Complementary and Alternative Medicine Use in Older Populations

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Complementary and Alternative Medicine Use in
Older Populations

• Bill Elder PhD
• Department of Family and Community Medicine
• University of Kentucky College of Medicine
• 13th Annual Southern AHEC Summer Conference

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Learning Objectives

• To define complementary and alternative medicine
  (CAM)
• Discuss trends in CAM use.
• To discuss characteristics, preferences and
  practices of aged CAM users
• Make recommendations for clinical approach
  folowing Jonas 4P model.
• Discuss research trends in CAM

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Summary

• The widespread and increasing
• use of CAM invites us
• to ask and listen to our patients
• to contribute what EBM offers
• to advocate for better research
• and at the same time
• to acknowledge that our patients are individuals
  with values and preferences that influence their
  treatment choices.

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Definitions

• CAM A group of diverse medical and health care
  systems, practices, and products that are not
  presently considered to be part of conventional
  medicine (1)
• Complementary Medicine. Treatment used together
  with conventional medicine.
• Alternative Medicine Treatment used in place of
  conventional medicine. An unrelated group of
  non-orthodox therapeutic practices, often with
  explanatory systems that do not follow
  conventional biomedical explanations (2)

(1) Eisenberg 1993 (2) Medline mesh term
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Integrative Medicine

• An effort to combine the best evidence based
  treatments while emphasizing the primacy of the
  patient-provider relationship and the importance
  of patient participation in health promotion,
  disease prevention and medical management.

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Major Domains of CAM

• Alternative medical systems
• Mind-body interventions
• Biologically-based treatments
• Manipulative and body-based methods
• Energy therapies

www.nccam.nih.gov
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List Changes Continually

• The list of what is considered to be CAM changes
  continually as those therapies that are proven to
  be safe and effective become adopted into
  conventional health care and as new approaches to
  health care emerge.

www.nccam.nih.org
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Some CAM modalities are ancient
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Some were tried and largely discarded Phrenologic
al brain mapping device
http//www.mtn.org/quack/devices/psycogrf.htm
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Some are being retried in new ways

• Transcranial magnetic stimulation with brain
  mapping

http//www.centerwatch.com/patient/studies/stu5452
7.html
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Who Uses CAM?

• Large increase in past 50 years in U.S. and
  other industrialized countries. (1)
• Between 1990 to 1997, increase from 34 to 42 of
  US households reporting CAM use. (2)
• Surveys of primary care clinic populations show
  28-47 utilization of CAM. (3)

(1) Kessler 2001 (2) Eisenberg 1998 (3) Palinkas
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White, et al, NEJM 1961
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Green, et al, NEJM 2001
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Who Uses CAM?

• Report of primary care clinicians in
• Kentucky Ambulatory Network
• Patient(s) asked about CAM 86
• Patient(s) reported CAM use 94
• Clinician used CAM 49
• Clinician recommended CAM 80

Flannery, KAN CAM, 2003
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(No Transcript)
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CAM Modalities Used in Self-Care
U Texas Galveston Medical School Class of 2005
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Driving Social Forces for CAM Research

• Costs and finances
• Out of pocket expenditures 34 billion 1997 (1)
• Safety
• Cultural diversitypluralistic health care
• Insurance/legislation changes
• Informed and activist patients
• Baby Boomers
• Influential-Known for changing every institution
  they encounter
• Cultural Creatives (2)
• New values sets
• Changes in expectations for doctor-patient
  relationships

(1) Eisenberg 1998 (2) Ray 2000
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Why Do People Use CAM?

• Desire for health and wellness and prevention of
  aging
• Use offers sense of empowerment, authenticity
• Nature- purification of self, return to
  simplicity from technological society
• Vitalism- enhancement of own life forces
• Tradition- relying on the history of human
  experience
• Spirituality-
• Conventional-connection between health and
  spirituality
• Psychological- religion of healthy
  mindedness-Wm. James

Wolsko 2002 Kaptchuk 2000
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Why do people use CAM?

