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Complementary and Integrative Medicine for an Aging Maine

Complementary and Integrative Medicine for an Aging Maine. September 25, 2008 Craig Schneider, MD Director of Integrative Medicine Maine Medical Center Family Medicine Residency Program. RELAX. Tongues up! Exhale gently Inhale 4 Hold 7 Exhale 8 Whoosh! REPEAT OFTEN.

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Complementary and Integrative Medicine for an Aging Maine

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  1. Complementary and Integrative Medicine for an Aging Maine September 25, 2008 Craig Schneider, MD Director of Integrative Medicine Maine Medical Center Family Medicine Residency Program

  2. RELAX • Tongues up! • Exhale gently • Inhale 4 • Hold 7 • Exhale 8 Whoosh! • REPEAT OFTEN

  3. By the end of this session • Better understanding of CAM and Integrative Medicine • Awareness of how common CAM and Integrative Medicine use is in elderly population • Reminded of the importance of open communication about CAM and Integrative Medicine with all patients and elderly in particular • Aware of reliable resources for answering questions pertaining to CAM and integrative medicine approaches.

  4. Alternative medicine ..in place ofconventional medicine. • a special diet to treat cancer instead of undergoing surgery, radiation, or chemotherapy recommended by a conventional doctor. • Complementary medicine ..together withconventional medicine. • using aromatherapy or acupuncture to decrease discomfort following surgery.

  5. Integrative Medicine healing oriented medicine • whole person (body, mind, spirit) • all aspects of lifestyle, health promotion and prevention of disease • emphasizes therapeutic relationship • makes use of appropriate therapies, both conventional, complementary and alternative..guided by evidence

  6. Integrative Medicine:the right thing to do • Creating a safe space where patients and families can consider the options, the evidence and find their way, to make their best possible decisions

  7. Integrative Medicine is practical • Increasingly common that people with chronic illness have healthcare providers with conventional and alternative philosophies and approaches. • Fostering openness reduces potential for adverse interactions, and patient guilt while increasing potential for good outcomes.

  8. Integrative Medicine = Restoring Balance

  9. Geriatrics is Integrative Medicine • Incorporates body, mind, spirit • Requires comprehensive multidisciplinary assessment • -QOL (physical, mental, familial, social, spirit) • -Nutrition (including DS, herbs) • -Medications (minimizing interactions and adverse effects, including DS, herbs) • -Meaning, community support • -Cognitive issues • -Ability to carry out activities of daily life • Beyond reduction of symptoms and prevention of disease • Towards restoration of purpose, meaning, dignity and overall wellbeing

  10. But is this what people want? • Older people are fixed in their ways…right? • According to the Census Bureau, there are currently 80,000 people aged 100 or older in the U.S, but there will be 580,000 - a seven-fold increase - by 2040. • According to the (2007) Evercare 100@100 survey of 70 female/30 males 99 or older Centenarians are: • forward-thinking, open to new experiences, eat healthy foods, don't smoke (the rebellious two percent not withstanding!) have strong religious faith, and cherish their independence.

  11. Back Pain Head colds Neck pain Joint pain Arthritis Anxiety/depression GI upset HA Recurring pain Insomnia

  12. 1. Thought CAM + Conventional would help 2. Thought it would be interesting to try 3. Thought conventional wouldn’t help 4. Their doctor recommended it 5. Conventional medicine costs too much

  13. Natural Products

  14. Geriatrics and CAM • CAM use only slightly lower than average in pop. over 65 years. • High use in “baby boom” generation (b. 1946-1964), the next Geriatric population. • Ernst E. White A. 2000. Complementary Therapies in Medicine • Wellman B. Kelner M. Wigdor B. 2001 Journal of Applied Gerontology 20 (1), 3-23.

  15. 41% of seniors enrolled in Blue Shield Medicare supplement in California use CAM Journal of Gerentology 2000

  16. N=1000 Iowans • 88% 65 years and older use CAM • Dietary supplements = 65% • Chiropractic = 46% • More alternative practitioner use correlated w/ • Higher income • Functional impairment • Frequent physician visits • Gerentologist 2005

  17. Worried Well? • CAM users have more medical problems • Report poorer overall health status • Problems tend to be chronic • More physician visits Palinkas LA - J Fam Pract 2000; 49(12): 1121-30

  18. Convenience sample of 60 adults from three ethnically diverse senior centers. • 80% used two or more CAM therapies. • Most commonly used: • prayer • vitamins • diet • massage • meditation. • Geriatric Nursing 2004

  19. Convenience sample N=100 elderly African Americans in Chicago • 65% used Multivitamins • 42% used Vit E • 31% used Calcium • 11% used Glucosamine • 8% used Ginkgo biloba • 7% used Omega 3 Fatty Acids • JAGS 2003

  20. 97% of dietary supplement users also took prescription medications • Only 60% told their physicians about D.S. use.

