion or oil, a full body massage is not necessary to achieve a noticeable shift towards relaxation. Facility staff and volunteers can receive skillful in-servicing to learn to provide a simple Aromatherapy hand massage. Buckle cites numerous dementia studies by her students using the gentle hand “M’ technique with Bergamot, Frankincense (Boswellia carteri), and Lavender at 2% dilution. (Buckle, 2015, p. 245) A DVD, “Touch with Oils® Hand Massage” by aromatherapist, Candace Newman, can be a useful in-servicing component for staff and volunteers of Alzheimer’s and end-of-life facilities. (Newman, 2001)
When I once introduced a small group of six patients to a variety of essential oils on a specialty Alzheimer’s unit, I noticed grey and blue bruises on both arms of a well-groomed, elderly lady. Suspecting a recent physical management occurrence, I couldn’t help but ask, “Whatever happened to your arms?” At first, she looked at me with a blank expression and then said with a laugh, “I think I got caught in a briar patch.” The other residents laughed along with her. I offered to apply a soothing Aromatherapy lotion to her arms and she agreed.
As an Aromatherapist contracted for hourly Aromatherapy activity groups, I was generally only given their names with a quick report of any pertinent information. I recommend that facility staff to be present for Aromatherapy groups, if possible. Once I received a phone call from the nurse on a unit where I had given an Aromatherapy group earlier in the day, complaining that a patient had been agitated all day since the Aromatherapy activity. She felt the group experience had agitated the patient. I had little opportunity to explore any of the facts further and the Aromatherapy activity group was discontinued.
Aromatic patches, sachets and other aromatic supports
There are commercially prepared Aromatherapy patches that release single scents or blended aromas for an identified purpose such as sedation, energizing, or nausea. Other patches are available to release the aromatic constituents through the skin by topical absorption, generally for relaxation or pain. There are small sticky backed felt patches available at many hobby stores that can be scented with essential oils and attached to clothing or furniture to release aromas for client benefit. To keep these available for staff to use easily is helpful. A cotton ball with several drops of essential oils or strip of felt can be pinned to the clothing or tucked into a pocket.
If the facility has volunteers who sew, explore if several would make little sachets from wide, open-weave ribbon, to fill with dried flowers or cotton batting to which you can add several drops of essential oil. These can be placed in the resident’s room, or taped to the back of a wheelchair or bedside lamp.
Depending on the environment, whether home or institutional, escargot shells, found in hobby or grocery stores, can be filled with cotton or felt to make a simple room deodorizer or room diffuser by evaporation. Additionally, one can apply a few drops of essential oils or blend on 2×2 gauze pads and leave in an environment, in a plastic medicine cup, to evaporate over the next few hours.
Aromatherapy footbaths can be useful for a variety of situations including clients who are restless, emotionally and mentally fatigued, having insomnia, or with chronically cold feet. Encouraging an agitated patient to sit down and enjoy a footbath can serve as a gentle distraction. It is important to remain calm with a “this can help” attitude. Assess for any contraindication to a footbath such as localized skin damage or inflammatory condition.
I have used Aromatherapy footbaths successfully in several situations for extreme agitation and wandering behavior that did not respond to re-direction and for a terminal AD client for reassurance and comfort-care in a hospice setting. This is an example of an Aromatherapy intervention that can be tried before sedating psychiatric medication.
Most facilities and homes have a small bath basin, large enough for two feet or use a basin for each foot. Add warm water with approximately three drops of essential oils with an emulsifier such as castile soap or other aromatherapy-specific emulsifier. Place a small towel or anti-slip bath mat under the basin to catch any water that may spill and another hand towel for drying the feet afterwards. Talk softly and explain to the client that a footbath is very enjoyable and relaxing and you will stay with them. Position yourself directly across the client with the foot basin between you and them. With only five minutes of aromatic warm water time for the feet, this simple activity breaks the cycle of repetitive, compulsive activity and can create a period of relaxation, if only briefly. If it is feasible, based on client interest and staff time, offer a simple aromatherapy foot massage to extend the period of distraction and further support a state of interpersonal connection and relaxation.
