and behavioral abnormalities Moyle et al12 (2014) Foot massage • Reduction in blood pressure and heart rate Schaub et al13 (2018 Hand massage • Decrease in stress markers, including serum cortisol and salivary alphaamylase Brooker et al4 (1997) Aromatherapy (exposure to lavender oil) and/or massage (hand and lower arm) • Normalization of disturbed or agitated behavior • No additional benefit of aromatherapy Smallwood et al14 (2001); Yang et al18,19 (2016); Turten Kaymaz & Ozdemir20 (2017); Fung & Tsang21 (2018) Aromatherapy with massage • Decrease in agitation and depressive symptoms • Decrease in neuropsychiatric symptoms, distress, and caregiver burden • Combination superior to massage therapy only • Reduction in agitated behavior Snow et al1 7 (2004) Per se aromatherapy with no massage • No effect on agitation in dementia patients • Remington23 (2002) Hand massage and/or calming music • Reduction in agitated behavior Moyle et al25 (2013) Massage therapy for nurses taking care of dementia patients • Improvement in mood and decrease in diastolic blood pressure Dimitriou et al22 (2018) Music therapy vs aromatherapy vs massage therapy • Superiority of music therapy over aroma and massage therapy Hodgson & Andersen24 (2008) Treatment with reflexology • Decrease in physiological distress Rowe & Alfred11 (1999); Anderson et al26 (2017); Fu et al27(2013); Moyle et al28 (2013) Massage therapy • Not effective in reducing agitation Yoshiyama et al29 (2015) Aroma therapy with massage • Did not improve mood and agitation a The table summarizes the studies, showing the effectiveness of massage therapy either alone or in conjunction with aromatherapy and calming music in attenuating agitation, stress, and anxiety for patients with dementia as well as for the nurses taking care of them. This article is protected by copyright. To share or copy this article, please visit copyright.com. Use ISSN#1078-6791. To subscribe, visit alternative-therapies.com Zhao—Massage Rherapy and Agitation in Patients With Dementia ALTERNATIVE THERAPIES, NOV/DEC 2020 VOL. 26 NO. 6 31 A recent, hospital-based, randomized controlled trial explored the effects of hand massage on stress and agitation in patients with dementia (N = 40).13 The hand massage, in the course of a period of 3 weeks, led to a significant decrease in stress markers, including a decrease in the levels of serum cortisol and salivary alpha-amylase during the second and third week. Effectiveness of Combined Therapies Massage and Aromatherapy. Aromatherapy is a nonpharmacological intervention in which patients are exposed to essential oils, and the fragrance of these oils has been found to produce calmness and reduce anxiety. However, it is essential to follow certain guidelines related to use of aromatherapy, such as performing skin testing for allergies before commencing therapy and using the oils at a low concentration—a maximum concentration of 3%—to avoid skin irritation. Because massage therapy and aromatherapy both have been found to attenuate anxiety and agitation, scientists considered combining these nonpharmacological interventions to attenuate anxiety and agitation in patients with dementia. A case study of patients with severe dementia found that participants receiving 8 to 12 treatments of aromatherapy—exposure to lavender oil for 30 minutes—or massage—hand and lower arm massage for 30 minutes—or both in the course of a 3-month period experienced a normalization of disturbed or agitated behavior.4 However, the study found that no additional benefits occurred by adding aromatherapy to massage therapy. In contrast, a randomized clinical trial with patients with dementia (N=21) found that the combination of aromatherapy with massage was superior to massage-only therapy in attenuating agitation, in terms of motor behavior, in these patients.14 Studies have reported that a decrease in olfactory thresholds occurs with aging, and it is severely diminished in patients with dementia.15,16 Therefore, scientists have suggested that the significant effects for aromatherapy in patients with dementia may be due to absorption of essential oil through the skin. A controlled trial to evaluate the particular effect of aromatherapy in decreasing agitation in patients with dementia (N = 7) has also been conducted.17 The patients received aromatherapy only—no massage—for 10 weeks with 3 different essential oils: lavender oil, thyme oil, and unscented grapeseed oil. In this aroma technique, essential oil was placed on a fabric pinned to a patient’s shirt, and the person was exposed to the aroma for 3 hours. However, this intervention did not produce any significant effects in decreasing agitation in patients with dementia. The lack of effectiveness of the aroma therapy may be due to the reduced olfactory functioning in patients with dementia, and absorption of oils from massage therapy may be necessary to produce any effect for essential oils in patients with dementia. A cohort study was conducted with an aim of comparing the relative efficacy of aroma massage therapy (n = 29), Malaquin-Pavan’s study of 4 older adults with Alzheimer’s disease revealed the efficacy of touch-massage in improving abnormal behavior in terms of wandering, restlessness, and shouting.10 The participants received 2 sessions