57: Considering Complementary & Alternative Medicines for Older Adults

Complementary and alternative therapies have been defined as therapies that either fall outside of the conventional thought and approach to a given disease or that are not taught in U.S. medical schools or widely provided by U.S. hospitals. The National Center for Complementary and Alternative Medicine divides these therapies into 5 major domains (Table 57–1).

Among older adults, the most commonly used complementary and alternative therapies are chiropractic therapy, herbal remedies, relaxation techniques, and high-dose or megavitamins.

Patients using complementary and alternative therapies often do not report their use to their physicians. Some therapies, such as herbs, may have side effects or may interact with conventional therapies. Physicians should ask specifically whether older patients are using them or seeing practitioners. Asking about interest in and use of complementary and alternative therapies may also strengthen the physician–patient relationship and facilitate exploration of a patient’s needs and expectations.

When an older patient elects to use complementary and alternative treatments, it is important to establish clear goals and endpoints, to apply the same evidence-based medicine principles to the literature, to be knowledgeable and open-minded, and to listen to and hear patient preferences. Practitioners should discuss evidence (or lack thereof) for safety and efficacy of both conventional and alternative options. Do not break the patient’s trust by quarreling over placebo effect if you note an improvement, the cost is manageable, there is low toxicity, and the patient is not rejecting other appropriate treatments. Finally, it is recommended that physicians get to know licensed complementary and alternative practitioners and develop a referral base.

Massage therapy and chiropractic therapy are the most widely used complementary and alternative therapies in the United States. Swedish massage, the Trager method, and reflexology are the most commonly used types of massage. Studies have consistently found benefit for massage therapy in the treatment of pain, including back pain, fibromyalgia, and headaches. Massage has also been found to be of benefit in the palliative care of patients with HIV, breast cancer, and terminal cancer pain. The improvements include decreases in pain, anxiety, and depression, along with improved sleep.

Chiropractic medicine has spinal manipulation as the core clinical activity. The vast majority of patients seek chiropractic care for back, neck, or head pain. On the basis of history, exam, and x-ray findings, the chiropractic doctor determines whether the patient’s condition will be amenable to chiropractic treatment and also plans a treatment regimen. Treatment involves spinal manipulation with or without adjunctive treatments such as heat, cold, traction, electricity, and counseling about exercise, fitness, nutrition, weight loss, smoking cessation, and relaxation techniques. Several systematic reviews have found sufficient evidence to support the beneficial use of chiropractic therapy for acute and chronic back pain. Spinal manipulation and mobilization have also shown benefit for mechanical neck pain, migraines, cervicogenic headaches, cervicogenic dizziness, and painful conditions in some extremity joints. Chiropractic treatment has not been shown to be effective treatment of nonmusculoskeletal illnesses, such as hypertension, dysmenorrhea, or asthma. As with most research, older persons make up a small minority of subjects in manipulation research trials.

Common side effects of manipulation and massage are usually mild and transient and include localized pain, headache, and fatigue. More serious side effects are very rare. Cauda equina syndrome from lumbar manipulation or stroke resulting from vertebral artery dissection has been reported. The risk of serious complications from lumbar manipulation has been estimated to be 1 in 100 million manipulations. The risk of stroke from cervical manipulation is also low, estimated at between 1 in 400,000 to 2 million manipulations. The most recent, large, case-control study found no increased risk of vertebrobasilar stroke with cervical manipulation.

Herbs are the second most common complementary or alternative therapy used by older persons. In contrast to pharmaceuticals, the production, marketing, and sale of herbs and supplements is regulated only by the Dietary Supplement Health and Education Act, which does not regulate the purity, quality, or standardization of preparations. As a result, active ingredients can vary among manufacturers and even from lot to lot for a given manufacturer. Patients and physicians should select products made by larger, more reputable companies, which specify the amounts of ingredients and standardization of the active ingredients to an accepted standard. In addition, most herbs and supplements are not routinely covered by insurance, and as such, may be cost prohibitive for many older individuals on a fixed retirement income. Table 57–2 lists the typical doses and uses of the most common herbs and supplements.

Ginkgo

Ginkgo is the top-selling herbal medicine in the United States. There are concerns about antiplatelet and warfarin-like effects of gingko, which should be avoided in patients taking anticoagulants. Although shown to reduce blood viscosity and clotting factors, gingko does not appear to cause a statistically significant increase in bleeding risk over placebo in patients not on anticoagulants. Ginkgo is clinically used and studied for dementia, memory impairment, cerebral insufficiency, tinnitus, and intermittent claudication. Overall, studies of Ginkgo are weak and the most rigorous trials show benefit for the treatment of tinnitus but speak against the use of ginkgo for treatment of dementia, memory impairment or prevention of cardiovascular events.

