Complementary and Alternative Care in the Long-Term Care Setting

INTRODUCTION

Complementary and alternative medicine (CAM) therapies, defined as “a diverse group of medical and health care systems, therapies and products that are not considered to be part of conventional medicine,” have become commonplace among older Americans.¹ Regardless of preconceived notions of the effectiveness of such therapies, clinicians must be knowledgeable about alternative treatment modalities in order to develop an effective care plan. This article will highlight the rationale and evidence, where it exists, of the most commonly utilized CAM therapies in older adults, with a focus on patients who require care in an institutional setting where a variety of supportive services are available, such as long-term care (LTC). Recent studies have highlighted the increased utilization of CAM therapies among older adults.²

It is estimated that 42% of Americans used CAM therapies in 1997, a number that has increased to 62% in 2002.^1-5 Estimates of utilization of all types of CAM therapies in older adults is reported between 30%2 and 47.8%.⁴ The most commonly utilized therapies in older adults are chiropractic services (11%), herbal remedies (8%), relaxation techniques (5%), high-dose megavitamins (5%), and religious or spiritual healing by others (4%).⁴ A recent survey of 31,000 adults assessing utilization of CAM therapies in the U.S. reported that 14.6% of those over 65 years of age utilized “manipulative and body based therapies, including chiropractic and massage.”⁴

The most common conditions treated with these alternative therapies are arthritis and back pain.5 In another recent survey of patients with osteoarthritis, 47% of patients reported using alternative care including massage therapy, chiropractic care, and nonprescribed alternative therapies.⁵ The reasons for the increased utilization of CAM therapies is not completely understood, but two of the reasons may include perceived effectiveness by users of these therapies as well as the toxicity associated with commonly utilized pain medications.^6-8

Many of the older adults who are utilizing alternative therapies will require care in a long-term care setting. It is estimated that the number of these older adults who require long-term care will continue to rise over the next 20 years, given the lifetime risk for nursing home placement of 43% in those over 65 years of age.^9,10 Older adults who are placed in LTC settings may benefit from alternative therapies, but it again is imperative that providers be aware of the potential benefits and also the potential harm from commonly utilized alternative therapies.

Most studies evaluating the use of CAM therapies in older adults have been performed on community-dwelling older adults, although there are some small reports on the utilization of CAM therapies in long-term care.^11-18 However, there is a paucity of formal studies evaluating the use of CAM therapies in a long-term care setting. This is surprising given the large number of older adults in LTC settings.

It is also surprising given the incidence of chronic illnesses and chronic pain, which is the most common reason for seeking out CAM therapies.^1-4 It is reported that 45-80% of nursing home residents have pain that contributes to functional impairment;¹⁹ yet, this pain is often undertreated or treated with only pharmaceutical agents.²⁰

The studies that have been performed in the LTC setting have reported on herbal remedies, chiropractic care, massage, acupuncture, aromatherapy, meditation, and guided imagery; the first two are the most commonly utilized with a growing utilization of massage therapy.^11-18 The specific therapies reviewed below will highlight the evidence for, the risk associated with, and the applicability to long-term care of the most commonly utilized CAM therapies in the older adult population. The Table illustrates the different types of CAM therapies and possible contraindications to each.

ENERGY THERAPIES

Therapeutic touch was developed in the early 1970s. It is based on the premise that a person is an open energy system, and illness is a reflection of an imbalance in the individual’s energy field. A recent review evaluated 33 studies on healing touch.¹⁴ Of the 33 studies evaluated, six were randomized, controlled trials; however, these were of low quality.^14,15 Four of the studies evaluated specifically looked at older adults. The results of these studies found improvement in pain, appetite, and sleep.¹²

Reiki, another form of therapeutic touch, is an energy therapy developed in Japan. Rei is defined as universal spirit or cosmic force of the universe, and ki is the life force or energy. The Reiki practitioner is thought to be the conduit for the Reiki energy.^12,14 There have been no randomized, controlled trials on the utilization of therapeutic touch or Reiki in the long-term care population.^12-16 Acupuncture was developed in China more than 5000 years ago, and it is the oldest of the CAM therapies. Acupuncture is based on the theory that a vital life force, known as qi or ch’i, flows through the body on 12 lines called meridians. Illnesses or disruptions to the body’s harmony can result if meridians become blocked or imbalanced.

