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Introduction
A large and growing percentage of Americans use complementary and alternative medicine (CAM): therapeutic modalities, practices, and products that either supplement or substitute for conventional approaches and are not conventionally used or taught in mainstream Western medicine.[1–3] These modalities can be broadly grouped under the categories of mind-body therapies, manipulative/body-based therapies, biologically based therapies, and alternative medical systems, and include such practices as meditation, chiropractic, herbal medicine, acupuncture, homeopathy, and energetic healing.[3, 4] In the United States, separation of CAM practices from mainstream medicine is often rationalized as being due to lack of evidence regarding safety or efficacy, but other factors, including historical trends, unfamiliarity with philosophies and approaches, financial disincentives, and strong influence of the pharmaceutical and insurance industries, are also responsible.[5] Whereas mainstream health care has been slow to incorporate CAM practices or education, the public has forged ahead in combining CAM use with conventional care, usually without communicating about CAM with their conventional care providers.[2] With upward trends in CAM use among all subgroups of aging populations, including the large cohort of aging baby boomers, the demand for CAM-savvy health-care providers is urgent.[6]
Fortunately, increasing numbers of conventionally trained health-care providers and institutions are recognizing the value of becoming familiar with CAM philosophies, techniques, and practitioners, both for enhancing patient communication as well as for improving clinical practice. Many are taking steps toward integrating CAM into care of their patients.[7] The terms “integrative medicine” or “integrative health care” refer to the selective incorporation of CAM diagnostic and healing approaches into mainstream health practices and systems.[4, 7] Ideally, integrative medicine draws on the formidable strengths of biomedicine and the benefits of holistic and natural healing modalities in an individualized, patient-centered approach that utilizes and enhances the patient‘s self-efficacy and self-healing capabilities.[7] Integration of CAM approaches into care of older people can be of significant benefit to their well-being and health outcomes, throughout the continuum of care.
This chapter begins with an overview of the demographics of CAM use in the US aging population, describes consumers’ rationales for use of CAM therapies, then reviews CAM modalities and uses for common conditions impacting health and function in the geriatric population. The chapter concludes with a discussion of the role that integrating CAM can play in enhancing health care of older people, the challenges of integration, and the steps that conventional practitioners can take to successfully integrate such approaches into their practices.
CAM use among older people
In 2007, the most recent national survey of CAM use confirmed the growing popularity of all CAM modalities, with approximately 40% of all adults reporting use of one or more types of CAM in the last twelve months.[3] Subgroups of high CAM users included those with higher education and income, those with greater numbers of chronic conditions, and cultural subgroups such as Native Americans and Native Hawaiians. Older people made up a substantial proportion of CAM users, with 41% of those aged 60–69, and 32% of those aged 70–84, reporting CAM use in the last twelve months.[3] When responses from baby boomers were compared with those from the previous generation of older people (the so-called silent generation), using data from the 2007 survey, striking findings emerged: while 35% of those born between 1925 and 1946 (aged 62–82) used CAM, a younger group aged 43–61 (the baby boomers, born between 1946 and 1964) reported CAM use of 43%. Overall, twice as many baby boomers reported accessing alternative medical systems (5.4% vs. 2.2%), massage (9.6% vs. 4.8%), and mind-body medicine (21% vs. 13.7%), while use of biologically based therapies was similar between groups (23.3% vs. 22.3%).[6] While not surprisingly the older group reported a substantially higher prevalence of chronic conditions (51% vs. 26%) and a slightly higher prevalence of painful conditions (56% vs. 52%), CAM use was higher for baby boomers than for the older generation, both for those with chronic diseases (45% vs. 38%) and for those with painful conditions (52.9% vs. 43.1%).[6] CAM use was particularly high for baby boomers with diabetes, cancer, and heart disease.[6] These data substantiate expectations that CAM use will continue to rise in parallel with aging of the baby boomer cohort, fueled by CAM’s growing popularity as well as baby boomers’ relatively higher rates of obesity and projected increased prevalence of chronic and painful conditions.[6]
Why are consumers using CAM?
