- Email: [email protected]
Complementary and Alternative Medicine (CAM)
ASSISTED LIVING COLUMN
Ethel Mitty
Sandi Flores
Complementary and Alternative Medicine (CAM) Barbara Moquin, PhD, APRN, BC-P, Marc R. Blackman, MD, Ethel Mitty, EdD, RN, and Sandi Flores, RN The use of complementary and alternative medicine (CAM) appears to be on the rise in all adult age groups, including the elderly population. Many herbal and biologic preparations offer promise, but they are largely of unproven benefit. The content(s) are unregulated by government agencies, such as the Food and Drug Administration, making their use problematic to recommend and guide. Use of CAM modalities in assisted living communities (ALCs) is by and large a hidden practice, but it is estimated that 5%–9% of residents ingest some kind of herbal remedy. Belief systems among residents and their families—for example, that a certain kind of tea is a cure for dementia—can be persuasive. Responsible for resident well-being, assisted living nurses are caught in the middle. Nurse licensure considers herbals as medications, yet physicians refuse to prescribe them, and nurses (or certified med techs) cannot administer them. In some states, ‘‘alternative practitioners’’ are not viewed as legal prescribers. Undaunted, residents (or their families) purchase alternative ‘‘medicines’’ that are contraindicated by their traditional medical regimen. Secreted in their room, nurses are unaware of the stash and the self-administrating practice. This article describes the state of the science regarding the efficacy and safety of CAM modalities and actions that ALC nurses might undertake to collaborate with residents to address their CAM interest and use respectfully. (Geriatr Nurs 2009;30:196-203) Complementary and alternative medicine (CAM), also known as ‘‘integrative’’ medicine, 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.’’1 It is suggested that the term ‘‘complementary medicine’’ speaks to modalities
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used in concert with conventional or traditional medicine, whereas the term ‘‘alternative medicine’’ applies when a CAM modality is used instead of conventional medicine.2 Although some scientific evidence exists regarding certain CAM therapies, key questions with regard to their effectiveness and safety are yet to be answered through well-designed research studies. The hundreds of CAM modalities include: Mind-body interventions that use systems of thought such as meditation, prayer, yoga, tai chi, biofeedback, relaxation, and art, dance and music therapies Biologically based therapies, such as herbal preparations, botanicals, and dietary supplements Manipulative and body-based methods, such as chiropractic, therapeutic massage, and osteopathic manipulation Energy therapies such as Reiki, therapeutic touch, and bioelectromagnetic-based therapies Whole medical systems, such as traditional Chinese medicine, Ayurvedic medicine, homeopathy, and naturopathic medicine, which incorporate many or all of the above-noted therapies1,2 Use of CAM is widespread. Among a nationally representative sample of more than 31,000 U.S. adults, 62% reported some use of 27 CAM modalities in the previous 12 months; at the time of the study, CAM was defined as including prayer for health reasons.3 At least 30% of those aged 65 and older used at least 1 CAM modality compared with those younger than 65 years.3 Most CAM use is complementary—that is, it is used in addition to mainstream interventions. Only a minority of CAM use serves as an alternative to conventional or traditional treatment. More than half of Alzheimer’s disease caregivers report having tried at least 1 CAM modality to improve the memory of the dementia sufferer.4 The most commonly used CAM modalities among older adults are chiropractic (used as much as younger adults),
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herbals, relaxation techniques, massage, highdose or mega vitamins, and religious or spiritual healing.4 Interestingly, older adults with a primary health care provider are more likely to use CAM than older adults who do not have a primary provider.4 This certainly speaks to assisted living community (ALC) residents, all of whom must have a physician or nurse practitioner provider. Older adults who see their physician frequently are more likely to use CAM than older adults who do not see their physician as frequently.4 One wonders if this is because they are not getting the comfort they need from traditional therapies or if the user is seeking to access all possible resources (or is an ‘‘overuser’’).4 It is also interesting to note that older adults with several years of college education and a comfortable income are likely CAM users.5 Approximately 60% of CAM users in the United States do not discuss their use of CAM modalities with their health care providers.4 Of these individuals, 6% are using herbals and prescription medications. 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 due to age-related changes in drug metabolism, pharmacodynamics, and pharmacokinetics. Agerelated alterations in hepatic and renal function contribute importantly to these phenomena, in both the absence and presence of disease.
Background The aging of the baby-boomer generation and influx of older people from other countries and ethnicities is contributing growing numbers to what was already the largest group of health care consumers: older adults (i.e., those aged over 65 years). Among them, the most common health challenges in men are diseases of the circulatory, musculoskeletal, and connective tissue and of the genitourinary system. In women, the most common health challenges are musculoskeletal, circulatory, and mental health disorders.6 Demographic indicators suggest that an expanding aging population with continuing need for medical services will continue to increase. As such, it is reasonable to predict that specific interest in and use of CAM modalities will expand as well. (Use of CAM modalities among those aged over 85 years is lowest among all age groups.3)
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The use of CAM by older adults is beginning to be more closely studied, in part to help design safer and more efficacious treatments specific to the needs of this population. CAM use can vary, depending on a particular geographic region (i.e., availability of specific practitioners) as well as ethnic group.7 Among more Hispanic than black or white individuals (and few Asians), the most widely used CAMs are herbal teas, fish oil, massage, ‘‘other,’’ and acupuncture. Differing sociocultural beliefs influence the frequency and pattern of CAM use. For example, among African Americans, CAM use is 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. A study of CAM use for 3 specific medical conditions—insomnia, back pain, and colds— demonstrated the influence of race and ethnicity on this decision among older adults.7 Being Hispanic, African American, and female is a good predictor of CAM use. Hispanic users are more likely than African Americans and Caucasians to use herbals to self-treat colds and insomnia and are more likely than Caucasians to self-treat back pain.
