CAM and Senior Health

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CAM and Senior Health

• September 2004
• William H. Hardt MD
• Assistant Professor of Medicine
• Loma Linda University School of Medicine
• Riverside County Regional Medical Center

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• Objectives
• Understand current types and patterns of CAM use
  in the United States.
• Recognize and address CAM related questions from
  your patients
• Discuss issues involving Quackery in CAM and
  Conventional medicine
• Provide resources for further study

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Nineteenth Century Professional Care

• Botanical healers
• Midwives
• Homeopathic healers
• Apothecaries
• uncounted cancer doctors, bonesetters,
  inoculaters, abortionists, and sellers of
  nostrums.
• Allopaths (M.D.s)

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• Complementary and Alternative Medicine (CAM)
• Integrative Medicine in 2002
• Medical interventions not widely taught in
  medical schools or generally available at U.S.
  hospitals.
• Eisenberg DM, et. al. NEJM 1993 Vol. 328

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• What most sets alternative medicine apart, in
  our view, is that it has not been scientifically
  tested and its advocates largely deny the need
  for such testing.
• Editors NEJM

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• The modern biomedical model of health and
  illness is based in part on seventeenth-century
  cartesian mind-body dualism, and has emphasized
  the body in isolation, often neglecting the
  mind.
• Osher Center for Integrative Medicine, UCSF

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CAM

• CAM is a group of diverse medical and health
  care systems, practices, and products that are
  not presently considered to be part of
  conventional medicine--that is, medicine as
  practiced by holders of M.D. (medical doctor) or
  D.O. (doctor of osteopathy) degrees and their
  allied health professionals, such as physical
  therapists, psychologists, and registered
  nurses.
• National Center for Complementary and Alternative
  Medicine www.nccam.nih/gov

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CAM and Conventional Medicine

• As Medical professionals, what is to be our
  approach to CAM?

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Charter on Medical Professionalism Fundamental
Principles and Professional Responsibilities
Blank, L. et. al. Ann Intern Med 2003138839-841
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Complementary and Alternative (CAM) Medicine Use

• Prevention Magazine (NIH supported telephone
  survey)
• In 1997 one-third of US population using CAM
  therapy
• 67.6 of respondents had used CAM at least once
  in their lifetime
• Lifetime use steadily increases with age across
  age cohorts
• Pre-baby boomers (Born before 1945) - 3/10
• Baby boomers (Born 1945-1964) - 5/10
• Post-baby boomers (Born 1965-1979) - 7/10

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National Health Interview SurveyNational Center
for Health StatisticsCenter for Disease Control

• 2002 edition of the NCHS's National Health
  Interview Survey (NHIS). 2004 release
• An annual study in which Americans are
  interviewed about their health- and
  illness-related experiences.
• 31,044 adults aged 18 years or older from the
  U.S. civilian non-institutionalized population.

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National Health Interview SurveyNational Center
for Health StatisticsCenter for Disease Control

• Estimated Annual U.S. Expenditures on CAM
• 36-47 Billion overall
• 12.2-19.6 Billion was paid out-of-pocket
• This is more than the U.S. public paid out of
  pocket for all hospitalizations in 1997 and about
  half that paid for all out-of-pocket physician
  services.

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CAM and Senior Health

• What has made a difference in average life
  expectancy and maximum life span in the last 100
  years?

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Leading Causes of Death in US

• 1900
• Pneumonia and flu
• Tuberculosis
• Diarrhea and intestinal ills
• Heart disease
• Stroke and brain lesions
• Kidney inflammation
• Accidents
• Cancer
• Senility
• Diphtheria

• 2001(latest CDC data)
• Heart disease
• Cancer
• Stroke and brain lesions
• Lung disease
• Accidents
• Diabetes
• Pneumonia and flu
• Alzheimer's disease
• Kidney inflammation
• Septicemia

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Public Health Measures Main Contributor to
Improvements in morbidity and mortality

• Water purification
• Sanitation
• Immunization (diphtheria, polio)
• Antibiotics

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Current Milieu in managing Senior Health

• Successful Aging
• Longevity
• Maintaining function
• Maintaining independence

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• Jeanne Calment
• Oldest documented human.
• Died at 122 years old, August 4, 1997

