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The Effect of Inhalation Aromatherapy with Lavender on Sleep Quality of the Elderly in Nursing Care Homes: A Randomized Clinical Trial

Authors:
Mod Care J. In Press(In Press):e61602.
Published online 2017 October 31.
doi: 10.5812/modernc.61602.
Research Article
The Effect of Inhalation Aromatherapy with Lavender on Sleep Quality
of the Elderly in Nursing Care Homes: A Randomized Clinical Trial
Ahmad Nasiri,1and Leila Fahimzade1,*
1Nursing and Midwifery Faculty,Birjand University of Medical Sciences, Birjand, Iran
*Corresponding author: Leila Fahimzade, MSC Student of Nursing, Nursing and Midwifery Faculty, Birjand University of Medical Sciences, Birjand, Iran, E-mail:
l.fahimzade@bums.ac.ir
Received 2017 August 28; Revised 2017 September 25; Accepted 2017 October 25.
Abstract
Background: Nurses who take care of elderly people have witnessed sleep disorders as one of the most common problems in these
geriatric patients. As a major non-pharmaceutical method, aromatherapy is considered as a holistic nursing intervention. The pur-
pose of this study was to investigate the effect of lavender aromatherapy on sleep quality of elderly people in nursing care homes.
Methods: This study conducted “randomized controlled field trial” on 50 elderly people in the nursing care home of Zabol County.
The representatives were selected with the help of available sampling method and randomly divided into 2 experimental and con-
trol groups. The participants of the experimental group were exposed to lavender essential oil for 7 nights from 10 pm to 6 am.
However, placebo (water) was used in the control group. The PSQI questionnaire was completed before and after the intervention
by both groups. The data was analyzed using the SPSS software and the statistical tests of chi-square, Fisher exact test, Independent
t-test, and paired t-test. This study was a randomized controlled field trial, with the purpose of determining the effect of aromather-
apy on sleep quality of elderly people in nursing care homes in the eastern region of Iran (Zabol County) in 2016.
Results: There was no significant difference between experimental and control groups as far as the mean score of sleep quality at the
beginning was concerned. However, a notable distinction between the 2 (experimental- 6.48 ±3.33 and control- 9.84 ±3.76) groups
was found in the end. The comparison of sleep mean scores before and after the intervention showed that there was a statistically
significant relationship in terms of delay in falling sleep, sleep disorders, and impaired daily functioning. The comparison of sleep
mean score change between the experimental and control groups observed delays in falling sleep, sleep duration, sleep disorders,
taking sleep medications, and impaired daily functioning (P < 0.05).
Conclusions: Lavender aromatherapy had a positive impact on improving the sleep quality of elderly people and may be used as a
non-invasive, easy, and low-cost method.
Keywords: Lavender, Aromatherapy, Nursing Care Home, Sleep Quality, Elderly
1. Background
Aging is a biological, natural, and inevitable phe-
nomenon. Increasing elderly population due to declines
in births, improving health conditions, and increasing life
expectancy has emphasized the problems of this group (1).
Sleep disorders, such as insomnia, interrupted sleep,
and daytime sleepiness has been estimated to be 35%
among the general population. However, it is more preva-
lent among elderly people (50%) (2). The global percentage
of individuals who are 65 years or more is expected to be
doubled by 2040. This would increase the number of peo-
ple suffering from sleep disorders (3). Insomnia is deter-
mined by symptoms like persistent inability to fall asleep
or maintaining sleep. Epidemiological studies have con-
cluded that prevalence of insomnia increases the need of
daily napping with increasing aging (4).
Sleep quality is the 3rd most common problem in el-
derly people, mainly after headache and digestive disor-
ders. It is considered as one of the most common com-
plaints (5). Sleep problems have significant negative im-
pacts on the physical and mental health of people, espe-
cially in elderly people, and they impair quality of life, and
increase the health care costs and mortality (4). Inabil-
ity to fall asleep can lead to shorter attention span, slow
response time, impaired memory and concentration, and
low performance. These are the symptoms of particular
concern among the elderly people as these symptoms may
be wrongly interpreted as a sign of dementia or mild cog-
nitive impairment. Slow response time is especially threat-
ening due to the fact that it can increase the risk of falls
and accidents (6). The important fact is that aging is asso-
ciated with qualitative and quantitative changes in sleep
patterns and distribution. On the other hand, inadequate
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Nasiri A and Fahimzade L
or poor sleep quality is associated with neurological dis-
orders, end-organ dysfunction, chronic diseases, and in-
creased mortality (7).
