October 15, 2007

Something to Think About
By Dan Orzech
For The Record
Vol. 19 No. 21 P. 26

Growing numbers of older adults are contemplating complementary or alternative medicine therapy. What does this mean for the healthcare profession?

You’re sitting in a session with a family whose grandmother, aged 74, is having memory problems. They’re worried about Alzheimer’s disease. “I’ve heard that ginkgo biloba can prevent Alzheimer’s,” one of them says, “but I don’t know if it really works. Should Gram be taking it?”

If you don’t know the answer to that question, you’re not alone. There’s been an explosion of alternative approaches to healing in recent years—everything from acupuncture and yoga to herbs and meditation, not to mention comprehensive approaches to medicine such as Ayurveda and naturopathy, which can make use of any number of specific therapies. This makes it difficult for anyone to keep up. But one thing is certain: Healthcare professionals working with older adults will increasingly see clients turning to alternatives to traditional Western medicine.

According to the Centers for Disease Control and Prevention (CDC), 36% of adults in the United States use some form of complementary or alternative medicine (CAM) therapy. Add in prayer aimed specifically at healing, and that number nearly doubles. At the moment, adults in their 40s and 50s tend to be the biggest users of CAM therapies. “The baby boomer generation was the first generation to become open to things like meditation, yoga, and health food,” says Elizabeth Mackenzie, PhD, a professor at the University of Pennsylvania who recently coauthored a book to help professionals understand CAM for older adults. But the boomers, she says, “are now on the threshold of old age. You’re going to see a huge increase in interest in this among older people.”

Fewer Side Effects
That could be a good thing, according to Harvey Zarren, MD, president of the Arlington, Mass.-based Integrative Medicine Alliance, because CAM therapies tend to be less invasive than conventional medicine and have fewer side effects. And older people, he says, “tend to be much more prone to encounter problems from standard medical treatment. They suffer more from side effects and complications, in part because their reserves for metabolizing and excreting things are lower.”

But what sets CAM apart from traditional medicine, says Zarren, is not only different techniques and medicines but the way medicine is practiced. “It’s not just about what tools are used,” he says. “There’s a focus on deepening the quality of the human experience. CAM practitioners generally relate to their patients with respect, spending lots of time with them and focusing on people’s wellness rather than their problems.”

Going Mainstream
Figuring out exactly what CAM is can be a challenge. The National Center for Complementary and Alternative Medicine (NCCAM) has divided the field into four general approaches: biologically-based practices such as herbs or supplements, mind-body medicine approaches such as meditation or music therapy, body-based practices such as massage or chiropractic, and energy medicine, which can include approaches such as Reiki or therapeutic touch (see sidebar). Many of these specific techniques are used by what the NCCAM calls whole medical systems such as traditional Chinese, homeopathic, and naturopathic medicines.

Increasingly, many of these practices are moving toward the mainstream. “Ten or 20 years ago, acupuncture was considered very bizarre,” says Mackenzie. “But now that people have discovered that it’s good for pain management, there are acupuncturists in rehabilitation medicine departments in almost every major hospital in the country. And if you go to most major cancer centers, you’ll find mind-body programs offering things like yoga and positive imagery classes. You wouldn’t see that 20 years ago.”

As CAM practices become more accepted, some conventionally trained physicians have begun integrating them with traditional medical treatments. Led by pioneers such as Andrew Weil, MD, the field of integrative medicine, as it’s known, is growing rapidly. More than three dozen medical schools, including Yale, Harvard, and Stanford, now offer training programs in integrative medicine.

Efficacy
The big question for many doctors and patients is whether complementary and alternative treatments work. In many cases, the answers are anything but clear. Take echinacea, for example, a root widely believed to ease the symptoms of the common cold and possibly prevent them altogether.

According to the CDC, echinacea is the most widely used natural product in the United States. However, one extensive study published in 2005 in The New England Journal of Medicine found no evidence that echinacea protected people from getting a cold or made any significant difference in their symptoms.

Critics of that study, however, suggested that the dose used was too low. And two years later, in July 2007, a meta-analysis of hundreds of studies on echinacea published in Lancet Infectious Diseases concluded that echinacea reduced the risk of catching a cold by 58% and significantly shortened the cold’s durations.

Similar controversies have dogged other CAM therapies. Two large studies found that the herb St. John’s Wort, widely used by doctors in Europe to treat depression, was no better than a placebo for treating major depression. Still other research indicates that it may be helpful after all, although perhaps more for mild to moderate depression than severe cases.

The lack of scientific consensus leaves many patients and their healthcare providers confused about what to do. As CAM treatments have moved into the mainstream, however, researchers are launching a steadily growing number of studies that may help to resolve some uncertainty. Many larger and more rigorous studies are now being funded by the National Institutes of Health (NIH) through the NCCAM.

One large study is looking at whether the herb ginkgo biloba can help prevent Alzheimer’s disease, memory loss, and cardiovascular disease in older adults. The results, due sometime in the next two years, could be significant for many older adults: More than 4 million Americans, most over the age of 65, have Alzheimer’s, according to the NIH. Jointly sponsored by the NCCAM, the National Institute on Aging, and the National Heart, Lung, and Blood Institute, the study is following more than 3,000 adults over the age of 75 for more than five years. One half of them are receiving ginkgo and one half a placebo, and every six months they undergo a battery of cognitive, neuropsychological, and cardiovascular tests.

“Americans spend a quarter billion dollars a year on ginkgo,” says Steven Dekosky, MD, chairman of the neurology department at the University of Pittsburgh and the study’s principal investigator. But while earlier studies have suggested that ginkgo may be helpful for treating the symptoms of Alzheimer’s and other types of dementia, according to Dekosky, there has been little research on whether it can cure or prevent Alzheimer’s, nor have questions about the appropriate dosage and safety been resolved.

