Complementary and integrative medicine for older adults in palliative care

The efficacy and tolerability of proteoglycan F in the treatment of knee osteoarthritis: A prospective, randomized, double-blind controlled trial

Objective

To identify the efficacy and tolerability of Proteoglycan F in patients with primary knee OA.Design: A 24-week randomized, placebo-controlled, double-blind clinical trial with two arms: (1) Proteoglycan F (received 10 ​mg proteoglycan daily, for 24 weeks) and (2) control group (received placebo). Knee symptoms and joint cartilage status (evaluated by ultrasound and MRI of knee joints), quality of life, serum cytokine levels (IL-1β and TNF-α), and safety evaluation were measured before, during, and after the treatment.

Results

After 24-week treatment, pain reduction (in the KOOS pain score) of at least 20% and at least 50% (NRS scale) compared to baseline in the PGF group was significantly higher than those in the control group. The PGF group had greater reductions in the total scores of subchondral bone marrow edema, and bone cocoon under cartilage on knee MRI (classification according to WORMs), which were -2.27 (-4.0; -0.51) and -1.77 (-3.08; -0.46), respectively (p ​< ​0.05). The two groups had no statistically significant difference in knee ultrasound characteristics. After 4 weeks, 12, and 24 weeks compared to baseline, there was no statistically significant difference in levels of urea, creatinine, aspartate aminotransferase, and alanine aminotransferase within the group and between the two study groups.

Conclusions

Salmon cartilage PG with 10 ​mg per day has potential to improve pain symptoms and subchondral bone marrow edema and bone cocoon under cartilage lesions in primary knee OA. However, the efficacy of PGF should be viewed with caution, and future studies are needed for more specific evaluation.

Integrative management of diabetic foot ulcers - A case series

Diabetic foot ulcer (DFU) is a serious complication of diabetes mellitus and a cause of significant morbidity, mortality and healthcare expenditure. Treatment of DFU includes multimodal approach like surgical debridement, infection control, vascular assessment, dressing etc. Multidisciplinary approach towards foot care is becoming a mainstay of therapy, and even with this comprehensive approach, there is still room for improvement in DFU outcomes. Integrative management includes the adoption of various systems of treatment with standard treatment for better outcomes. In the present case series, six cases of DFU were managed with the integration of Ayurveda and allopathic treatments. The cases were managed according to the standard diabetic foot ulcer management principles like surgical debridement, insulin therapy, along with incorporation of Ayurveda procedures like Vimlapana, Prakshalana, Bandhana etc. Standard assessment of ulcers at different time points was done using the Bates- Jensen Ulcer assessment tool. All the six DFU healed with minimal scar formation and in less time, lowering the risk of further amputation. Promising results were obtained in all six cases by adopting integrated Ayurveda and allopathic treatments, which indicates the potential benefits of alternative systems of medicine.

Household Income and Older Adult Population Predict Number of Integrative Medicine Providers Around US Hospitals: An Environmental Scan Study

Background

Integrative medicine (IM) is a growing subspecialty among the American healthcare system, but little is known about geographical and sociodemographic variability in access to services.

Objective

To better understand access to IM healthcare services, we aim to: 1.) document the number of IM providers within the hospital service area (HSA) of various hospitals across the United States (US) and, 2.) explore the relationship between age, income, and race as predictors of the number of IM providers.

Methods

We conducted an environmental scan to document the number of IM providers including naturopathic, acupuncture, chiropractic, and massage therapy providers within the HSA of 16 US hospitals using state and national search databases. We examined predictors of the number of providers per HSA using population and demographic data from the U.S. Census Bureau. Search database quality was evaluated using the Center for Disease Control and Prevention Clear Communication Index.

