practical integrative medicine in geriatric healthcare€¦ · •dietary supplements • herbs...

PRACTICAL INTEGRATIVE MEDICINE IN GERIATRIC HEALTHCARENW GWEC Spring 2019 Geriatric Healthcare SeriesJune 4, 2019

Lianne Hirano, MDClinical Assistant ProfessorDiv. Gerontology & Geriatric MedicineUW School of Medicine

No disclosures to report.

Integrative Medicine (Hirano), NW GWEC Spring 2019 1

Case #1:87 yo woman “told to come” to Senior Care Clinic by

ENT. She is accompanied by her daughter/caregiver who lives with her.

On her intake questionnaire she lists “advancing age!”as her most important health problem.

She was seeing ENT for tx of SCC of her R cheek and maxillary sinus (for which she had undergone surgery w/ flap and reconstruction) and was now undergoing XRT.

Case #1 Cont:

She has had several falls within the past year and endorses balance and strength problems on ROS.

She denies having any other medical problems or PMHx.

Her MMSE score was 15/30 (-3 orientation, -3 registration, -5 calculation and attention, -3 recall). She believes her memory is "not as good as it used to be" but attributes this to advancing age.


MedicationsEfudex 5% topical BIDFolic Acid 1ml injection qweekCyanocobalamin 2ml injection qweekCoQ10 100mg po qdVit C 1000mg po tidFish Oil 1 tsp po qdayFlax Oil 1 Tbsp po qdayCalcium/Mag/Zinc 1cap po tid"Vision Essentials" Vitamin 4 caps po qd (Vit C, Vit A, Zinc, Copper)

Medications Nutritional Yeast 1 Tbsp po tid Rhodiola Rosea 50mg po qday Taurine 600mg po qdayQuercelin 300mg po qday Carrot Powder 260mg po qday N-acetyl-L-cystiene 260mg po qday Schisandra (berry) 160mg po qday Eyebright Laerial Part 60mg po qday Bilberry Extract 320mg po qdayGingko Extract (Leaf) 60mg po qday L-Glutamic Acid HCl 60mg po qdayGlycine 60mg po qday Alpha Lipoic Acid 10mg po qday Lutein (from Marigold Flower) 15mg po

qday Lycopene 3mg po qday Zeaxanthine 2mg po qday Astaxanthin (from algea) 1mg po qday

• Betaine HCl 648mg po tid• Pepsin (1:10,000) 130mg po tid• Amylase 10,000DU po tid• Protease 30,000 HUT po tid• Lipase 200 FCCLU po tid• Invertase 400 SU po tid• Malt Dictase 200 DP po tid• Lactase 300 ALU po tid• Cellulase 100 CU po tid


Questions:

Where to begin?

How do we address the use of complementary, alternative, and integrative treatments and practices?

Why do our patients turn to these treatments and practices?

Efficacy? Harm? Evidence? Regulation?

Definitions:

• Conventional Medicine

• Complementary• Care that may have origins outside of usual conventional “Western

Medicine”

• Non-mainstream practice is used together with conventional medicine

• Alternative• Non-mainstream practice is used in place of conventional medicine

• Integrative • Incorporating complementary approaches into mainstream health

care

• “Functional Medicine”, Naturopathy


Complementary Health Approaches:

• Natural Products (Dietary Supplements)• Herbs (botanicals)

• Vitamins and minerals

• Probiotics

• Cannabis

• Mind and Body Practices• Encompasses a large number of procedures or techniques

• Yoga, chiropractic and osteopathic manipulation, meditation

Other Approaches:

• Traditional Healers

• Ayurvedic Medicine

• Traditional Chinese Medicine

• Homeopathy

• Naturopathy

• Functional Medicine


• Most popular complementary health approach

• Dietary Supplements• Herbs “botanicals” (St. John’s Wort, Garlic, Ginseng)

• Vitamins and minerals (Calcium, Vitamin D, Folic Acid)

• Specialty products – Probiotics, Fish oils, glucosamine, resveratrol (designer supplements)

• Majority of adults in the US take one or more dietary supplements either every day or occasionally

Natural Products


• 1994 – Congress passes the Dietary Supplement Health and Education Act (DSHEA)

• Defines herbal medicines as “dietary supplements”, neither food nor drugs.

