Use of Complementary and Alternative Medicine in Residential Aged Care

Abstract

Objectives:

There is increasing evidence of the use of complementary and alternative medicine (CAM) by older people living in the community; however, little is known about the use of CAM in residential aged-care facilities (RACF). This review examined the literature on the use of CAM in RACF, focusing on prevalence, motivations, and support for use.

Methods:

A search of multiple databases between 2000 and 2010 was conducted. Articles were analyzed under five key themes: prevalence of CAM use, CAM user profile, motivations for use, expectations for and satisfaction with CAM use, and institutional and/or staff support for CAM use.

Results:

Only five articles were found that met the inclusion criteria. The review highlights the absence of evidence regarding the use of CAM by older people in RACF.

Conclusions:

To inform policy and improve clinical practice in line with the aging of the population, nationally representative, population-based studies are required.

Introduction

T here is unequivocal evidence that older people in the West (over the age of 65) are substantial users of complementary and alternative medicine (CAM), and this use continues to surge. In the United States and Canada, the prevalence of CAM use among people over the age of 65 years has been reported to be between 41% and 87%,^1

–7 and one U.S. study reported CAM use to be as high as 92% among people aged 80 years or older.⁸ In the United Kingdom, CAM use among older people is somewhat lower than in North America, although still significant at between 28%⁹ and 42%,¹⁰ while in Australia 58% of people over the age of 65 have used 1 of 17 common CAM modalities in the past 12 months and of these, 65% had visited a CAM practitioner.¹¹ In the United States⁶ and Australia,¹² it is estimated that the number of visits to CAM providers is now almost identical to the number of visits to primary care physicians.

CAM is generally used by older people to manage a wide range of mainly chronic medical conditions that become more common with advancing age,¹³ particularly musculoskeletal ailments and recurring pain,¹⁴ but CAM is also used as a means of maintaining physical health and social functioning.¹⁵ Research consistently reports the most common CAM used by older people to be herbal medicine,^1
–3,8,11 chiropractic and massage,^1,2,8,11 vitamins,^3,8 and dietary supplements,^3,8,11 acupuncture,^1,2 spiritual healing or prayer,³ and meditation.^2,11

Self-medication with CAM is also known to be high among the elderly, particularly with over-the-counter vitamins and minerals, herbal products, and nutritional supplements.^14,16

Studies suggest that older people's satisfaction with CAM as an adjunct to conventional medical care is high^10,17 and that CAM is seen to be beneficial in maintaining quality of life and well-being.¹⁵ Women and those with higher levels of education and greater household incomes are typical of older CAM users; however, unlike younger CAM users, there is a larger proportion of older CAM users without private health insurance.¹¹ While Adams and colleagues¹⁸ found that CAM use in Australia did decline with age among women (from 15% at the age of 70–75 years to 10% at ages 79–84 years), they note this could be an indication of less disposable income for this group and the increased out of pocket expenses, rather than a loss of interest in utilizing CAM as a form of health care.

A number of studies examining the clinical efficacy of specific CAM treatments and interventions for older people in the long-term care environment have been reported^{19

–28}; however, none of these studies give us any indication of the prevalence of CAM use by older people living in aged-care facilities, nor the motivations for and satisfaction with use, despite an increasingly large number of frail older people living in the long-term care setting.²⁹ The purpose of this literature review was to determine the state of our knowledge about existing patterns of CAM use among older people living in residential aged-care facilities, namely, nursing homes and assisted-living facilities, and how residents view CAM as a treatment option. Such a review provides the basis for important information to guide future research and policy in this area.

Methods

The literature was reviewed to address five key themes: popularity of CAM use, profile of CAM users, motivations for CAM use, expectations of and satisfaction with CAM, and institutional and/or staff support for CAM use.^30,31

Search strategy

The following databases were searched for English language peer-reviewed articles between the years 2000 and 2010: Cochrane Collaboration, PubMed, MEDLINE,^® CINAHL, AMED, Ageline, Social Services Abstracts, and Psychinfo. The search strategy included the following keywords singly or in combination: complementary medicine(s), alternative medicine(s), integrated medicine, holistic care, CAM, intervention, treatment, nonpharmacological, nursing home, long-term care, assisted living, residential, geriatric, elderly, aged, and old. Reports on the outcomes of specific therapeutic treatments or interventions, randomized controlled trials or clinical trials, commentaries, or letters to the editor were not included.