• To control pain 87
• Heard it will help 86
• CAM is safe and will not hurt 72
• Helped someone else 62
• Prescribed medication not working 46
• Will cure my condition 10

Rao 1999
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What do CAM users want?
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CAM Use by Older Adults Mt. Sinai Study

• Primary Care Geriatrics Practice
• Ages 6574 (26), 7584 (47), 85 (27)
• 73 using CAM
• Focus on percentage of patients taking
  anticoagulants_garlic, ginger, vitamin E, ginko
  biloba

Cohen, Ek, Pan 2002
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CAM Use by Older Adults Mt. Sinai Study
Cohen, Ek, Pan 2002
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CAM Use by Older Adults Mt. Sinai Study
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Use with Selected Conditions Patients of
Rheumatologists

• Excluded nursing home residents, dementia
• Avg. age 55, Disease duration 10.8 years
• Diagnoses RA, fibromyalgia, OA
• Did not include relaxation, exercise, OTC salves
• 56 currently, 90 regularly in the past
• Avg 2.6 modalities.
• Found helpful chiropracty (73), spiritual
  healing (75), copper bracelets (21), vinegar
  (22), megadose vitamins and herbals (50)
• 10 using glucosamine or chondritin 33 found
  helpful

(1) Rao, Mihhaliak, Kroenke, Bradley, Tierney
Weinberger 1999
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Use with Selected Conditions Cancer Patients

• Average 31 , range 7 to 64 (1)
• MD Anderson Comprehensive Cancer Care Center (2)
• 55 older than age 55
• 83.3-used a CAM approach
• 68.75 if exclude spiritual practices and
  psychotherapy
• 25 use seven plus CAM therapies
• Reasons to use
• 73 desire to feel hopeful
• 48 approach is nontoxic
• 43 more control in medical decisions
• Distant disease RR11.6
• Incurable disease RR14.2
• 76 improve quality of life
• 71 boost immune system
• 62 prolong life
• 44 relieve symptoms
• 37.5 expect to cure

• Ernst Cassileth, 1998 (2) Richardson, Sanders,
  Palmer, Singletary 2000

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Use with Selected Conditions Cardiovascular
Disease

• Mean age 64
• Diagnoses atrial fibrillation, CHF, Ischemic
  heart disease
• 64 use CAM
• 40 Nutraceuticals 35 megadose vitamins
• 80 indicated discussed with their phsysician
• 58 taking potentially medication with potential
  interactiondigoxin, warfarin, sotalol,
  amiodarone-
• 61 lacked information on risks and adverse
  effects

Wood, Stewart, Merry, Johnstone Cox 2003
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Differences in Aged

• It has been assumed that aged adhere to passive
  model
• Some older adults may be seeking to control costs
  or have access problems (1)
• Relatively few individuals rely exclusively upon
  alternative modalities (1).
• Many use CAM because of preference, and the
  perception that the combination of CAM and
  conventional treatments is superior to either
  alone (2).

(1) Cuellar, Aycock, Cahil Ford 2003 (2) Astin
1998 (3) Eisenberg 2001
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Importance of Therapeutic Relationship to Older
Adults

• Study of 77 Canadian patients, mean age 67
• No difference in perception of health or
  satisfaction
• Those selecting CAM
• More likely to be female 60 vs. 76, college
  grads, managers or professionals higher income
• Less life threatening problems however feel more
  limited
• Have different expectations for relationship
  want more egalitarian more time more closeness
• More skeptical about medicine
• Stronger sense of self-responsibility

Kelner Wellman http//www.utoronto.ca/CAMlab/ p
ublications/col_older_adults_use_of.html
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What Do CAM Users Want?

• Empowerment in medical interactions
• Chance to share their own views about health and
  healing
• Health provider who will spend time with them
• Someone who will answer their questions

Weil 2000
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Advising Patients About CAM
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General Guidelines for Advising Patients Who Seek
Alternative Medical Therapies

• Ask, dont tell
• Be willing to learn
• Communicate, Collaborate
• Diagnose
• Explain and Explore options/preferences

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Ask the Unasked Questions

• What, if any, alternative therapies have you
  tried for this problem?
• Considered?
• Have questions about?
• Besides these prescriptions, are you taking any
  over the counter products, supplements, or herbs?

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(No Transcript)
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Advising Patients About CAM

• Use evidence for
• efficacy
• safety
• to place therapy on continuum
• recommend
• accept
• discourage

Weiger 2002
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Framework for approaching CAMin clinical
situations

• Protect against dangerous practices.
• Permit practices that are harmless and that may
  help.
• Promote and use practices that are safe and
  effective.
• Partner with patients and encourage communication
  about CAM.

