Ecological momentary assessment combined with aromatherapy on postoperative depression in elderly patients with colostomy

Abstract

BACKGROUND

Colostomy is a common surgical procedure that significantly impacts patients’ psychological well-being, particularly among the elderly. Postoperative depression is a prevalent complication that hinders recovery and reduces quality of life. Ecological momentary assessment (EMA) offers real-time, dynamic monitoring of emotional states, while aromatherapy serves as a non-invasive adjunct therapy for alleviating depressive symptoms. However, the combined effect of EMA and aromatherapy in elderly colostomy patients remains underexplored.

AIM

To investigate the intervention effect of EMA combined with aromatherapy on postoperative depression in elderly patients with colostomy.

METHODS

From March 2023 to December 2024, a total of 100 elderly patients undergoing colostomy surgery were recruited and divided into a control group and an observation group based on treatment methods. Perioperative parameters, Hamilton Depression Rating Scale scores, Pittsburgh Sleep Quality Index, and Stoma Quality of Life Scale were compared. Postoperative complications (stomach retraction, gastrointestinal disorders, and infections) were recorded and compared.

RESULTS

There were no statistically significant differences in the time to bowel sound recovery and time to first flatus between the observation group and the control group (P > 0.05). The length of hospital stay in the observation group was shorter than that in the control group (P < 0.001). After the intervention, the observation group had significantly lower Hamilton Depression Rating Scale and Pittsburgh Sleep Quality Index scores, and a significantly higher Stoma Quality of Life Scale score than the control group (P < 0.05). There was no significant difference in postoperative complications (P > 0.05).

CONCLUSION

EMA combined with aromatherapy can effectively alleviate postoperative depression in elderly patients with colostomy surgery and improve their quality of life, demonstrating promising clinical application value.

Key Words: Ecological momentary assessment; Aromatherapy; Elderly patients with colostomy; Postoperative depression; Postoperative recovery

Core Tip: This study explores the combined intervention of ecological momentary assessment and aromatherapy for postoperative depression in elderly colostomy patients. The study demonstrates that this approach significantly reduces depressive symptoms, improves sleep quality, and enhances quality of life, without increasing complication rates. The integration of real-time psychological monitoring with non-pharmacological therapy offers a novel, personalized nursing strategy for this vulnerable population.

INTRODUCTION

Enterostomy is a common surgical procedure that creates an opening in the outer layer of the large or small intestine on the anterior abdominal wall to allow feces to be discharged from the body. It is suitable for emergency or selective management of several gastrointestinal illnesses, both benign and malignant[1]. The presence of an enterostomy presents significant challenges that negatively impact a patient’s well-being and daily functioning[2]. Research highlights that mental and emotional health are crucial in shaping the experiences of individuals adapting to life with an ostomy[3]. Psychological factors like mood, coping strategies, and perceived self-efficacy play a key role in patients’ adjustment to physical changes, social interactions, and maintaining normalcy. Therefore, fostering psychological resilience is vital for improving long-term quality of life in this population. For elderly patients who undergo enterostomy surgery, the postoperative recovery process not only faces physiological challenges, but also involves serious mental health problems. Following surgical intervention for enterostomy, a notable proportion of patients experience depressive symptoms, which represent a frequently encountered postoperative complication, which brings an additional burden to the patient’s recovery. The impact of depression on elderly enterostomy patients is not only reflected in mental symptoms such as low mood and social isolation, but also further affects the effect of postoperative rehabilitation, and may even lead to reduced treatment compliance and increased incidence of complications[4]. Therefore, how to effectively intervene in postoperative depression and improve the patient’s mental state has become an important research topic in clinical treatment in recent years.