Growing global consciousness and increased access to information have brought heightened awareness and acceptance of other systems of health care as well as increased knowledge of CAM options. A primary motive for CAM use – whether alone or with conventional care – is philosophical, and includes congruence with holistic beliefs, attraction to natural/organic products and treatments, placing a high value on preventing illness, and being motivated to treat the cause of illness rather than merely eliminating symptoms. For example, in one national survey, those who agreed with the statement that “the health of my body, mind and spirit are related, and whoever cares for my health should take that into account” were more likely to use CAM (46%) than those who did not endorse this item (33%).[8] Population subgroups whose health beliefs and philosophies differ from those of mainstream medicine, whether or not they are cultural minorities, have long been major users of traditional or alternative therapies.[9–13]
A common reason given for utilizing CAM therapies is their emphasis on prevention or to maximize well-being. For example, there is a growing popularity of mind-body approaches such as meditation and yoga for managing stress. Another common rationale is to provide a non-pharmaceutical or surgical alternative for a particular condition. For example, a patient may choose to avoid gallbladder surgery or diabetes by changes in diet, adding a mindful exercise regimen, and managing stress. An AARP survey of CAM use by people aged 50 and older, in which 53% reported CAM use, found that for CAM users, 66% used CAM to treat a specific condition, 65% for overall wellness, 45% to supplement conventional medicine, and 42% to prevent illness.[14]
Those who seek to recover from life-threatening diseases are often highly motivated to use CAM treatments, usually as complements to conventional care. For example, patients diagnosed with cancer use CAM in greater percentages than the general population, including for management of conventional-treatment side effects.[15] Those who suffer from chronic diseases, including those with symptoms that are either poorly understood, treated with only partial success by conventional medicine, or whose treatments include unwanted side effects, often investigate CAM treatments. Many patients with arthritis, Alzheimer’s disease, diabetes, hypertension, cardiovascular disease, chronic fatigue, fibromyalgia, insomnia, irritable bowel syndrome, autoimmune syndromes, chronic pain, and a range of stress-related disorders have sought benefit from CAM.[16–20] Additionally, high CAM users include those wishing to enhance the likelihood of success of a particular health care encounter. For example, patients undergoing surgery may choose to incorporate particular CAM therapies, such as herbs, hypnosis, visualization, homeopathic remedies, or energetic therapies.
Those dissatisfied with conventional treatment, providers, practice settings, or the health-care system also are regular users of CAM services.[8] Some consumers report concerns about the safety or efficacy of specific conventional therapies; many are dissatisfied with the high costs of technological medicine. For others, there is a reduced tolerance for conventional medicine’s paternalism and dissatisfaction with the conventional doctor-patient relationship.
Finally, those who use mainly alternative forms of health care may do so because they desire control over health matters and place a high value on their inner life and experiences.[8] These values and attitudes are supported by most alternative care providers and are in alignment with the philosophies undergirding their treatments. Providers of integrative medicine, to varying degrees, are also supportive of this philosophical perspective.
Patient-provider disconnect about CAM in conventional health care
One striking finding in research on use of complementary modalities is that, although 95% of US patients are using alternative as well as conventional care, often for the same condition, the vast majority of patients – about 70% [2, 14] – do not tell their conventional practitioners about their use of alternative modalities. Reasons given by patients for not discussing alternative therapy use with their physicians include the belief that physicians would not understand or be knowledgeable about the therapy; that they are not asked; fear of disrespect or disapproval; and their belief that the physician is uninterested.[2] This lack of communication may result in increased medical errors, noncompliance, and possible duplication of services, as well as greater health-care costs and undocumented outcomes. Integrative medicine offers a patient-centered approach to care that recognizes the need to understand and respect the patient’s beliefs and values, thereby enhancing trust, cooperation in care, and skillful utilization of the powerful role that beliefs play in illness and health. Continuity and quality of care is enhanced when health professionals can communicate knowledgeably, and even coordinate care, with other members of the patient’s health-care team, who may include chiropractic physicians, acupuncturists, massage therapists, or homeopaths. An integrative health-care perspective, whether through an individual provider or a health-care system, could facilitate such communication.
Overview of CAM and use for specific conditions
Following is a brief overview of CAM therapies in use in the United States, with examples of those shown to have therapeutic value in the care of older people. Texts and in-depth reviews of CAM therapies and research provide much greater detail.[21–25]
Mind-body therapies
Mind-body therapies incorporate an understanding of the inseparability and interaction of cognitive and emotional processes with the body organ-systems, and the underlying psychobiological mechanisms by which communication occurs, including immune and neurotransmitter substances. Examples are biofeedback, hypnosis, guided imagery, mindfulness meditation, and various forms of mindful exercise.
