Effectiveness of aromatherapy on anxiety and sleep quality among adult patients admitted into intensive care units: A systematic review

The intensive care unit (ICU) is a complex environment, where patients are constantly monitored for their critical conditions (Gezginci et al., 2020). Being admitted into ICU is a stressful event for patients, which often causes anxiety (Garrouste-Orgeas et al., 2017) and sleep deprivation (Gezginci et al., 2020). In several studies, anxiety was consistently observed in all critically ill patients (Castillo et al., 2016), with a significantly higher prevalence of anxiety among patients on mechanical ventilator than those not placed on a ventilator (Puntillo et al., 2010). Poor sleep quality has also been reported by many patients in the ICU, with research showing significant alterations in their sleep cycle (Beltrami et al., 2015). In fact, anxiety and sleep disruption are interrelated, and it is commonly reported with other psychological symptoms (Kalmbach et al., 2018). These are attributed to various sources of stressors in the ICU.

Environmental stressors in the ICU are contributors to anxiety and sleep disruption. Excessive noise arising from machines and alarms can be disturbing (Beltrami et al., 2015), with research showing that the noise levels were beyond the recommended noise level set by the World Health Organisation’s external review policy guidelines on community noise (Pulak & Jensen, 2014). Unnecessary exposure to light, particularly at night, can also alter patients’ circadian rhythm and suppress melatonin production, which are important regulators of sleep (Beltrami et al., 2015, Engwall et al., 2015, Reuter-Rice et al., 2020). Moreover, patient care activities performed in the ICU, such as serving medications, performing procedures and assessments, were disruptive to patients’ sleep (Beltrami et al., 2015, Pisani et al., 2015, Pulak and Jensen, 2014). Psychological stressors experienced by patients can also worsen anxiety and insomnia. A study by Yava et al. (2011) found that fear of death was the top stressor for these patients. Additionally, the sense of unfamiliarity from procedures, tests, staff, and environment can evoke a sense of fear and anxiety in some patients (Gezginci et al., 2020).

Pharmacological treatment, such as sedatives and anxiolytics, are often prescribed in the ICUs to sedate patients and relieve anxiety (Wang et al., 2018). However, prolonged reliance on sedatives and anxiolytics leads to withdrawal symptoms (Szokol & Vender, 2001), and is linked to neuropsychiatric outcomes (Beltrami et al., 2015, Kok et al., 2018). Opioids also decreases rapid eye movement (REM) and non-REM sleep, leading to poor sleep quality (Cao & Javaheri, 2018). With increased risks linked to reliance on pharmacological treatments, many have turned to complementary and alternative medicine (CAM). Its approach has been effective in treating stress, anxiety, and other complications experienced by unstable patients in the ICU, who do not respond well to standard treatment solely (Erdoğan & Atik, 2017).

Aromatherapy is a form of CAM that uses concentrated essential oils extracted from herbs, flowers, leaves and other plant parts to treat illnesses or relieve symptoms (Cooke & Ernst, 2000). Commonly used essential oils are lavender, peppermint, eucalyptus, lemon and rose (Manion & Widder, 2017). These essential oils typically have anxiolytic, anti-inflammatory and antioxidant properties (Ramsey et al., 2020). Aromatherapy can be administered via inhalation, massage, oral, and internal (Manion and Widder, 2017, Reis and Jones, 2017).

In recent years, studies have shown that aromatherapy has been effective in improving anxiety and sleep quality among various groups of patients. Several meta-analyses concluded a significant reduction in anxiety (Guo et al., 2020, Turan Kavradim et al., 2021, Tabatabaeichehr and Mortazavi, 2020) and significant improvement in sleep quality (Hwang and Shin, 2015, Kim et al., 2019) among various groups of patients after administering aromatherapy. However, no systematic review on aromatherapy was conducted on specific settings such as the ICUs. Hence, this systematic review aims to synthesise evidence on the effectiveness of aromatherapy on anxiety and sleep quality across adult patients in ICUs.

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