Ecological momentary assessment (EMA) is a tool for real-time and dynamic assessment of individual health status. By collecting real-time data from patients in their natural living environment, it can more accurately capture emotional fluctuations and related psychological states. Unlike traditional retrospective questionnaires, EMA can reduce recall bias and more realistically reflect the emotional changes of patients in their daily lives[5]. Empirical research has shown preliminary validation for the application of this strategy in the area of psychological well-being, especially among older adult populations[6]. On the other hand, aromatherapy, as a non-invasive auxiliary treatment, has achieved remarkable results in relieving stress, improving sleep and reducing anxiety and depression in recent years[7]. By using essential oils for olfactory stimulation, aromatherapy can activate the emotional regulation center in the brain, thereby affecting the neuroendocrine system and promoting mental health. For elderly patients with postoperative colostomy, the potential of aromatherapy as an auxiliary treatment deserves further exploration.

This study aimed to investigate the effects of combining EMA with aromatherapy on postoperative depression in elderly patients undergoing colostomy surgery. By monitoring patients’ moods in real time and providing personalized aromatherapy interventions, the effectiveness of this intervention on postoperative depression was evaluated. The results of this study will not only help inform more scientific psychological intervention strategies for elderly patients undergoing colostomy surgery but also offer theoretical justification and useful direction for further studies in related disciplines.

MATERIALS AND METHODS

General information

A total of 100 elderly patients who underwent colostomy surgery in our hospital between March 2023 and December 2024 were selected as the research subjects. The patients were split up at random into a control group (conventional treatment + EMA) and an observation group (aromatherapy + EMA) using a random number table method, with 50 cases in each group.

Inclusion criteria: (1) First diagnosis of colon or rectal cancer with colostomy; (2) Age at diagnosis over 60 years old; and (3) Patients voluntarily participated in the study and signed the informed consent form.

Exclusion criteria: (1) Patients with a history of mental illness; (2) Patients with rhinitis and allergy to aromatherapy essential oils; and (3) Patients with a history of gastrointestinal surgery.

Methods

Both groups underwent colostomy surgery by the same medical team, and the nursing period lasted from admission to one month after discharge. The control group received routine care combined with ecological transient assessment. Routine care included dissemination of disease information and surgical procedures, explanation of postoperative chemotherapy cycles and precautions, basic physical examinations, dietary and lifestyle adjustments, and psychological counseling. The EMA process involved distributing a questionnaire link to patients via WeChat groups or completing a paper questionnaire at fixed intervals. The questionnaires were distributed eight times daily from 10:00 am to 10:00 pm, with each questionnaire distributed 90 minutes apart for seven consecutive days. During each questionnaire, participants were asked to rate their current negative emotional state.

Participants assigned to the observation group underwent aromatherapy interventions as an adjunct to the standard care regimen administered to the control group. A homemade disposable essential oil bag was used, replaced every 24 hours. Two 2 cm × 2 cm medical cotton pads, made of breathable nonwoven fabric, were placed inside the bag. Bergamot essential oil, known to relieve stress and anxiety, was used. The bergamot essential oil was mixed with a 1% to 5% diluent, adding 1 to 5 drops of essential oil to every 5 mL of carrier oil. Three to five drops of the mixed essential oil (0.3 mL to 0.5 mL) were then applied to the cotton pads, and the bag was sealed. The patient then inhaled the oil using the homemade disposable essential oil bag. Every morning at 9:00 am, before lunch, and before bed, a plug-in household incense burner was placed on the bedside table. Three drops of bergamot essential oil were placed in the container of the burner, along with 20 mL of distilled water. The individual was directed to assume a horizontal position on their back, maintaining a relaxed and steady posture throughout the procedure. Once comfortably positioned, they were guided to engage in slow, rhythmic, and controlled breathing to promote physical relaxation and minimize any potential discomfort. The aromatherapy burner was removed after the liquid evaporated. This process lasted approximately 40 minutes. After the aromatherapy session at noon and in the evening, if the patient is asleep, the nurse will remove the aromatherapy lamp.

