Complementary and Alternative Medicine Use in Older Populations

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 1 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 Jona’s 4P model. • Discuss research trends in CAM 2 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. 3 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 4 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. 5 Major Domains of CAM • • • • Alternative medical systems Mind-body interventions Biologically-based treatments Manipulative and body-based methods • Energy therapies www.nccam.nih.gov 6 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 7 Some CAM modalities are ancient 8 Some were tried and largely discarded Phrenological brain mapping device http://www.mtn.org/quack/devices/psycogrf.htm 9 Some are being retried in new ways Transcranial magnetic stimulation with brain mapping http://www.centerwatch.com/patient/st udies/stu54527.html 10 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 11 White, et al, NEJM 1961 12 Green, et al, NEJM 2001 13 14 Who Uses CAM? Report of primary care clinicians in Kentucky Ambulatory Network • Patient(s) asked about CAM • Patient(s) reported CAM use • Clinician used CAM 86% 94% 49% • Clinician recommended CAM Flannery, KAN CAM, 2003 80% 15 16 CAM Modalities Used in Self-Care 35 30 25 20 15 10 5 0 Percentage Biological-based Intervention Manipulative/body-based methods Energy Therapies Alternative Medical Systems Mind-body Therapies U Texas Galveston Medical School Class of 2005 17 Driving Social Forces for CAM Research • Costs and finances – Out of pocket expenditures $34 billion 1997 (1) • • • • Safety Cultural diversity—pluralistic 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 18 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 19 Why do people use CAM? • • • • • • To control pain Heard it will help CAM is safe and will not hurt Helped someone else Prescribed medication not working Will cure my condition 87% 86% 72% 62% 46% 10% Rao 1999 20 What do CAM users want? 21 CAM Use by Older Adults: Mt. Sinai Study • • • • Primary Care Geriatrics Practice Ages: 65–74 (26%), 75–84 (47%), 85 + (27%) 73% using CAM Focus on percentage of patients taking anticoagulants:_garlic, ginger, vitamin E, ginko biloba Cohen, Ek, Pan 2002 22 CAM Use by Older Adults: Mt. Sinai Study Cohen, Ek, Pan 2002 23 CAM Use by Older Adults: Mt. Sinai Study 24 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 25 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 RR=11.6 Incurable disease RR=14.2 76% improve quality of life 71% boost immune system 62% prolong life 44% relieve symptoms 37.5 expect to cure 26 (1) Ernst & Cassileth, 1998; (2) Richardson, Sanders, Palmer, & Singletary 2000 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 interaction—digoxin, warfarin, sotalol, amiodarone• 61% lacked information on risks and adverse effects Wood, Stewart, Merry, Johnstone & Cox 2003 27 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; 28 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/ publications/col_older_adults_use_of.html 29 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 30 Advising Patients About CAM 31 General Guidelines for Advising Patients Who Seek Alternative Medical Therapies • • • • • Ask, don’t tell Be willing to learn Communicate, Collaborate Diagnose Explain and Explore options/preferences 32 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?‖ 33 34 Advising Patients About CAM Use evidence for  efficacy  safety to place therapy on continuum recommend accept discourage Weiger 2002 35 Framework for approaching CAM in 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 36 Five Giants of Geriatric Care • • • Iatrogenic Causes – – ―Herbal medications as polypharmacy‖ (1) See handouts from Dr. Cooper Cognitive Decline 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 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 37 Incontinence (1,2) 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 38 Framework for approaching CAM in clinical situations Question: Is ―permit‖ the right word here? Do health professionals have the power to ―permit‖ practices that their patients choose? 39 If your decision is to PERMIT. • Document the patient’s decision in the chart • Observe for changes that indicate a need for re-evaluation • Monitor for adverse effects • Assist the patient in evaluating outcomes 40 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 • 41 Framework for approaching CAM in 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 42 PARTNER with patients and communicate about CAM • • ASK! ALWAYS! “Build” a history that includes CAM use. (Don’t “take” one.) When patients tell, LISTEN! • Haidet 2003 43 Evidence-based Medicine (EBM) and CAM EBM aims to integrate – best research evidence – clinical expertise – patient values Sackett 2000 44 Interdisciplinary CAM Curriculum Integration Project Conceptual Model for CAM Project CAM Knowledge and Skills Patient Centered Care Skills and Self Awareness Medical Knowledge and Skills Critical Thinking: Open Mindedness Analytical Training 45 College of Medicine Critical Thinking and CAM & College of Health Sciences Perhaps no discipline demands critical thinking more than the study of complementary and alternative medicine. Lynn Freeman, In Mosby’s 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 46 College of Medicine Specific Aims of the CAM Project & College of Health Sciences The specific aims of this project are to measurably improve among faculty and students: 1. The delivery and utilization of scientifically-based CAM knowledge, with an open-mindedness towards modalities based in alternate belief system 2. The number and types of role models who teach CAM. 3. The ability of learners to apply CAM knowledge in a patient centered manner, including negotiating care plans and without encumbrance of health-belief biases 4. Knowledge, skills and attitudes towards interdisciplinary care with CAM practitioners 47 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 48 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 http://nccam.nih.gov/research/extramural/award s/2003/index.htm www.nccam.nih.gov/clinicaltrials 49