  21. Why they use CAM? • To supplement diet • Stay well (Most) • For specific medical conditions • Osteoporosis (7%) • Arthritis (6%) • Dementia (6%) • Cancer (6%) • (5%)??? • Can’t remember why!!

  22. Why? Just a fad? …more congruent with their own values, beliefs, and philosophical orientations toward health and life. Astin JA. JAMA. 1998;279(19):1548-53 …twice as likely to use CAM if interested in… Environmentalism Or Spiritual development

  23. Some Top Reasons Integrative Approaches are Used Anxiety IFM

  24. Fatigue

  25. Depression

  26. Chronic Pain

  27. Central Obesity

  28. A Fear that something is not right

  29. Premature? Aging

  30. Why? Just cosmetic?

  31. Dissatisfied with effectiveness of conventional med Perceived negative side effects of drugs Dislike for the “production-like nature of conventional med” Perception of disempowering Holistic and personalized More time in consultation Spiritual dimension Perceived safety Empowering A form of resistance against paternalism and perception of patronizing experiences with conventional med Why? “Pulled” “Pushed”

  32. Influencing factors • Media advertisements • Physician’s advice • Immediate family members • Acquaintances • Self help books • Other health professionals

  33. Evidence exists that these therapies are… • Beneficial…useless…dangerous • Thousands of studies in English-language peer reviewed journals… • Quality varies greatly • Remember….One of our jobs as healthcare providers… • to help create a safe space where patients can consider the evidence, their options and find their way, to make their best possible decisions

  34. Mr. Newman is 67 year old male CC: urinary sx (nl UA, Nl Cr, PSA WNL, DRE no nodules, diffuse prostate enlargement AUS symptoms score = 18 (top of moderate) Tried Finasteride, but didn’t tolerate, low libido Tried alpha blockers but didn’t tolerate, dizzy “I’d really rather not take a pharmaceutical, what else can I try”

  35. Saw Palmetto (Serenoa repens) • antiandrogenic, antiproliferative, and anti-inflammatory properties. • Inhibits 5-alpha reductase and reduces prostate growth by preventing the conversion of testosterone to dihydrotestosterone

  36. Saw Palmetto May be as effective as finasteride (Proscar) Seems to be better tolerated Less impotence than w/ finasteride Wilt T, Et al. In: The Cochrane Library, Issue 3, 2000. Unlike finasteride, saw palmetto doesn't reduce PSA levels.

  37. http://www.naturaldatabase.com

  38. Most clinical studies have used a liposterolic extract of saw palmetto berry containing 80% and 90% fatty acids. This formulation is similar to Quanterra Prostate (Warner-Lambert), Super Saw Palmetto (Enzymatic Therapy), ProstaPro (Phytopharmica), Saw Palmetto (Centrum), Standardized Saw Palmetto Extract (Nature's Way), and others. DOSAGEORAL: 160 mg twice daily or 320 mg once daily

  39. Saw Palmetto: Bottom Line • Conflicting evidence • In systematic reviews saw palmetto as effective as finasteride in relieving obstructive symptoms, but did not decrease prostate volume. A subsequent placebo-controlled trial found no evidence saw palmetto was superior to placebo • Boyle, P, Robertson, C, Lowe, F, Roehrborn, C. Meta-analysis of clinical trials of permixon in the treatment of symptomatic benign prostatic hyperplasia. Urology 2000; 55:533. • Bent, S, Kane, C, Shinohara, K, et al. Saw Palmetto for Benign Prostatic Hyperplasia. N Engl J Med 2006; 354:557. • Inconsistent findings might be due to different outcome measures, product selection, etc. • Safe

  40. Pygeum African Plum Tree bark Decrease nocturia, increase peak urine flow, and reduce residual urine volume in men with BPH. Wilt T, et al. Pygeum africanum for benign prostatic hyperplasia. Cochrane Database 2002 antiproliferative and anti-inflammatory effects. preliminary evidence it suppresses epithelial growth factor (EGF), basic fibroblast growth factor (bFGF)...insulin-like growth factor (IGF). This might help shrink prostate epithelial Pygeum may also have anti-inflammatory activity...it decreasesproduction of leukotrienes and other 5-lipoxygenase metabolites.

  41. A standardized preparation of Pygeum africanum may be a useful treatment option for men with lower urinary symptoms consistent with BPH. • Pygeum extract 75-200 mg daily • Unknown if any more effective than standard treatments or long term safety. • Pygeum is very well tolerated...the most common side effect is GI upset • Cochrane 2002

  42. http://www.consumerlab.com/ One-year (12 months) subscription is $29.95 Two-year (24 months) subscription is $49.50

  43. Beta-sitosterol • plant's version of cholesterol. • found in many foods and herbs used for BPH. • seems to have antiproliferative effects on prostate tissue. • Kassen A, et al. Effect of beta-sitosterol on transforming growth factor-beta-1 expression and translocation protein kinase C alpha in human prostate stromal cells in vitro. Eur Urol 2000;37:735-41

  44. http://www.naturalstandard.com/

  45. Plant sterols/stanols

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