• Labels are required to state: “this product is not intended to diagnose, treat, cure, or prevent any disease.”

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• No oversight of contents, efficacy, or safety of herbal medicines. JAMA 2003;289:1568-70.

• In vitro or animal studies are not required prior to human trials because of belief that traditional use implies efficacy and proof of safety. Ann Intern Med 2002;136:616-618.

• Direct to consumer marketing without need for FDA approval (no incentive to conduct RCTs)

• DSHEA initially did not require reporting of adverse events to FDA!

DSHEA


http://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/ February 3, 2015

Herbal MedicationsHerbals may be adulterated w/ contaminants and/or prescription medications.Herbals are NOT required to pass preliminary safety studies so adverse events may not be noted until many pts have used the product over many years.Most adverse events are reported to Poison Control Centers rather than to the FDA.


• Exercise caution, start low and go slow

• Older persons may be more vulnerable to herb-drug interactions due to age-related changes in pharmacokinetics.

• Risk of poly-herbacy and herb-herb interactions.

• Herbal medications can cause delirium and increase pill burden

Elderly-Specific Issues

• Previously 3 categories:• Mind-body interventions (meditation, relaxation techniques)

• Manipulative Methods (chiropractic, massage therapy)

• Energy Therapies (Reiki, therapeutic touch, electromagnetic fields)

Mind and Body Practices


• Yoga (and Pilates)• Tai Chi, Qigong• Chiropractic and Osteopathic

manipulation• Meditation• Aromatherapy• Massage therapy• Acupuncture• Breathing exercises• Guided imagery• Progressive muscle relaxation

Mind and Body Practices

• Healing touch• Reiki/Energy therapy• Light therapy• Music therapy• Animal-assisted

therapy• Hypnotherapy• Special Diets• Laughter therapy• Journaling• Art therapy

• Acupuncture

• Yoga

• Massage

• Meditation

• Music Therapy

• Tai Chi

• Light Therapy

• Animal-assisted Therapy

What works?


Tai Chi for Fall Reduction

• Chinese martial art w/ exercises based on slow movement w/ meditative component

• 470 community dwelling older adults (avg age 78) at risk of falls, 6 month follow-up

• Reduced falls by 31%

JAMA Intern Med. 2018;178(10):1301-1310. doi:10.1001/jamainternmed.2018.39

???

What works for elderly patients?

“Benefits are equivocal. It is important to note there were several methodological difficulties with the included studies. More well-designed, large-scale randomized controlled trials are needed before clear conclusions can be drawn regarding [insert complementary therapy for particular elderly condition here]”


• Poor standardization of therapies

• Difficult to create appropriate control group (music therapy vs usual care, light therapy vs usual care)

• Not many studies in elderly

• Small sample sizes

• Bias

Research Issues

• Healing touch, therapeutic touch, Reiki

• Reflexology

• Music therapy

• Art therapy

• Biofeedback

• Meditation

What doesn’t cause harm?


• Natural Products: Probiotics, Melatonin, others (cannabis)?

• Mind and Body Practices: Tai chi, Yoga, Acupuncture

• In Hospitals and Facilities: Animal-assisted therapy, Art therapy, Acupuncture, Music therapy, Massage

What are we currently “integrating”?

Therapy Description Potential Safety Concerns

Potential Benefits

Yoga Involves postures/positions and breath control

Aggravation of preexisting physical conditions, muscle pain

Improved strength, balance, decreased pain

Acupuncture Stimulation of specific bodypoints by using small needles

Risk of injury to skin or nerves, infection. Addition of TCM.

Reduced pain

Aromatherapy Use of essential oils as therapy

Allergic reactions, skin irritation

Decreased stress, pain, nausea. Improved energy, sleep

Animal-assisted therapy

Animals as a form of therapy Bites/infections Increased socialization, reduced stress and axiety

For consideration:


• Meditation, Guided Imagery, Progressive Muscle Relaxation

• Laughter Therapy

• Music Therapy

• Light Therapy

• Art Therapy

• Reiki

For consideration:


• Do you use any other dietary supplements, over the counter medications, or natural therapies?

