Aromatherapy and elderly patients
Researchers at Oldham Cottage hospital recently investigated the potential of essential oil of lavender to aid rest and relaxation and thereby encourage the healing process in elderly patients.The patients were monitored for seven days during which time their sleep patterns, dozing and alertness during the day were recorded. The following seven days one drop of Lavender augustfolia was put on each patient’s pillow at night. No other changes were made to the patients’ daily routine or medications that they were receiving.
At the end of the seven days, all of the patients’ records were collated and analyzed. Interestingly, all of the patients reacted favorably to the treatment; the researchers observed increased daytime alertness, improved sleep patterns and those patients who had previously experienced confusion were observed to display as much as a 50 per cent decrease in their symptoms. Hudson R. The value of lavender for rest and activity in the elderly patient. Complementary Therapies in Medicine. 1996: 4; 52-57.

Aromatherapy and High Blood Pressure
Aromatherapy is widely used for the purpose of relaxation and researchers are now investigating the alleged benefits. One small, pilot study was conducted by Jolanta Basnyet, aromatherapist at the Natural Health Centre in Preston, Lancashire, UK.
Twenty patients were divided into two groups; the first group to receive five 45 minute aromatherapy treatments using 15ml of unrefined grapeseed carrier oil containing one drop of each of Ylang-ylang (Cananga odorata) , Clary sage (Salvia sclarea) and Marjoram (Origanum marjorana) over a period of six weeks. The second group received the same massage but without the essential oils.
The massage techniques used were effleurage (stroking), petrissage (kneading), gentle friction, vibration and feathering using 15ml of unrefined grapeseed carrier oil which in the aromatherapy group contained one drop of each of the essential oils.
At the end of the treatment period, the results revealed that 7/10 in the treatment group and 6/10 in the control experienced a reduction in their raised blood pressure. The improvement in pulse rate of patients in the treatment group was consistently higher than improvement observed in the control group.
The report concludes that 'overall blood pressure readings in both groups improved successfully, which would indicate that this type of tactile treatment can have a beneficial effect on the raised arterial blood pressure.
Alternatives in Health Vol 3:4

Essential oil of thyme is antibacterial
Essential oil of thyme is an effective agent against Salmonella typhimurium according to researchers at the Institute of Technology and Storage of Agricultural Products, Volcani Centre, Bet Dagan, Israel.
Viable counts of Salmonella typhimurium on nutrient agar (NA) were found to decrease upon the addition of either the essential oil of thyme or its constituent thymol, especially under anaerobic conditions. Antagonistic effects of thymol against Staphylococcus aureus were also greater under anaerobic conditions. In contrast to the phenolic constituents of the oil, thymol and carvacrol, the chemically related terpenes p-cymene and gamma-terpinene had no antagonistic effects against Salm. typhimurium. However, the antibacterial action was inhibited when bovine serum albumin (BSA) was added to the medium.
Juven BJ; Kanner J; Schved F; Weisslowicz H. Factors that interact with the antibacterial action of thyme essential oil and its active constituents. Appl Bacteriol (ENGLAND) Jun 1994, 76 (6) p626-31

Aromatherapy & Depression
Aromatic oils have been used for literally thousands of years in healing; for instance, lavender oil was used in ancient Egypt for healing skin complaints and Eucalyptus oil has been used for centuries to help clear sinus congestion. However, recent research by Dr G Schwartz, professor of Psychology and psychiatry at Yale University, revealed that certain aromas can even lower blood pressure. Some oils have been shown in research to have analgesic (pain reducing) qualities whereas others have been shown to be antibacterial, antiseptic and anti-inflammatory. Clinical trials have shown essential oils to be beneficial in alleviating labor pains, reducing emotional stress, improving circulation, and even in helping patients with mental disorders. (1)
The essential oils have a complex action on the body which is still not fully understood. This may be due to the fact that one oil can have hundreds of different compounds. Interestingly, your sense of smell is over 10,000 more sensitive than your sense of taste and researchers have shown how aromas cause a brain reaction, activating the hypothalamus gland, the pituitary gland and the body's hormones as well as stimulating the limbic system (centre for emotion and memory) in the brain.
Work carried out by Dr. Gary Schwartz, Professor of Psychology and Psychiatry at Yale University, found that the aromas of some essential oils by themselves affect the nervous system and even reduce blood pressure. The calming and relaxing effect of the essential oils and massage can help relieve accumulated tensions and anxieties.
The following essential oils are also beneficial in the treatment of depression as they have properties helping to balance and relax the nervous system.