Sleeping drugs may improve sleep latency, total sleep
time, sleep quality, and will reduce the number of awaken-
ing periods during sleep (4). Furthermore, the amount of
sleeping pills’ effect is not clear. It likely reflects the differ-
ent population using sleeping pills and reported follow-up
period. In addition, the increased risk of adverse events
was statistically significant. The potential risks for older
people falling and suffering from cognitive impairment
have adverse mental and physical consequences, such
as emotional and psychological deterioration, impaired
mental ability, and cognitive function (4).
Recently, non-pharmacological interventions were
proposed, which are better than available techniques in
the treatment of sleep disorders among elderly people
(8). A drug-free approach is preferred, considering the
potential risks of tolerance and dependence over the large
number of other drugs, which older people with insomnia
often take (4). Previous studies reported that non-drug
treatment for elderly patients with insomnia is more
effective than medication (4).
Aromatherapy is one of the main non-pharmaceutical
methods available (9). Reportedly, nurses sometimes fail
to pay enough attention to non-pharmacological proce-
dures, even though they are sufficiently competent in ap-
plying them in order to promote and maintain health (10).
Considered as a holistic nursing intervention, aromather-
apy can help fulfill the objectives of nurses (9). It stands
2nd among the procedures most routinely applied in clin-
ical practice by nurses (11).
Efforts were actively made in nursing to scientifically
prove the effects of aromatherapy as a relaxation facilitator
and as a holistic intervention (12).
Medical and non-medication interventions lie within
the duties of nurses. Therefore, this treatment may reflect
nursing art, where treatments create a deep relationship
between nurses and patients (11).
Aromatherapy may also be appropriate as it can de-
crease costs and complications (9).
Implementation of the aromatherapy is simple, safe,
available at relatively low cost, and involves minimal com-
plications (8). Aromatherapy is the therapeutic use of
essence oils, which is absorbed by the body in different
ways-such as massage, inhalation, compression, aroma
baths, and showers (9).
Inhalation or absorption of essence causes some
changes in the brain’s limbic system, which is related to
memory and emotion of a person. The system can stimu-
late physiological nervous responses, endocrine, and im-
mune systems, which affect the heart rate, blood pressure,
breathing, brain wave activity, and release various hor-
mones in the body (13).
One of the volatile aromatic plant oil that has many
applications in aromatherapy is lavender oil. Lavender is
a plant with sedative, calming, antiseptic, analgesic, anti-
spasmodic, and healing properties. Hence, it is used to en-
hance the mood and eliminate moderate depression (9).
It also helps to reduce insomnia, increase deep sleep with
slow waves in people, and leaves one more alert during
the day (13). The results of the Goel study showed that aro-
matherapy can improve sleep quality and its essence helps
to fall asleep faster, increasing the 2nd stage of sleep, and
decreased rapid eye movement (14).
The main constituents of lavender are linalool, linalyl
acetate, 1 and 8 cineol B ocimene, trippen OL4, and cam-
phor. The linalool and linalyl acetate of this plant can stim-
ulate the parasympathetic system. In addition, lynalyl ac-
etate has drug effects and linalool acts as a sedative (9).
There is a rising concern over the high prevalence of
poor quality sleep, disorders in the elderly people, and
the negative consequences of sleeplessness on health and
quality of life. Lavender proved to have special effects on
the quality of sleep. Moreover, the use of aromatherapy
was found to be an easy, safe, and cost-effective treatment
of sleeplessness, even for the elderly people. Therefore, the
aim of this study was to survey the effect of aromatherapy
on the sleep quality of elderly people in old-age nursing
care homes situated in the eastern part of Iran.
2. Methods
2.1. Study Plan
This study is a randomized controlled blind-field trial
with the purpose of determining the effect of aromather-
apy on sleep quality of the elderly people in nursing care
homes in the eastern region of Iran (Zabol County) in 2016.
The sample size was determined using the results of the
study done by Cho et al. (2012) (12). Changes in the mean
sleep quality score were obtained in 2 groups with the help
of error type 1 (alpha error of 0.05), test power of 90%, and
formula
(1)n=(u+v)2S2
1+S2
2
(m1m2)2
One group had 17 participants in it and the other had
25.