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• Senior Health and CAM
• A daunting array of options

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• Massage Therapy
• Dietary supplements
• Therapeutic Touch
• Hormone replacement therapy
• Chelation therapy
• Cancer remedies
• Others

• Homeopathy
• Naturopathy
• Herbal Medicine
• Traditional Medicine
• Mind-Body Medicine
• Energy Medicine
• Ayurvedic Medicine
• Biomedicine

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Alternativism and Health

• A Multibillion dollar industry and rising
• 1992 Congress establishes Office of Alternative
  Medicine, under the NIH
• 1994 Dietary Supplement Health and Education Act
  (DSHEA)

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Problems with Supplements

• Few clinical trials with good methodology
• Issues of standardization (selection bias, lack
  of controls)
• Absence of standards for supplements
• Where clinical trials are performed different
  preparations are used
• Evaluations of label contents found gross errors

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• Dr. Nelson and colleagues advertise that algae
  (marketed as Sun Chlorella) is a radical
  discovery that will. . .
• Destroy viruses, bacteria and foreign invaders
  "I haven't had a cold in two years
• Clobber cholesterol powerful natural
  breakthrough
• Soothe joints 88 percent success rate - new
  study  
• End tiredness The real reason people get
  tired-and an easy solution for you
• Banish brain fog Keep your mind as sharp as a
  tack with this secret  
• Beautiful, smooth, creamy looking skin Amazing!
• Stay trim and slim "50 pounds just vanished"-
  one woman's story  
•     

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  High amounts of DNA RNA have been shown to
have considerable beauty benefits!
Now you can fool your friends into thinking
you're years younger with the help of these same
nucleic acids, along with other nutrients.Your
friends won't believe how good you look - year
after year after year. Because you'll just keep
getting healthier and looking younger, while they
grow older and gain more wrinkles!
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A rejuvenated love life! "I can't get enough of
Sun Chlorella, that is... It's rejuvenated my
love life. I am an athletic 53-year old man. I
have found in the past that I routinely hibernate
during the winter and am more tired. Now that
I've been taking Sun Chlorella, I am re-awakened
and my much younger fiancée is very pleased. Our
love life has reached its peak. Thanks, Sun
Chlorella, for the stamina." -Eric Macias,
Redondo Beach, CA
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• What leading medical doctors,scientists and
  health
• experts say about this amazing discovery...

"This is the most significant nutritional
breakthrough I've seen in over 25 years - I've
seen my patients go from couch potatoes to active
dynamos. It has had a remarkable effect on
thousands..." - Michael E. Rosenbaum, M.D., noted
physician, nutritionist and expert on Chronic
Fatigue Syndrome
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     "A remarkable, 100 natural
detoxifier. "When my patients come to me
with unsolvable health problems, I often start
them on a detoxifying antioxidant program.
There's nothing better for rejuvenating and
cleansing body tissues than this discovery..."
- David C. Freeman, M.D., Fellow, American
Geriatrics Society and former Director of the
American Academy of Medical Preventics
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  "I strongly advise the addition of this
breakthrough to the diet of anyone interested
in better health. My own clinical studies - and
studies from around the world - have convinced me
of its value. My family and I use it regularly,
and I recommend it to my patients." - David
Steenblock, M.S., D.O., President of the
Anti-Aging Research Institute of America
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• (16)Merchant FL, Rice CC, Young HF, et al.
  Dietary chlorella pyrenoidosa for patients with
  malignant glioma. Phytotherapy Research,
  19904(6)220-230
• (17)Wilkinson, S. Golding KH, Robinson PK, et
  al. Mercury removed by immobilized algae in batch
  culture systems, J Appl Physical, 19902223-230

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• Open-mindedness and Healthy Skepticism

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CAM

• Benefits (Perceived)
• Patient autonomy
• Personal control over health care
• Prevention
• Improvements in chemical balance, energy, and
  harmony with nature
• Costs

• Risks
• Medical decision making without appropriate
  training
• False sense of safety
• Generally lacking in scientific evidence of
  safety and efficacy
• Claims that are difficult to substantiate
• Costs

