An Investigation of Aromatherapy and Hand Massage on Disruptive Behaviour in People with ...

241 Pages·2012·0.94 MB·English

An Investigation of Aromatherapy and
Hand Massage on Disruptive Behaviour
in People with Dementia

Chieh-Yu (Jamie) FU
RN BSN MSN

School of Nursing and Midwifery
Griffith Health
Griffith University

Submitted in fulfilment of the requirements of the degree of
Doctor of Philosophy

December 2009

Statement of originality

This work has not previously been submitted for a degree or diploma in any university.
To the best of my knowledge and belief, the thesis contains no material previously
published or written by another person except where due reference is made in the
thesis itself.

Chieh-Yu (Jamie) Fu

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Abstract

Agitation and aggression are some of the most difficult behaviour symptoms to
manage in older people living with dementia. These disruptive behaviours can lead to
staff injury and burnout, decreased job satisfaction, as well as recruitment and
retention challenges. Disruptive behaviours can also influence the quality of care
received by residents. Therefore management of such behaviours is paramount to staff
satisfaction and quality of care. Complementary and Alternative Medicine (CAM)
therapies such as aromatherapy and massage have been applied to a range of health
problems including dementia. Such therapies have become popular in residential care
and in some cases additional cost for these therapies are invoiced to residents. While
both aromatherapy and hand massage therapies have been reported to have some
benefit in people with dementia, there are a number of limitations in the research
design of reported studies.

This study aimed to overcome some of the design problems of previous studies to
investigate the effect of Aromatherapy (3% lavender angustifolia mist) with or
without hand massage (five minutes with aqua cream) on disruptive behaviour in
people with dementia living in residential aged care facilities (RACF). Sixty-one
residents with a diagnosis of dementia and a history of disruptive behaviour from
three RACF were randomized into three groups: (1) Combination (aromatherapy and
hand massage), (2) Aromatherapy, (3) Control (placebo). The intervention was given
twice a day, at two time periods, 9am to 11am and 2pm to 4pm, seven days a week for
six weeks. Data (resident behaviour and cognition) were collected using three
instruments: MMSE (pre and post intervention), Cohen-Mansfield Agitation
Inventory (CMAI) and Revised Memory and Behaviour Problems Checklist (RMBPC)
at 5 time periods: pre-intervention, week 2 and week 4, at the end of the intervention
period (week 6), and 6 weeks post-intervention.

The mean for verbal agitation 2.33 (SD = 1.09) and memory loss 2.31 (SD = 1.27)
were the highest scores in CMAI and RMBPC measurements. However, none of the
interventions significantly reduced disruptive behaviour and in fact in one control
group (age group 60-84 years) there was a significant effect for the control
intervention at four weeks (p<.05) and six weeks (p<.02). On the other hand,
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aromatherapy combined with hand massage treatment seemed to increase disruptive
behaviours in the 60-84 year old group. In participants older than 84 years, there were
non-significant effects, which could be interpreted to mean that water is as effective
as aromatherapy, or aromatherapy and massage (p>.05). Although the water mist used
for the control group had a better effect in decreasing disruptive behaviours, two
participant case studies demonstrate the positive effects of aromatherapy and hand
massage treatments.

There were a number of challenges in undertaking this study that may have influenced
the findings. The initial mean scores of the CMAI and RMBPC were low which may
be related to several factors: the lack of a formal diagnosis, participants’ level of
cognitive impairment, limited level of mobility, organizational and environmental
issues, nursing staff attitudes and knowledge, social desirability bias (SDB), and
measurement challenges.

A number of conclusions can be drawn from this study with the main conclusion
being the need for further research that takes into consideration formal dementia
diagnosis, dementia subtypes, dementia educational programmes for nursing staff,
pain and psychotropic medication use.

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Acknowledgements

By the end of my PhD, I have realised that I could not have succeeded without the
support of other people, self-control and strong will. Therefore, there are many people
who have given me a great support; it is my pleasure to thank those who made this
thesis possible.

First, my thanks go to my principal supervisor, Professor Wendy Moyle, and associate
supervisor, Professor Marie Cooke. You are the two people most responsible for
successfully guiding me through the PhD journey. Thank you for always being
available and helping to solve my ongoing questions and concerns. Without your
extensive knowledge and encouragement, my goal would not be accomplished.