Chamomile - relaxant and calmative	Marjarom - emotional balancer
Clary Sage - antispasmodic	Rose - anti depressant
Cypress - anti-spasmodic	Rosewood - calmative
Lavender - relaxant and calmative	Ylang-Ylang - sedative and antidepressant

The therapeutic massage combined with selected essential oils makes aromatherapy an excellent aid in countering the effects of stress and inducing relaxation. Massage improves the blood circulation in several ways without putting additional strain on the heart. It helps the flow of blood through the veins and also stimulates the nerves which control the blood vessels. It has the added benefit of relaxing tense muscles and tight connective tissues which may have been constricting blood vessels and thus enabling blood to flow more freely. It is for this reason that soothing massage helps reduce emotional tension, it induces relaxation and calms stress-related cardio-vascular conditions.
In fact, massage treatment alone has been shown to be an effective treatment to help patients with depression. In one study conducted at the University of Miami, 52 teenagers hospitalized for depression were split into two groups. For 5 days, the first group were each given a 30 minute massage and the second group watched television. The massage group felt less anxious, more co-operative, had lowered pulse rates and lower levels of cortisol ( a chemical produced under stress) in their saliva.(3)
Further work carried out by Dr. Schwartz, found that the aromas of essential oils by themselves reduced blood pressure. The scent of spice apple, for example, was found to reduce blood pressure by an average of 3 to 5 points in healthy volunteers.(2) The preceding essential oils are also beneficial in the treatment of hypertension. The therapeutic massage combined with selected essential oils makes aromatherapy an excellent aid in countering the effects of stress and inducing relaxation.

Guidelines for using Aromatherapy Essential Oils:
Essential oils can be used at home in one of the following ways:

• Massage - mix 5 -10 drops to 10 ml of a vegetable base oil.
• Baths - add 5 -10 drops to a pre-run bath and swish.
• Inhalation - add 2 - 3 drops to a bowl of steaming water, cover head with a towel.
• Tissue - put one drop on a tissue and inhale when required.
• Room - put between 1 - 10 drops in a humidifier filled with water or on a piece of cotton wool and place on a radiator.

IMPORTANT NOTE: Do not take any oils internally or use on babies under 18 months. Always consult a qualified aromatherapist before using any essential oils to treat a health problem, or if you are pregnant or breast-feeding.
(1) Massage Therapy, Adam J Jackson (Optima 1993)
(2) The Complete Book of Massage - Clare Maxwell Hudson Dorling Kindersley 1988 p.18
(3) Massage Therapy, Adam J Jackson (Optima 1993)

Hypericum (St. John's Wort) & Depression
A report in the British medical Journal highlights the use of Hypericum in the treatment of depression. Apparently, German doctors prescribed over 66 million doses of hypericum perforatum in 1994 and a review of 23 randomized clinical trials of hypericum extracts showed them to be superior to a placebo in the treatment of depressive symptoms.
The report acknowledges that hypericum "may offer an advantage in terms of relative safety and tolerability" over traditional pharmacological medicines. Furthermore, commercially available hypericum products are relatively economical as the herb is cheap to grow and easy to harvest.
Vervain, lavender and borage are all traditionally used nervine herbal remedies which can help counter depressed feelings. Ginseng is also commonly used to help overcome depression. It is, of course, important to consult a qualified practitioner to obtain the most effective course of treatment.
Psychiatric medications are notorious for undesirable side effects to the patient's mental and physical well-being and the need for safer antidepressants is now widely acknowledged. However, researchers have recently discovered one natural herbal remedy which is considered to be as effective as most traditional allopathic antidepressants but with the added advantage of being free from side effects. The herb in question is St John's Wort (Hypericum Perforatum).
St John's Wort was tested in a double-blind study of 105 patients suffering from mild-moderate depression. The patients were male and female , 20 to 64 years of age, and diagnosed as having neurotic depression or temporary depressive mood. They were then divided into two groups and monitored over a period of four weeks. One group were given 300mg of St John's Wort extract, three times daily, and the other group were given a placebo. All of the patients were given psychiatric evaluations before the start of the study , and after two and four weeks of treatment.
The results revealed that, after the four weeks, 67% of the Hypericum group had responded positively to the treatment without any adverse side effects whereas only 28% of the placebo group showed any signs of improvement.
The authors of the study state clearly that the study was deliberately confined to patients affected by mild forms of depression because, for those patients, the possible risks of traditional antidepressants often outweighed any expected benefits. Indeed many patients within that category were known to refuse medications because of the possible side effects. Therefore, whilst there was no evidence to suggest that Hypericum would be of any benefit to patients suffering from the more serious forms of depression, in relation to the lesser but more common forms of depression, the researchers recommend: 'Hypericum should be used as a remedy of choice'.
Harrer. G, and Sommer.H., Treatment of Mild/Moderate Depressions With Hypericum, Phytomedicine, Vol. 1, 1994, pp 3 - 8.