Sham Reiki?
Rigorous, pharmaceutical-style clinical trials may be useful for herbal medicines, but they won’t necessarily answer the question of whether other types of complementary and alternative treatments work. “Double-blind, randomized, controlled trials aren’t going to help us understand how Reiki works,” says Zarren. “How do you do sham Reiki? What would be the control?”

That doesn’t mean those types of studies aren’t useful, Zarren says. They can help establish whether a particular approach is safe. But based in a reductionist point of view, he says, they lack an understanding of the wholeness of life found in complementary approaches.

Take tomatoes, for example. “Traditional Western medicine,” says Zarren, “would say that if tomatoes contain lycopene and lycopene can help, say, prostate cancer, then we’ll make a pill and just put lycopene in it. But that ignores the fact that in the tomato, lycopene is combined with all sorts of other things. Could eating tomatoes be better for you than taking lycopene pills?”

So while traditional research does provide some answers, it’s not the only source of information about what works, says Zarren. “There’s anecdotal evidence; there’s experiential evidence. There’s the fact that some of these approaches have been around for thousands of years, and we see them working on people,” he says.

Even Western medicine isn’t always based on research. “We did bypass surgery for years before anyone did any kind of a study on it,” says Zarren.

Keeping CAM Secret
Complementary and alternative treatments are becoming more accepted by mainstream medicine, but that doesn’t mean all physicians are knowledgeable about them, which can lead to a communication breakdown: Among people aged 50 or older, 69% of those who use CAM do not talk to their doctors about it, according to a survey conducted by the American Association of Retired Persons and the NCCAM.

“Physicians are in an awkward position,” says Mackenzie. “They’re not trained in this, and they may not know which herbs could be dangerous or if homeopathy actually does work. And patients don’t want to be admonished or told they’re silly for trying these things.”

But CAM treatments—particularly herbs—are medicines and can interact powerfully with other treatments. Ginkgo biloba, for example, can inhibit blood platelet aggregation and has caused increased bleeding in people taking prescription blood thinners. Other dietary supplements known to interact with prescription drugs include garlic, glucosamine, ginseng, saw palmetto, soy, valerian, and yohimbe.

In other words, if you’re taking pharmaceuticals, don’t experiment with herbal supplements without guidance. “Using herbs, especially if you’re on a lot of medications, is something you really want to do with the advice of either a really good herbalist or a physician,” says Mackenzie.

— Dan Orzech is a Philadelphia-based freelance writer.

Do They Work?
Zinc Lozenges for Colds
Despite 20 years of research, the benefits of zinc lozenges as a therapy for the common cold have not been proven. A review of 14 placebo-controlled studies from the past two decades finds significant problems with 10 of the studies. Three of the other studies report no therapeutic effect from zinc lozenges or nasal spray. The remaining study, however, reports positive results from zinc nasal gel.

Ginkgo Biloba for Alzheimer’s
Studies have shown that ginkgo may be useful in reducing the symptoms of Alzheimer’s disease and other types of dementia. There is no research, however, demonstrating that ginkgo can prevent or cure Alzheimer’s. The National Institutes of Health (NIH) is currently conducting a major clinical trial to examine these possibilities. It is also testing ginkgo for use with asthma, symptoms of multiple sclerosis, cognitive decline, and sexual dysfunction due to antidepressants.

St. John’s Wort for Depression
Widely prescribed in Europe for depression, St. John’s Wort may be useful for mild to moderate depression, according to a review of 23 clinical studies. A major NIH research study, however, found that it was not effective for treating major depression of moderate severity.

— DO

What is CAM?
For those seeking healing approaches outside traditional Western medicine, there are numerous complementary and alternative approaches available. The National Center for Complementary and Alternative Medicine divides them into four major types, along with whole medical systems, which can incorporate various healing practices.

Mind-body Medicine
Mind-body medicine includes various techniques aimed at an integration of brain, mind, body, and spirit. These include meditation, mindfulness-based stress reduction, prayer, hypnosis, and imagery, as well as therapies such as art, music, or dance. Some 17% of adult Americans make use of mind-body interventions; 45% of that population uses prayer for health reasons.

Biologically-based Practices
Herbs, vitamins, and other substances found in nature are often used in complementary or alternative medicine healing approaches and include botanicals, minerals, amino acids, and probiotics such as acidophilus, as well as enzymes such as Nattokinase, a soy derivative. Biologically-based approaches can also constitute diets, including vegetarian, vegan, and macrobiotic.

Manipulative and Body-based Practices
Manipulative and body-based practices focus primarily on the systems of the body, including the bones and joints, soft tissues, and circulatory and lymphatic systems. They include massage and chiropractic or osteopathic manipulation, as well as techniques such as reflexology, Rolfing, Trager bodywork, Alexander technique, and Feldenkrais method.

Energy Medicine
Energy therapies such as Reiki, therapeutic touch, and the traditional Chinese qigong seek to achieve healing and wellness by affecting the body’s energy fields. While the existence of these energy fields has not been proven scientifically, they have long been recognized as chi, or life force, by Chinese culture. In Reiki, practitioners place their hands on or near the patient, while qigong combines movement, meditation, and breath work. Other approaches to energy work involve magnets or electrical fields.

Whole Medical Systems
Whole medical systems provide a comprehensive system of theory and practice for the use of other healing practices such as acupuncture, herbs, or yoga. Some systems evolved within the last century or so, such as naturopathic medicine or naturopathy, and homeopathy, which seeks to activate the body’s natural healing abilities by giving very small doses of highly diluted substances that in larger doses would produce illness or symptoms. Other systems have been around much longer, including traditional Chinese medicine, Ayurveda, which originated in India, and Japanese traditional herbal medicine, known as Kampo.

— DO