CHAPTER 11—COMPLEMENTARY AND ALTERNATIVE MEDICINE
HEALTH CARE FOR THE AGING POPULATION
CURRENT ISSUES: SAFETY AND EFFICACY
CAM USE FOR MANAGING ILLNESS IN OLDER PERSONS
Complementary and alternative medicine (CAM), as currently defined by the National Center for Complementary and Alternative Medicine (NCCAM) of the National Institutes of Health, refers to “a group of diverse medical and health care systems, practices, and products that are not presently considered to be part of conventional medicine.” Although some scientific evidence exists regarding certain CAM therapies, for most there are key questions that are yet to be answered through well-designed research studies—questions such as whether they are safe and whether they work for the diseases or medical conditions for which they are used.
NCCAM conceptualizes the diversity of CAM modalities as follows:
The list of what is considered to be CAM is continually evolving, as therapies that are proved to be safe and effective become adopted into conventional health care and as new approaches to health care emerge.
The use of CAM is widespread. The National Health Interview Survey (NHIS) selected a nationally representative sample of over 31,000 U.S. adults. Sixty-two percent of those interviewed noted some use of 27 different CAM modalities during the previous 12 months when CAM was defined to include prayer for health reasons. Most CAM use is complementary, that is, in addition to mainstream interventions; only a minority of CAM use serves as an alternative to conventional treatment. Approximately 60% of CAM users in the United States do not discuss their use of CAM modalities with their health care providers. This is of particular concern in the care of older adults because of the increased risk for adverse interactions between conventional drugs and various CAM biologic agents. Moreover, aging impacts the metabolism of numerous prescription and over-the-counter medications, and possibly that of many herbal preparations, botanicals, and dietary supplements. Age-related alterations in hepatic and renal function contribute importantly to these phenomena, both in the absence and presence of disease.
The aging of the baby-boomer generation is contributing to the already established largest group of health care consumers—older adults. Among the most common health challenges in aged men are diseases of the circulatory, musculoskeletal, and connective tissue and of the genitourinary systems. In aging women, the most common health challenges are musculoskeletal, circulatory, and mental health disorders. Demographic considerations assure that the need of the expanding aging population for medical services will continue to increase, and it is logical to predict that specific interest in, and use of, CAM modalities will expand as well.
The use of CAM by older persons is beginning to be more closely studied, in part to help design safer and more efficacious treatments specific to the needs of those older than 65 years. In one small study, 30% of adults surveyed aged 65 and older (N = 311) reported using alternative medicine, and 19% visited an alternative medicine provider. The CAM modalities used most commonly by the older adults in this study were herbal preparations and chiropractic, both of which can cause problems in this population. Of note, CAM use can vary, depending on a particular geographic region as well as ethnic group.
In a study reported in 2003, which was conducted in three ethnically diverse groups of community-dwelling elderly persons (N = 525) in southern California, 251 respondents (47.8%) reported CAM use. The differences in predominant patterns of CAM use among the three groups—Asian, Hispanic, and white non-Hispanic—suggested that differing sociocultural beliefs influence the frequency and pattern of CAM use. Another such example can be found in the large variety of home remedies used by older black Americans, which can be related to regional customs in the United States. CAM use by black Americans is viewed as a combination of European, Native American, and African customs. In addition, Native American and black American groups also view spirituality as integral to the prevention of illness and maintenance of health. Knowledge of patients’ spiritual beliefs can assist physicians to provide sensitive, culturally specific care. Recognition of the individual patient’s cultural heritage may augment communication and trust between physicians and patients about CAM, resulting in improved, comprehensive health care. (See also Cultural Aspects of Care.)
Currently in the United States, a wide variety of CAM modalities are available from practitioners, or as self-care practices. These span the spectrum from indigenous health practices that are centuries old to CAM modalities that are licensed and provided by a trained practitioner. However, most CAM practices have not been regulated, and licensure and certification can vary among practices and by geographic location. There are numerous anecdotal reports or claims of the efficacy and safety of diverse CAM modalities, yet there is a general lack of product and practice standardization and a dearth of credible scientific information supporting these practices. There is substantial potential for adverse reactions with the use of herbal preparations and of botanical and dietary supplements in older adults (Table 11.1). Nonetheless, most consumers are satisfied, and few malpractice or wrongful injury lawsuits are filed.