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5-TP/TryptophanAloe Vera DrinkAlpha-Lipoic
AcidAndrostenedioneArginineBeta Carotene
BilberriesBlack CohoshBlue-Green
AlgaeCalciumCat's ClawChaparral
CholestinCholine Chondroitin SulfateChromium
  PicolinateCLACoenzyme Q-10Colostrum, Bovine
Creatine
DHEAEchinaceaEphedraEvening Primrose
  OilExercise in a Bottle Fat Trapper
Feverfew
Herbal (Diet) TeasHuman Growth 
HormoneHuperzine AJuice PlusKavaLysineLutein
MelatoninMemory and Brain  SupplementsMicrohyd
rinMilk ThistleMinerals, ChelatedMinerals,
Colloidal MSM
PycnogenolQuercetinRose HipsRoyal
JellySAM-eSassafrasSaw PalmettoSeleniumSenior
Moment    Soy IsoflavonesSt. John's
WortStanol/Sterol  SupplementsTocotrienolsVale
rianVanadyl SulfateVitamin AVitamin
B-12Vitamin CVitamin DVitamin EVitamin
KYohimbeZinc  
Flaxseed    Folic AcidGarciniaGarlic
PillsGBLGero VitaGinger
 
Ginkgo BilobaGinsengGlucosamineGoldensealGrape
Seed ExtractGuggulipidHawthorn 
Multivitamins NiacinNoni Juice Phosphatidylserin
e
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The Risk-Benefit Profile of Commonly Used Herbal
TherapiesAnnals of Internal Medicine 1 January
2002, Vol. 136. No. 1

• Ginkgo
• St. Johns Wort
• Ginseng
• Echinacea
• Saw Palmetto
• Kava Kava

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The Risk-Benefit Profile of Commonly used Herbal
Therapies

• Ginkgo (Ginkgo biloba)
• Memory impairment no compelling evidence
• Dementia 3 pooled difference, likely relevant
• Tinnitis Therapeutic value uncertain
• Intermittent Claudication less effective than
  walking exercises
• Safety risks bleeding (subdural hematoma),
  seizures, may interact with anticoagulants

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The Risk-Benefit Profile of Commonly used Herbal
Therapies

• St. Johns Wort (Hypericum perforatum)
• Herbal antidepressant
• Probable SSRI, SDRI, NRI mechanism of action
• For mild to moderate depression
• Similar in effectiveness to low-dose Tricyclic
  antidepressants
• Excellent safety profile
• clearly superior to conventional
  antidepressants.
• Safety risks induces hepatic enzymes P450
  system,
• Combination with SSRIs may increase risk for
  Serotonin Syndrome

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The Risk-Benefit Profile of Commonly used Herbal
Therapies

• Ginseng (Panax ginseng)
• Complex terminology and lack of clear distinction
  between different types of ginseng
• recommended as having ability to improve stamina,
  concentration, vigilance, and well-being.
• Compelling evidence of efficacy lacking.
• Safety risks insomnia, diarrhea, vaginal
  bleeding, mastalgia, severe headache,
  schizophrenia, and Stevens-Johnson syndrome

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The Risk-Benefit Profile of Commonly used Herbal
Therapies

• Echinacea (Echinacea species)
• Products vary considerably, no single ingredient
• Pharmacologic actions include stimulation of
  immune system
• Best researched indications are treatment of
  upper respiratory tract infections
• Results non-conclusive, may be efficacious, trial
  data weak and inconclusive
• Safety risks Hepatitis, asthma, rash, rash with
  myalgias and nausea, dizziness and swollen
  tongue, anaphylaxis

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The Risk-Benefit Profile of Commonly used Herbal
Therapies

• Saw Palmetto (Serenoa repens)
• Benign prostatic hyperplasia
• Antiandrogen activity, inhibition of
  5-?-reductase
• Good evidence indicates efficacy short-term and
  probably medium term, unknown long-term benefits
• Withdrawal rates (rough indicator of patient
  acceptance) better than finasteride
• Safety risks Constipation, decreased libido,
  diarrhea, headache, hypertension, nausea, urinary
  retention. All are rare and usually mild

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The Risk-Benefit Profile of Commonly used Herbal
Therapies