Safety and Efficacy of CAM Use A wide variety of CAM modalities in the United States are available from practitioners or as selfcare practices. They range from indigenous health practices that are centuries old to modalities that are licensed and provided by a trained practitioner (e.g., acupuncture, Reiki). However, most CAM practices are not regulated; licensure and certification can vary among practices within and between geographic locations. Echinacea, Gingko biloba, and garlic supplements are reported to be the most commonly used herbals.3 Many of the biologically based CAM modalities are regulated under the Dietary Supplemental and Education Act of 1994 but are not required to be tested for purity, safety, or efficacy.2 Despite numerous anecdotal reports or claims of the efficacy and safety of diverse CAM modalities, there is a general lack of product and practice standardization and a dearth of credible scientific information supporting these practices. The potential for adverse reactions with the use of herbal preparations and of botanical and
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dietary supplements in older adults is shown in the Table 1. Nonetheless, most users are satisfied, given that few malpractice or wrongful injury lawsuits are filed.
CAM Use for Managing Illness in Older Adults In the normal course of time, CAM modalities are most often used for back pain and problems, head or chest colds, neck pain or problems, joint pain or stiffness, anxiety, or depression.3 Given how debilitating and distressing these conditions can be, particularly affecting quality of life, interest in CAM modalities is not surprising. Use with regard to specific medical conditions is discussed in this section.
effects mechanistically in much the same way as conventional nonsteroidal anti-inflammatory treatments. Lower back pain is among the most difficult health challenges for which CAM modalities are widely used. In particular, therapeutic massage, acupuncture, mind-body relaxation, and energy modalities are often used for lower back pain. The combined use of massage, self-care relaxation, and acupuncture may be more effective than the use of any of these modalities separately. A metaanalysis 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, thus confounding the results.6 Chiropractic, specifically spinal manipulation, is believed safe for older adults and is recommended as a treatment for low back pain.
Musculoskeletal Disorders Osteoporosis. Phytoestrogen is a naturally occurring substance found in soy and red clover that the body converts to the hormones estrogen and testosterone. Increasingly used to prevent or treat osteoporosis in postmenopausal women, there is little evidence confirming their benefits. Dehydroepiandrosterone (DHEA), a widely used dietary supplement, is the most abundant adrenal steroid in humans. Levels decline progressively with age. Small-scale trials of DHEA supplementation in older persons have produced conflicting results regarding its effects on bone density. Further studies are necessary to determine its utility in preventing or treating osteoporosis in older people. It can also be risky for women with a history of estrogen-sensitive breast cancer (discussed later). Osteoarthritis is among the most common chronic diseases affecting older adults, and almost half (47%) of older adults with osteoarthritis report using some CAM modality. Techniques specifically focused to provide stress relief, such as relaxation breathing and music therapy, may be of benefit as adjunctive therapy in addressing the experience of suffering that often accompanies pain. Gentle movement and stretching techniques, such as those in yoga, tai chi, and warm-water aquatics, are an alternative to more vigorous exercise regimens. Other CAM modalities include acupuncture, massage, chiropractic manipulation, glucosamine supplements, Reiki, and prayer. Herbal preparations, including capsaicin cream and Phytodolor, are thought to exert
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Cardiovascular Disorders A heart-healthy diet and aerobic exercise are the first recommendations to manage high blood pressure and dyslipidemia. The 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 hearthealthy diet decreased both systolic and diastolic blood-pressure measurements.8 Recent studies suggest that diets including essential fatty acids may lower blood pressure, increase levels of high-density lipoproteins (i.e., the ‘‘good’’ cholesterol), and lower levels of triglycerides and lowdensity lipoproteins. Examples of essential fatty acids are omega-3 (found in fresh deep-water fish and in flaxseed oil) and omega-6 linoleic acid (found in raw nuts and seeds). Stressmanagement techniques, such as relaxation breathing, music therapy, and meditation, may reduce blood pressure in hypertensive older adults and improve sleep quality. Neurologic and Emotional Disorders Depression is among the most common and debilitating major public health problems; incidence increases with advancing age. Although depression is more common in women, increasing attention is focused on men, in whom it is more often unrecognized or untreated. (There is an alarming prevalence of depression and suicide
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Table 1. Potential Adverse Effects Associated with CAM Supplements and Medications CAM Supplement Coenzyme Q10
Dehydroepiandrosterone (DHEA) Echinacea Gingko biloba Glucosamine Omega-3 fatty acids S-adenosylmethionine (SAM-e) Saw palmetto St. John’s wort
Adverse Effects
Interactions
Relatively infrequent: headache, nausea, vomiting, epigastric pain .300 mg/day is associated with increased liver transaminase Women: weight gain, voice change, facial hair, headache Men: prostatic hypertrophy Allergic reactions, hepatitis, asthma, vertigo All rare: serious bleeding, seizure, headache, dizziness Nausea, diarrhea, heartburn Belching, halitosis, blood glucose elevation Nausea, vomiting, diarrhea, anxiety, restlessness
Warfarin (Coumadin)
All rare: constipation, diarrhea, decreased libido, headache, hypertension, urine retention Nausea, allergic reaction, dizziness, headache, photosensitivity (rare)
None described
CAM 5 complementary and alternative medicine; SSRI 5 selective serotonin reuptake inhibitor. From Geriatric Nursing Review Syllabus 2. New York: American Geriatrics Society.