Results

The number of IM providers varied from 11.6 – 67.4 providers/100,000 persons. Massage therapists were the most prevalent (n = 13.8/100,000), followed by chiropractors (n = 5.2/100,000), acupuncturists (n = 4.6/100,000), and naturopathic physicians (n = .5/100,000). Higher average household income and population >65 years old were associated with more IM providers within an HSA (Rate Ratio (RR) 4.22, 95% CI 1.49-12.01; and 1.14, 1.05 - 1.24, respectively). In addition, the quality of publicly available search databases varied widely among US states (4.84 - 8.00/10), but less so among IM provider types (6.21 - 7.57/10).

Conclusions

The high variability in number of IM providers and search database quality among various HSAs across the US warrants further investigation into factors influencing access to services. Our findings regarding income and older adult population raise concern for inequitable access to care, but are also promising when considering the increasing demand for healthcare services among the older adult population.

The use of complementary alternative medicines in advanced cancer patients followed at home

Objectives

To assess the use of complementary alternative medicines (CAM) in advanced cancer patients followed at home.

Methods

A consecutive sample of advanced cancer patients admitted to a home palliative care program was invited to participate in the study in a period of two months. Demographic characteristics, religious belief, education level, diagnosis, and socio-economic condition were recorded. Patients were asked about the use of CAM, considered to be a health-related treatment practiced outside the established health services. Information about CAM indications and those who prescribed or suggested CAM were also collected.

Results

Two hundred and eighty-three advanced cancer patients followed at home were surveyed. Twelve patients (4.2%) were receiving CAM. The indication and type of CAM were variable, as well as the costs. Given the low number of patients taking CAM, no further analysis was performed.

Conclusion

A limited number of advanced cancer patients followed at home were using CAM. Further multicenter studies with a larger sample should be performed to provide information about such therapies, also including eventual benefits.

Knowledge and clinical dialogues about complementary health approaches among nurse practitioners specialized in geriatrics

BACKGROUND

In the United States, people over the age of 65 years will account for 20% of the population by 2030, and these elders are more likely to have chronic comorbid complex health problems. Sixty-three percent use complementary health approaches (CHAs) but less than half disclose their use to their health care providers. Nurse practitioners (NPs) are the fastest growing population of primary care health providers.

PURPOSE

This study identifies to what degree NPs with specialized training in geriatrics understand CHAs, use them themselves, encourage their patients to access them, and engage in CHA clinical dialogue.

METHODS

Cross-sectional online survey collecting quantitative and narrative data; US NPs with specialized training in geriatrics (n = 170, mean age 52 years, SD: 9.0, range: 29-73).

RESULTS

Although NPs are knowledgeable about some CHA and believe they are beneficial for older adults to use, they want more education to help understand the effects of a variety of CHA, be more aware of possible treatment interactions, and to integrate CHA into the current health care system. Patient factors (impaired cognitive function, acute health problems, and not open to CHA), provider factors (inadequate CHA knowledge, limited referral paths and resources), and system factors (limited accessibility and availability of CHA in in-patient setting, CHA not covered by insurance, and limited clinical time) disrupt NPs from assessing and discussing CHA with their patients.

IMPLICATIONS FOR PRACTICE

There is a need to develop and implement NP practice guidelines for CHA clinical management for older adults and provide educational opportunities to incorporate CHA into clinical practice.

Integrating Traditional and Complementary Medicine Recommendations into Clinical Practice Guidelines for People with Diabetes in Need of Palliative and End-of-Life Care: A Scoping Review