The incidence of osteoporosis and nontraumatic fractures of the wrist, spine, and hip increase with age in women and men. Phytoestrogen and soy products are increasingly used to prevent or treat osteoporosis in postmenopausal women, although there is little evidence confirming their benefits. Dehydroepiandrosterone (DHEA), a widely used dietary supplement, is the most abundant adrenal steroid in humans. Circulating DHEA levels decline progressively with age. Small-scale trials of DHEA supplementation in older persons have produced conflicting results regarding its effects on bone density, and further studies are needed to determine its utility in preventing or treating osteoporosis in older people.
Osteoarthritis is one of the most common chronic diseases affecting older men and women. In one recent study, almost half (47%) of the patients with osteoarthritis aged 55 to 75 years reported using some CAM modality. Because the personal experience of pain can increase the levels of associated suffering, addressing any negative beliefs and emotions that the patient may be struggling with is as important as addressing the physical symptoms. CAM techniques specifically focused to provide stress relief, such as relaxation breathing and music therapy, may be of benefit as adjunctive therapy. Gentle movement and stretching techniques, such as those in yoga, Tai Chi, and warm-water aquatics, can provide an alternative to more vigorous exercise regimens. Other CAM modalities that are chosen by osteoarthritis patients include acupuncture, massage, chiropractic manipulation, glucosamine supplements, Reiki, and prayer. Large multicenter trials are under way to assess the separate and combined effects of glucosamine, chondroitin sulphate, and acupuncture in the treatment of pain associated with osteoarthritis of the knee. Herbal preparations, including capsaicin cream and Phytodolor, may have limited but unproven efficacy in reducing pain and improving motility; they are thought to exert effects mechanistically in much the same way as conventional nonsteroidal anti-inflammatory treatments. (See also Musculoskeletal Diseases and Disorders, and Persistent Pain.)
Lower back pain is one of the most difficult health challenges for which CAM modalities are used, particularly, therapeutic massage, acupuncture, mind-body relaxation, and energy modalities. One study reported that the combined use of massage, self-care relaxation, and acupuncture may be more effective than the use of any of these modalities separately. (See also Back and Neck Pain.) A meta-analysis of randomized trials of acupuncture for lower back pain found it to be superior to various control modalities, but a significant placebo effect was found.
Cardiovascular disease affects at least 60% to 70% of the population older than 65 years. Of particular relevance is the higher incidence of cardiovascular disease occurring in obese patients or those with type 2 diabetes mellitus. Increased individual and public health efforts to prevent disease and identify those older adults at risk of developing disease should contribute to decreases in morbidity and mortality.
Healthy diet and aerobic exercise are the first recommendations to manage high blood pressure and dyslipidemia. A heart-healthy diet includes limiting sodium intake, refined sugar, and saturated fat while increasing amounts of complex carbohydrates, fruits, and vegetables. In the Dietary Approach to Stop Hypertension (DASH) trial, nearly 70% of participants following the healthy diet decreased both systolic and diastolic blood-pressure measurements. In addition, recent studies suggest that diets including essential fatty acids may lower blood pressure, increase levels of high-density lipoproteins, and lower levels of triglycerides and low-density lipoproteins. Examples of essential fatty acids are omega-3 and omega-6 acids. The omega-3 fatty acids can be found in fresh deep-water fish and in flaxseed oil. Omega-6-linoleic acid is found in raw nuts and seeds. For further reduction of the risk of developing hypertension and obesity, aerobic exercise, such as swimming or brisk walking, is advised for at least 30 minutes three times a week. Recent reports suggest that even mild to moderate increases in physical activity, such as walking slowly or gardening, have beneficial cardiovascular effects. Increased blood pressure can also be associated with inadequate sleep. The use of stress-management techniques, such as relaxation breathing, music therapy, and meditation, may reduce blood pressure in hypertensive patients and improve sleep quality in aging patients. (See also Hypertension; Physical Activity; and Sleep Problems.)
Depression is one the most common and debilitating major public health problems, and its incidence increases with advancing age. Although depression is more common in women, increasing attention is focused on the issue of depression in men, in whom it is more often unrecognized or untreated. There is an alarming prevalence of depression and suicide in widowed men aged 70 years and over. CAM use by the aging patient may assist in the management of mild to moderate depression. However, adequate treatment of severe depression may involve psychotherapy and psychotropic medication to prevent further morbidity and mortality. Recent research suggests that depression is also a systemic disease and is associated with an increased incidence of sleep disorders, osteoporosis, obesity, insulin resistance, and immune dysfunction. The impact of CAM modalities on these outcomes is unclear.