John’s Wort

St. John’s wort is widely used in Europe to treat depression. St. John’s wort is believed to work through selective inhibition of the reuptake of serotonin, dopamine, and norepinephrine in the brain. Several meta-analyses and qualitative systemic reviews have found St. John’s wort to be superior to placebo and comparable to tricyclic antidepressants and selective serotonin reuptake inhibitors (SSRIs) with similar side effect rates but fewer withdrawals. St. John’s wort may be used cautiously in the treatment of mild depression but is not currently recommended for moderate-to-severe depression, which should be treated with pharmacologic or cognitive–behavioral interventions with more rigorous efficacy data. Patients should not take tricyclic antidepressants, SSRIs, or monoamine oxidase inhibitors while taking St. John’s wort. St. John’s wort activates P450 enzymes, so care should be used in treating patients who are also taking warfarin, digoxin, or other drugs with hepatic metabolism.

Glucosamine/Chondroitin

Glucosamine and chondroitin are commonly used for the treatment of osteoarthritis. Both glucosamine and chondroitin are components of proteoglycans found in articular cartilage and synovial fluid. How oral glucosamine or chondroitin work physiologically is not clear, and there is little evidence that patients with osteoarthritis are deficient in these substances or that oral glucosamine or chondroitin is selectively taken to joints. Studies have found these substances to be very safe, with no more side effects than placebo.

Meta-analyses of early clinical trials of glucosamine and chondroitin have shown both to be superior to placebo in improving pain and disability. More recent trials have shown glucosamine, with or without chondroitin, to be as efficacious as nonsteroidal antiinflammatory drugs (NSAIDs) to reduce pain and disability in knee and hip osteoarthritis with fewer side effects. It is unknown whether glucosamine and chondroitin improve symptoms of osteoarthritis at other sites such as the hand or hip.

Saw Palmetto

Saw palmetto (also known as Serenoa repens) is commonly used to treat symptoms of benign prostatic hypertrophy (BPH) by inhibiting the 5α-reductase enzyme that converts testosterone to 5-dehydrotestosterone, prostaglandin synthesis, and growth factor actions. In Western Europe, saw palmetto is used much more commonly than finasteride or α blockers for BPH. Despite early evidence of benefit, the most recent meta-analysis and several randomized controlled trials found no improvement in urinary symptoms with the use of saw palmetto over placebo. There is also no evidence to support the use of saw palmetto to reduce the size of the prostate. It does not seem to affect prostate-specific antigen levels, but further studies are needed to determine the role of saw palmetto in men with or at risk of prostate cancer. Given the body of evidence speaking against the use of saw palmetto for symptoms of BPH, it should not be recommended for this use.

Ginseng

Ginseng is among the best-selling herbal supplements. It is also one of the herbs with the most reported benefits, including central nervous system effects of increased vigilance, increased concentration, increased sense of well-being, and increased relaxation along with systemic anticancer, antidiabetic, and aphrodisiac effects. The incidence of side effects is low but some can be serious, such as vaginal bleeding, Stevens-Johnson syndrome, hypertension, warfarin interactions, and hypoglycemia.

Ginseng is traditionally used as a component of traditional Chinese medicine for overall health and antiaging. Multiple studies have attempted to determine the evidence for the multiple health claims made for ginseng. To date, reviews are limited by significant methodologic issues and possible publication bias. In healthy subjects, ginseng has been shown to improve cognitive performance and may delay onset of dementia. The evidence for benefit in patients with dementia is weaker. Early trials support the use of ginseng for cardiovascular health. Currently, there is moderate and mixed evidence that ginseng improves cardiac function and reduces vascular disease. More rigorous clinical trials are needed to better describe the role and benefit of ginseng as a therapeutic and preventive agent for cardiovascular disease. There is strong evidence that ginseng improves pulmonary function but does not enhance physical performance. Overall, there is limited data to support the widespread recommendation for ginseng.

Garlic

Garlic is widely advertised and used in the United States with the aims of lowering cholesterol and blood pressure and preventing cancer. The active ingredient is allicin, and most preparations are standardized to contain 0.6% to 1.3% allicin. The most widely studied form is the Kwai powder, which contains 1.3% allicin. Side effects include odor, flatulence, diarrhea, and stomach upset. The most serious, although rare, side effect is increased bleeding, which may be a consequence of reductions in platelet aggregation.

Garlic has been found to be superior to placebo in reducing total cholesterol but not blood pressure. The total reduction in cholesterol is 12–25 mg/dL at 3 months, which is similar to the effect of dietary intervention and less than the effect of statins. None of the underlying studies lasted more than 10 months, and 1 meta-analysis suggested that the benefit of garlic may not last beyond 6 months.

Garlic was associated with reduced rates of stomach and colorectal cancer in cohort and case-control studies, but there are no randomized studies of garlic to support these findings. The effect of garlic on cancer at other sites has not been studied sufficiently to support any conclusions.