Calcium channel blockers, sildenafil Immunosuppressants Anticoagulants Reduces effectiveness of hypoglycemic drugs Antiplatelets, anticoagulants, antihypertensives Tricyclics and SSRIs
Anticoagulants, antiretrovirals, SSRIs, immunosuppressants, and chemotherapeutic drugs
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in widowed men aged 70 years and older.) A CAM modality might help manage mild to moderate depression. However, adequate treatment of severe depression may involve psychotherapy and psychotropic medication to prevent further morbidity and mortality. A healthy diet can be one of the first recommendations to assist in 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 (e.g., swimming, brisk walking) is also recommended for mild to moderate depression. 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 is widely used, although a large multicenter study failed to show the efficacy of this agent in patients with major depression of mild to moderate degree. The adverse effects and potential harmful interaction of St. John’s wort with many significant medications are shown in the Table 1. S-adenosylmethionine (SAM-e), a naturally occurring compound that is necessary for the brain to produce sufficient dopamine and serotonin, is currently marketed as an antidepressant. Adverse interactions with other drugs have not been described.9 Dementia. Some, but not all, studies investigating the use of supplements for treatment of dementia demonstrate that Ginkgo biloba extract has some benefit in improving cognitive ability and memory impairment in Alzheimer’s patients. Brain tissue studies and spinal fluid abnormalities found in Alzheimer’s patients provide a reasonable rationale for supplementing with various antioxidants, including vitamins A, C, and E and selenium, although evidence of their effect has yet to be demonstrated in clinical trials. Parkinson’s disease patients have reduced brain levels of glutathione, an antioxidant involved in neuroprotective functions, and of coenzyme Q10. Also known as ubiquinone, coenzyme Q10 is necessary for basic cell function; it has also been implicated in blood pressure reduction.10 In very small, unblinded clinical trials, supplementation with these 2 naturally occurring substances slows the progression of disease
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and reduces the severity of symptoms. 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, but evidence about their effectiveness is lacking. Sleep disorders are common in older adults, affecting both sleep quality and quantity. Studies suggest that abnormalities in slow-wave and rapid-eye-movement (REM) sleep may also be linked to psychological, endocrine-metabolic, and immune system dysfunctions. Approaches to ameliorate sleep disorders include biologic compounds (e.g., valerian, melatonin), mindbody therapy, and manipulation. Nutritional and exercise modifications are among the safest recommendations when working with older adults who have sleep disturbance problems. Milk contains tryptophan, 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, an herbal tea, is also known for its relaxing properties. Melatonin, a hormone produced by the pineal gland, apparently significantly influences the circadian sleep-wake cycle. Evidence suggests that melatonin may promote improved sleep quality or efficiency and thereby reduce excessive daytime sleepiness.2 Age-related changes, certain medications (e.g., beta-blockers, nonsteroidal anti-inflammatories), and some comorbid conditions (e.g., persistent pain, acute myocardial infarction) can reduce melatonin levels.2 The effectiveness of melatonin in treatment of insomnia has not been empirically demonstrated. Various studies report melatonin interference with calcium channel blockers and immunosuppressants, but the data are limited. Valerian has few side effects and appears to be useful for mild insomnia and for treatment of sleep disruption associated with cancer and rheumatoid arthritis.2 Aerobic, but not strenuous, exercise in the early (not late) evening can contribute to improved sleep quality. Tai chi, a combination of low impact exercise and meditation, might improve sleep onset and quality as well as reduce
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daytime sleepiness. Acupuncture, by virtue of its ability to reduce pain as a result of release of neurotransmitters (e.g., endorphins, serotonin) and facilitate dopamine utilization, can be an effective modality. Acupressure—stimulation of ‘‘meridian’’ or acupoints using finger pressure—can reduce sleep disruption, improve sleep efficiency and quality, and reduce agitation.2 This treatment can be given by nursing staff (or by a family member). Mind-body interventions such as guided imagery and meditation, are purportedly effective CAM modalities to improve sleep patterns but require further empiric demonstration. Yoga reduces anxiety levels and as such, has been recommended to improve sleep quality. Other CAM modalities for improving sleep used by older adults include aromatherapy (e.g., lavender), a warm bath, and relaxing music. Urogynecologic Disorders Menopause lends itself to the use of behavioral, nutritional, and exercise interventions as well as nonpharmacologic supplements to manage some of the symptoms associated with it. More than 30% of menopausal women report using 1 or more CAM modalities, such as acupuncture, natural and plant estrogens, and other herbal preparations, despite a lack of scientific evidence of efficacy.11 This number is likely to increase because of the expanding population of older adult women and increasing concerns about the longterm safety of estrogen or hormone replacement therapy (reported in 2002 by the Women’s Health Initiative study). It is particularly important 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. There is no evidence that DHEA has any positive effect on hot flashes. Women at risk for diseases or conditions affected by hormones (e.g., breast, ovarian, or uterine cancer; fibroids) or those on tamoxifen (a selective estrogen receptor modulator taken by some women with a history of breast cancer) are advised to use these products with extreme caution.11 The herb ginseng has shown some benefit for managing mood disturbances, sleep disorders, and improving the sense of well-being.11 However, it appears to have no effect on hot flashes. The evidence about soy use is mixed; long-term use is associated with increasing the thickness
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of the lining of the uterus. Aerobic exercise and mind-body relaxation techniques are helpful in decreasing irritability, restlessness, and anxiety associated with menopause. Symptomatic benign prostatic hyperplasia (BPH) affects more than 40% of men aged 70 and older. Men are increasingly self-treating this condition with the herbal compound known as ‘‘saw palmetto,’’ the fifth leading medicinal herb consumed in the United States.12 Saw palmetto and other supplements (e.g., pygeum) have been studied but require more rigorous scientific investigation to confirm initial claims that its efficacy exceeded that of placebo treatment and was similar to that of standard pharmacologic treatment.12 Diabetes Normal aging is associated with increased insulin resistance and glucose intolerance and increased risk of developing type 2 diabetes. Type 2 diabetes mellitus is associated with increased incidence of obesity, hypertension, dyslipidemia, and macro- and microvascular disease. Approximately 50%–60% of diabetic patients report using CAM interventions, including folk remedies in ethnic populations. There is considerable scientific interest in examining the potential benefit of using various CAM biologic agents (e.g., chromium, vitamin C, other dietary antioxidants such as green tea) or other modalities (e.g., stressreduction techniques) in combination with dietary modifications, exercise, and weight management.13 Acupuncture has shown some benefit in managing the pain associated with diabetic neuropathy. Cancer Approximately 30%–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 immune system as well as to manage the adverse effects of conventional treatments, such as chemotherapy and radiation. Many cancer patients who use CAM modalities report feeling 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.14 The CAM therapies most frequently used are