Biofeedback
Through training in biofeedback and a subset, neurofeedback, the older patient can learn to modify his or her own vital functions (such as breathing, skin temperature, heart rate, or even EEG brain waves), preventing, controlling, and treating a range of syndromes, including back and neck pain, pelvic floor dysfunction, difficulty swallowing, migraine and tension headaches, asthma, stress-related symptoms, hypertension, and palpitations related to arrhythmias.[26–37]
Hypnosis and guided imagery
Hypnosis uses the power of suggestion to induce trance-like states so as to access deep, often unconscious, levels of the mind to effect positive behavioral change. It has been used effectively to treat symptoms of asthma, irritable bowel syndrome, acute and chronic pain, sleep disorders, anxiety, phobias, and substance abuse.[38–42] Guided imagery involves auditory suggestions, either given by another individual or through a recording device, for purposes of relaxation and stress management. For example, one might imagine being on a beach or another favorite, safe place to facilitate a peaceful, relaxed, or receptive state of mind. Guided imagery is often incorporated in to hypnotic inductions. Important uses of hypnosis and guided imagery in a geriatric population include their substitution for or supplementation of anesthesia during surgery and in pain control.[39, 41, 43]
Mindfulness meditation
Meditation has been used and taught since its roots in ancient India and is increasingly popular in the United States. In mindfulness meditation, the practitioner usually focuses on an image, a sound, or simply the breath as an anchor to being in the present moment, noticing whenever the mind becomes distracted by thoughts of past or future, gently letting go of the distracting thoughts, and bringing the attention back to the present moment. Mindfulness and other meditation techniques can be useful in lowering stress responses and regulating emotional reactivity,[44] and have been shown to reduce such stress markers as heart rate, pulse rate, and plasma cortisol as well as to enhance electroencephalogram (EEG) alpha state, inducing deep relaxation.[22] Meditation also has been shown to enhance immune function and decrease anxiety, hypertension, and chronic pain.[45–64]
Mindful exercises
Mindful exercises includes such practices as yoga, tai chi, qigong, Alexander Technique, Pilates, and Feldenkrais – some thousands of years old, others developed only recently. These practices are adaptable for use by older people in varying states of health and can be used to improve mental and physical function. For example, tai chi has been found to improve sleep, to reduce pain in people suffering from osteoarthritis, to enhance balance in frail older people, and to improve symptoms of Parkinson’s disease.[65–79] Yoga has been adapted for older people with varying degrees of fitness, including wheelchair-bound elders, and has been shown to improve risk factors for heart disease, diabetes, side effects of cancer, and musculoskeletal pain.[24, 25, 80–90]
Manipulative/body-based therapies
Manipulative and body-based therapies range from traditional to contemporary techniques, usually performed by a skilled practitioner, emphasizing physical touch, manual manipulation of tissues or energetic systems, and often involving movement. Examples are chiropractic (described under Alternative Health Systems), massage, other forms of bodywork (such as reflexology, functional integration, structural integration, and kinesiology) as well as various touch therapies.[21–25]
Massage and bodywork
Massage and bodywork involve many subcategories and techniques and can easily be individualized based on clients’ needs and preferences. Research has shown that massage can promote relaxation, relieve muscle pain and headaches, and alleviate a range of stress-related conditions, thus lessening the need for pharmacological therapies.[91–102] This therapy can reduce swelling and increase lymphatic circulation, thus alleviating chronic inflammatory conditions, facilitating the removal of toxins from the body, and enhancing recovery from illness.[103] Massage has been used effectively in hospitals, nursing homes, and hospice settings.[104–117] Another example of bodywork, functional integration, involves individualized hands-on touch and movement in which the practitioner directs the client’s body through movements tailored to the client’s needs. Structural integration, also known as Rolfing, was founded by Ida Rolf in 1970, and is based on the philosophy that proper alignment of body segments (head, torso, pelvis, legs, feet) via manual manipulation and stretching of the body’s fascial tissues improves body movement and function. Reflexology is a form of acupressure, which is based on the same system as acupuncture. It originated in ancient China and was also used in ancient Egypt. Introduced to the United States early in this century by William Fitzgerald, MD, and further developed by physiotherapist Eunice Ingham, it involves applying precise pressure to points of the hands and feet that correspond to organs, glands, and other parts of the body to relieve tension, increase circulation, and stimulate deep relaxation. Applied kinesiology, a diagnostic system recently developed by George Goodheart, a chiropractic physician, involves determining imbalances in the body’s organs and glands by identifying weaknesses in specific muscles. Once imbalances have been identified, various techniques may be used to strengthen the muscles involved in the underlying dysfunction. More research on these forms of bodywork could determine their application to specific conditions in the elderly.