2.2. Samples
As many as 50 elderly people of 3 NCH, who matched
the criteria, were selected and systematic randomly di-
vided into 2 groups, using the simple sampling method
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Nasiri A and Fahimzade L
(available). The 2 groups were experimental, which
smelled of lavender essence (25 people), and control
group, which breathed distilled water (15). The inclusion
criteria were: willingness to cooperate in the study and
signing the consent form freely, no history of allergy to
any drug, herbal ingredients, smell of flowers, poor sleep
quality based on Pittsburgh sleep quality index (getting
score 5 or more), non-use of herbal medicines in the past
2 weeks, minimum age of 60 years, history of neurological
disease leading to hospitalization or medication nerves,
having normal cognitive status (no Alzheimer’s or demen-
tia disease), and avoiding caffeine or alcoholic drinks at
least 3 hours before the intervention. The exclusion crite-
ria were: patient’s unwillingness to continue to cooperate
in the research, showing allergy symptoms, and illness or
death during the study. None of the participants were ex-
cluded from the study.
2.3. Ethical Considerations
The study was proposed to the research council and re-
ceived the approval of the ethics committee of University
of Medical Sciences (Code: Ir.bums.2015.314). It was then
registered in the Iranian registry of clinical field trial with
the number (IRCT2016022126680N1). The researcher ex-
plained the purpose of the study and the research method
in the beginning to the elderly participants of the study.
They signed the consent forms and were told that during
the study they were not required to pay any fee and can
leave the study any time they wished.
2.4. Intervention
At first, lavender essential oil was purchased from the
Kashan Barij Essence company. NCH was referred to be-
fore selecting the participants. Information regarding the
50 participants were investigated (score 5 or more of the
overall score of the Pittsburgh questionnaire), who were
selected based on inclusion criteria. They were then asked
to complete and sign a written consent form. The Pitts-
burgh questionnaire on demographic information was
completed. In the next step, the samples were randomly di-
vided into 2 categories-experimental and control groups-
with 25 participants in each group.
For every elderly participant, a small pocket of leather
fabric was designed and was attached to their clothes at
20 centimeters from their nose. Two drops of lavender
essence were poured on a small clean cotton ball before
bedtime. It was poured with the help of a dropper and
placed inside the pocket. The elderly individuals smelled it
throughout the night and while sleeping during the time
10 pm to 6 am. After waking up at 6 am, researchers went
to the NCH and removed the cotton ball from their pock-
ets and repeated the same process again at night. The work
was performed for 7 consecutive nights (16).
The placebo was used for the control group for 7 nights
and they smelled it the same way as the other group at
the end of the 7th night, the questionnaire was again com-
pleted by both groups, with the help of a researcher who
was unaware about the type of intervention.
2.5. Data Collection
Demographic information and Pittsburgh sleep qual-
ity index (PSQI) questionnaires were used in this study.
The personal data questionnaire included the demo-
graphic data of patients. The data of this form was on age,
sex, educational level, marital status, the staying period of
the elderly participants in NCH, and their daily activities.
PSQI is a standard tool for determining the quality of
individual’s sleep. The questionnaire was designed in 1989
by Buysse et al., (17). It was a self-report questionnaire,
which investigated the quality of sleep during the past
month and included 7 aspects: sleep quality, sleep latency,
sleep duration, sleep efficiency, sleep disorder, using sleep
medications, and impaired daily function. The sum of the
points of these 7 aspects of the questionnaire formed the
total score of the questionnaire, which ranged between 0
and 21. Moreover, each aspect of the questionnaire was
given scores between 0 and 3. Higher scores indicated a
lower quality of sleep. A score of 5 or more indicated that
the person was experiencing troubled sleep (18).
The validity and reliability of these instruments were
reported by several researchers in Iran (19). The reliability
was calculated by internal consistency. Cronbach’s alpha
coefficient was reported to be 0.77 and the correlation coef-
ficient was 0.30 to 0.75 (19). In this study, sleep quality ques-
tionnaire was completed, once before the intervention and
once at the end of the 7th night.
2.6. Statistical Analysis
After collecting and entering data into SPSS15, the
Smirnov-Kolmograph test was conducted to determine
data normalization. This showed the normal distribution
data. The statistical test was conducted to compare the de-
mographic characteristics in 2 groups. However, the Chi-
square and Fisher Exact tests were conducted to compare
the mean of variables in the 2 groups. The independent
t-test was done to compare the pre- and post-intervention
scores in each group.
3. Results
In this study, 50 subjects were examined in 2 groups:
experimental (n = 25) and control (n = 25).