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herbal preparations, exercise, and spiritual and energy modalities (such as qi gong, therapeutic touch, Reiki, polarity, healing touch, or Johrei). Controversy persists regarding the role of diet as a possible risk factor for developing breast cancer. There appears to be a 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 decreased risk of breast cancer. Biologic agents, herbal preparations, and vitamins have all been tried, but their efficacy has not been scientifically evaluated. Lifestyle changes that include exercise and stress management are helpful in managing mood and energy changes associated with breast cancer. Prostate cancer usually develops slowly in older men. Use of CAM in combination with conventional treatment is reported to reduce associated discomfort and improve the quality of life.14 In fact, risk of death in this population is higher from heart disease than from prostate cancer. The botanical mixture known as PC-SPES had been used as a CAM dietary supplement that in early small-scale trials showed a decrease in serum prostate-specific antigen (PSA) levels and pain, as well as 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, and as a result, it 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. Lung cancer has been linked not only to smoking but also to excesses in dietary intake of dairy products, red meats, and saturated fats, although these associations have been questioned. In addition, preliminary research suggests 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.14 There are no herbal preparations or botanic supplements that appear to be useful in the prevention or management of patients with colon
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cancer at the present time. A fiber-rich diet has been postulated possibly to 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. The National Cancer Institute and the National Center for Complementary Alternative Medicine (i.e., NCI, and NCCAM, respectively) are co-sponsoring several studies, among which are the use of acupuncture to reduce symptoms of colorectal cancer, a comparison of chemotherapy and administration of pancreatic enzyme for treatment of pancreatic cancer, and the use of mistletoe extract and chemotherapy for solid tumor treatment.14
Assisted Living Nursing and CAM Modality Safety Older adults’ erroneously assume that dietary supplements and related biologic products— among the most popular CAM therapies—are both safe and effective because these products are characterized as ‘‘natural.’’ The Food and Drug Administration does not have the authority to evaluate or regulate dietary supplements. In addition, the industry is not required to prove that the advertised ingredients actually provide the health benefits or safety they claim. 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 older adults; as a result, proper dosage adjustments for these compounds are unknown. Coupled with the increased likelihood of older adults’ taking several potent medications, there is an increased risk for adverse herbal-drug interactions. Without knowledge of what these products contain in their entirety, or the consequences of their use, residents and ALC health care professionals need to talk with each other. It is imperative to ask new (and continuing stay) residents specifically about their use of dietary supplements and biologic products and look at the ingredients in those supplements. Make inquiries about the use of CAM modalities (particularly the ‘‘ingestibles’’) part of the
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admission and annual assessment. Consider asking about CAM use when the resident has an unexpected medical or functional event (e.g., exacerbation of a previously well-controlled condition; fall). Gently probe tea drinking habits by having a cup of tea with a resident or two, and while sitting there, say ‘‘My this cup of tea hits the spot.’’ (pause) ‘‘What kind of tea do you like to drink?’’ (black, green, other). Few older adults escape significant challenges to their well-being or health. As a health care professional, you are likely helping your residents view their treatment options. There is no risk in asking, ‘‘Have you thought about using an herbal remedy or XX for your pain?’’ You can then say something such as, ‘‘In considering your options, you probably should think about: the benefits that can be expected with (the CAM) approach/option; the risks and burdens associated with (the CAM) option (This is the classic risk/benefit/burden discussion); possible side effects with each CAM option; and the possible interference of one treatment regimen with another.’’
10.
References
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1. National Center for Complementary and Alternative Medicine, National Institutes of Health. What is complementary and alternative medicine? Available at http://nccam.nih.gov/health/whatiscam. Cited Feb. 20, 2009. 2. Gooneratne NS. 2008. Complementary and alternative medicine for sleep disturbances in older adults. Clin Geriatr Med 2008;24:121-38. 3. 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. 4. Foster DF, Phillips RS, Hamel MB, et al. Alternative medicine use in older Americans. J Am Geriatr Soc 2000; 48:1560-5. 5. American Association of Retired Persons. Complementary alternative medicine research report. Available at http://aarp.org/research/health/prevention/ cam_2007.html. January 2007. Cited February 16, 2009. 6. Wertkin AD, Cizza G, Blackman MR. Complementary and alternative medicine in aging. In: Hazzard WR, Blass JP,
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7.
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11.
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Halter JB, eds. Principles of geriatric medicine and gerontology. 5th ed. New York: McGraw-Hill; 2003. p. 231-42. Cherniack EP, Ceron-Fuentes J, Florez H, et al. 2008. Influence of race and ethnicity on alternative medicine as a self-treatment preference for common medical conditions in a population of multi-ethnic urban elderly. Complement Ther Clini Pract 2008;14:116-23. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-24. Wong, C. SAM-e. Updated January 23, 2008. Available at http://altmedicine.about.com/od/treatmentsfromatod/a/ SAMe.htm. Cited February 16, 2009. MayoClinic.com. Coenzyme Q10. March 1, 2008. Available at www.mayoclinic.com/health/ coenzyme-q10/NS_patient-coenzymeq10. Cited February 16, 2009. National Center for Complementary and Alternative Medicine, National Institutes of Health. Menopausal symptoms and CAM. Updated February 2009. Available at http://nccam.nih.gov/health/menopause/D406.pdf. Cited February 16, 2009. MayoClinic.com. Saw palmetto (Serenoa repens [Bartram] Small). February 1, 2008. Available at www. mayoclinic.com/health/saw-palmetto/ NS_patient-sawpalmetto. Cited February 16, 2009. National Center for Complementary and Alternative Medicine, National Institutes of Health. CAM and diabetes: a focus on dietary supplements. June 2008. Available at http://nccam.nih.gov/health/diabetes/ CAM-and-diabetes.htm. Cited February 16, 2009. National Cancer Institute. Complementary and alternative medicine in cancer treatment: questions and answers. Available at www.cancer.gov/cancertopics/ factsheet/Therapy/CAM. Cited February 16, 2009.