I am very pleased to give warm thanks to all participants, relatives, staff members and
the aged care facility managers for their enormous contribution to this research;
without their participation, I could not have started or finished this thesis.

I would also like to acknowledge and thank the Queensland Nursing Council for the
research grant and financial support for this study. The funding enabled me to employ
RAs to assist with data collection.

Special thanks go to Dr. Peter Grimbeek and Dr. Jesus Lopez who provided statistical
expertise and advice to this study.

I would like to extend appreciation to my parents and Tim Huang, for inspiring me
with nursing, for sending me to Australia, for unconditional support and
encouragement to pursue my interests, and belief in me.

Last, but not least, a special thanks to all my PhD colleagues, Cathy Wu, Sarah Huang,
Juli Yeh, Andy Chia, Susan Chang, Zoe Wei, Jane Yeh, Xiao-Feng Luo and Aggie
Wu for valuable emotional support, for sharing their experiences of the dissertation
writing endeavour with me, for listening to my complaints and frustrations, and for
offering delicious meals when I had no time to cook, thank you.

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Dissemination of Study Results

Conference Presentations

Fu, C. Y., Moyle, W. & Cooke, M. (2007). “An Investigation of Complementary
Therapy on Disruptive Behaviour in People with Dementia: An RCT”, oral
presentation at the 2007 Alzheimer’s Australia Conference, Perth, WA., Australia,
May 30th.

Fu, C. Y., Moyle, W. & Cooke, M. (2008). “An Investigation of Complementary
Therapy on Disruptive Behaviour in People with Dementia: A Randomized
Controlled Trial (RCT)” – “失智症破壞行為輔助療法之研究: 隨機受控制性實驗”,
oral presentation at the 11th Asia-Pacific Regional Conference of Alzheimer’s
Disease International, Taipei, Taiwan, June, 15th.

Poster Presentations

Fu, C. Y., Moyle, W. & Cooke, M. (2008). “An Investigation of Complementary
Therapy on Disruptive Behaviour in People with Dementia: A Randomized
Controlled Trial (RCT)” poster presented at the Asia Pacific Research Symposium,
Gold Coast, QLD, Australia, July, 1st-2nd.

Fu, C. Y., Moyle, W. & Cooke, M. (2009). “An Investigation of Aromatherapy and
Hand Massage on Disruptive Behaviour in People with Dementia” poster presented at
the Quality of Care and Quality of Life: An Ageing Research Symposium, Brisbane,
QLD, Australia, November, 19th.