Observation indicators

(1) Perioperative indicators: The time of postoperative bowel sound recovery, time of first flatus and length of hospital stay were recorded in both groups; (2) The assessment of depressive symptomatology in patients was conducted using the Hamilton Depression Rating Scale (HAMD)[8]. The assessment instrument comprises a total of 17 distinct items designed to evaluate various dimensions of depressive symptomatology. Among these, ten items are evaluated with response options ranging from 0 to 4, reflecting increasing levels of symptom intensity. The remaining seven items are rated on a 4-point scale, with scores assigned from 0 to 2, capturing milder or less frequent manifestations. When all item scores are aggregated, the maximum possible total reaches 54 points, representing the upper threshold of symptom severity. A higher composite score is interpreted as an indicator of greater psychological distress and more pronounced depressive features, while lower totals suggest milder symptom expression; (3) The Pittsburgh Sleep Quality Index (PSQI)[9] was used to assess sleep quality. The scale has 7 items (sleep time, sleep efficiency, sleep disorders, etc.). Each item is scored from 0 to 3 points. The total score is 21 points. The higher the score, the worse the sleep quality; (4) The Stoma Quality of Life Scale (SQOL) was used to assess the quality of life of patients[10]: The scale contains 7 dimensions. The scale is a self-assessment questionnaire. Each item contains four options: Not at all, a little, moderately, and very much. Each option is assigned a value of 1 to 4 points. The overall score for the scale ranges from a minimum of 30 points to a maximum of 120 points, providing a broad quantitative spectrum for evaluating the construct under investigation. Scores are derived by summing responses across all subscales or items, with each contributing incrementally to the final composite value. In this scoring framework, elevated totals are indicative of more favorable outcomes, reflecting a higher level of well-being and overall life satisfaction; and (5) The incidence of postoperative complications in the two groups of patients was recorded: Including stoma retraction, edema, infection, prolapse, etc.

Statistical analysis

Statistical analysis was performed using Statistical Software 23.0. Measurement data are expressed as mean ± SD, and intergroup comparisons were performed using the t-test. Enumeration data are expressed as n (%), and intergroup comparisons were performed using the χ² test. P < 0.05 was considered statistically significant.

RESULTS

Comparison of general information

Table 1 indicated that there were no statistically significant differences in the two groups of patients’ general information, including gender (χ² = 0.040, P = 0.841), age (t = 0.258, P = 0.797), body mass index (t = 0.125, P = 0.901), and nature of intestinal stoma (χ² = 0.437, P = 0.509).

Table 1 General information, mean ± SD/n (%).

	Control group (n = 50)	Observation group (n = 50)	t/χ2	P value1
Gender			0.040	0.841
Male	26 (52.00)	25 (50.00)
Female	24 (48.00)	25 (50.00)
Age (years)	68.19 ± 3.11	67.95 ± 3.06	0.258	0.797
BMI (kg/m2)	22.14 ± 2.29	22.08 ± 2.41	0.125	0.901
Nature of enterostomy
Permanent	16 (32.00)	13 (26.00)	0.437	0.509
Temporary	34 (68.00)	37 (74.00)

¹This table compares the continuous variables (e.g., age, body mass index) of the two groups of patients by t-test and the categorical variables (e.g., gender, nature of enterostomy) by χ² test, and the results show that there is no statistically significant difference between the groups (P > 0.05).

BMI: Body mass index.

Comparison of perioperative parameters

Table 2 indicated that there was no apparent difference in postoperative bowel sound recovery time and first flatus time between the two groups, while the observation group had a shorter length of hospital stay (P < 0.001).

Table 2 Comparison of perioperative parameters, mean ± SD.

Group	n	Postoperative bowel sound recovery time (hours)	First exhaust time (hours)	Length of hospital stay (days)
Control group	50	17.23 ± 2.01	62.29 ± 3.23	18.83 ± 2.04
Observation group	50	17.18 ± 1.89	61.67 ± 3.07	14.61 ± 2.10
t		0.130	0.993	10.200
P value1		0.897	0.323	< 0.001

¹This table compares the continuous variables (postoperative bowel sound recovery time, first exhaust time, length of hospital stay) of the two groups of patients by t-test. The results show that there is no statistically significant difference in postoperative bowel sound recovery time and first exhaust time between the groups (P > 0.05), while there is a statistically significant difference in length of hospital stay (P < 0.001).

Comparison of depression

Table 3 indicated that the observation group exhibited significantly lower HAMD scores than the control group across all intervention time points (all P < 0.05), with significant main effects of group, time, and group-by-time interaction (all P < 0.001).