BARBARA E. MOQUIN, PhD, APRN, BC-P, is a senior nurse specialist (research) at the National Center for Complementary and Alternative Medicine (NCCAM), a component of the National Institutes of Health (NIH), Bethesda, MD. MARC R. BLACKMAN, MD, is affiliated with the Division of Intramural Research of NCCAM, a component of the NIH; and an adjunct professor at the University of Maryland, School of Medicine, Baltimore, MD. ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, John A. Hartford Institute for Geriatric Nursing, New York University, New York, NY. SANDI FLORES, RN, C, is the executive director of the American Assisted Living Nurses Association and the education director of Community Education, LLC (www. communityed.com), San Marcos, CA. 0197-4572/09/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2009.03.002
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Ethel Mitty
Sandi Flores
Complementary and Alternative Medicine (CAM) Barbara Moquin, PhD, APRN, BC-P, Marc R. Blackman, MD, Ethel Mitty, EdD, RN, and Sandi Flores, RN The use of complementary and alternative medicine (CAM) appears to be on the rise in all adult age groups, including the elderly population. Many herbal and biologic preparations offer promise, but they are largely of unproven benefit. The content(s) are unregulated by government agencies, such as the Food and Drug Administration, making their use problematic to recommend and guide. Use of CAM modalities in assisted living communities (ALCs) is by and large a hidden practice, but it is estimated that 5%–9% of residents ingest some kind of herbal remedy. Belief systems among residents and their families—for example, that a certain kind of tea is a cure for dementia—can be persuasive. Responsible for resident well-being, assisted living nurses are caught in the middle. Nurse licensure considers herbals as medications, yet physicians refuse to prescribe them, and nurses (or certified med techs) cannot administer them. In some states, ‘‘alternative practitioners’’ are not viewed as legal prescribers. Undaunted, residents (or their families) purchase alternative ‘‘medicines’’ that are contraindicated by their traditional medical regimen. Secreted in their room, nurses are unaware of the stash and the self-administrating practice. This article describes the state of the science regarding the efficacy and safety of CAM modalities and actions that ALC nurses might undertake to collaborate with residents to address their CAM interest and use respectfully. (Geriatr Nurs 2009;30:196-203) Complementary and alternative medicine (CAM), also known as ‘‘integrative’’ medicine, 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.’’1 It is suggested that the term ‘‘complementary medicine’’ speaks to modalities
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used in concert with conventional or traditional medicine, whereas the term ‘‘alternative medicine’’ applies when a CAM modality is used instead of conventional medicine.2 Although some scientific evidence exists regarding certain CAM therapies, key questions with regard to their effectiveness and safety are yet to be answered through well-designed research studies. The hundreds of CAM modalities include: Mind-body interventions that use systems of thought such as meditation, prayer, yoga, tai chi, biofeedback, relaxation, and art, dance and music therapies Biologically based therapies, such as herbal preparations, botanicals, and dietary supplements Manipulative and body-based methods, such as chiropractic, therapeutic massage, and osteopathic manipulation Energy therapies such as Reiki, therapeutic touch, and bioelectromagnetic-based therapies Whole medical systems, such as traditional Chinese medicine, Ayurvedic medicine, homeopathy, and naturopathic medicine, which incorporate many or all of the above-noted therapies1,2 Use of CAM is widespread. Among a nationally representative sample of more than 31,000 U.S. adults, 62% reported some use of 27 CAM modalities in the previous 12 months; at the time of the study, CAM was defined as including prayer for health reasons.3 At least 30% of those aged 65 and older used at least 1 CAM modality compared with those younger than 65 years.3 Most CAM use is complementary—that is, it is used in addition to mainstream interventions. Only a minority of CAM use serves as an alternative to conventional or traditional treatment. More than half of Alzheimer’s disease caregivers report having tried at least 1 CAM modality to improve the memory of the dementia sufferer.4 The most commonly used CAM modalities among older adults are chiropractic (used as much as younger adults),
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herbals, relaxation techniques, massage, highdose or mega vitamins, and religious or spiritual healing.4 Interestingly, older adults with a primary health care provider are more likely to use CAM than older adults who do not have a primary provider.4 This certainly speaks to assisted living community (ALC) residents, all of whom must have a physician or nurse practitioner provider. Older adults who see their physician frequently are more likely to use CAM than older adults who do not see their physician as frequently.4 One wonders if this is because they are not getting the comfort they need from traditional therapies or if the user is seeking to access all possible resources (or is an ‘‘overuser’’).4 It is also interesting to note that older adults with several years of college education and a comfortable income are likely CAM users.5 Approximately 60% of CAM users in the United States do not discuss their use of CAM modalities with their health care providers.4 Of these individuals, 6% are using herbals and prescription medications. 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 due to age-related changes in drug metabolism, pharmacodynamics, and pharmacokinetics. Agerelated alterations in hepatic and renal function contribute importantly to these phenomena, in both the absence and presence of disease.
Background The aging of the baby-boomer generation and influx of older people from other countries and ethnicities is contributing growing numbers to what was already the largest group of health care consumers: older adults (i.e., those aged over 65 years). Among them, the most common health challenges in men are diseases of the circulatory, musculoskeletal, and connective tissue and of the genitourinary system. In women, the most common health challenges are musculoskeletal, circulatory, and mental health disorders.6 Demographic indicators suggest that an expanding aging population with continuing need for medical services will continue to increase. As such, it is reasonable to predict that specific interest in and use of CAM modalities will expand as well. (Use of CAM modalities among those aged over 85 years is lowest among all age groups.3)
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The use of CAM by older adults is beginning to be more closely studied, in part to help design safer and more efficacious treatments specific to the needs of this population. CAM use can vary, depending on a particular geographic region (i.e., availability of specific practitioners) as well as ethnic group.7 Among more Hispanic than black or white individuals (and few Asians), the most widely used CAMs are herbal teas, fish oil, massage, ‘‘other,’’ and acupuncture. Differing sociocultural beliefs influence the frequency and pattern of CAM use. For example, among African Americans, CAM use is 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. A study of CAM use for 3 specific medical conditions—insomnia, back pain, and colds— demonstrated the influence of race and ethnicity on this decision among older adults.7 Being Hispanic, African American, and female is a good predictor of CAM use. Hispanic users are more likely than African Americans and Caucasians to use herbals to self-treat colds and insomnia and are more likely than Caucasians to self-treat back pain.
Safety and Efficacy of CAM Use A wide variety of CAM modalities in the United States are available from practitioners or as selfcare practices. They range from indigenous health practices that are centuries old to modalities that are licensed and provided by a trained practitioner (e.g., acupuncture, Reiki). However, most CAM practices are not regulated; licensure and certification can vary among practices within and between geographic locations. Echinacea, Gingko biloba, and garlic supplements are reported to be the most commonly used herbals.3 Many of the biologically based CAM modalities are regulated under the Dietary Supplemental and Education Act of 1994 but are not required to be tested for purity, safety, or efficacy.2 Despite numerous anecdotal reports or claims of the efficacy and safety of diverse CAM modalities, there is a general lack of product and practice standardization and a dearth of credible scientific information supporting these practices. The potential for adverse reactions with the use of herbal preparations and of botanical and
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dietary supplements in older adults is shown in the Table 1. Nonetheless, most users are satisfied, given that few malpractice or wrongful injury lawsuits are filed.