St John's Wort (Hypericum) beats depression
The number of visits to alternative medicine practitioners in this country is estimated at 425 million, which is more than the number of visits to allopathic primary care physicians in 1990. Patients' use of St. John's Wort (SJW) has followed this sweeping trend. The purpose of our study was to examine the reasons people choose to self-medicate with SJW instead of seeking care from a conventional health care provider.
The researchers used open-ended interviews with key questions to elicit information. Twenty-two current users of SJW (21 women; 20 white; mean age = 45 years) in a Southern city participated. All interviews were transcribed, and descriptive participant quotes were extracted by a research assistant. Quotes were reviewed for each key question for similarities and contextual themes.
Four dominant decision-making themes were consistently noted. These were: (1) Personal Health Care Values: the patients had a history of alternative medicine use and a belief in the need for personal control of health; (2) Mood: all SJW users reported a depressed mood and occasionally irritability, cognitive difficulties, social isolation, and hormonal mood changes; (3) Perceptions of Seriousness of Disease and Risks of Treatment: SJW users reported the self-diagnosis of "minor" depression, high risks of prescription drugs, and a perception of safety with herbal remedies; and (4) Accessibility Issues: subjects had barriers to and lack of knowledge of traditional health care providers and awareness of the ease of use and popularity of SJW. Also of note was the fact that some SJW users did not inform their primary care providers that they were taking the herb (6 of 22). Users reported moderate effectiveness and few side effects of SJW.
SJW users report depression, ease of access to alternative medicines, and a history of exposure to and belief in the safety of herbal remedies. Users saw little benefit to providing information about SJW to primary care physicians.
Wagner PJ, Jester D, LeClair B, Taylor AT, Woodward L, Lambert J Department of Family Medicine, Medical College of Georgia, Augusta 30912-3500, USA. pwagner@mail.mcg.edu

Hypericum (St. John's Wort) & depression - a review
Depressive disorders are often found to be chronic and recurring illnesses that lead to severe personal suffering for sufferers and their families. Major depression alone is estimated as the fourth most important cause of worldwide loss in disability-adjusted life years and is considered likely to become the second most important within 20 years. A continued quest for more effective treatments has spawned newer antidepressants and herbal treatments, which have contributed to explosive growth in antidepressant prescribing, increasing pharmacy costs, and wider choices for clinicians and patients.
A comprehensive evaluation of the benefits and adverse effects of newer pharmacotherapies and herbal treatments for depressive disorders in adults and children was undertaken.
Literature published between 1980 to January 1998 was identified from a specialized registry of controlled trials, meta-analyses, and experts. The registry contained trials addressing depression that had been identified from multiple electronic bibliographic databases, hand searches of journals, and pharmaceutical companies. The search, which yielded 1,277 records, combined terms "depression," "depressive disorder," or "dysthymic disorder" with a list of 32 specific "newer" antidepressant and herbal treatments.
Randomized controlled trials were reviewed if they (1) were at least 6 weeks in duration; (2) compared a "newer" antidepressant with another antidepressant (newer or older), placebo, or psychosocial intervention; (3) involved participants with depressive disorders; and (4) had a clinical outcome. 315 trials that met these criteria.
Data was independently abstracted from each trial by two persons. The researchers looked at the response rate, total discontinuation rates (dropouts), and discontinuation rates due to adverse events. Response rates were defined as a 50 percent or greater improvement in symptoms as assessed by a depression symptoms rating scale or a rating of much or very much improved as assessed by a global assessment method.
There were 264 trials that evaluated antidepressants in patients (adults and children) with major depression. Of these, there were 14 trials evaluating hypericum (St. John's wort), and a review of these studies revealed that the herb was more effective than placebo in treating mild to moderately severe depressive disorders (risk ratio 1.9, 95% CI 1.2 to 2.8). However, the question as to whether hypericum (St. John's wort) is as effective as standard antidepressant agents given in adequate doses was not established.
Mulrow CD, Williams JW Jr, Trivedi M, Chiquette E, Aguilar C, Cornell JE, Badgett R, Noel PH, Lawrence V, Lee S, Luther M, Ramirez G, Richardson WS, Stamm K. Treatment of depression--newer pharmacotherapies. Psychopharmacol Bull 1998;34(4):409-795