Table 3 Comparison of depression status, mean ± SD.

Group	HAMD score
	1-day intervention	3-day intervention	5-day intervention	7-day intervention
Control group (n= 50)	31.18 ± 3.12	28.30 ± 3.28	26.80 ± 3.11	23.80 ± 3.69
Observation group (n= 50)	29.14 ± 3.18a	24.36 ± 4.34a	21.02 ± 3.09a	17.96 ± 3.88a
Between groups	F =178.561; P < 0.001
Time	F =122.104; P < 0.001
Between groups·time1	F =6.456; P < 0.001

¹This table compares the continuous variable (Hamilton Depression Rating Scale score) of the two groups of patients at different intervention time points by repeated-measures ANOVA. The results show that there are statistically significant differences in Hamilton Depression Rating Scale scores between the groups, across different time points, and in the interaction between group and time (all P < 0.001).

^aP < 0.05.

HAMD: Hamilton Depression Rating Scale.

Comparison of sleep conditions

Table 4 displayed significantly lower PSQI scores in the observation group compared to the control group at all assessments (all P < 0.05), with significant changes over time and a notable group-time interaction (all P < 0.001).

Table 4 Comparison of sleep status, mean ± SD.

Group	PSQI index
	1-day intervention	3-day intervention	5-day intervention	7-day intervention
Control group (n = 50)	19.10 ± 2.29	17.26 ± 2.46	14.80 ± 2.04	11.22 ± 1.96
Observation group (n = 50)	18.12 ± 2.02a	14.42 ± 2.35a	11.06 ± 1.90a	8.22 ± 1.71a
Between groups	F = 142.535; P < 0.001
Time	F = 342.169; P < 0.001
Between groups·time1	F = 8.421; P < 0.001

¹This table compares the continuous variable (Pittsburgh Sleep Quality Index index) of the two groups at different intervention time points by repeated-measures ANOVA. The results show statistically significant differences in Pittsburgh Sleep Quality Index between groups, across time points, and in the group-time interaction (all P < 0.001).

^aP < 0.05.

PSQI: Pittsburgh Sleep Quality Index.

Comparison of quality of life between the two groups

Repeated measures ANOVA in Table 5 revealed that the observation group achieved significantly higher SQOL scores than the control group throughout the intervention (all P < 0.05), with significant main effects of group, time, and group-by-time interaction (all P < 0.001).

Table 5 Comparison of quality of life, mean ± SD.

Group	Stoma Quality of Life Scale score
	1-day intervention	3-day intervention	5-day intervention	7-day intervention
Control group (n = 50)	58.73 ± 3.66	61.29 ± 3.63	66.81 ± 3.24	70.33 ± 3.57
Observation group (n = 50)	60.25 ± 3.47a	64.36 ± 4.06a	67.06 ± 3.41a	75.19 ± 3.62a
Between groups	F = 61.027; P < 0.001
Time	F = 231.892; P < 0.001
Between groups·time1	F = 7.474; P < 0.001

¹This table compares the continuous variable (Stoma Quality of Life Scale score) of the two groups at different intervention time points by repeated-measures ANOVA. Statistically significant differences are observed in Stoma Quality of Life Scale score between groups, across time points, and in the group-time interaction (all P < 0.001).

^aP < 0.05.

Comparison of postoperative complication rates

Table 6 indicated that there was no significant difference in the incidence of postoperative complications between the two groups (P > 0.05).

Table 6 Comparison of postoperative complication rates, n (%).

Group	n	Stoma retraction	Edema	Infect	Prolapse	Overall incidence
Control group	50	2 (4.00)	1 (2.00)	1 (2.00)	0 (0.00)	4 (8.00)
Observation group	50	1 (2.00)	1 (2.00)	0 (0.00)	1 (2.00)	3 (6.00)
χ2						0.154
P value1						0.695

¹This table compares the categorical variable (postoperative complication incidence) of the two groups by χ² test. The results show no statistically significant difference in the overall complication incidence between the two groups (P > 0.05).