The most common reason why people seek acupuncture is to alleviate pain, although acupuncture also has been shown to provide benefits for addictions, asthma, nausea, osteoarthritis, Menriere’s disease, depression, AIDS, migraines, and chronic obstructive pulmonary disease.¹⁶ The exact mechanism of action of acupuncture is unknown. It is thought however to act on the descending inhibitory system of the central nervous system.²¹

There are no randomized, controlled trials of utilization of acupuncture in older adults or in long-term care facilities. Most studies that have evaluated acupuncture have had methodological flaws, which have made the drawing of definitive conclusions difficult.²¹ However, acupuncture does appear to be a relatively safe treatment modality. The most significant issue for its utilization in long-term care would be the risk of significant bruising in the patient with anticoagulation.²¹

HERBAL REMEDIES

Herbal products are considered dietary supplements; they can be easily obtained and are presumed by the public to be safe and effective. The sale of herbal products increased exponentially in the past 10 years. In 1995 Americans spent $1.5 billion on herbal products,22 and in 1997 $5.1 billion was spent.¹ Estimates range from 8% to 49% of older adults utilizing herbal remedies.^1,4 The most recent survey on alternative care found that 48.8% of those over age 65 reported utilizing biologically-based therapies including megavitamins.⁴

All of the studies done up to this point on the utilization of herbal remedies in older adults have been done on community-dwelling adults.^1,4 Although the direct risk of adverse reaction is low with the use of herbal remedies, the greatest risk—particularly in the long-term care population—is with drug–herb interaction.

In the case of drug–herb or drug–nutrient interaction, there is a risk that the natural agents may potentiate or modify the action of certain prescription medications. This is of greatest concern when the patient is taking a drug with a narrow therapeutic window. The most commonly utilized herbal medicinal products are echinacea (40.3%), ginseng (24.1%), ginkgo biloba (21.1%), garlic supplements (19.9%), glucosamine sulfate (14.9%), and St. John’s wort (12.0%).⁴

Echinacea has traditionally been used topically and orally for diverse indications, including wound healing, abscesses, burns, eczema, and leg ulcers, which are all common conditions in long-term care.^22,23 The efficacy of echinacea for either treatment or prevention of illness has yet to be determined. There are approximately 16 trials evaluating the effectiveness of echinacea for upper respiratory infection with moderate to good methodology.²² There have been no systematic reviews evaluating adverse events from echinacea.

The Australian Adverse Drug Reaction Advisory Committee received only 11 reports of adverse reactions from echinacea over a 1-year period.²⁴ There have been no randomized trials on the utilization of echinacea in a LTC setting. Ginseng has been used for its alleged sedative, hypnotic, demulcent, aphrodisiac, antidepressant, and diuretic activity. It is often recommended for improving stamina, concentration, vigilance, and well-being.²²

A systematic review included 16 randomized, double-blind, placebo-controlled trials.²⁵ Most of these studies were of low methodological quality, using healthy subjects rather than patient samples. Evidence from the clinical trials did not support utilization for the above-mentioned indications.^22,25 The exact incidence of adverse reactions from ginseng is unknown.

Several adverse reactions have been reported but there has been no systematic analysis of these reactions. There are also concerns about the quality of many commercial ginseng products, which may contain contaminants.^22,25 There have been no randomized, clinical trials on the utilization of ginseng in a LTC setting. Ginkgo fruits and seeds have been utilized in Chinese medicine for thousands of years.²⁶

In vitro and in vivo studies suggest that ginkgo has antiedemic, antihypoxic, free radical scavenging, antioxidant, metabolic, antiplatelet, hemorheologic, and microcirculatory actions.^26,27 Ginkgo has been used experimentally for myocardial reperfusion injury, depression, brain trauma, free radical damage to the retina, cochlear deafness, vertigo, male impotence, and asthma.²³ There have been systematic reviews of the studies for memory impairment, dementia, tinnitus, and intermittent claudication. These data show that there may be some therapeutic effect of ginkgo on these conditions but it requires further study.^27-29

The adverse effects of ginkgo have been reported to be mild and transient. The most serious adverse event is likely associated with the antiplatelet activity, which may cause an interaction between anticoagulants and the ginkgo.³⁰ This side effect is very relevant in the LTC population, given the high utilization of anticoagulants in this setting.⁹ Although the therapeutic benefit of utilizing ginkgo for conditions such as memory impairment and dementia is enticing, the benefits may not outweigh the risks.^22,29,30 It is imperative that randomized, controlled trials be carried out prior to recommending this therapy in the LTC setting.