Aromatherapy & Arteriosclerosis
The therapeutic massage alone can reduce blood pressure by up to 40 points and when combined with selected essential oils as in an aromatherapy treatment, it becomes an excellent aid in countering the effects of stress, inducing relaxation and improving the blood circulation without putting additional strain on the heart. It helps the flow of blood through the veins and also stimulates the nerves which control the blood vessels. It has the added benefit of relaxing tense muscles and tight connective tissues which may have been constricting blood vessels, thus enabling blood to flow more freely. It is for this reason that soothing massage helps reduce emotional tension, it induces relaxation and calms stress-related conditions. It will therefore help improve your general health and well-being.
Massage therapist, Clare Maxwell-Hudson works at NHS hospitals Victorian Cardiologist, Sir Lauder Brunton, wrote that: "in cases of cardiac disease, massage allows other treatments to be carried out more easily than it would otherwise be, for it removes the feeling of weariness and irritability, fidgetiness and unrest. The appetite increases and the spirits become brighter." (2)
It should also be noted that aromatherapy massage has been shown to be an excellent treatment for headaches which are commonly associated with high blood pressure, post-stroke and other cardiovascular conditions.
IMPORTANT NOTE: Do not take any oils internally or use on babies under 18 months. Essential oils are very potent and it is therefore always advisable to consult a qualified aromatherapist before using any essential oils, and especially when pregnant or breast-feeding.
(1) Massage Therapy AJ Jackson (Optima)
(2) The Complete Book of Massage - Clare Maxwell-Hudson (Dorling Kindersley)

The benefits of aromatherapy and massage in palliative care :
Complementary therapies, such as massage and aromatherapy, are rising in popularity among patients and healthcare professionals and are increasingly being used in palliative care to improve the quality of life of patients. Research conducted by Marie Curie Cancer Care, London, UK provides new clinical evidence of the benefits that these therapies offer cancer patients.
The researchers assessed the effects of massage and aromatherapy on 103 cancer patients in a palliative care setting. The patients were randomly allocated to receive massage using a carrier oil (massage) or massage using a carrier oil plus the Roman chamomile essential oil (aromatherapy massage).
The results revealed that there was a statistically significant reduction in anxiety after each massage and the patients who received aromatherapy massage also also noted improvements in their disposition, physical comfort and their quality of life.
The report concludes that massage with or without essential oils appears to reduce levels of anxiety, but the benefits are clearly enhanced by the addition of Roman chamomile essential oil as this seems to help improve physical and psychological symptoms, as well as the patients' overall quality of life.
Source: Palliat Med 1999 Sep;13(5):409-17. An evaluation of aromatherapy massage in palliative care. Wilkinson S, Aldridge J, Salmon I, Cain E, Wilson B

Key Benefits Aromatherapy Massage
Aromatherapy and Massage for the Elderly Aromatherapy and Massage can be used to relax, invigorate and improve the health of elderly people. It can also enable people to become more aware and appreciative of their senses of touch and smell.
Aromatherapy and Massage can be used to relax by:
Promoting Sleep
Reducing Anxiety
Helping to release Emotional Tension
Assisting memory and concentration
Promoting a feeling of well being

This relaxation works on many levels, not just the physical, and can create a sense of comfort, acceptance and reassurance that can affect the way that the person chooses to respond to different situations in their life.
Aromatherapy and Massage can help people to learn to trust, share and interact with each other. Massage is a form of non-verbal communication and enables the development of positive interactions, assisting individuals to become more aware of other people as well as themselves.
Aromatherapy and Massage can aid health by:
Assisting the body's ability to combat infection
Promoting growth of healthy new cells
Reducing pain and stiffness in joints
Improving circulation
Improving muscle tone and flexibility
Aiding digestion
Reducing the symptoms related to tension
Relieving depression