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TABLE OF CONTENTS

CHAPTER 1 INTRODUCTION ................................................................................ 1
CHAPTER OVERVIEW .................................................................................................. 1
1.1 THE ECONOMIC IMPACT OF DEMENTIA ON HEALTH CARE SYSTEMS IN
AUSTRALIA ......................................................................................................... 2
1.2 MANAGEMENT STRATEGIES IN RESIDENTAL CARE FACILITIES IN AUSTRALIA ... 5
1.3 ISSUES IN CARE OF PEOPLE WITH DEMENTIA ...................................................... 7
1.3.1 Diagnosis from General Practitioners ...................................................... 7
1.3.2 Restraints and Falls ................................................................................... 9
1.3.3 Nursing Staff Attitudes and Knowledge ................................................... 10
1.3.4 Pain in Older Residents in the RACF ...................................................... 11
1.3.4.1 Pain medication management .............................................................. 11
1.3.4.2 Nurses’ perception of pain in people with dementia ........................... 12
1.4 CURRENT STATUS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE USE ... 14
1.5 AROMATHERAPY AND MASSAGE IN AUSTRALIA ............................................... 15
1.5.1 Aromatherapy .......................................................................................... 15
1.5.1.1 Regulation and standards of aromatherapy .......................................... 17
1.5.1.2 Essential oil administration and toxicity .............................................. 17
1.5.1.3 The effects of essential oils .................................................................. 19
1.5.2 Massage ................................................................................................... 21
1.5.2.1 The effects and adverse events of massage on the body ...................... 22
1.5.3 Aromatherapy and Massage in Older People .......................................... 25
1.6 OVERVIEW OF THE THESIS ................................................................................ 27
1.7 SUMMARY ......................................................................................................... 29
CHAPTER 2 BACKGROUND TO DEMENTIA ................................................... 30
CHAPTER OVERVIEW ................................................................................................ 30
2.1 DEMENTIA ........................................................................................................ 30
2.1.1 Types of Dementia.................................................................................... 31
2.2 DISRUPTIVE BEHAVIOURS ................................................................................. 34
2.2.1 Agitation and Aggression ......................................................................... 34
2.2.2 Verbal Agitation and Aggression ............................................................. 36
2.2.3 Physical Agitation and Aggression .......................................................... 37
2.2.4 Sundown Syndrome .................................................................................. 37
2.3 CAUSES OF AGITATION AND AGGRESSION ........................................................ 38
2.4 PHYSICAL AND PHARMACOLOGICAL INTERVENTIONS ....................................... 39
2.4.1 Physical Approach ................................................................................... 40
2.4.1.1 The ethics and strategies of using physical restraints .......................... 41
2.4.2 Pharmacological Approach ..................................................................... 42
2.5 SUMMARY ......................................................................................................... 45
CHAPTER 3 LITERATURE REVIEW .................................................................. 46
CHAPTER OVERVIEW ................................................................................................ 46
3.1 THEORETICAL BASIS FOR AROMATHERAPY AND HAND MASSAGE ................... 46
3.1.1 The Olfactory System ............................................................................... 46
3.1.2 Behavioural and Emotional Changes ...................................................... 47
3.1.3 Olfactory Function in People with Dementia .......................................... 48
3.1.4 Aromatherapy for Improvement of Cognitive Function ........................... 49
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3.1.5 The Basis of Aromatherapy ...................................................................... 52
3.1.6 The Basis of Hand Massage ..................................................................... 55
3.2 AROMATHERAPY AND TOUCH MASSAGE RESEARCH ........................................ 57
3.2.1 Aromatherapy Research for Agitation and Aggression in Dementia ...... 63
3.2.2 Massage Research for Agitation and Aggression in Dementia ............... 73
3.2.3 Summary .................................................................................................. 77
3.3 CONCLUSIONS ................................................................................................... 79
CHAPTER 4 METHODOLOGY ............................................................................. 80
CHAPTER OVERVIEW ................................................................................................ 80
4.1 BACKGROUND TO RANDOMIZED CONTROLLED TRIAL (RCT) ........................... 80
4.2 FUNDAMENTALS OF RANDOMIZED CONTROLLED TRIAL (RCT) ....................... 81
4.2.1 Manipulation ............................................................................................ 81
4.2.1.1 Design .................................................................................................. 81
4.2.1.2 Participant Size .................................................................................... 81
4.2.2 Control ..................................................................................................... 82
4.2.3 Randomization ......................................................................................... 82
4.2.3.1 Bias ...................................................................................................... 83
4.2.3.2 Blinding................................................................................................ 83
4.2.3.3 Intention-to-Treat (ITT) ....................................................................... 84
4.2.4 Strengths and Limitations of RCT ............................................................ 84
4.3 QUALITY INDICATORS RANDOMIZED CONTROLLED TRIAL (RCT) .................... 85
4.4 ETHICS OF RANDOMIZED CONTROLLED TRIAL (RCT) ...................................... 93
4.5 RANDOMIZED CONTROLLED TRIAL (RCT) IN DEMENTIA RESEARCH ............... 95
4.6 THEORETICAL FRAMEWORK INTEGRATING AROMATHERAPY AND HAND
MASSAGE .......................................................................................................... 96