Garlic is a traditional medicinal herb used throughout the world. It has been hypothesized as an antiplatelet, antiparasitic, antifungal, antiviral, anti-inflammatory, and anti-cancer agent.³¹ Animal in vitro and ex vivo studies suggest inhibition of lipid uptake by aortic cells, inhibition of smooth muscle proliferation, and decreased oxidation of low-density lipoproteins.^31,32

Two recent meta-analyses showed an average reduction of 9-12% in total cholesterol and 13% in triglycerides.^32,33 Garlic has only a weak antihypertensive effect. Meta-analyses of eight studies showed a significant reduction of diastolic blood pressure in four studies and systolic blood pressure in three studies.³⁴ Several small, nondefinitive randomized, clinical trials also support garlic’s antiplatelet, antithrombotic, and fibrinolytic properties.³⁵

The majority of reported side effects of garlic have been reported as mild. These side effects include gastrointestinal discomfort, bloating, headache, sweating, lightheadedness, menorrhagia, and garlic odor.³⁵ Caution should be exercised—especially in the older adult population—of combining garlic with other anticoagulation agents, such as aspirin, ginkgo, feverfew, and nonsteroidal anti-inflammatory drugs. Garlic may increase the international normalized ratio of patients on warfarin; therefore, high-dose garlic should be used with caution in a LTC setting.³⁶ There are no randomized, controlled trials on the utilization of garlic in a LTC setting.

Glucosamine sulfate is a natural substance and is the building block of the ground substance of articular cartilage, the proteoglycans. The rationale for the use of glucosamine sulfate is based largely on in vitro and animal models of osteoarthritis. It has been experimentally shown to normalize cartilage metabolism and rebuild damaged cartilage, and has demonstrated mild anti-inflammatory properties.

One systematic review evaluated 16 randomized, controlled trials; they concluded that there needs to be further research to confirm the long-term effectiveness of glucosamine sulfate for the treatment of osteoarthritis. With regard to side effects, it appears that glucosamine sulfate is safe. Of 1000 patients who participated in the randomized, controlled trials evaluating glucosamine sulfate, only 14 withdrew due to toxicity. The most common side effect from glucosamine sulfate was mild gastrointestinal tract complaints, which occurred in 12% of the patients in the trials and were described as mild.³⁷

Given the prevalence of osteoarthritis in older adults, especially in the LTC setting,⁹ it is important in the future to evaluate the role of glucosamine sulfate in this setting. There are currently no randomized, controlled trials that have evaluated the benefits of glucosamine sulfate in the LTC setting. St. John’s wort is used almost exclusively as an antidepressant. Its mechanism is thought to be similar to that of tricyclic antidepressants. It is thought to lie in selective inhibition of serotonin, dopamine, and norepinephrine reuptake in the central nervous system.^38,39

A recent meta-analysis evaluated 27 randomized, double-blind clinical trials. These authors confirmed that St. John’s wort is more effective than placebo in the treatment of mild-to-moderate depression and is similar in effectiveness to low-dose tricyclic antidepressants.³⁹

Depression is a common comorbidity in the LTC setting; however, none of the studies evaluating St. John’s wort have been done in this setting. Taken alone, St. John’s wort has an excellent safety profile. However, when taken with other medications St. John’s wort can cause serious side effects. Evidence indicates that it can decrease plasma levels of a large range of prescribed drugs, such as anticoagulants, oral contraceptives, and antiviral agents.^22,40 Evidence also indicates that the combination of St. John’s wort with selective serotonin reuptake inhibitors can lead to serotonin overload or serotonin syndrome, particularly in older adults.⁴¹ 

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MASSAGE THERAPY

Massage therapy is a commonly utilized form of alternative therapy in the older adult population. In a recent survey of older adults with osteoarthritis, it was the most commonly utilized form of alternative therapy.⁵ Soft tissue massage is thought to improve physiologic and clinical outcomes by offering symptomatic relief of pain through physical and mental relaxation and increasing the pain threshold through the release of endorphins.^42,43

A recent systematic analysis of the literature revealed no randomized, controlled trials that have specifically evaluated the effects of massage therapy in the older adult.⁴² One small study did report a decrease in anxiety in institutionalized older adults with massage therapy.⁴³

The Cochrane database identified nine publications reporting on eight randomized trials involving massage therapy for lower back pain.⁴³ Three studies had low methodological quality scores and five trials had high scores. Massage has been compared to an inert treatment (sham laser) in one study that showed that massage was superior, especially if given in combination with exercise and education. In the other seven studies, massage was compared to different active treatments. They showed that massage was inferior to manipulation and to transcutaneous electrical nerve stimulation; it was equal to corsets and exercises; and it was superior to relaxation therapy, acupuncture, and self-care education.⁴³