Aromatherapy uses the therapeutic properties of natural aromatic oils (essential oils) obtained from plants, to benefit health. It is a holistic therapy which seeks to treat the whole person - not just physical symptoms. The oils can be inhaled, applied directly to the skin by way of massage (in a carrier oil or lotion) or used in the bath.
Each oil has different therapeutic properties, for example, oils may be analgesic (relieve pain), relaxing, stimulating, decongestant, hormone balancing, warming… these are just a few examples. The oils’ properties are many and varied. When essential oils are inhaled or absorbed through the skin they reach the bloodstream and are then carried to every part of the body including the brain, enabling them to affect the physical body and the emotions. An aromatherapy treatment is so effective because it combines the many benefits of massage with the powerful healing properties of essential oils.

History of Aromatherapy
Essential oils have been in use for thousands of years. Their benefits were well known to the ancient Egyptians and the Bible contains many references to them. The oils were in common use until the 19th century when natural remedies began to be replaced by modern drugs. At the beginning of the 20th century the benefits of essential oils were rediscovered by doctors treating the wounded during the first World War. Since then the use of essential oils has spread rapidly and aromatherapy is now used in many hospitals, hospices and nursing homes.

Who is it for?
Aromatherapy is suitable for almost everyone including the elderly and children. It can be used to treat many conditions including stress related conditions, muscular strains, emotional problems, hormonal imbalances (e.g. PMS), headaches, digestive problems, insomnia, general aches and pains, rheumatism, asthma, bronchitis, skin problems and many others. It has been found to be of great comfort to people suffering from terminal illnesses.
Further Reading: Aromatherapy for Common Ailments - by Shirley Price; Aromatherapy an A-Z - by Patricia Davis andAromatherapy for Healing the Spirit by Gabriel Mojay

Applications of Essential Oils
by Sebastian Liew Copyrights © 2003
Most elderly suffers from one chronic ailment or another. Chronic ailments include arthritis, painful joints, skin problem, immunity and not forgetting emotional stresses like depression ( feeling of uselessness, apathy, fear ), anxiety and mood swings. These stresses may further lead to insomnia, restlessness, constipation and perception of pain all over the body. Disabilities or limitation in activities may result from this process.
More and more people realized the benefits gained from using natural health remedies. One of them is particularly popular especially in nursing homes and hospice in some Western countries like the UK - Aromatherapy.
So what is aromatherapy ? It is the skillful use of 100% pure, complete and natural essential oils to restore or maintain physical, emotional and aesthetic well being. Essential oils are non- oily, volatile, fragrant substances extracted from plants through mainly distillation. Essential oils can be from the seeds (fennel), root (ginger), blossoms (orange blossoms), wood (sandalwood) and berries (Juniper berry) etc. Most essential oils are antiseptic while some has anti-fungal (e.g. for ringworm), anti-viral (e.g. for flu), cells regeneration (e.g. for mature skin, wound healing) and analgesic (pain relief for muscle aches and arthritis).
Each type of essential oil has its own distinct scent. For example it can be floral (e.g. rose), woody (cedarwood) or green (e.g. basil). Scents acting on your mind, can be sedative (e.g. for calming, sleep), stimulating (e.g. for mental concentration) or it may be euphoric (promotes sense of well being). Examples of sedative oils are Chamomile, True lavender and orange. They may be helpful for reducing tension and anxiety.

Respiratory disorders:
Because of lower immune function, the elderly is especially at risk of contracting air borne infection. The anti-bacterial, expectorant and anti-viral properties of certain essential oils are well documented. Two essential oils that are very helpful and at the same time safe to use are Eucalyptus Radiata and Ravensara aromatica. Ravensara has the added benefit of increasing energy and optimism with its pleasant and refreshing scent. Dr Kurt Schnaubelt in his book ' Medical Aromatherapy' mentioned the anti-asthmatic properties of these two oils as well.
You can use these two oils in a massage blend for daily application on the chest area and the back. Usually a low dilution is recommended for the elderly. Or alternatively vaporize these oils during the day.
The beautiful thing about this method is that it can also be used for mood enhancement e.g. vaporizing bergamot for its antiseptic effect and reduction in anxiety.