Mod Care J. In Press(In Press):e61602. 3
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Nasiri A and Fahimzade L
Elderly people in nursing care
homes
Studying in terms of entry and exit
criteria, selecting 50 participants and
obtaining the informed consent
Random assignment to two groups and
completion of PSQI questionnaire
Control group (25 ones)
Experiment group (25
ones)
Placebo (water)
Lavender intervention
Complete the PSQI
questionnaire
Complete the PSQI
questionnaire
Comparing the sleep
quality score in two
groups
Figure 1. Study Flowchart
The mean ages were 70.80 ±9.56 and 67.96 ±6.61 (P
= 0.075) in the experimental and control groups, respec-
tively.
There was no statistically significant difference be-
tween the 2 groups in terms of demographic characteris-
tics (Table 1).
The mean sleep quality score and its components (ex-
cept sleep duration) before intervention were not signif-
icantly different in the experimental and control groups
(P > 0.05). However, after the intervention, the mean
sleep quality score in general and the components of de-
lay in falling sleep, sleep disorders, and daily function dis-
order were significantly lower in the experimental group
than the control group (P < 0.05). In the experimental
group, the post intervention mean sleep quality score in
general and the components of sleep mental quality, de-
lay in falling sleep, sleep duration, and daily function dis-
order were significantly lower than before. Whereas, in
the control group, the post-intervention mean sleep qual-
ity score in general and the components of sleep disorders,
pills, and daily function disorder significantly increased (P
< 0.05) (Table 2).
The results also showed that the mean change in sleep
quality score in total and its components (except effective
sleep), before and after intervention, in the experimental
group was significantly higher than that in the control
group (P < 0.05) (Table 2).
4. Discussion
According to the results of this study, the mean of
sleep quality score in total and the components of delays
in falling asleep, sleep disorders, and daily function dis-
order after intervention was significantly lower in the ex-
4Mod Care J. In Press(In Press):e61602.
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Nasiri A and Fahimzade L
Table1. Demographic Characteristics of the 2 Groups
Demographic Variables Number P Value
Experimental Control
Gender 0.777a
Female 13 (52) 12 (48)
Male 12 (48) 13 (52)
Education 0.816b
Illiterate 17 (68) 14 (56)
High school 6 (24) 9 (36)
Diploma 2 (8) 2 (8)
Marital status 0.545a
Single 5 (20) 5 (20)
Married 3 (12) 7 (28)
Widow 9 (36) 7 (28)
Divorced 8 (32) 6 (24)
Activity 0.186b
Inactive 5 (20) 1 (4)
Little 7 (28) 11 (44)
higher than average 13 (52) 13 (52)
aChi-Square.
bFisher Exact test.
periment group than that in the control group. However,
the mean of changes in sleep quality score in total and its
components (except for effective sleep), before and after
intervention, in the experimental group was significantly
higher than that of the control group.
In a study done by Takeda et al., (2017) on the elderly de-
mentia patients, the results showed that the use of laven-
der essential oil improved the symptoms of sleep disor-
der in elderly people (20). Najafi et al., (2014) studied
hemodialysis patients. The results showed that the mean
score of sleep quality in general and its components (ex-
cept for the adequacy of sleep and taking sleep medica-
tions) after intervention was significantly lower in patients
in the experimental group than in the control group (16).
Moini et al., (2010) studied the effect of aromatherapy with
lavender on the quality of sleep in patients with ischemic
heart disease. The results showed that the mean sleep
quality score in the intervention group after aromather-
apy with lavender significantly improved (12). Although
the study population in the above studies differs from the
statistical population of the present study, the results are
similar and indicate the effect of lavender on the quality of
sleep in patients.
However, the results of the study by Dehkordi et al.
(2015), assessing the effect of lavender on the quality of
sleep in hemodialysis patients, showed that the mean
sleep quality score and its components were not signif-
icantly different in both the experimental and control
groups (21). Shamsikhani et al. (2014) studied the effect
of aromatherapy with lavender on students’ sleep quality.
The results showed that the mean sleep quality score after
intervention was not significantly different in both experi-
mental and control groups (22). The results of the study by
Salimi et al., (2016) on patients with burns, showed that the
aroma of lavender essential oil does not have a significant
effect on the sleep quality of the patients (23). The results
of these studies are not consistent with the results of the
present study.
These can be due to the difference in how research is
done, the type and concentration of essential oil used, and
the time of intervention. For example, in the study done by
Dehkordi et al., the time of intervention was during the day
and during the hemodialysis process in the hospital for 1
month (12 sessions). In the study done by Shamsi Khani et
al., although the intervention was conducted for 7 nights
on the students, the tissue containing the lavender essen-
tial oil was kept for 20 minutes at a distance of 20 centime-
ters from the nose. In the present study, patients were ex-
posed to lavender oil essence from 10 pm to 6am. More-
over, in the study conducted by Salimi et al., the interven-
tion was performed for 3 nights with 7 drops of lavender
essential oil.