DISCUSSION

As a common surgical procedure, enterostomy is mainly used to treat severe intestinal diseases or trauma, and can effectively prolong the patient’s life[11]. However, psychological and physiological problems after enterostomy surgery, especially depressive symptoms, have become an important factor affecting the postoperative recovery of elderly patients[12]. Depressive symptoms post-enterostomy in older adults have crucial clinical and psychosocial impacts. These manifestations can severely affect patients’ well-being and daily functioning, leading to increased risks of negative medical outcomes during recovery. Emotional distress may hinder immune responses, delay wound healing, and lower adherence to postoperative care. Thus, addressing mood disturbances promptly is essential for improving both mental health and physical rehabilitation in this vulnerable group. Studies have shown that elderly patients with temporary enterostomy face many challenges, including burden, lack of self- care ability, information deficiency and emotional needs[13]. Studies have shown that the mental health of patients with enterostomy is positively correlated with the duration of stoma and age[14]. Consequently, identifying and implementing efficacious therapeutic strategies to alleviate depressive conditions following surgery is crucial for enhancing both psychological well-being and overall convalescence in patients. Elderly patients with enterostomy are more likely to suffer from postoperative depression, which is closely related to multiple factors, including physical illness, decreased quality of life, loss of physical function and other reasons. The manifestations of postoperative depression are not limited to low mood, but may also lead to a series of adverse symptoms such as insomnia, loss of appetite, anxiety, etc., which affect the patient’s recovery process. In response to this challenge, EMA serves as a valuable instrument for psychological evaluation, enabling real-time monitoring of patients’ emotional and mental conditions. By capturing dynamic psychological data in natural settings, EMA facilitates early detection of mood fluctuations and stressors, thereby offering reliable, context-rich information to inform the development of individualized therapeutic strategies. Studies have shown that EMA can be used as a measurement tool for depression trials. By conducting EMAs in patients in the early postoperative period, changes in their psychological state can be detected in a timely manner, thereby providing a basis for subsequent intervention measures[15]. In addition, EMA is also one of the methods to capture real-time data on personal daily experiences and behaviors[16]. Aromatherapy is a complementary therapy that uses plant-derived essential oils to enhance emotional well-being and bodily functions through olfactory stimulation and skin absorption. It can effectively reduce stress, promote relaxation, and improve sleep. Its advantages include affordability, accessibility, minimal logistical requirements, and quick results, making it an attractive option for holistic patient care, especially in non-invasive and patient-friendly settings[17,18]. Recent studies highlight the promising use of aromatherapy as a complementary strategy for managing various medical conditions. Research indicates that essential oil exposure can significantly reduce depression symptoms and improve sleep efficiency in clinical populations, suggesting its potential as a supportive therapeutic tool with broad applicability in healthcare settings[19]. In this study, the control group received both conventional treatment and ecological momentary evaluation, whereas the observation group received both aromatherapy and EMA. The result reflects the facilitation of postoperative recovery by combining EMA with aromatherapy. A shortened hospital stay not only indicates faster physical recovery but also suggests an improvement in psychological well-being. In elderly patients, postoperative psychological well-being has a significant impact on recovery, with anxiety and depression symptoms delaying the patient’s recovery process. Improving patients’ mood can improve treatment compliance, reduce postoperative complications, and ultimately shorten hospital stays and lower medical costs. Furthermore, by comparing the HAMD scores, we found that depression in the observation group was significantly better than in the control group after intervention. This result further confirms the role of aromatherapy in alleviating postoperative depression, and that EMA can provide precise guidance for symptomatic intervention, thereby improving treatment efficacy.

Sleep disorders are a common problem for patients with colostomies after surgery. Many patients experience poor sleep quality and daytime sleepiness[20,21]. Good sleep quality is crucial for promoting postoperative recovery. Poor sleep quality may lead to impaired immune function and an increased risk of postoperative complications. Therefore, improving patients’ sleep quality has become an important goal of postoperative care. In this study, we assessed patients’ sleep quality using the PSQI. The results showed that individuals in the observation group had significantly lower PSQI scores than those in the control group. This result implies that older persons with colostomies have a noticeable improvement in the quality of their sleep when aromatherapy is incorporated into their care routine. Aromatherapy, through its relaxing effect, reduces patients’ anxiety and tension, promotes physical and mental relaxation, and thus improves sleep quality. In addition, EMA, by dynamically monitoring patients’ sleep status, can timely adjust treatment plans and provide patients with more precise nursing support.