• Are there any other treatments or therapies that you find helpful?

How do you ask your patients about their complementary health approaches?


Practical Tips:

• Meditation, Guided Imagery, Progressive Muscle Relaxation – there’s an app for that• Download and print out scripts

• Find guided meditation on YouTube, CDs at local library, iTunes

• Aromatherapy• Have a few small bottles (lavender, ginger, lemon, bergamot),

cotton balls, and a ziplock

• Tai Chi, Yoga• YouTube, DVDs from local library, YMCA, second hand stores

• Acupuncture, Massage, Reiki• Find local providers, visit and make connections you trust

https://nccih.nih.gov/


A few bonus tips on cannabis:

Cannabis Pharmacology

Route Time to effect Duration

Oral/Sublingual (edibles, tinctures, sprays)*

30min-4 hours 6-8 hours

Inhaled (Combustion, Vaporization)

Within minutes A few hours

Topical/Transdermal ? ?

Rectal/Vaginal (Yes, suppositories are available)

??? ???

*Increased absorption with food/fed state, lipophilic


Metabolism

• Extensive hepatic metabolism! ( = extensive drug interactions), diff effects on diff CYP450 isoforms

• CBD – CYP3A4, 2C19, 2D6, 2E1, 3A4, 3A5

• THC – CYP2C, 2C19, 3A4, 3A5

Δ9-THC

11-OH-THC(4-5x more potent psychoactive)

• Fecal excretion > Urinary excretion• Clearance minimally changed in renal failure

Drug Interactions

• Warfarin! (↑INR)

• Anticholinergics (additive, eg ↑ sedation)

• Benzodiazepenes/Barbiturates (additive CNS depressant)

• Alcohol (may ↑THC levels)

• CBD may increase levels of SSRIs, TCAs, antipsychotics, Beta blockers, opioids


How to have the talk

• Open up the conversation

• Ask pts specifically if they are using cannabis, or even considering it (especially if they have symptoms that have been challenging to manage)

• Ask caregivers (like adult children)

• Share that you are open and willing to discuss how cannabis might fit into their medical care

• Do not discuss all risks upfront; appearing too negative immediately may push pts to assume you will judge them for considering and/or using cannabis

Cannabis Considerations

• Think of cannabis as a supplement (similarly unregulated, unknown effects, don’t know what might be in it)

• Visit a dispensary (I did!)

• Consider having a dispensary in mind to recommend to a pt who is set on trying cannabis (harm reduction)


Advice for Our Patients (Harm Reduction)

• DO NOT buy products from the internet, on the street, or synthetic products from gas station stores!

• Same approach as to medication: Start low, go slow (try 1/4-1/2 of “recommended dose”)

• There has been research done on cannabis and some of it is promising (seizures in children, pain, nausea/ vomiting) but most studies have not included older folks

• Recommend topical/transdermal products > oral

• Recommend products w/ CBD > THC concentration, or pure CBD

Advice for Our Patients

• Recommend against smoking/inhaling if immune-compromised

• Try new product on a day you’re not going to drive, go out, or make important decisions and have a caregiver or family member nearby just in case of adverse effects (particularly w/ oral route cannabis)

• Unfortunately, cannabis products are not tested, regulated, or quality-controlled


Advice for Our Patients

• Be aware that products are expensive! And only cash is accepted (most dispensaries have ATMs inside)

• Try to go with a friend/in a group, during the day.

• Remember: Cannabis is not legal in all states, and definitely not in most other countries (consideration for travel)

• Don’t forget: cannabis remains a controlled substance.

• If you work, review your job’s policy on cannabis/drug testing.

• Lock it up! Especially if you have grandchildren who visit or live with you.

• Cochrane Reviews

• https://nccih.nih.gov/health

Sources cited throughout, in addition:


practical integrative medicine in geriatric healthcare€¦ · •dietary supplements • herbs...

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