CAM Use for Managing Illness in Older Adults In the normal course of time, CAM modalities are most often used for back pain and problems, head or chest colds, neck pain or problems, joint pain or stiffness, anxiety, or depression.3 Given how debilitating and distressing these conditions can be, particularly affecting quality of life, interest in CAM modalities is not surprising. Use with regard to specific medical conditions is discussed in this section.
effects mechanistically in much the same way as conventional nonsteroidal anti-inflammatory treatments. Lower back pain is among the most difficult health challenges for which CAM modalities are widely used. In particular, therapeutic massage, acupuncture, mind-body relaxation, and energy modalities are often used for lower back pain. The combined use of massage, self-care relaxation, and acupuncture may be more effective than the use of any of these modalities separately. A metaanalysis 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, thus confounding the results.6 Chiropractic, specifically spinal manipulation, is believed safe for older adults and is recommended as a treatment for low back pain.
Musculoskeletal Disorders Osteoporosis. Phytoestrogen is a naturally occurring substance found in soy and red clover that the body converts to the hormones estrogen and testosterone. Increasingly used to prevent or treat osteoporosis in postmenopausal women, there is little evidence confirming their benefits. Dehydroepiandrosterone (DHEA), a widely used dietary supplement, is the most abundant adrenal steroid in humans. Levels decline progressively with age. Small-scale trials of DHEA supplementation in older persons have produced conflicting results regarding its effects on bone density. Further studies are necessary to determine its utility in preventing or treating osteoporosis in older people. It can also be risky for women with a history of estrogen-sensitive breast cancer (discussed later). Osteoarthritis is among the most common chronic diseases affecting older adults, and almost half (47%) of older adults with osteoarthritis report using some CAM modality. Techniques specifically focused to provide stress relief, such as relaxation breathing and music therapy, may be of benefit as adjunctive therapy in addressing the experience of suffering that often accompanies pain. Gentle movement and stretching techniques, such as those in yoga, tai chi, and warm-water aquatics, are an alternative to more vigorous exercise regimens. Other CAM modalities include acupuncture, massage, chiropractic manipulation, glucosamine supplements, Reiki, and prayer. Herbal preparations, including capsaicin cream and Phytodolor, are thought to exert
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Cardiovascular Disorders A heart-healthy diet and aerobic exercise are the first recommendations to manage high blood pressure and dyslipidemia. The 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 hearthealthy diet decreased both systolic and diastolic blood-pressure measurements.8 Recent studies suggest that diets including essential fatty acids may lower blood pressure, increase levels of high-density lipoproteins (i.e., the ‘‘good’’ cholesterol), and lower levels of triglycerides and lowdensity lipoproteins. Examples of essential fatty acids are omega-3 (found in fresh deep-water fish and in flaxseed oil) and omega-6 linoleic acid (found in raw nuts and seeds). Stressmanagement techniques, such as relaxation breathing, music therapy, and meditation, may reduce blood pressure in hypertensive older adults and improve sleep quality. Neurologic and Emotional Disorders Depression is among the most common and debilitating major public health problems; incidence increases with advancing age. Although depression is more common in women, increasing attention is focused on men, in whom it is more often unrecognized or untreated. (There is an alarming prevalence of depression and suicide
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Table 1. Potential Adverse Effects Associated with CAM Supplements and Medications CAM Supplement Coenzyme Q10
Dehydroepiandrosterone (DHEA) Echinacea Gingko biloba Glucosamine Omega-3 fatty acids S-adenosylmethionine (SAM-e) Saw palmetto St. John’s wort
Adverse Effects
Interactions
Relatively infrequent: headache, nausea, vomiting, epigastric pain .300 mg/day is associated with increased liver transaminase Women: weight gain, voice change, facial hair, headache Men: prostatic hypertrophy Allergic reactions, hepatitis, asthma, vertigo All rare: serious bleeding, seizure, headache, dizziness Nausea, diarrhea, heartburn Belching, halitosis, blood glucose elevation Nausea, vomiting, diarrhea, anxiety, restlessness
Warfarin (Coumadin)
All rare: constipation, diarrhea, decreased libido, headache, hypertension, urine retention Nausea, allergic reaction, dizziness, headache, photosensitivity (rare)
None described
CAM 5 complementary and alternative medicine; SSRI 5 selective serotonin reuptake inhibitor. From Geriatric Nursing Review Syllabus 2. New York: American Geriatrics Society.