Results

Only five articles published between 2001 and 2010 were identified, and these are included in this review.^19,32

–35 Of these, one was a nonrefereed publication³⁵ and another³³ was a university-based online journal of interdisciplinary conference articles. Three (3) additional articles were found that related to the use of CAM in hospice care^36
–38; however, these have not been included as hospice care can include residents of various ages with specific medical conditions related to the provision of palliative care. A summary of the articles included in this review is provided in Table 1.

Table 1.

Details of Articles in Literature Review

						Themes
Country	Author/year	Focus of study	CAM modalities	Method	Sample characteristics & study setting	I	II	III	IV	V
Hong Kong	Wong et al. (2010)³⁴	Explored needs for, application of & factors impacting on accessibility of TCM	Traditional Chinese Medicine	Semistructured group interviews	n=18 Older residents (63–93 years) from three long-term nursing homes	N	Y	Y	Y	Y
Taiwan	Chen et al. (2005)¹⁹	Explored frail elders perspectives of t'ai chi	T'ai chi	Focus groups Seven focus groups (3 t'ai chi user groups & 4 no-t'ai chi groups)	n=40 Frail older residents (mean age 76 years) in long-term residential aged care	N	Y	N	N	N
Australia	Webber (2003)^{33 a}	Investigated the prevalence of use of CAM in dementia care	Aromatherapy, music, aromatherapy massage, massage, prayer, healing touch, Reiki, therapeutic touch, t'ai chi, light therapy, meditation, reflexology, reminiscence therapy, pet therapy, snoezelen^®, validation therapy, chiropractic, doll therapy, craft, hot towel, red cross (hand & nails), multi-sensory, three phase therapy	Survey	n=117 Managers, nurses, personal care staff, diversional therapists from 81 high-care facilities (nursing homes)	N	N	N	Y Staff	N
United Kingdom	Allcock et al. (2002)^{32 a}	Investigated the prevalence of use of CAM for pain management	Aromatherapy, massage, acupuncture, reflexology	Questionnaire	n=68 Managers of nursing homes	N	N	Y	N	N
Australia	Henry (2001)^{35 a}	Described CAM use in a low- care facility (assisted living)	Aromatherapy massage, reflexology, spa/hydrotherapy, clay packs, ear candling	Retrospective review of nursing care plans	n=6 Observation of aged-care residents	N	N	Y	Y Staff	Y

Participants (care providers, managers, and diversional therapists) provided proxy responses.

I, prevalence of CAM use; II, CAM user profile; III, motivations for CAM use; IV, expectations of and satisfaction with CAM; V, institutional and/or staff support for CAM use. N, No; Y, Yes. CAM, complementary and alternative medicine; TCM, Traditional Chinese Medicine.

Characteristics of studies

The study populations and sample sizes varied considerably. Studies were conducted in Australia,^33,35 the United Kingdom,³² Taiwan,¹⁹ and Hong Kong.³⁴ Two (2) studies^{19, 34} report on the responses from aged care residents themselves, and the remaining are proxy responses from care providers and managers.^32–33,35

Prevalence of CAM use in aged-care facilities

None of the articles provided details on the use of CAM in residential age-care facilities; however, three articles reported on the use of CAM among small numbers of aged-care residents.^19,34,35 Three (3) articles^32,33,35 also reported on a range of CAM interventions including the unusual interventions of hot towel, red cross (hand and nails), three-phase therapy, clay packs, and ear candling. One (1) article reported on the use of Traditional Chinese Medicine (TCM),³⁴ and another on the use of t'ai chi.¹⁹

CAM user profile

Only the studies conducted in Taiwan and Hong Kong^19,34 provided a profile of the users. In one,³⁴ the CAM users were women (56%), whose medium age was 85 years (range 72–93 years). Not all of the aged-care facilities from which the study sample was drawn offered TCM services, and 4 women (out of 18) reported stopping CAM use after moving to the aged-care facility. Unlike typical CAM users reported more generally, who are usually affluent with higher levels of educational attainment, these CAM users had little or no formal education. In the second study,¹⁹ the CAM users were mainly retired widowed men (55.6%) with a mean age of 76 years (range 69–81 years) whose educational levels ranged from no formal education to completed high school education.

Motivations for CAM use

Only three of the five studies reviewed^32,34,35 reported on motivations for CAM use in aged-care facilities, although only one study reporting on the use of TCM directly reflects the user's perspective.³⁴. Users of TCM believed it to be holistic in nature and used it to cure acute non-life-threatening diseases such as cough, colds, and stomach aches; enhance recovery from and reduce the pain associated with chronic diseases associated with old age such as arthritis; and promote health and well-being and empower them in their own health care decisions. Motivations for use as reported by care providers, managers, and diversional therapists^32,35 describe CAM use for the reduction of pain and the improvement of residents' quality of life.