• Kava Kava (Piper methysticum)
• Anxiolytic
• South Pacific recreational drink
• Central muscle relaxant and anticonvulsant
  actions
• Short administration of kava is effective in
  reducing anxiety
• Safety risks Reversible yellowish discoloration
  of skin, nails, and hair (chronic abuse), visual
  disturbances, dizziness, stupor, GI discomfort,
  extrapyramidal effects (rare), hepatitis

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FDA warning

• Kava (Piper methysticum)
• Warning about severe liver injury, including
  hepatitis, cirrhosis, and liver failure

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California Department of Health Services

• PC SPECS and SPES capsules from Botaniclab, Brea
  California
• for prostate health strengthening the immune
  system.
• Contains undeclared prescription drug ingredients
  
• PC SPECS contains warfarin
• SPES contains alprazolam

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Hormone replacement therapy and anti-aging

• Human Growth Hormone and Secretagogues
• Replacement promoters claim remarkable increases
  in life span.
• Decrease central fat, improves lipid and glucose
  levels, reduces severity of Crohns, and others
• More studies needed

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Hormone replacement therapy and anti-aging

• DHEA (dehydroepiandrosterone)
• Promoters claim improved stamina, concentration,
  mood.
• Little know about DHEA physiologic function
• Health food stores generally dont contain DHEA
  but rather plant sterols that are botanical
  building blocks of DHEA
• Unknown long term side effects
• Warning in use with hormone responsive tumors
• Drug companies not likely to pursue

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Senior Health, Longevity, and Quality of Life

• Studies that identify factors that contribute to
  longevity and health have not yet shown that
  supplements have any effect.
• Caveat Omega-3 fatty acids, Glucosamine.

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Known factors associated with health and
longevity

• Non-smoking
• Moderation in alcohol use
• Exercise
• Weight control
• Stable relationships and coping mechanisms
• Personal control over lifestyle

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Prevention in Senior CareUS Preventive Services
Task Force Guidelines

• Detection and Treatment of hypertension
• Managing modifiable risk factors for CAD
• Breast cancer screening
• Colon cancer screening
• Sensory screening (hearing, vision)
• Diet counseling
• Injury prevention
• Immunization

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Education

• The Key to protection and safety

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Quackery in Health Care
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• Quackery
• anyone who promotes medical schemes or remedies
  known to be false, or which are unproven, for a
  profit.
• Congressman Claude Pepper, 1984

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• Quackery
• Anything involving over promotion in the field of
  health
• Example Total body scans?
• Vitamin B12 shots?

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Ten Ways for Patients to Avoid Being Quacked

1. Quackery seldom looks outlandish
2. Faulty nutrition causes most diseases and
   requires supplements
3. Be wary of anecdotes and testimonials
4. Be wary of pseudomedical jargon
5. Be skeptical of paranoid accusations

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Ten Ways to Avoid Being Quacked

1. Watch out for secret cures
2. Maintain a healthy skepticism of herbal remedies
3. Be wary of products treating a wide range of
   unrelated diseases
4. Ignore appeals to vanity, think for yourself
5. Dont let desperation cloud judgment

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• Summary
• 1. Keep open-minded about new or unproven
  treatments
• 2. Maintain a healthy skepticism, and apply EBM
  techniques.
• 3. Encourage patients to report use of
  alternative therapies in an uncritical
  environment
• 4. Provide reliable resources for education of
  patients
• 5. Guide patients in appropriate lifestyle
  changes to maintain functionality and improve
  longevity
• 6. Apply USPSTF guidelines to all senior patients

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• Resources
• National Center for Complementary and Alternative
  Medicine. www.nccam.nih.gov
• German Commission E Monographs www.herbalgram.org
• Consumer Health Digest, National Council Against
  Health Fraud www.ncahf.org
• ConsumerLab.com www.consumerlab.com
• Medical Clinics of North America
• January 2002
• National Library of Medicine, PubMed
  www.ncbi.nlm.nih.gov

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Resources PDA downloadable

• Tarascon Pocket Pharmacopoeia, Deluxe
• 2004 Tarascon Publishing and USBMIS, Inc.
  www.tarascon.com
• ePocrates RxPro, Version 6.13 Palm version
• www.epocrates.com

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• I took pleasure when I could. I acted clearly
  and morally and without regret. Im very lucky.
• Jeanne Calment