Touch therapies
Touch therapies are energy-based healing systems that include laying on of hands, Reiki, and therapeutic touch. In laying on of hands, an ancient art found in various spiritual traditions, the practitioner directs healing energy, purported to come from a universal force, to the patient or to the site of illness. Reiki, which traces its origins from Tibet, is one form of this therapy. Therapeutic touch, another variation, was developed by Dolores Krieger, PhD, RN, and Dora Kunz, a healer, and is now being used in hospitals in the United States, particularly by the nursing profession. Therapeutic touch may be useful in reducing pain and anxiety and promoting healing, and can be particularly applicable to the elderly who need gentle and loving care.[100, 118–122]
Biologically based therapies
Biologically based therapies encompass a diverse array of approaches including dietary therapies, herbal medicines, and dietary supplements, and they comprise the most popular CAM category used in the United States.[3] Although many of these are utilized by conventional medicine, they are much more central to the care plans of CAM practitioners such as naturopathic physicians, chiropractic physicians, and homeopathic practitioners, as well as integrative medicine providers, such as physicians trained in functional medicine.[21, 23] A few of these include the following.
Dietary therapies
Conventional and alternative medicine agree on the optimizing effects on function of a diet high in fresh fruits and vegetables and the protective effects of phytochemicals, but beyond that, there are many variations in diet espoused, both within conventional medicine and within CAM.[123] CAM therapies and integrative health care are allied with the natural foods movement, which emphasizes the importance of whole, organic foods and the elimination from food products of pesticides, antibiotics, hormones, and food additives (such as preservatives, dyes, and artificial flavors) – substances that may play a role in decreased immune function, increased food allergies, increased chemical sensitivities, and other disorders. Individualized nutritional prescriptions that take into account the health and preferences of the older person are essential, and can be helpful in preventing disease, restoring function, and controlling pain.[21, 23]
There are a variety of nutritional prescriptions for preventing illness and promoting healing. The simplest is an organic, plant-based, whole-foods diet, which decreases the body’s burden of chemical additives, maximizes natural vitamin and mineral intake, decreases fat and sugar, and increases fiber. Macrobiotics is a dietary prescription formulated by Michio Kushi based on the ancient Chinese philosophy and practice of balancing yin and yang, and emphasizing whole foods. A vegetarian diet calls for the elimination of all meat; a vegan diet eliminates all animal products, including milk and eggs. Raw food diets, on the other hand, do include animal products, but stress the importance of their being organic as well as uncooked. Juice therapies provide supplementary nutrients, particularly vitamins and minerals, both to prevent illness (i.e., during times of stress) and to restore the body to health. Fasting is a time-tested ritual, used for centuries in all societies to purge the body of toxic substances, enhance immune function, and increase spiritual awareness. Extreme fasts (not recommended for vulnerable people) may involve drinking only pure water; modified juice fasts include fresh organic vegetable juices and sometimes fruit juices. Ayurvedic medicine practitioners make dietary recommendations based on constitutional types, and traditional Chinese medicine practitioners prescribe diets based on both constitutional and illness characteristics.[22]
Herbal medicines and nutraceuticals
Using herbs and other plants as remedies can be traced back to prehistoric times. Often gathered from surrounding environments and prepared by knowledgeable laypeople, these medicines have long been used as tonics for preventing illness and as remedies for most functional disorders known to humankind (i.e., dyspepsia, respiratory disorders, menstrual disorders, anxiety, and depression) as well as treatments for more serious organic disorders such as cancer. Until the late nineteenth century, physicians prescribed herbal preparations extensively, but with the growth of manufactured drugs, the medical profession’s knowledge and use of herbs declined and practically ceased in the United States.