Essential oil recommendations
Of course, there are many essential oil choices available for environmental enhancement, sensory stimulation, memory enhancement, insomnia, anxiety and emotional support. Educating staff about the best oils to use in the morning and evening, the various delivery methods and cost factors can play a part in the overall success of an Aromatherapy program. Even though research has identified Melissa (Melissa officinalis) useful for anxiety, this essential oil is expensive and often adulterated. Comparing the first two key constituents of Melissa and May Chang (Litsea cubeba), we can recognize May Chang may be a good substitute for Melissa in an institutional setting (Tisserand and Young, 2013), for reasons of cost. However, May Chang is lacking in sesquiterpines and other useful components for relaxation.
Anxiolytic and relaxing oils:Bergamot (Citrus aurantium), Clary Sage (Salvia sclarea), Frankincense (Boswellia carterii), Lavender (Lavendula angustifolia), Sweet Marjoram (Origanum majorana), Roman Chamomile (Anthemis nobilis), (Setzer, 2009,Kerkhof-Knapp Hays, M. 2015).
Uplifting and energizing oils: Eucalyptus (Eucalyptus globulus), Peppermint (Mentha piperita), Rosemary (Rosemary officinalis), Lemongrass (Cymbopogon citratus), Grapefruit (Citrus paradisi) and Mandarin (Citrus reticulata). (Kerkhof-Knapp Hays, M. (2015).
Some essential oils, Bergamot, Geranium (Pelargonium graveolens), Mandarin and Ylang ylang (Cananga odorata), are versatile in their properties and applications making them useful as adaptogenic, balancing oils for either calming or uplifting outcomes.
Potential considerations and challenges
Objections to scented ambient air from clients, staff and visitors can stem from environmental allergies, asthma and aversion to particular aromas. For this reason, large space diffusers are often not feasible in common areas. Small space aromatic spritzing or stick-on patches may be more useful for as-needed use.
There are often budget considerations for initiating and maintaining Aromatherapy programs. Depending on the size of the facility and number of residents served, start-up costs including essential oils, diffusers, lotion, containers can be in the range of $300-500, with replacement of supplies approximately $50 month. Often the budget and storage of Aromatherapy supplies are organized within the Activities Department.
While a sensitive issue to include in this discussion, a long-term care Nursing Administrator revealed that, in recent years, there has been an increased trend for representatives of essential oil companies that engage in network marketing seek to present Aromatherapy activities in long term care and ask facilities to use their essential oils. Carnarius pointed out that this can be a challenge as, generally speaking, direct-sales essential oil distributors believe they have more information about essential oils and their uses than they actually have, including accepted safety guidelines. According to Carnarius (2017), “They attend some workshops and believe they have the only therapeutic grade essential oils when this nomenclature is not an accepted grading system in Aromatherapy commerce.”
Long-term care facilities are subject to frequent staff turnover and Aromatherapy programs require staff education. Facility policies generally include a system reflecting informed consent for various complementary treatment options that are signed off on admission with clients, their family and the attending physician. Environmental allergies, sensitivities and medical contraindications are part of the client’s record. Because of the high dilution used in these settings, restricting the use of aromatherapy has generally only been an issue in the case of allergies and personal preference. One should cross-reference uses of essential oils with any concern regarding a particular medication. In personal discussion with Dr. Daniel Penoel, a well known French clinical aromatherapist MD regarding essential oil and drug interactions, Dr. Penoel stated, “there is no risk of drug interaction at the percentages we use in massage and diffusion.” (2007).
Aromatherapy Support for Caregivers
Individuals with AD commonly stay at home with family with ancillary care until care needs and safety issues exceed the family’s ability. Caring for a loved one with Alzheimer’s disease is a difficult journey with many challenges and uncertainties, for an unknown length of time. Normal coping abilities are challenged and self-care becomes very important and often difficult to maintain (Carnarius, 2015).
With exquisite compassion and sensitivity, author Barbra Cohn, cared for her husband with early onset Alzheimer’s for ten years, and published a resource book for caregivers with contributions from holistic specialists representing over twenty modalities that can be used by both the caregiver and the memory impaired individual alike. In addition to essential oil therapies, including aromatic baths, massages, use of diffusers and incense, she included additional healing modalities: dance, drumming, exercise, gardening, music therapy, light and color therapy, nutrition, yoga, art therapy, journaling, meditation, breath work, acupuncture and animal-assisted therapy. It should be noted that this seminal work, Calmer Waters serves as an inspiring and useful resource for any caregiver or one living with a chronic disease (Cohn, 2015).