Calcium channel blockers, sildenafil Immunosuppressants Anticoagulants Reduces effectiveness of hypoglycemic drugs Antiplatelets, anticoagulants, antihypertensives Tricyclics and SSRIs
Anticoagulants, antiretrovirals, SSRIs, immunosuppressants, and chemotherapeutic drugs
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in widowed men aged 70 years and older.) A CAM modality might help manage mild to moderate depression. However, adequate treatment of severe depression may involve psychotherapy and psychotropic medication to prevent further morbidity and mortality. A healthy diet can be one of the first recommendations to assist in 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 (e.g., swimming, brisk walking) is also recommended for mild to moderate depression. 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 is widely used, although a large multicenter study failed to show the efficacy of this agent in patients with major depression of mild to moderate degree. The adverse effects and potential harmful interaction of St. John’s wort with many significant medications are shown in the Table 1. S-adenosylmethionine (SAM-e), a naturally occurring compound that is necessary for the brain to produce sufficient dopamine and serotonin, is currently marketed as an antidepressant. Adverse interactions with other drugs have not been described.9 Dementia. Some, but not all, studies investigating the use of supplements for treatment of dementia demonstrate that Ginkgo biloba extract has some benefit in improving cognitive ability and memory impairment in Alzheimer’s patients. Brain tissue studies and spinal fluid abnormalities found in Alzheimer’s patients provide a reasonable rationale for supplementing with various antioxidants, including vitamins A, C, and E and selenium, although evidence of their effect has yet to be demonstrated in clinical trials. Parkinson’s disease patients have reduced brain levels of glutathione, an antioxidant involved in neuroprotective functions, and of coenzyme Q10. Also known as ubiquinone, coenzyme Q10 is necessary for basic cell function; it has also been implicated in blood pressure reduction.10 In very small, unblinded clinical trials, supplementation with these 2 naturally occurring substances slows the progression of disease
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and reduces the severity of symptoms. 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, but evidence about their effectiveness is lacking. Sleep disorders are common in older adults, affecting both sleep quality and quantity. Studies suggest that abnormalities in slow-wave and rapid-eye-movement (REM) sleep may also be linked to psychological, endocrine-metabolic, and immune system dysfunctions. Approaches to ameliorate sleep disorders include biologic compounds (e.g., valerian, melatonin), mindbody therapy, and manipulation. Nutritional and exercise modifications are among the safest recommendations when working with older adults who have sleep disturbance problems. Milk contains tryptophan, 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, an herbal tea, is also known for its relaxing properties. Melatonin, a hormone produced by the pineal gland, apparently significantly influences the circadian sleep-wake cycle. Evidence suggests that melatonin may promote improved sleep quality or efficiency and thereby reduce excessive daytime sleepiness.2 Age-related changes, certain medications (e.g., beta-blockers, nonsteroidal anti-inflammatories), and some comorbid conditions (e.g., persistent pain, acute myocardial infarction) can reduce melatonin levels.2 The effectiveness of melatonin in treatment of insomnia has not been empirically demonstrated. Various studies report melatonin interference with calcium channel blockers and immunosuppressants, but the data are limited. Valerian has few side effects and appears to be useful for mild insomnia and for treatment of sleep disruption associated with cancer and rheumatoid arthritis.2 Aerobic, but not strenuous, exercise in the early (not late) evening can contribute to improved sleep quality. Tai chi, a combination of low impact exercise and meditation, might improve sleep onset and quality as well as reduce
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daytime sleepiness. Acupuncture, by virtue of its ability to reduce pain as a result of release of neurotransmitters (e.g., endorphins, serotonin) and facilitate dopamine utilization, can be an effective modality. Acupressure—stimulation of ‘‘meridian’’ or acupoints using finger pressure—can reduce sleep disruption, improve sleep efficiency and quality, and reduce agitation.2 This treatment can be given by nursing staff (or by a family member). Mind-body interventions such as guided imagery and meditation, are purportedly effective CAM modalities to improve sleep patterns but require further empiric demonstration. Yoga reduces anxiety levels and as such, has been recommended to improve sleep quality. Other CAM modalities for improving sleep used by older adults include aromatherapy (e.g., lavender), a warm bath, and relaxing music. Urogynecologic Disorders Menopause lends itself to the use of behavioral, nutritional, and exercise interventions as well as nonpharmacologic supplements to manage some of the symptoms associated with it. More than 30% of menopausal women report using 1 or more CAM modalities, such as acupuncture, natural and plant estrogens, and other herbal preparations, despite a lack of scientific evidence of efficacy.11 This number is likely to increase because of the expanding population of older adult women and increasing concerns about the longterm safety of estrogen or hormone replacement therapy (reported in 2002 by the Women’s Health Initiative study). It is particularly important 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. There is no evidence that DHEA has any positive effect on hot flashes. Women at risk for diseases or conditions affected by hormones (e.g., breast, ovarian, or uterine cancer; fibroids) or those on tamoxifen (a selective estrogen receptor modulator taken by some women with a history of breast cancer) are advised to use these products with extreme caution.11 The herb ginseng has shown some benefit for managing mood disturbances, sleep disorders, and improving the sense of well-being.11 However, it appears to have no effect on hot flashes. The evidence about soy use is mixed; long-term use is associated with increasing the thickness
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of the lining of the uterus. Aerobic exercise and mind-body relaxation techniques are helpful in decreasing irritability, restlessness, and anxiety associated with menopause. Symptomatic benign prostatic hyperplasia (BPH) affects more than 40% of men aged 70 and older. Men are increasingly self-treating this condition with the herbal compound known as ‘‘saw palmetto,’’ the fifth leading medicinal herb consumed in the United States.12 Saw palmetto and other supplements (e.g., pygeum) have been studied but require more rigorous scientific investigation to confirm initial claims that its efficacy exceeded that of placebo treatment and was similar to that of standard pharmacologic treatment.12 Diabetes Normal aging is associated with increased insulin resistance and glucose intolerance and increased risk of developing type 2 diabetes. Type 2 diabetes mellitus is associated with increased incidence of obesity, hypertension, dyslipidemia, and macro- and microvascular disease. Approximately 50%–60% of diabetic patients report using CAM interventions, including folk remedies in ethnic populations. There is considerable scientific interest in examining the potential benefit of using various CAM biologic agents (e.g., chromium, vitamin C, other dietary antioxidants such as green tea) or other modalities (e.g., stressreduction techniques) in combination with dietary modifications, exercise, and weight management.13 Acupuncture has shown some benefit in managing the pain associated with diabetic neuropathy. Cancer Approximately 30%–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 immune system as well as to manage the adverse effects of conventional treatments, such as chemotherapy and radiation. Many cancer patients who use CAM modalities report feeling 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.14 The CAM therapies most frequently used are