Meanwhile, there has been a major resurgence of interest and use of herbals and a growing consumer awareness of the roles played by various nutraceuticals in health and illness. Raw herbs and a wide variety of nutraceuticals are available in health food stores, and many nutraceutical products can be purchased over the counter in pharmacies. CAM practitioners and integrative care providers, as well as many pharmacists, have been trained to advise on consumption of these products, including their interactions with pharmaceuticals, but conventional medicine continues to lag behind in education and training regarding uses and drug interactions. Although effective use of many herbal preparations has been established by tradition, increasingly, randomized controlled clinical trials are showing efficacy of certain herbal preparations in specific conditions. For example, research has established the efficacy of St. John’s Wort for mild to moderate depression.[124] With the widespread use of herbals and supplements for self-care among elderly people, it is essential that care providers facilitate good, open communication with their patients about their use. As noted above, the majority of older persons do not communicate about CAM use with their providers [14]. Moreover, in one study, 80% of hospitalized patients reported use of a dietary supplement, with 52% reporting use of nonvitamin/nonmineral dietary supplements, while inquiry by providers about dietary supplement use was documented only 20% of the time.[125] It is essential that care providers incorporate knowledge about herbals and nutraceuticals into their continuing medical education to avoid harm and optimize care. There are excellent online reference sources to consult, such as the Natural Medicines Comprehensive Database, to stay abreast of the ever-changing science.
Aromatherapy; use of essential oils
Plant essences, including essential oils, have been used therapeutically for thousands of years in numerous cultures. “Aromatherapy,” a term coined in 1937 for this ancient practice by the French chemist Rene Maurice Gattefosse, has been used for the treatment of such conditions as immune deficiency, bacterial and viral infections, and skin disorders, and as a tool for stress management.[22, 126] The oils transmit their healing properties not only by inhalation but also by absorption through the skin, exerting much of their effect through their pharmacological properties and small molecular size. Aromatic molecules interacting with the cells of the nasal mucosa transmit signals to the limbic system through which they connect with parts of the brain controlling heart rate, blood pressure, breathing, memory, and hormone balance. Research has shown that inhalation of particular essential oils can have either a calming or stimulatory effect on brain waves.[127] Aromatherapy, often combined with massage, has been used for pain, dementia symptoms, and anxiety in elderly patients in hospitals, nursing homes, and hospice care.[93, 115, 128–130]
Alternative healing systems
Traditional Chinese medicine/traditional Oriental medicine
Acupuncture and acupressure are part of a complete system of healing developed in China over 5,000 years ago. Both within China and in other oriental cultures such as Korea and Japan, variations in philosophy and techniques have developed. In general in this system, health is dependent on the balanced flow of chi or qi, the vital life energy, throughout the body, and illness is due to a disturbance of chi. Acupuncture treatment balances the chi by inserting needles at points on the body where the chi flows, through one of twelve channels or meridians. Diagnosis involves inspection (visual assessment of the patient, particularly the spirit, form, and bearing), feeling the pulse, observing the tongue and eyes, and questioning the patient about physical and social environment. Acupuncture treatment can be useful for pain management (e.g., back pain, knee pain, and migraine), cancer-related symptoms (including nausea and vomiting), substance abuse treatment, depression, dementia symptoms, and stroke.[131–141]
Homeopathic medicine
Since ancient times, in India and Greece, it has been known that a remedy can have a curative effect if it produces, in a healthy person, symptoms similar to those of the disease. Samuel Hahnemann, a German physician disheartened with the medical practice of his day, in the early 1800’s formally tested this principle – similia similibus curentur, “like is cured by like” – and subsequently established it as the basis of a system of medicine.[21, 22] Central to homeopathic therapeutics is the infinitesimal dose, the smallest dose necessary to produce a healing response. Through experimenting with lower and lower doses of drugs in efforts to minimize side effects, Hahnemann developed a technique called potentization, in which the original substance is repeatedly diluted and succussed (shaken vigorously after each dilution) to produce a medicinal substance diluted in many cases beyond Avogadro’s number (6.23 × 10−23), the point at which there is unlikely to be a single original molecule left.