There have been no randomized, controlled trials of massage therapy in the LTC setting. Side effects of massage therapy are generally mild and transient, although serious complications have been reported. The most commonly reported side effects involve transient soreness after the treatment.⁴⁴ There are several contraindications to massage therapy being applied to areas over acute inflammation, skin infection, nonconsolidated fracture, burn areas, deep vein thrombosis, or active cancer tumor.⁴⁵

CHIROPRACTIC CARE

In 1998 the American Geriatrics Society published guidelines on the management of chronic pain in older persons.⁴⁶ These guidelines listed chiropractic care among the nonpharmacologic strategies for pain management that have been helpful in older adults. The utilization of chiropractic care among the geriatric population has been estimated at between 11% and 20%.^2,47

In the Iowa 65+ Rural Health Study, they found that a higher percentage of older adults were utilizing chiropractic services for their lower back pain.⁴⁸ A subanalysis of a small group of patients in a large study observed that older adults who received chiropractic care were less likely to be hospitalized, less likely to have used a nursing home, more likely to report a better health status, more likely to exercise vigorously, and more likely to be mobile in the community.⁴⁹

Chiropractic management involves many techniques and procedures; the most common are manual therapies and exercise.⁴⁰ Over the past 10 years there has been a significant increase in the literature in the number of randomized, controlled trials on spinal manipulation. To date, at least 73 randomized, clinical trials of a broadly defined spinal manipulation procedure can be found in the English language literature. The clinical trials include placebo-controlled comparisons, comparisons with other treatments, and pragmatic comparisons of chiropractic management with “normal medical care.”⁵⁰

A systematic review conducted by Koes et al⁵¹ in 1996 assessed 35 randomized, controlled studies involving manipulation and mobilization for chronic and acute spine pain. This systematic review provided limited evidence that spinal manipulation or mobilization would benefit patients with chronic low back pain.

Van Tulder et al⁵² reviewed nine studies involving patients with chronic low back pain, including five of the studies from the Koes et al⁵¹ review. The investigators concluded that there was strong evidence that manipulation is more effective than placebo in the management of chronic low back pain. They also found moderate evidence that manipulation was more effective than bed rest, analgesics, massage, and care by a general physician.⁵²

Four systematic reviews have found that manipulation or mobilization versus other treatments improves symptoms in patients with chronic neck pain.^53-56 In the geriatric patient, however, issues of safety must be taken into consideration given the reduced strength, endurance, and tissue capacity associated with aging and disease.⁵⁷ Spinal manipulation has been shown to be safe in the general population. Six prospective studies have been done looking at spinal manipulation; these studies evaluated over 2000 patients. In these six prospective studies, not a single incident of serious complication was noted.⁵⁸

The most valid studies suggest that about half of all patients will experience adverse events after spinal manipulation therapy. These events are usually mild and transient. No reliable data exist about the incidence of serious adverse events. These data indicate that mild, transient adverse events seem to be frequent. Serious adverse events are probably rare.

Senstad et al,^59,60 who performed the largest of the prospective studies, reports, “The most common incidents are related to innocuous physiologic reactions or short-term discomfort, generally in the site treated. These are self-limiting events that resolve within 24 hours, much like the soreness following intramuscular injection.” There have been no randomized, controlled trials on the utilization of chiropractic care in the long-term care setting.

A model of successful integration of a chiropractic clinic in a long-term care setting has been presented.^17,18 A chiropractic clinic was established in a university-affiliated long-term care facility. This clinic has integrated chiropractic care into basic treatment algorithms for pain management. The preliminary data from the clinic have been promising, with patients showing improvements in quality-of-life surveys as well as decrease in pain levels. This model has also demonstrated the safety of chiropractic care in the LTC population, with the reported side effects being lower than those reported in the younger, community-dwelling population.^17,18 While there is a need for randomized, controlled trials evaluating chiropractic services in long-term care, these preliminary data do seem promising that chiropractic care may play a role in pain management for residents of LTC facilities.

CONCLUSION

The growth in long-term care utilization is predicted to be substantial over the next 10-20 years, with estimates of increased growth of 10-25%.⁶¹ This fact, combined with the trends in utilization of complementary and alternative care in older adults,^1-4 necessitates that those involved in the treatment of patients in LTC settings should be informed about alternative care. This article has reviewed the evidence base for and side effects of the most commonly utilized forms of alternative care. While there is a growing amount of data on the safety and efficacy of complementary and alternative care, there remains a need for further high-quality trials to best assess the role of these therapies in older adults, and specifically, those in long-term care settings. The current literature, however, is encouraging for the possibility of the utilization of these different therapies to give long-term care residents diverse options for their care. “The integrated medicine of today will simply be the medicine of the new century.”⁶²