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herbal preparations, exercise, and spiritual and energy modalities (such as qi gong, therapeutic touch, Reiki, polarity, healing touch, or Johrei). Controversy persists regarding the role of diet as a possible risk factor for developing breast cancer. There appears to be a 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 decreased risk of breast cancer. Biologic agents, herbal preparations, and vitamins have all been tried, but their efficacy has not been scientifically evaluated. Lifestyle changes that include exercise and stress management are helpful in managing mood and energy changes associated with breast cancer. Prostate cancer usually develops slowly in older men. Use of CAM in combination with conventional treatment is reported to reduce associated discomfort and improve the quality of life.14 In fact, risk of death in this population is higher from heart disease than from prostate cancer. The botanical mixture known as PC-SPES had been used as a CAM dietary supplement that in early small-scale trials showed a decrease in serum prostate-specific antigen (PSA) levels and pain, as well as 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, and as a result, it 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. Lung cancer has been linked not only to smoking but also to excesses in dietary intake of dairy products, red meats, and saturated fats, although these associations have been questioned. In addition, preliminary research suggests 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.14 There are no herbal preparations or botanic supplements that appear to be useful in the prevention or management of patients with colon
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cancer at the present time. A fiber-rich diet has been postulated possibly to 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. The National Cancer Institute and the National Center for Complementary Alternative Medicine (i.e., NCI, and NCCAM, respectively) are co-sponsoring several studies, among which are the use of acupuncture to reduce symptoms of colorectal cancer, a comparison of chemotherapy and administration of pancreatic enzyme for treatment of pancreatic cancer, and the use of mistletoe extract and chemotherapy for solid tumor treatment.14
Assisted Living Nursing and CAM Modality Safety Older adults’ erroneously assume that dietary supplements and related biologic products— among the most popular CAM therapies—are both safe and effective because these products are characterized as ‘‘natural.’’ The Food and Drug Administration does not have the authority to evaluate or regulate dietary supplements. In addition, the industry is not required to prove that the advertised ingredients actually provide the health benefits or safety they claim. 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 older adults; as a result, proper dosage adjustments for these compounds are unknown. Coupled with the increased likelihood of older adults’ taking several potent medications, there is an increased risk for adverse herbal-drug interactions. Without knowledge of what these products contain in their entirety, or the consequences of their use, residents and ALC health care professionals need to talk with each other. It is imperative to ask new (and continuing stay) residents specifically about their use of dietary supplements and biologic products and look at the ingredients in those supplements. Make inquiries about the use of CAM modalities (particularly the ‘‘ingestibles’’) part of the
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admission and annual assessment. Consider asking about CAM use when the resident has an unexpected medical or functional event (e.g., exacerbation of a previously well-controlled condition; fall). Gently probe tea drinking habits by having a cup of tea with a resident or two, and while sitting there, say ‘‘My this cup of tea hits the spot.’’ (pause) ‘‘What kind of tea do you like to drink?’’ (black, green, other). Few older adults escape significant challenges to their well-being or health. As a health care professional, you are likely helping your residents view their treatment options. There is no risk in asking, ‘‘Have you thought about using an herbal remedy or XX for your pain?’’ You can then say something such as, ‘‘In considering your options, you probably should think about: the benefits that can be expected with (the CAM) approach/option; the risks and burdens associated with (the CAM) option (This is the classic risk/benefit/burden discussion); possible side effects with each CAM option; and the possible interference of one treatment regimen with another.’’
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1. National Center for Complementary and Alternative Medicine, National Institutes of Health. What is complementary and alternative medicine? Available at http://nccam.nih.gov/health/whatiscam. Cited Feb. 20, 2009. 2. Gooneratne NS. 2008. Complementary and alternative medicine for sleep disturbances in older adults. Clin Geriatr Med 2008;24:121-38. 3. 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. 4. Foster DF, Phillips RS, Hamel MB, et al. Alternative medicine use in older Americans. J Am Geriatr Soc 2000; 48:1560-5. 5. American Association of Retired Persons. Complementary alternative medicine research report. Available at http://aarp.org/research/health/prevention/ cam_2007.html. January 2007. Cited February 16, 2009. 6. Wertkin AD, Cizza G, Blackman MR. Complementary and alternative medicine in aging. In: Hazzard WR, Blass JP,
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Halter JB, eds. Principles of geriatric medicine and gerontology. 5th ed. New York: McGraw-Hill; 2003. p. 231-42. Cherniack EP, Ceron-Fuentes J, Florez H, et al. 2008. Influence of race and ethnicity on alternative medicine as a self-treatment preference for common medical conditions in a population of multi-ethnic urban elderly. Complement Ther Clini Pract 2008;14:116-23. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of the effects of dietary patterns on blood pressure. N Engl J Med 1997;336:1117-24. Wong, C. SAM-e. Updated January 23, 2008. Available at http://altmedicine.about.com/od/treatmentsfromatod/a/ SAMe.htm. Cited February 16, 2009. MayoClinic.com. Coenzyme Q10. March 1, 2008. Available at www.mayoclinic.com/health/ coenzyme-q10/NS_patient-coenzymeq10. Cited February 16, 2009. National Center for Complementary and Alternative Medicine, National Institutes of Health. Menopausal symptoms and CAM. Updated February 2009. Available at http://nccam.nih.gov/health/menopause/D406.pdf. Cited February 16, 2009. MayoClinic.com. Saw palmetto (Serenoa repens [Bartram] Small). February 1, 2008. Available at www. mayoclinic.com/health/saw-palmetto/ NS_patient-sawpalmetto. Cited February 16, 2009. National Center for Complementary and Alternative Medicine, National Institutes of Health. CAM and diabetes: a focus on dietary supplements. June 2008. Available at http://nccam.nih.gov/health/diabetes/ CAM-and-diabetes.htm. Cited February 16, 2009. National Cancer Institute. Complementary and alternative medicine in cancer treatment: questions and answers. Available at www.cancer.gov/cancertopics/ factsheet/Therapy/CAM. Cited February 16, 2009.
BARBARA E. MOQUIN, PhD, APRN, BC-P, is a senior nurse specialist (research) at the National Center for Complementary and Alternative Medicine (NCCAM), a component of the National Institutes of Health (NIH), Bethesda, MD. MARC R. BLACKMAN, MD, is affiliated with the Division of Intramural Research of NCCAM, a component of the NIH; and an adjunct professor at the University of Maryland, School of Medicine, Baltimore, MD. ETHEL MITTY, EdD, RN, is an adjunct clinical professor of nursing at the College of Nursing, New York University, John A. Hartford Institute for Geriatric Nursing, New York University, New York, NY. SANDI FLORES, RN, C, is the executive director of the American Assisted Living Nurses Association and the education director of Community Education, LLC (www. communityed.com), San Marcos, CA. 0197-4572/09/$ - see front matter Ó 2009 Mosby, Inc. All rights reserved. doi:10.1016/j.gerinurse.2009.03.002
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