Homeopathic treatment involves selection of a homeopathic preparation that produces symptoms in a healthy person similar to that of the patient’s complete symptom picture. Even for acute conditions, prescribing takes into account the individualized response to illness. Particularly in chronic conditions, it may incorporate the person’s entire symptomatology not only with regard to the present complaint, but over the course of a lifetime. The latter is termed constitutional prescribing. Although the mechanism by which the similar remedy acts is unknown, homeopathic theory maintains that in some way it stimulates the organism’s own innate healing capacities. Illness is viewed as a disturbance of the vital force, as manifested in physical, mental, and emotional responses that are unique to each individual. Symptoms are viewed as the organism’s expression of its life energy, and care is taken not to suppress them, but to use them to guide healing.
Although homeopathic remedies can be purchased at health food and drug stores, they are best prescribed under the care of professional homeopaths, skilled integrative medicine physicians, or naturopathic physicians, since much training is required to be able to accurately prescribe an effective remedy or series of remedies, particularly for older people with complex life and treatment histories and often fragile constitutions. Homeopathy may be a useful and gentle healing modality for a wide range of acute and chronic ailments found in older people, including respiratory infections, allergies, insomnia, gastric upsets, fatigue, prolonged grief, anxiety, depression, and palliative care.[142–145]
Naturopathic medicine
Founded by Benedict Lust in the latter part of the nineteenth century, naturopathic medicine is a distinct primary health-care profession that emphasizes prevention and the self-healing capability of the individual. Naturopathic physicians focus on identifying and removing obstacles to healing and recovery, and treating the underlying causes of illness rather than merely eliminating or suppressing symptoms. Naturopathic physicians strive to use the gentlest healing methods possible, educating their patients and encouraging the patient’s responsibility. The healing methods emphasize treating the whole person, including physical, mental, emotional, genetic, environmental, social, and spiritual factors. Therapeutic modalities include nutritional and botanical medicine, homeopathy, acupuncture, and hydrotherapy.[21, 22] Interviews with older people who utilized naturopathic practitioners found that patients sought naturopathic medical care because it was aligned with their values, including an emphasis on prevention, self-care, and healthy aging.[146]
Chiropractic medicine
Chiropractic, founded in 1895 in Iowa by D. D. Palmer, a self-educated healer,[22] is based on the understanding that structural distortions can cause functional abnormalities. Vertebral subluxation of the spine is an important structural distortion that disturbs body function primarily through neurologic pathways. Chiropractic adjustment is a specific and definitive system for correcting vertebral subluxation, harmonizing neuronal function, and stimulating the body’s innate healing potential, focusing primarily on manual adjustment or manipulation of the spine. Chiropractic is the third largest independent health profession in the western world, following allopathic medicine and dentistry, with more than 65,000 licensed practitioners in the United States, trained in four-year post-baccalaureate programs and seeing over 20 million patients per year.[22] Patients visit chiropractic physicians particularly for the prevention and treatment of neuromusculoskeletal conditions of low back pain, neck pain, and headaches.[22, 147–149]
Prevalence of chiropractic use among Medicare beneficiaries aged 70 and older ranges from 4.1% to 5.4%; in younger beneficiaries it ranges from 6% to 7%.[147] Research comparing outcomes between users of chiropractic and users of medical care for treatment of uncomplicated back care suggests that chiropractic care may provide a protective effect on decline in function and self-rated health, as well as provide higher satisfaction with follow-up care.[148]
Spiritual healing practices
Spirituality is a powerful component of the healing process and is particularly important in the care of older people.[150–153] Faith healing is one prevalent form of spiritual healing.[154, 155] Shamanism is another manifestation and is one of the oldest healing traditions known to humans.[22, 156] A shaman is a man or woman trained to journey outside time and space via an altered state of consciousness, often to perform healing rituals. Traditionally, shamans have been called upon to diagnose and treat illnesses, perform divinations, and communicate with the spirit world. Recently in the United States, due particularly to the work of Michael Harner and his students, there has been a revival of the study of shamanic rituals and journeying for those needing spiritual healing.[156]
Rationales for integrating CAM therapies into the care of older people
There are several important reasons to consider incorporating the use of complementary therapies into the care of older individuals and patient populations. These include enhanced communication with patients and their caregivers, patient empowerment and its positive impact on health-care outcomes, research evidence of therapeutic effectiveness of many CAM therapies, increased therapeutic options for both patient and caregiver, and the potential for positive impacts on therapeutic environments and synergistic effects on therapeutic outcomes. Specific benefits for the geriatric population include an emphasis on non-pharmacological therapies, prevention, and self-care. These rationales will be discussed below.