Ginger

Ginger has been used in Chinese and Ayurvedic medicine for more than 2500 years for the treatment of musculoskeletal pain and gastrointestinal illnesses. Ginger has been studied for the prevention of postoperative nausea and motion sickness and the treatment of vertigo and osteoarthritis pain, with mixed but overall slightly positive results.

Omega-3 Fatty Acids

Omega-3 (n-3) polyunsaturated fatty acids (PUFAs) are the most commonly used supplement in the United States; however, dietary sources appear to be the best way to enrich tissue levels. The richest sources of dietary PUFAs are from oily fish, such as tuna, salmon, sardines, mackerel, and herring. PUFAs can also be found in land meats (beef, pork, and chicken), but in much lower quantities. There is not currently a recommended daily allowance of PUFAs because of the paucity of scientific evidence for adequate intake levels in healthy adults; however, the American Heart Association recommends intake of 8 ounces of fish at least 2 times a week. Studies suggest 2–3 g/day to lower cholesterol and 1 g/day for secondary cardiovascular prevention. The maximum recommended daily amount is 3 g, although 4 g is often used.

The role of n-3 PUFAs in disease prevention and treatment is still being elucidated, but is most likely a result of antiinflammation and immune modulation. Diseases associated with systemic inflammation increase production of cytokines, which can be modulated by n-3 PUFAs. Studies indicate that those with chronic inflammatory conditions are likely to be more sensitive to the antiinflammatory effects than are healthy people.

The use of PUFAs for prevention of cardiovascular disease remains controversial. Early studies suggested a benefit in mortality and morbidity outcomes for both primary and secondary cardiovascular disease prevention. However, more recent randomized trials fail to reproduce this benefit in secondary prevention. There may still be a role for PUFAs in primary prevention of cardiovascular disease, and they are still recommended as part of a well-balanced, healthy diet. It is also reasonable to recommend PUFAs in people with cardiovascular disease who cannot tolerate HMG-CoA reductase inhibitors. A meta-analysis of 10 randomized controlled trials found a statistically significant reduction in arterial stiffness. Further clinical studies are needed to confirm if this equates to improved cardiovascular fitness and reduced disease and to uncover the role of PUFAs in prevention or treatment of retinal disease, cancer, mental illness, cognitive decline, and autoimmune diseases.

Acupuncture

Acupuncture is a popular alternative therapy that involves the use of sterile, disposable stainless-steel needles to stimulate points on the surface of the body along vital energy meridians. Treatments consist of weekly to biweekly sessions involving the insertion of up to 15 needles at selected points for times ranging from several seconds to 30 minutes. Once inserted, the needles can be stimulated manually or with electricity, heat, or burning herbs. Adverse effects are typically mild and include pain, bleeding, fatigue, nausea, and dizziness. Serious events (pneumothorax or vascular injuries) are rare.

Acupuncture has been shown to be efficacious in the treatment of postoperative and dental pain and for the management of nausea and vomiting resulting from a wide variety of causes. Acupuncture has also been used to treat chronic pain, osteoarthritis, headache, and back pain, but its efficacy in treating these conditions has not been established. A systematic review of the use of acupuncture in the treatment of chronic pain found insufficient evidence of benefit, and one randomized trial found acupuncture to have no benefit in the treatment of chronic back pain. However, acupuncture as a part of traditional Chinese medicine has been shown to be effective for treatment of fibromyalgia. It was shown to be ineffective for functional recovery poststroke or for reducing hot flushes.

Homeopathy

Homeopathy is an alternative medical system based on the vitalistic theory that illness results from imbalances in the patient’s vital force. The goal of homeopathy is to use medications to restore the balance and then to rely on the self-healing potential of the body to lead to a cure. A practitioner selects a remedy, after a thorough history and physical exam, by matching symptoms and findings to remedies.

Homeopathic remedies have been shown to be effective, but are limited by methodologic flaws (eg, small numbers, lack of control groups or randomization, selection bias) and publication bias. Studies of better methodologic quality were more likely to report negative results. Until rigorous studies have validated the use of specific remedies, it would be prudent to approach their use with caution.

Aromatherapy

The practice of aromatherapy consists of using volatile essential oils extracted from plants for the relief of anxiety and agitation. Essential oils can be topically applied, aerosolized, or used in massage. Side effects are rare and typically mild, making aromatherapy a useful therapeutic adjunct. A systematic review found evidence of a mild anxiolytic effect and improvement in quality of life with essential oils combined with massage in several populations, including terminal cancer patients receiving palliative care and hospitalized dementia patients. Aromatherapy has been safely used in the treatment of behavioral disturbances in people with dementia; however, benefit in clinical dementia trials is short-term and most pronounced when combined with other individualized nonpharmacologic modalities.

When counseling patients regarding complementary and alternative it is most important to maintain a trusting and open therapeutic alliance. Inquire about the use of complementary and alternative and strive to understand the reasons people choose to pursue these therapies. Learning which modalities are supported by the best evidence and which have been shown to not be effective is also important when discussing the pros and cons of using complementary therapies.