Expectations of and satisfaction with CAM use

Care providers using CAM in aged-care facilities reported that CAM had calming, soothing, and settling effects and improved behavior,³³ enhanced quality of life, and also reduced the need for some types of medications.^33,35 Care providers in the article by Henry³⁵ introduced CAM therapies to residents in an assisted-living facility to help residents attain and maintain good health, something they believed was achievable through CAM use. Webber³³ suggests there was a high degree of satisfaction with CAM use. Wong et al.³⁴ report that older people expected TCM to be available as an adjunct to Western medicine, believing it to be important to the maintenance of their overall health and well-being, in addition to being empowering with regard to health care choices.

Institutional and/or staff support for CAM use

Only two studies reported on institutional and/or staff support for the use of CAM in aged-care facilities.^34,35 The residents in one study³⁴ cited a lack of institutional support and staffs' negative attitudes to TCM as barriers to their access to this type of health care. Negative staff attitudes were linked to fears of litigation, a lack of knowledge about TCM, and issues about medical responsibility for residents. In the second study,³⁵ staff with the support of management, initiated and introduced CAM to the residential aged-care facilities and further encouraged ongoing staff development and education. It should be noted that the CAM used in this facility was massage, aromatherapy, and reflexology, which are generally low-impact and noninvasive therapies.

Discussion

The literature shows that the use of CAM as a health care option by Australians is increasing across all ages. Internationally, various CAM modalities are offered as routine care options in aged care, and many older individuals use CAM for health promotion, illness prevention, and to alleviate chronic pain. There is a large literature on specific CAM interventions in aged care; however, only five publications were found that reported on the use of CAM by older people living in aged-care facilities. While this review cannot make any real cultural or social comparisons between countries or between studies, it does point to similarities found in the general literature on CAM use and use by older people in aged-care facilities, particularly with regard to motivations for use.^32,34,35 The diversity of modalities and practices reported in the studies reviewed reinforce the lack of a clear or common definition of CAM in much of the published literature.

This review highlights our limited insight into the use of CAM in this setting. Very little is known about individual preferences for and barriers to use, and this raises the question of what should be included as CAM in health research to further our knowledge in this area. The exclusion of older peoples' views on their preferences, motivations, and satisfaction with CAM is a major gap in the evidence, especially in light of the large number of older CAM users.

Middle-aged and older adults are now more than ever investing to improve their health,⁶ and many are increasingly “smart” consumers,^16,39 seeking to inform themselves about care and treatment options that will improve their health and well-being. For many older people, the use of CAM is seen to be empowering by providing choice, opportunities to be more involved in treatment decisions, and a sense of ownership over the treatment process.¹⁵ For some older people, dissatisfaction with conventional medical care is the driver for seeking alternative health care options.⁴⁰ It has been noted that the conventional health care model is often hierarchical, reductionist, mechanical, and aggressive and as such disempowering for older people by making them dependent on the formal health care system, while removing any self-control over their own care.⁴¹

A high proportion of the “baby boomer” generation are users of CAM,⁴² and the leading edge of this generation have now started to reach retirement age. As this generation continues to age, the number of older people interested in and using CAM is likely to rise further and place previously unseen demands on health care service providers to meet their needs for complementary and alternative health care. With the possibility that CAM use can reduce frailty, increase independence, and enhance successful aging, as well as supplement expensive conventional health care,⁴³ its continued use in residential aged care warrants attention. Consideration must also be given to safe clinical practice in aged care and the potential for CAM to interact with conventional pharmaceutics and treatments.

Much more knowledge is needed on the prevalence of CAM use in aged-care facilities, user profiles, and importantly older peoples' choices regarding CAM as a health care option. The authors' own recent research (focus groups and interviews with residents, family members, and staff in aged-care facilities in Victoria, Australia) shows that residents officially and unofficially use various forms of CAM for pain relief and to improve health and well-being and they would like to use it more, but access and cost are seen as substantial barriers.¹

Conclusions

The existing literature provides very limited descriptive data on CAM use in residential aged-care facilities. More research including larger national studies are required as increasing numbers of “baby boomers,” who are used to exercising choice and having access to different health care options, move into older age. This gap in the evidence has implications for policy development, education, and service provision, resident safety, and funding in health and aged care.

Footnotes

Disclosure Statement

No competing financial interests exist.

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