Objectives: This study was conducted before an evidence review on Traditional and Complementary Medicine (TCM) to update the clinical practice guidelines (CPGs): "Deciding palliative and end-of-life (P/EoL) care for people with diabetes." The aim was to frame the PICO (population/problems, interventions/comparisons, and outcomes), ascertain their importance, and identify other modifying factors for grading recommendations. Design: A systematic scoping review mapped information about diabetes P/EoL problems and outcomes, TCM use, provision, benefits and risks, and stakeholder preferences and values. Thirteen electronic databases were searched in 2017/18 until no new information was identified. Relevant data were extracted, rated for quality, directness, and relevance, and synthesized using triangulation methods. Excluded was diabetes prevention or treatment, as this is not an important P/EoL problem. Results: Of the 228 included articles, except for diabetes P/EoL problems, insufficient direct evidence led to data being extrapolated from either adults with diabetes or any P/EoL diagnosis. The findings affirmed that caring for people with diabetes in need of P/EoL care is complex due to multiple fluctuating needs that are influenced by the P/EoL trajectories (stable, unstable, deteriorating, terminal, or bereaved), multimorbidity, and difficult-to-manage chronic and acute problems. The only problem specific to diabetes P/EoL care, was unstable glycemia. Over 50 TCM interventions commonly used by patients and/or provided by services were identified, of which, many might simultaneously address multiple problems and 18 had been appraised in systematic reviews. Physical and psychologic symptom reliefs were most often evaluated; however, these were only one aspect of a "good death." Other important outcomes were the quality and location of care, personal agency, relationships, preparations for the dying process, spirituality, and affirmation of the whole person. Other important modifying factors included opportunity costs, affordability, availability, preferences, cultural appropriateness, and alignment with beliefs about the meaning of illness and death. Conclusions: There is a role for TCM in the multidisciplinary holistic P/EoL care of people with diabetes. Due to the paucity of evidence specific to this population, the generalizability of some of these results is broader and the updated CPG will also need to consider indirect evidence from other patient groups. Along with recommendations about indications for TCM use, the CGP should provide guidance on ceasing unnecessary interventions, reducing polypharmacy and managing unstable glycemia is required. Before ceasing a TCM, a broader risk-benefit analysis is recommended, as unlike many conventional therapies, there may be multiple benefits warranting its continuation.

Access to Home and Community Health Services for Older Adults With Serious, Life-Limiting Illness: A Study Protocol

OBJECTIVES

The objective of this study is to identify contextual access factors to home and community health services for end-of-life support for older adults with serious life-limiting illness, as well as determine if access to home and community services is associated with health-care utilization.

DESIGN

This study includes an environmental scan, grey literature review, qualitative interviews, and health-care utilization analysis. This study is a subproject of the Grudzen et al. Primary Palliative Care for Emergency Medicine (PRIM-ER) study.

SETTINGS/LOCATION

Analysis will include data collection from 17 health systems implementing the PRIM-ER intervention.

PARTICIPANTS

For the qualitative interviews, one emergency medicine (EM) physician and one EM nurse will be interviewed from each of the 17 participating health systems. For the health-care utilization analysis, we will use the Senior Care Services Scale (SCSS), American Hospital Association Annual Survey of Hospitals (AHA-ASH), and Medicare claims for all emergency department (ED) visits for serious illness who present at each participating health system.

OUTCOME MEASURES

The contextual analysis will obtain data on home and community services, such as hospice, home health services, assisted living, integrative medicine services, etc., available around each health system's highest volume ED, federal and state regulations influencing access to services, as well as EM provider perspectives on access to services. The health-care utilization analysis will determine if SCSS scores, which measure service availability, are associated with health-care usage. High or low SCSS scores are determined by comparing health system service availability on the AHA-ASH to the national median SCSS value.

Efficacy of complementary and integrative medicine on health-related quality of life in cancer patients: a systematic review and meta-analysis