A healthy diet can be one of the first recommendations to assist with improving mood. Dietary intake that includes complex carbohydrates can improve serotonin levels. Increasing essential fatty acids and protein intake may increase alertness and mood. Of equal importance is discontinuing excess alcohol, caffeine, and tobacco, which can contribute to depression and irritability.
Aerobic exercise is also prescribed as a treatment for mild to moderate depression in aged patients. Exercise in combination with antidepressants can yield faster, more lasting results than either alone.
The botanical known as St. John’s wort has received considerable attention and remains widely used. A large multicenter study failed to show the efficacy of this agent in patients with major depression of mild to moderate degree. Whether St. John’s wort will prove to be efficacious in patients with mild symptoms of depression, social phobia, and seasonal affective disorder remains to be determined. The adverse effects of St. John’s wort include gastrointestinal upset, fatigue, dizziness, headache, dry mouth, and photosensitivity. St. John’s wort interacts with the hepatic P-450 enzyme system that induces the metabolism of many drugs, thus causing clinically significant adverse interactions and potential therapeutic failure with various antiretroviral, anticoagulant, immunosuppressant, antidepressant, and chemotherapeutic drugs.
S-adenosylmethionine (SAM-e) is a naturally occurring compound that is necessary for the brain to adequately produce dopamine and serotonin. This compound is currently marketed as an antidepressant. In one promising study involving 195 patients, taking 400 mg of SAM-e daily was found to lessen depressive symptoms.
See also Depression and Other Mood Disorders.
Some studies have investigated the use of supplements for treatment of dementia from Alzheimer’s disease and vascular insufficiency. Ginkgo biloba extract (EGb 761) has shown some benefit in improving cognitive ability and memory impairment in Alzheimer’s patients, in some, but not all studies. Brain tissue studies and spinal fluid abnormalities in Alzheimer’s patients also offer reasonable rationale for supplementing with various antioxidants, including vitamins A, C, and E and selenium, though evidence of their effect has yet to be demonstrated in clinical trials. (See also Dementia.)
Studies have shown that Parkinson’s disease patients have reduced brain levels of glutathione, an antioxidant involved in neuroprotective functions. Parkinson’s patients also have deficiencies in coenzyme Q10. Supplementation with these two naturally occurring substances has been shown to slow the progression of disease and reduce the severity of symptoms in very small unblinded clinical trials. Patients with Parkinson’s disease may also benefit from a combination of dietary food additions containing higher amounts of coenzyme Q10, as found in salmon, sardines, and mackerel. Acupuncture, music therapy, and physical therapy are used by Parkinson’s patients to attempt to reduce disabilities and improve cognitive, emotional, and social functioning. (See also Neurologic Diseases and Disorders.)
Sleep disorders are common in older persons, affecting both sleep quality and quantity. Studies suggest that abnormalities in slow-wave and rapid-eye-movement sleep may also be linked to psychologic, endocrine-metabolic, and immune system dysfunctions. Nutritional and exercise modifications are among the safest recommendations when working with the elderly patients. Milk contains tryptophan, which is a precursor of serotonin. Having warm milk before bedtime or eating other tryptophan-containing foods such as bananas, brown rice, and turkey may be helpful in relieving depression-associated sleep difficulties. Chamomile is an herbal tea that is also known for its relaxing properties. Evidence suggests that use of valerian root or melatonin may also promote improved sleep quality. Aerobic exercise in the early evening has been shown to contribute to improved sleep quality. However, exercise later in the evening can be too stimulating and counteract restful sleep. Other CAM modalities for improving sleep used by older patients include aromatherapy combined with a warm bath and relaxing music. (See also Sleep Problems.)
Menopause is now seen more as a natural progression of aging than as a pathologic process. This perspective lends itself to the use of behavioral, nutritional, and exercise interventions as well as nonpharmacologic supplements to manage some of the symptoms associated with menopause. More than 30% of menopausal women report using one or more CAM modalities, such as acupuncture, natural and plant estrogens, and other herbal preparations, despite a lack of scientific evidence of efficacy. This number is likely to increase because of the expanding population of aged women and increasing concerns about the long-term safety of conventional estrogens. (See also the section on estrogen replacement therapy in Endocrine and Metabolic Disorders.) Of particular importance is the necessity to use caution when recommending phytoestrogen to women with hormone-dependent cancers. Phytoestrogen has yet to be proven conclusively to be an agonist or antagonist of the estrogen receptor. Black cohosh is an herb that has shown some benefit for managing hot flushes, mood disturbances, and sleep disorders. Both aerobic exercise and mind-body relaxation techniques are also helpful in decreasing irritability, restlessness, and anxiety.