Skin problems:
As we grow older, our skin often shows signs of poor circulation, slower skin cells renewal and poor lymphatic drainage. Along with some medications, these may result in itchy, inflamed,dry skin and even torn skin. Long term application and proper use of the correct base oils together with rejuvenating essential oils may help to preserve 'youth' and healthy skin. A very good base for older people is calendula which has anti-inflammatory properties. For example Aromatic Science Calendula oil is infused with Sweet Almond oil which has the added benefits of moisturizing dry skin and reduce itchiness of the skin. Essential oils which have rejuvenating properties are True Lavender, Frankincense, Rose Otto and German Chamomile. In my personal experiences both for myself and my clients, there is no doubt that essential oils with a good cold pressed vegetable oils and floral waters are all that is needed to promote skin rejuvenation with a fraction of the costs associated with expensive commercial preparations.

Constipation:
Another symptom associated with aging is constipation. Constipation may be due to poor diet, lack of exercise, immobility, side effects of some medications and slower bowel movements. Essential oils that may assist with this condition are black pepper and Chamomile. These can be blended in a carrier oil and massage into the abdominal area. By massaging the oil of chamomile around the abdominal area and smelling the oil at the same time, it may helps to calm the person.

Joint Pain:
Most elderly suffers from body aches in one way or another. The most common ones are rheumatism and arthritis. Aromatherapy is a good complementary therapy for pain management. Aromatherapy recognizes the connection between mind and body. Some of these oils have the added therapeutic properties of reducing stress and therefore pain perception. You should check with your physician exactly what is the cause of the pain and seek whatever treatment necessary ( including lifestyle factors like diet and activity level). However the use of certain analgesic essential oils can help in pain management especially if it involves the smooth muscles. Essential oils commonly used are Juniperberry, Sweet Marjoram, Peppermint, Rosemary CT camphor and Lemongrass. They can be used in the bath, massage, compress or foot bath.

Mood enhancement:
The most frequently occurring mood disorders of the elderly are depression, anxiety and mood swings. Though aromatherapy may not act as a single treatment for these ailments, but I have found it very useful as a complementary treatment in these areas. We are beginning to see many benefits in the home especially among dementia patients. There is an increased in sensory stimulation, improved mood stability, spontaneous appreciation e.t.a. Diffusion of uplifting oils (e.g. lemon ) in the morning can combat lethargy and using sedative oils in the evening helps oneself to calm down and relax - good for sleep.
Working in the nursing home for the elderly has certainly convinced me of the potential benefits of aromatherapy in preventive health care and as a complementary treatment for the elderly. Now I am not suggesting that it is only helpful if you are old. Aromatherapy should be use as part of one's healthy lifestyle program. To use aromatherapy correctly, always consult a qualified aromatherapist and use only quality oils.

Some basic safety rules
· Never use perfume grade oils. Do not buy essential oils which do not have enough information: safety, botanical name, producing organ, country of origin and biochemical specificity. Buy from a specialist shop that has a qualified aromatherapist who can give you proper guidance.

· Never use neat or undiluted essential oils on the skin without proper guidance.

· If you have hypersensitive skin, test yourself by diluting a tiny amount of oil and rubbing onto the back of the hand. See any irritation after a day or so.

· Seek professional advise from a qualified aromatherapist before using oils during pregnancy, small children, weak elderly or persons in clinical condition e.g. cancer

· Keep essential oils from heat, direct sunlight or excessive air exposure and children

· Do not take essential oils internally

· Do not apply undiluted essential oils on mucus membranes (mouth, vagina, rectum and the eyes).
Sebastian Liew is a full member of the International Federation of Aromatherapists (UK). He was the first Asian Aromatherapist who has obtained advanced training in essential oils from Purdue University. He is the co-founder of Aromatic Science, a brand of 100% pure, natural and complete essential oils. Sebastian Liew conducts workshops and courses in aromatherapy and sits on the advisory board of two health publications. For more information and consultation, visit Aromatic Science Center, Chinatown Point, 133, New Bridge Road, #03-10, Singapore 059413, Tel: 65388978 © Copyright, Sebastian Liew, 2003