The effect of lavender essential oil on the quality of
sleep in elderly people can be attributed to the stimula-
tion of the liqueur system and neurobiological changes.
Different neurotransmitter neurons can be released, de-
pending on the type of aroma. These neurotransmitters
include enkephalin, endorphin, noradrenaline, and sero-
tonin (24). Linalool in the lavender prevents the release of
acetylcholine and changes the function of the ion channel
at the site of the neuromuscular attachment. In addition,
linalool acetate has narcotic function and acts as a sedative
(15).
One of the possible causes of lavender’s impact on
sleep quality can be due to the reduction of the aged pa-
tient’s pain. One of the main health problems in old age is
chronic pain (25), which leads to sleep disturbances (26).
On the other hand, the results of the study conducted by
Bagheri et al. (2012) showed that lavender essential oil has
a significant effect on a wide range of pains. Therefore, the
use of lavender essential oils is effective in reducing the
pain of the elderly people and improving their sleep qual-
ity (27).
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Nasiri A and Fahimzade L
Table2. Comparison of Mean Score of Total Sleep Quality and Its Components in Both Experimental and Control Groups Before and After Interventiona
Sleep Aspects Before Intervention After Intervention P Value MeanDifference
Sleep mental quality
Experimental 1.56 ±0.76 1.08 ±0.57 < 0.001 -0.48 ±0.58
Control 1.32 ±0.48 1.36 ±0.56 0.57 0.04 ±0.35
P value 0.19 0.89 - < 0.001
Delays in falling sleep
Experimental 2.44 ±0.82 1.52 ±0.91 < 0.001 -0.92 ±0.70
Control 2.40 ±0.81 2.44 ±0.71 0.66 0.04 ±0.45
P value 0.86 < 0.001 - < 0.001
Sleep duration
Experimental 1.24 ±1.09 0.64 ±0.86 0.001 -0.60 ±0.76
Control 0.56 ±0.96 0.60 ±0.95 0.33 0.04 ±0.20
P value 0.02 0.88 - < 0.001
Effective sleep
Experimental 0.64 ±0.90 0.48 ±0.91 0.36 -0.16 ±0.85
Control 0.72 ±0.73 0.60 ±0.64 0.08 -0.12 ±0.33
P value 0.73 0.60 - 0.83
Sleep disorders
Experimental 1.56 ±0.65 1.32 ±0.55 0.06 -0.24 ±0.59
Control 1.60 ±0.57 1.80 ±0.64 0.02 0.20 ±0.40
P value 0.81 0.007 - 0.004
Takingsleeping pills
Experimental 0.92 ±1.32 0.76 ±1.23 0.10 -0.16 ±0.47
Control 1.16 ±1.40 1.32 ±1.40 0.04 0.16 ±0.37
P value 0.53 0.14 - 0.011
Daily function disorder
Experimental 1.16 ±1.21 0.68 ±0.90 0.003 -0.48 ±0.71
Control 1.44 ±1.15 1.72 ±1.13 0.005 0.28 ±0.45
P value 0.40 0.001 - < 0.001
Total
Experimental 9.52 ±3.54 6.48 ±3.33 < 0.001 -3.04 ±2.15
Control 9.20 ±3.66 9.84 ±3.76 0.02 0.64 ±1.22
P value 0.75 0.002 - < 0.001
aValues are expressed as mean ±SD.
4.1. Conclusions
Aromatherapy with lavender essence can have a posi-
tive effect on improving sleep quality and other aspects re-
lated to sleep in elderly people. Furthermore, aromather-
apy is useful, low-cost, and convenient. Moreover, there is
a high prevalence of sleep disorders in the elderly patients.
Therefore, it is recommended that aromatherapy should
be used by nurses in charge of elderly individuals as an effi-
cient method to improve their sleep quality. Improving the
sleep quality of the elderly people can lead to better health
conditions and daily life styles.
6Mod Care J. In Press(In Press):e61602.
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Nasiri A and Fahimzade L
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Mod Care J. In Press(In Press):e61602. 7
Uncorrected Proof
... Sadeghpoor and et al. (2017) also fully confirmed Nasiri's and Fahimzade's findings in their experiment [12][13] . Ilali and et al. (2017) did research on sleep disorders in elderly people but replace orange blossom with lavender. ...
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