Expanded options for patient care
By its nature, an integrative clinical practice provides an expanded array of health-care options. Conventional therapies are often limited by significant negative side effects, high cost, physiologic vulnerability, or patients’ preferences. Although therapies such as prescription drugs may effectively address a particular condition, not every individual will respond well to a particular protocol, and many older people would prefer nonpharmaceutical options. For example, for mild to moderate depression, a practitioner may suggest aerobic exercise, acupuncture, or St. John’s wort as an alternative or complement to an antidepressant.[157–162] Another example is an approach to management of hypertension that includes a combination of diet modification, a mind-body therapy (e.g., hypnosis, biofeedback, tai chi, or mindfulness), and medication.[74, 90, 163]
Enhanced patient and provider communication and satisfaction
CAM practices, while varied, in general share a holistic perspective on healing, one that emphasizes an individualized approach to diagnosis and treatment. Although many good health practitioners spend ample time with patients and provide a multifactorial assessment, it is often the disease, rather than the person, that guides the approach to treatment. CAM and integrative-care providers generally spend more time getting to know the patients’ individual needs and desires, providing a patient-centered approach to diagnosis and treatment that may improve both patient and caregiver satisfaction.[23] Importantly, an integrative approach to patient care may improve communication among health-care providers and their patients. As described earlier, patients’ lack of communication about their CAM practices is due in part to providers’ perceived lack of knowledge, interest, time, or respect for patients’ choices. Increased physician knowledge of CAM and respect for patients’ choices could result in improved communication and satisfaction with care. Integration can also improve a patient’s personal decision making and enhance physical and emotional well-being by increasing knowledge of a broader range of health-promoting practices. Furthermore, integration of complementary treatments such as mind-body therapies may increase patients’ conscious participation in the healing process and feelings of empowerment. Health-care providers may also experience greater satisfaction through learning about integrative treatment strategies and developing skill in implementing them.
Decreasing dependency and overuse of pharmacological therapies
Increased use – and misuse – of pharmaceuticals is a significant motivator for integrating CAM with conventional medicine, particularly in caring for older persons. The conventional clinician-patient dyad is often content to passively employ multiple medications in the name of symptom reduction, efficiency, and convenience. With the proliferation of medical specialties, each with its own cadre of medicines, polypharmacy and adverse drug interactions have become the rule rather than the exception, particularly for the elderly patient with chronic illnesses.[164–166] Substituting non-pharmacologic therapies may reduce potential iatrogenic effects of multiple medications, including the potential for drug dependency and negative side effects, and could lower costs while maintaining positive health outcomes. For example, in a comparative outcome study in which older patients with major depression were randomized to an aerobic exercise regimen, or treatment with sertraline, or a combination of exercise and sertraline, all three groups showed equivalent improvement after four months. The aerobic exercise group significantly improved in respiratory capacity, and showed a marked reduction in relapse rate, compared with the sertraline-alone group.[167]
Enhancing health-care outcomes
There is evidence that the combination of conventional and complementary treatments often produces better outcomes than conventional therapies alone, particularly when outcomes include reduction of negative side effects of treatment. The synergy of integrative care in many clinical situations offers a variety of benefits, including, for example, decreased presurgical anxiety, accelerated recovery from surgery, decreased reliance on medications, reduction of side effects, and better outcomes.[168–170]
Added emphasis on disease prevention, wellness, and self-care
Although conventional medicine, including medical education, still emphasizes disease diagnosis and management over prevention,[171] CAM philosophies and CAM and integrative medicine practitioners tend to place greater emphasis on prevention, wellness, and self-care, and these philosophies and practices are attractive to many elders.[146, 172] Examples of preventive and self-care approaches emphasized in CAM and integrative medicine practices include dietary management, exercise, stress reduction, biofeedback, and the use of supplements. Many alternative therapies require for their use a large degree of self-determination, self-motivation, and self-efficacy – attitudes associated with enhanced healing. For example, mind-body and bodywork therapies require discipline of both mind and body over a long period of time, working to change habitual patterns of behavior or learn a new skill. The philosophy of many alternative therapies encourages self-education through reading books, listening to recordings, searching the Internet, and attending workshops and seminars that emphasize stress management and optimizing well-being.