Complementary and integrative medicine (CIM) has been used for improving health-related quality of life (HRQOL) in patients with cancer. The objective of this review is to evaluate the effects of CIMs on the HRQOL of cancer patients. We identified randomized controlled trials (RCTs) involving patients with cancer at any stage by retrieving electronic databases from the inception to February 14, 2018 (Systematic Review Registration: PROSPERO CRD42018091609). The main outcomes were HRQOL scores and related domains such as physical well-being scores. The standardized mean difference was used for the analysis and heterogeneity was assessed with the I ² statistic. A Bayesian framework was used to estimate the ranking order of efficacy in HRQOL change. Finally, 34 RCTs with 3,010 patients were included. As a whole, the results showed clearly superior efficacy of CIM in improving HRQOL. For different domains of HRQOL, different CIM interventions may play different roles. The ranking order of efficacy in change HRQOL was qigong plus mindfulness, Chinese herbal medicine, multimodal complementary medicine, qigong, nutritional supplement, mindfulness, acupuncture, yoga, and massage, and it was different among different domains. There was no evidence of publication bias. In conclusion, CIM may improve the HRQOL of cancer patients. More studies, especially focusing on male cancer patients, are needed to increase the confidence level of our findings.

Complementary and alternative medicine use among persons with multiple chronic conditions: results from the 2012 National Health Interview Survey

BACKGROUND

Although a quarter of Americans are estimated to have multiple chronic conditions, information on the impact of chronic disease dyads and triads on use of complementary and alternative medicine (CAM) is scarce. The purpose of this study is to: 1) estimate the prevalence and odds of CAM use among participants with hypercholesterolemia, hypertension, diabetes, and obesity; and 2) examine the effects of chronic condition dyads and triads on the use of CAM modalities, specifically manipulative and body-based methods, biological treatments, mind-body interventions, energy therapies, and alternative medical systems.

METHODS

Data were obtained from the 2012 National Health Interview Survey and the Adult Alternative Medicine supplement. Statistical analyses were restricted to persons with self-reported hypercholesterolemia, hypertension, diabetes, or obesity (n = 15,463).

RESULTS

Approximately 37.2% of the participants had just one of the four chronic conditions, while 62.4% self-reported multiple comorbidities. CAM use among participants was as follows (p < 0.001): hypercholesterolemia (31.5%), hypertension (28.3%), diabetes (25.0%), and obesity (10.8%). All combinations of disease dyads and triads were consistently and significantly associated with the use of mind-body interventions (2-4%, p < 0.001). Two sets of three dyads were associated with use of manipulative methods (23-27%, p < 0.05) and energy therapies (0.2-0.3%, p < 0.05). Use of biological treatments (0.04%, p < 0.05) and alternative systems (3%, p < 0.05) were each significant for one dyad. One triad was significant for use of manipulative methods (27%, p < 0.001).

CONCLUSIONS

These findings point to future directions for research and have practical implications for family practitioners treating multimorbid patients.

Rehabilitation Needs of the Elderly Patient with Cancer

Physiatrist taking care of the geriatric patient with cancer should be able to manage an array of conditions that might present from diagnosis throughout completion of treatments and beyond. The elderly cancer population is at greater risk of functional impairments. The physician should anticipate changes in clinical status and must adjust rehabilitation goals accordingly. Treatment options and rehabilitation goals should be tailored to help maximize quality of life in these patients.

New and Future Directions in Integrative Medicine Research Methods with a Focus on Aging Populations: A Review

This review discusses existing and developing state-of-the-art noninvasive methods for quantifying the effects of integrative medicine (IM) in aging populations. The medical conditions of elderly patients are often more complex than those of younger adults, making the multifaceted approach of IM particularly suitable for aging populations. However, because IM interventions are multidimensional, it has been difficult to examine their effectiveness and mechanisms of action. Optimal assessment of IM intervention effects in the elderly should include a multifaceted approach, utilizing advanced analytic methods to integrate psychological, behavioral, physiological, and biomolecular measures of a patient's response to IM treatment. Research is presented describing methods for collecting and analyzing psychological data; wearable unobtrusive devices for monitoring heart rate variability, activity and other behavioral responses in real time; immunochemical methods for noninvasive molecular biomarker analysis, and considerations and analytical approaches for the integration of these measures. The combination of methods and devices presented in this review will provide new approaches for evaluating the effects of IM interventions in real-life ambulatory settings of older adults, and will extend the concept of mobile health to the domains of IM and healthy aging.