Symptomatic benign prostatic hyperplasia affects more than 40% of men aged 70 and older. During the past several years, men have increasingly begun to self-treat this condition with the herbal compound known as saw palmetto, which has become the fifth leading medicinal herb consumed in the United States. Saw palmetto and other supplements (eg, pygeum) have been studied and need further, more rigorous scientific investigation to confirm initial efficacy claims. In one study, older men averaging 65 years of age with moderate benign prostatic hyperplasia were evaluated for 3 months. The efficacy of saw palmetto was found to exceed that of placebo treatment and to be similar to that of standard pharmacologic treatment. (See also Prostate Disease.)
Type 2 diabetes mellitus, a major public health problem, is associated with increased incidence of obesity, hypertension, dyslipidemia, and macro- and microvascular disease. Normal aging is associated with increased insulin resistance and glucose intolerances, and increased risk of developing type 2 diabetes. In one survey, approximately 50% to 60% of diabetic patients reported the use of CAM interventions, including folk remedies in ethnic populations. There is considerable interest in examining the potential benefit of using various CAM biologic agents (eg, chromium, vitamin C, other dietary antioxidants) or other modalities (eg, stress-reduction techniques) in combination with dietary modifications, exercise, and weight management. Acupuncture has shown some benefit in managing the pain associated with diabetic neuropathy. (See also Diabetes Mellitus.)
Approximately 30% to 50% of cancer patients in one survey noted that they were using CAM interventions to manage their specific cancer. Cancer CAM therapies purportedly can be used to strengthen the body’s innate immune systems as well as to manage the adverse effects of conventional treatments, such as chemotherapy and radiation. One of the most important benefits for many cancer patients who use CAM modalities is the experience of being more empowered while dealing with the challenges of cancer. This has been substantiated by numerous studies examining various indices of health-related quality of life. The CAM therapies most frequently used are herbal preparations, exercise, and spiritual and energy modalities (such as qi gong, therapeutic touch, Reiki, polarity, healing touch, or Johrei).
Controversy remains regarding the role of diet as a possible risk factor for developing breast cancer. Of particular importance is the link between obesity and increased estrogen levels that may contribute to de novo breast cancer and recurrence after early-stage disease. High-fiber, low-fat diets with fruits, vegetables, whole grains, fish, and legumes are associated with a decreased risk of disease. Biologic agents, herbal preparations, and vitamins have all been tried by patients; however, most of these modalities have not had much scientific study. In addition, life-style changes to include exercise and stress management have been helpful with managing mood and energy changes associated with breast cancer.
Prostate cancer usually develops slowly in older men, and CAM use in combination with conventional treatment has been reported to reduce associated discomforts and improve the quality of life. Risk of death in this population is higher from heart disease than from prostate cancer per se. Until recently, the botanical mixture known as PC-SPES had been used as a CAM dietary supplement that in early small-scale trials was found to lead to decreases in serum prostate-specific antigen levels and pain, plus improved quality of life. However, in June 2002 several lots of PC-SPES were found to be adulterated with diethylstilbestrol, warfarin, and other undeclared prescription ingredients. As a result, PC-SPES was removed from the market. At present, exercise and healthy diet remain the safest CAM recommendations to assist with the management of side effects and improvement of quality of life in these patients. (See also Prostate Disease.)
Lung cancer has been linked not only to smoking but also to excesses in dietary intake of dairy products, red meats, and saturated fats, though these associations have been questioned. In addition, preliminary research has suggested that ingestion of vitamin A by those who smoke may be harmful, whereas vitamin A intake in those who do not smoke may be beneficial. Dietary changes as well as mind-body interventions may assist lung cancer patients to manage emotional distress and the adverse effects of treatment. Cancer patients using relaxation and stress-management techniques have been able to manage cravings when pursuing tobacco cessation. These mind-body techniques are also effective in managing the emotional and physical distress associated with the adverse effects of treatment.
Currently, there are no herbal preparations or botanic supplements that appear to be useful in the prevention or management of patients with colon cancer. A fiber-rich diet has been postulated to possibly prevent the onset of colon cancer; however, studies are inconclusive. Lutein, which is present in broccoli, carrots, oranges, and spinach, was found in one study to be beneficial for colon cancer prevention.
See also Oncology.