Principles and practices of integrative medicine
Improving and sustaining function in elderly people is a multifactoral process, involving physical, cognitive, and social elements. The use of CAM therapies is compatible with a holistic healing perspective that recognizes the self-healing capacity of the organism and provides mechanisms to enhance those abilities. Many CAM and integrative health-care practices subscribe to a holistic model of health and healing, emphasizing the following principles and processes:
1. emphasizing self-care and empowerment;
2. preventing ill health by strengthening homeostatic balance and remaining in harmony with the psychosocial and physical environment;
3. enhancing wellness with optimal diet, exercise, and stress-reducing regimens;
4. stimulating and nourishing the body’s self-healing abilities, recognizing that healing can be a gentle and gradual, developmental process;
5. individualizing treatment to the particular patient, rather than focusing on the disease condition;
6. addressing the underlying causes of illness, including emotional, environmental, and spiritual factors, rather than simply eliminating (suppressing) its surface manifestations;
7. using natural, nonpharmaceutical substances or techniques, while avoiding use of prescription medications (particularly those that might suppress symptoms or compromise the body’s self-healing abilities);
8. viewing the mind, body, and spirit as interactive and inseparable;
9. acknowledging the electromagnetic nature of the human organism and the role of vitality in healing;
10. appreciating the importance of intuitive awareness in both the patient and provider.
As well as enhancing function, some CAM therapies, such as tai chi and meditation, which are often practiced in groups, promote socialization with other individuals. This socialization is particularly important, as many elderly people may have lost a spouse, close siblings, or friends, and are therefore at increased risk of becoming isolated and depressed.
Approaches to integrative health care
For the conventional practitioner, becoming educated about integrative health care may involve first becoming familiar with CAM by purchasing a textbook or taking a survey course so as to simply feel comfortable talking to patients about their CAM use. Learning about CAM providers who are practicing in the surrounding community is a second step toward integration. Later, the practitioner may be inspired to acquire specific knowledge and skills about one or more complementary/alternative modalities sufficient to practice at some level as well as to network with CAM providers, perhaps even joining a group practice. Many models of integrative care delivery are possible. While at one end of the spectrum there is the solo provider, at the other end of the spectrum are more complex models such as multidisciplinary practices, where a mix of complementary and conventional practitioners share space, and interdisciplinary practices, which involve various levels of integrated patient management through a partnered arrangement. One type of practice does not necessarily evolve into other, more elaborate, arrangements. The initial form and subsequent development depend on practitioner interests, resources, experience with integration, motivation, skills, and the ability to adapt within the culture of integration.
The challenges and promise of integrative medicine in the care of the elderly
Despite considerable interest on the part of health-care consumers and many practitioners, and the perceived and documented benefits, CAM integration with mainstream medicine is occurring relatively slowly. Reasons include simple inertia, financial disincentives, differences in beliefs about healing, lack of access to education about CAM, and limited information on clinical outcomes about complementary and alternative therapies. The challenge to health-care practitioners is to understand and address the key issues that are raised as conventional, complementary, and alternative healing systems interact and perhaps converge.
For the conventional practitioner who treats older people, the most compelling factor in the movement toward integrative health care may be the continually growing use of complementary and alternative therapies and practitioners by their patients, including the upcoming generations of older people. There is consumer demand for CAM, and future health-care providers must keep pace, if only to become knowledgeable about CAM, including risks, benefits, and comparative effectiveness of CAM and conventional care. Moreover, since patients’ reason for not discussing CAM with their providers is partially because they perceive lack of knowledge or interest, and this lack of communication is to the detriment of patient-provider relationships and care outcomes, it becomes a matter of professional responsibility to become more conversant about CAM options. That includes staying current with the burgeoning medical literature on CAM efficacy and comparative effectiveness with conventional medicine.
Another compelling reason to make steps toward integrative medicine for the care of the elderly is that, in many cases, it is simply “good medicine” for older patients – particularly when use of a CAM therapy promotes self-care, preventive self-maintenance, lower health-care costs, or reduction in inappropriate use of pharmaceutical medicine. Finally, joining or leading an integrative medicine team may bring with it the personal and professional satisfaction that many providers of integrative health care enjoy, as they care for their patients in a patient-centered, humanistic atmosphere that emphasizes healing of mind, body, and spirit while enhancing care.
An integrative approach to caring for the elderly, throughout the continuum of care, could be a win-win-win solution – for the older patient, the care provider, and the health-care system.
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