Quality of life is an important indicator for evaluating a patient’s recovery status. For elderly patients with colostomies, postoperative quality of life is not only limited by physical function but also by psychological state. Negative emotions can directly reduce patients’ quality of life, preventing them from effectively adapting to a post-stomotic lifestyle. Therefore, improving the quality of life of elderly patients with colostomies is crucial for enhancing their post-stomotic recovery outcomes. In this study, we used the SQOL assessment to assess patients’ quality of life. The findings demonstrated that the observation group’s SQOL score was much higher than the control group’s, suggesting that aromatherapy and EMA can greatly enhance the quality of life for elderly colostomy patients. Aromatherapy can help patients better adapt to the post-stomotic living environment and colostomy care requirements by relieving emotions and improving sleep quality, thereby improving their overall quality of life. Furthermore, significant differences in the HAMD score, PSQI index, and between-group and time interactions were observed for the SQOL score, suggesting that the intervention combining EMA with aromatherapy has a greater advantage in long-term outcomes.

Postoperative complications are a significant factor influencing patient recovery, particularly for elderly patients with colostomies, as their occurrence can significantly delay their recovery. This study found no significant differences in stoma retraction, edema, infection, and prolapse between the observation and control groups. This result suggests that the combination of EMA and aromatherapy has no significant effect on the incidence of postoperative complications. The possible reason why the combined intervention has no significant effect on complications is that postoperative complications of colostomy are mainly related to surgical techniques, intraoperative conditions, postoperative wound care and patients’ basic physical conditions. The combined intervention of EMA and aromatherapy mainly acts on the psychological level of patients, improving their emotional state and sleep quality, but does not directly affect the physiological factors related to complications. Therefore, while the intervention significantly improved psychological outcomes and quality of life, its scope did not extend to directly altering the biological or mechanical risk factors for these specific surgical complications.

This study demonstrates that combining EMA with aromatherapy has significant efficacy in the intervention of postoperative depression in elderly patients with colostomies. This approach not only improves patients’ psychological well-being but also effectively enhances their quality of life, demonstrating promising clinical application prospects. In the future, with the advancement of medical nursing technology, the combination of EMA and aromatherapy may become a novel, comprehensive postoperative intervention, providing more scientific and personalized nursing support for the rehabilitation of elderly patients with colostomies. This study introduces an innovative approach by combining EMA with aromatherapy for the first time to manage postoperative depression in elderly colostomy patients. Unlike previous studies that applied EMA solely for monitoring or used aromatherapy as a standalone intervention, our integrated protocol enables real-time, dynamic monitoring of patients’ emotional states through EMA, coupled with timely, personalized aromatherapy adjustments. This synergy allows for responsive intervention intensification, potentially enhancing efficacy. Furthermore, the intervention’s impact was comprehensively evaluated across multiple dimensions, including depression, sleep quality, and quality of life, thereby providing robust and multi-faceted evidence to support its clinical application. Although this study has achieved some results, it still has some limitations. First, the results may not be as broadly applicable as they may be because this study was a single-center study with a small sample size and was restricted to a subset of patients at our hospital. Second, a thorough evaluation of the intervention’s long-term impacts was not possible due to the study’s brief duration. Thus, more extensive, multicenter, long-term clinical research is required to confirm the effectiveness of aromatherapy and ecological momentary evaluation in treating postoperative depression in older colostomy patients. In order to create a more methodical and thorough intervention plan, more research is also required to examine how other adjunctive treatments might be integrated with this one.

CONCLUSION

In conclusion, EMA combined with aromatherapy has a significant effect on the intervention of postoperative depression in elderly patients with colostomy, effectively alleviating patients’ depression and improving their sleep quality and quality of life. This method provides a new approach for comprehensive intervention in elderly patients with colostomy after surgery and has good clinical application value.