There are several important concerns regarding the safety of the use of CAM modalities by elderly persons. They often assume that the use of dietary supplements and related biologic products, which are among the most popular CAM therapies, are both safe and effective because these products are characterized as “natural.” Under the Dietary Supplement Health and Education Act (DSHEA) of 1994, the U.S. Food and Drug Administration is not empowered to evaluate or regulate dietary supplements, and the industry is not required to prove that the advertised ingredients provide the health benefits or safety they claim. Multiple studies have found that dietary supplements often can contain little, none, or more of what the product labels claim, as well as contaminants or adulterants with unlisted products and prescription drugs.
There is little information related to possible differences in the pharmacokinetics and pharmacodynamics of various CAM biologic agents in elderly persons; as a result, proper dosage adjustments for these compounds are unknown. Coupled with the increased likelihood of elderly persons’ use of multiple medications, there is an increased risk for adverse herbal-drug interactions in older persons. Without the knowledge of what these products contain in their entirety, or the consequences of their use, consumers and health care professionals must increase communication while continued research is conducted to provide accurate evaluations. It is imperative that practitioners ask patients specifically about their use of dietary supplements and biologic products and look at the ingredients in those supplements.
CAM use in the United States continues to increase in all age groups. The life stressors experienced by older adults, including depression, cognitive decline, chronic pain, musculoskeletal changes, and sleep disorders, may be ameliorated by CAM interventions. Given the particular concerns inherent in managing the health challenges of the aging population, more research to establish the safety and efficacy of CAM modalities commonly used by older persons is imperative.
■ Barnes PM, Powell-Griner E, McFann K, et al. Complementary and alternative medicine use among adults: United States, 2002. Advance data from the Vital and Health Statistics; No. 343. Hyattsville, MD: National Center for Health Statistics; 2004.
The National Health Interview Survey (NHIS) provides the most comprehensive, current information describing the use of complementary and alternative medicine (CAM) in the U.S. adult population. By comparison with earlier surveys, the NHIS includes the most extensive list of CAM modalities and choices for specific health conditions. In-person interviews yielded a representative population of those with lower incomes and minorities who were previously excluded.
■ Fink S. International efforts spotlight traditional, complementary, and alternative medicine. Am J Pub Health. 2002; 92(11):1734–1739.
This article highlights the gap between traditional and allopathic medicine in developing countries and the public health challenge that this presents in the United States and other countries because of regulation and treatment issues.
■ Foster DF, Phillips RS, Hamel MB, et al. Alternative medicine use in older Americans. J Am Geriatr Soc. 2000;48(12):1560–1565.
This nationally representative, random telephone survey reported complementary and alternative medicine (CAM) use in a total of 2055 adults, 311 of whom were aged 65 and older. Thirty percent of adults aged 65 and older used at least one CAM modality, including chiropractic, herbal remedies, relaxation techniques, high-dose or megavitamins, and religious or spiritual healing by others. Six percent of older people were taking prescription drugs and herbal preparations, and 57% of overall CAM users did not discuss their use of the modalities with their health care provider.
■ Kaptchuk TJ. Acupuncture: theory, efficacy, and practice. Ann Intern Med. 2002;136(5):374–383.
This is an excellent review of acupuncture, with very useful summary tables of the evidence surrounding its use for various pain and nonpain conditions. The mechanisms of the effects of acupuncture are also explored.
■ Najm W, Reinsch S, Hoehler F, et al. Use of complementary and alternative medicine among the ethnic elderly. Altern Ther Health Med. 2003; 9(3):50–57.
This article discusses the results of a seven-page questionnaire that inquired about health status, current medical problems, and the use of complementary and alternative medicine (CAM) by older ethnic community-dwelling persons. In the 525-person convenience sample, Asian and Hispanic Americans were over-represented and white non-Hispanic Americans were under-represented. The questionnaire was translated into Spanish and Vietnamese and used as an interview tool by translators. In all, 47.8% of the elderly immigrants reported using CAM over the past year. Modalities and usage varied with the ethnicity of responders. Asians were higher users of acupuncture and Oriental medicine; Hispanics used more dietary supplements, home remedies, and curanderos; and white non-Hispanics were higher users of chiropractic, massage, and vitamins. Among the respondents, 62.4% reported that they did not discuss their use of CAM with their physicians.
■ Wertkin AD, Cizza G, Blackman MR. Complementary and alternative medicine in aging. In: Hazzard WR, Blass JP, Halter JB, et al., eds. Principles of Geriatric Medicine and Gerontology. 5th ed. New York: McGraw Hill; 2003:231–242.
This is a comprehensive chapter that highlights the use and misuse of complementary and alternative medicine, specifically focusing on common disorders of the older adult patient.
Barbara Moquin, PhD(c), MSN, APRN
Marc R. Blackman, MD