4.7 JUSTIFICATION FOR USING RANDOMIZED CONTROLLED TRIAL (RCT) .............. 97
4.7.1 Research Hypotheses ............................................................................... 98
4.7.2 Research Objectives ................................................................................. 98
4.7.3 Complementary Therapy Intervention Protocol ...................................... 99
4.7.3.1 Before the intervention ........................................................................ 99
4.7.3.2 Aromatherapy spray ............................................................................. 99
4.7.3.4 Hand Massage .................................................................................... 103
4.8 SUMMARY ....................................................................................................... 106
CHAPTER 5 METHODS ....................................................................................... 108
CHAPTER OVERVIEW .............................................................................................. 108
5.1 STUDY DESIGN ............................................................................................... 108
5.2 THE INTERVENTION ........................................................................................ 110
5.2.1 Aromatherapy ........................................................................................ 111
5.2.2 Hand Massage ....................................................................................... 111
5.3 THE SETTINGS ................................................................................................. 112
5.4 THE SAMPLE ................................................................................................... 112
5.4.1 Selection Criteria ................................................................................... 113
5.4.2 Power Calculation ................................................................................. 114
5.5 MEASURES ...................................................................................................... 116
5.5.1 Demographic Data................................................................................. 116
5.5.2 Instruments for the Agitation and Aggression ....................................... 116
5.5.2.1 Behavioral Pathology in Alzheimer's Disease Rating Scale (BEHAVE-
AD) .................................................................................................... 117
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5.5.2.2 Cohen-Mansfield Agitation Inventory (CMAI) ................................. 117
5.5.2.3 Dementia Behaviour Disturbance Scale (DBDS) .............................. 118
5.5.2.4 Nursing Home Behaviour Problem Scale (NHBPS) ......................... 118
5.5.2.5 Neuropsychiatric Inventory (NPI) ..................................................... 118
5.5.2.6 Neurobehavioural Rating Scale (NRS) .............................................. 119
5.5.2.7 Pittsburgh Agitation Scale (PAS) ...................................................... 119
5.5.2.8 Rating Scale for Aggressive Behaviour in the Elderly (RAGE) ........ 119
5.5.2.9 Revised Memory and Behaviour Problems Checklist (RMBPC) ...... 119
5.5.3 Instruments for the Assessment of Cognitive Status .............................. 121
5.5.3.1 Alzheimer’s Disease Assessment Scale-Cognition (ADAS-Cog) ..... 121
5.5.3.2 Memory Status- Mini Mental Status Examination (MMSE) ............. 121
5.5.3.3 Test for Severe Impairment (TSI) ...................................................... 122
5.6 STATISTICAL ANALYSIS .................................................................................. 122
5.6.1 Post Analysis-Case Study ....................................................................... 124
5.7 ETHICAL CONSIDERATIONS ............................................................................. 126
5.7.1 Informed Consent ................................................................................... 126
5.7.2 Ethical Management of Allergy and Data Security ............................... 128
5.8 SUMMARY ....................................................................................................... 128
CHAPTER 6 RESULTS .......................................................................................... 129
CHAPTER OVERVIEW .............................................................................................. 129
6.1 CHARACTERISTICS OF THE SAMPLE ................................................................. 129
6.2 PARTICIPANT DEMOGRAPHIC PROFILE ............................................................ 133
6.3 THE BEHAVIOURAL MEASURES OF DESCRIPTIVE STATISTICS ......................... 135
6.3.1 Mean Scores for Cohen-Mansfield Agitation Inventory ........................ 136
6.3.2 Mean Scores for Revised Memory and Behaviour Problem Checklist .. 139
6.4 DISRUPTIVE BEHAVIOURS AND STAFF REACTION IN REVISED MEMORY AND
BEHAVIOUR PROBLEM CHECKLIST (RMBPC) ................................................ 142
6.5 LINEAR REGRESSION AND GOODNESS OF FIT: INVESTIGATING COGNITION AS A
MODULATING VARIABLE OF INTERVENTIONAL CHANGES .............................. 145
6.5.1 Linear Regression and Goodness of Fit for Cohen-Mansfield Agitation
Inventory (CMAI) .................................................................................... 145
6.5.2 Linear Regression and Goodness of Fit for Revised Memory and
Behaviour Problem Checklist ................................................................... 147
6.6 KRUSKALL-WALLIS H TEST ............................................................................ 149
6.6.1 Cohen-Mansfield Agitation Inventory (CMAI) ...................................... 149
6.6.2 Revised Memory and Behaviour Problem Checklist (RMBPC) ............ 154
6.7 OVERVIEW OF THE HYPOTHESES ..................................................................... 156
6.8 CASE STUDIES ................................................................................................. 157
6.9 SUMMARY ....................................................................................................... 161
CHAPTER 7 DISCUSSION ................................................................................... 163
CHAPTER OVERVIEW .............................................................................................. 163
7.1 KEY FINDINGS ................................................................................................ 165
7.1.1 Level of Cognitive Impairment............................................................... 166
7.1.2 Levels of Mobility Limitation ................................................................. 169
7.1.3 Physical Restraint Use ........................................................................... 170
7.1.4 Impact of Antipsychotics Medication ..................................................... 171
7.1.5 Impact of Pain Relief Medication .......................................................... 172
7.1.6 Pain/Discomfort and Hand Massage ..................................................... 172
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