Jonas 2000
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Five Giants of Geriatric Care

• Iatrogenic Causes
• Herbal medications as polypharmacy (1)
• Cognitive Decline
• See handouts from Dr. Cooper
• Acute Confusional States
• Drug interactions
• Urinary tract infections (2)
• Increase fluids and decrease known irritants
• Flaxseed (mucialge) Vitamin C to increase
  acidity
• Unsweetened cranberry juice-300 mL QD
• Falls
• Tai Chi
• Dance therapy
• Incontinence (1,2)
• Urinary Drug therapy less effective than
  behavioral training. biofeedback
• Fecal biofeedback -- intral-anal
  electomyographic sensors 3 balloon system to
  increase awareness of rectal distension
• (1) Ness, Johnson Nisly 2003 (3) Rakel 2003
  Teunissen, de Jonge, van Weel Lagro-Janssen
  2004 Norton 2004

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First, PROTECT!

• Assure that an adequate diagnostic evaluation has
  been performed
• Be certain that no contraindications to exist
• Assess the safety of the CAM modality

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Framework for approaching CAMin clinical
situations

• Question
• Is permit the right word here?
• Do health professionals have the power to
  permit practices that their patients choose?

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If your decision is to PERMIT.

• Document the patients decision in the chart
• Observe for changes that indicate a need for
  re-evaluation
• Monitor for adverse effects
• Assist the patient in evaluating outcomes

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Is this a treatment you wish to PROMOTE?

• Good evidence for safety and efficacy
• Knowledge of credentials of CAM practitioner
• OR
• Confidence in quality of product

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Framework for approaching CAMin clinical
situations

• Protect against dangerous practices.
• Permit practices that are harmless and that may
  help.
• Promote and use practices that are safe and
  effective.
• Partner with patients and encourage communication
  about CAM.
• Jonas 2000

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PARTNER with patients and communicate about CAM

• ASK! ALWAYS!
• Build a history that includes CAM use. (Dont
  take one.)
• When patients tell, LISTEN!
• Haidet 2003

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Evidence-based Medicine (EBM) and CAM

• EBM aims to integrate
• best research evidence
• clinical expertise
• patient values

Sackett 2000
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Interdisciplinary CAM Curriculum Integration
Project
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Critical Thinking and CAM

• Perhaps no discipline demands critical thinking
  more than the study of complementary and
  alternative medicine.
• Lynn Freeman, In Mosbys Complementary
  and Alternative Medicine
• (Critical thinking) depends on the ability to
  adjust our thinking to different domains of
  thought-to conceptualize different questions from
  different points of view

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Specific Aims of the CAM Project

• The specific aims of this project are to
  measurably improve among faculty and students
• The delivery and utilization of
  scientifically-based CAM knowledge, with an
  open-mindedness towards modalities based in
  alternate belief system
• The number and types of role models who teach
  CAM.
• The ability of learners to apply CAM knowledge in
  a patient centered manner, including negotiating
  care plans and without encumbrance of
  health-belief biases
• Knowledge, skills and attitudes towards
  interdisciplinary care with CAM practitioners

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NIH Funding

• FY 1992 OAM 2 M
• FY 1999 NCCAM 50M
• 2005 121 M
• Total NIH funding for CAM 273.4 M
• Total NIH Budget FY 2004 Approx 24 B
• NCCAM Mission
• Research
• Research Training and Career Development
• Integration
• Outreach
• http//nccam.nih.gov/health/magnet/magnet.htm

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NCCAM Award Types

• Research Awards
• P01, R01, R15, R21, U01, U19 Competing Research
  Project Grants
• P01, R01, R21, U01 Non-Competing Research
  Project Grants
• R01, R21 Administrative Supplements
• R42, R43, R44 Small Business Research Grants
• P20, P30, P50 Centers
• Center for CAM Research in Aging, Columbia
  University, New York
• K01, K05, K07, K08, K23, K24, K30 Career
  Development Awards
• R13 Conference Grants
• Nutritional Modulation of Aging and Age-Related
  Diseases, Am Aging Assoc
• R25 CAM Education Project Grants
• F05, R24, S07, T15, U09, U10 Other Research
• Training
• F31, F32 Individual Training
• T32 Institutional Training
• Multidisciplinary Respiratory Diseases Research
  Training, UCHSC
• www.nccam.nih.gov/clinicaltrials

http//nccam.nih.gov/research/extramural/awards/20
03/index.htm