A British study evaluated the effects of a weekly aromatherapy massage on 12 carers of patients with AD over a period of eight weeks. Outcome measures, taken at intervals of one, four and eight weeks, showed a reduction in stress and depression. (Atkins & Smith, 2009)
Introducing and using essential oils with Alzheimer clients, staff and family is rewarding, even if challenging at times. With aromatherapy applications, the senses of smell and touch are impacted in safe, affordable and enjoyable ways. Acknowledging the on-going need for documented outcomes and formal evidenced based clinical research, aromatherapy clinicians who work with this population are encouraged to report on case studies and conduct randomized controlled trials for publication. Let us continue to share our experiences, what works and what doesn’t. In this way we will continue to develop new health care protocols for the Alzheimer’s disease population and those affected by it.
“Smell is a potent wizard that transports us across a thousand miles and all the years we have lived. The odor of fruits wafts me to my Southern home, to my childish frolics in the peach orchard. Other odors, instantaneous and fleeting, cause my heart to dilate joyously or contract with remembered grief.”
Helen Keller, 1908
References and additional reading
Alzheimers Association. (2017). Alzheimer’s Disease Facts and Figures. Alzheimers & Dementia. p5-6,325-373. http: www.alz.org./alzheimers disease_what is alzheimers.asp. Last accessed 21 February 2017.
Atkins, R, Smith F. (2009). The use of aromatherapy massage with carers of dementia patient: a preliminary evaluation. Int J Clin Aromatherapy. 6(2):9-14.
Burns A, Perry E, Holmes C, Francis P, Morris J, Howes M J, Chazot P, Lees G, Ballard C. (2011). A double-blind placebo-controlled randomized trial of Melissa officinalis oil and donepezil for the treatment of agitation in Alzheimer’s disease. Dementia and Geriatric Cognitive Disorders. Epub. Feb 19 (2), p158-164.
Buckle, J. (2015), Clinical Aromatherapy: Essential Oils in Healthcare. St. Louis, MO/Elsevier. P242-246.
Carnarius M. (1998). Alzheimer’s and Aromatherapy. NAHA: Scentsivity. 7 (4), p4-7.
Carnarius M. (2015). A Deeper Perspective on Alzheimer’s and other Dementias. Forres, Scotland: Findhorn Press. p157-158.
Carnarius M. (2017). Personal interview: Aromatherapy use in Alzheimer facility.
Cohn B. (2016). Calmer Waters. Indianapolis, Indiana: Blue River Press.
Gruentzner,, Howard. (2001) Alzheimer’s: A Caregivers Guide and Sourcebook. (USA: John Wiley & Sons, Inc.), p41-2.
Jimbo D, Kumura Y, Taiguchi , Inoue M, Urakami K. (2009). Effect of Aromatherapy on patients with Alzheimer’s disease. Psychogeriatrics. 12-0 (4) , p173-179.
Kerkhof-Knapp Hays, M. (2015) Complementary Nursing in End of Life Care. (Wernhout, Netherlands/Kicozo), p35-62.
Lin P W, Chan W C, Ng B F, Lam L C. (2007). Efficacy of Aromatherapy (Lavendula angustifolia) as an intervention for agitated behavious in Chinese older persons with demntia: a crossover randomized trial. International Journal of Geriatric Psychiatry. 5;22(5), p. 405-10
Penoel, D. Personal communication with the author, June, 2007.
Setzer W N. (2009). Essential oils and anxiolytic Aromatherapy. Natural Products Communication. 4 (9), p1305-1316.
Tisserand R and Young R. (2014). Essential Oil Safety. New York. Churchill Livingston/Elsevier. p349-350.
Ward-Smith P 1, Llanque S M, Curran D. (2009). The effect of multisensory stimulation on persons residing in an extended care facility. Am J Alzheimers Disease & Other Dementias. 12:10; 246. pp. 450-455.