“I Wouldn’t Mind Trying It. I’m in Pain the Whole Time”: Barriers to the Use of Complementary Medicines by Older Australians in Residential Aged-Care Facilities

Abstract

Older people living in the community use complementary medicine (CM) to manage the symptoms of chronic illness; however, little is known about CM use by older people living in care settings. Using focus groups and individual interviews, this study explored the use of CM from the perspective of 71 residents, families, and health professionals from six residential aged-care facilities in Victoria, Australia. Residents used CM to manage pain and improve mobility, often covertly, and only with the financial assistance of their families. Facility policies and funding restrictions constrained CM use at the individual and facility level. An absence of evidence to support safety and efficacy coupled with the risk of interactions made doctors wary of CM use in older people. These findings have relevance for the large number of CM using “baby-boomers” as they move into residential aged-care.

Keywords

complementary medicine residential aged-care choice cost control

Introduction

In Australia (Adams, Lui, & McLaughlin, 2009; McLachlan, Lui, & Adams, 2012; Sarris, Robins Wahlin, Goncalves, & Byrne, 2010; Xue, Zhang, Lin, da Costa, & Story, 2007; Zhang, Xue, Lin, & Story, 2007), and elsewhere (Cheung, Wyman, & Halcon, 2007; Nahin et al., 2009; Ness, Grillo, Weir, Nisly, & Wallace, 2005), community-dwelling older people are significant users of complementary medicine (CM). In 2005, 58% of older Australians used CM (Xue et al., 2007) to manage the symptoms of chronic illness, especially pain (Armstrong, Thiebout, Brown, & Nepal, 2011) and immobility (Yen, Jowsy, & McRae, 2013). Older people use CM to “supplement” conventional treatments and regularly visit their doctors (Lin, Canaway, & Carter, 2014; Sarris et al., 2010; Zhang et al., 2007).

Terms such as complementary, alternative, and integrative are used synonymously leading to definitional debates in the literature about what CM is not, rather than the intrinsic quality that it brings to health care (Willis & Rayner, 2015). In the absence of a universally accepted definition (Wieland, Manheimer, & Berman, 2011), in this article, CM will include all products, therapies, practices, and interventions used to promote health and well-being and treat illness/symptoms that are not considered to be part of conventional medicine and that are self-administered or delivered by therapists.

The bulk of CM used by older Australians is self-administered dietary supplements including vitamins, minerals, and natural health products or herbal medicines, purchased over-the-counter from pharmacies, supermarkets, and increasingly via the Internet (Australian Institute of Health and Welfare, 2012a; Wilkinson & Jelinek, 2009; Xue et al., 2007; Zhang, Story, Lin, Vitetta, & Xue, 2008; Zhang et al., 2007). In 2015, 48% of Australian women and 34% of men, aged ≥65 years, reported using supplements such as fish oils and multivitamins in the previous 6 months (Roy Morgan Research, 2015a). High supplement use among older people is also reported in other countries (Arcury et al., 2012; Bailey, Gahche, Miller, Thonas, & Dwyer, 2013; Ness et al., 2005). Consultations with CM therapists are also increasing among older people, especially among older women and those with chronic illness (Yen et al., 2013). In 2015, one in 10 Australians paid to see a CM therapist, half of whom also consulted their medical doctor in an average 4-week period (Roy Morgan Research, 2015b); and in 2005, 60% of older Australians reported visiting a chiropractor, naturopath, or acupuncturist (Xue et al., 2008; Zhang et al., 2007), these visits almost equaling the number of consultations with medical doctors (Xue et al., 2007).

Besides the management of chronic illness (Arcury et al., 2012; Armstrong et al., 2011; Cartwright, 2007; Cheung et al., 2007; Schnabel, Binting, Witt, & Teut, 2014), factors which may explain CM use include a need for more control in health care (Andrews, 2002), the “naturalness” (Iedema & Velijanova, 2013), and the cost-effectiveness of some CM in comparison with conventional treatments (Access Economics, 2010). The increasing use of CM by older Australians, particularly among those with chronic illnesses (Kirby, Broom, Sibbritt, Refshauge, & Adams, 2015; Lin et al., 2014), has also occurred within the move to a choice-based health care market that is commercially driven, politically supported, and partially subsided (Stoelwinder, 2002). In Australia, the cost of using CM is borne by individuals. Consultations with CM therapists are not subsidized by the universal health insurance scheme—Medicare¹—and private health insurance² provides limited rebates for select services (Australian Institute of Health and Welfare, 2008). In 2010, the out-of-pocket expenses associated with CM in the management of chronic illness was AUD$91 million (Spinks, Hollingsworth, Manderson, Lin, & Canaway, 2013). Older people are more likely to have limited incomes, and are less likely to have private health insurance (Moses, 2005), which may explain the decrease in CM use among the “very old” (aged ≥85 years) (Adams, Sibbritt, & Young, 2009; Walkom, Loxton, & Robertson, 2013).

Although chronic illness may be a reliable indicator of CM use among older people, little is known about the use of CM in residential aged-care settings,³ where increasing numbers of older, frailer people live. A review of the literature to determine patterns of CM use in residential aged-care facilities, nursing homes, and assisted-living found only five papers (Bauer & Rayner, 2012) and none reported prevalence of use, individual motivations for use, or satisfaction with CM among users. Recent international research suggests that residents’ experiences of using CM in nursing homes are positive and that integrating CM into health care in long-term care settings has benefits for residents, families, and staff alike (Evans, Vihstadt, Westrom, & Baldwin, 2015). However, international research has also identified barriers to providing CM in these settings, including a lack of knowledge and competence of CM by staff and financial constraints (Johannessen & Garvik, 2015; Ortiiz et al., 2014).

This article reports findings from a study undertaken to address this gap in the literature. The research was exploratory and was undertaken to provide the much-needed views about CM use in residential aged-care facilities in Australia from the perspective of residents who may use CM, their families, and care staff, as well as facility managers and medical practitioners who are responsible for the delivery of health care. Ethical approval to conduct the study was attained from the La Trobe University, Faculty of Health Sciences Human Research Ethics Committee (FHEC10/47), and written informed consent was obtained from all participants.

Method

The use of CM was explored in six residential aged-care facilities in Victoria, Australia, from the perspectives of residents (aged ≥65 years), family members, staff, and medical doctors. Maximum variation sampling was used to select facilities on the basis of geographic location (metropolitan and regional), type of facility (private, public, and charitable/religious), and care level (high care or low care). Four metropolitan and two regional facilities agreed to take part in the research, and 71 individuals were recruited from these sites (see Table 1).

Table 1.

Facilities and Participants.

Sites (n = 6)					Participants (n = 71)
Site	Location	Facility	Level of care	Number of beds	Residents and family	Care staff	Key informants
1	Regional	Private	Low/high	80	9	4	3
2	Metropolitan	Private	Low/high	90	9	5	3
3	Regional	Public	High	40	8	5	2
4	Metropolitan	Charitable	Low	51	5	4	2
5	Metropolitan	Private	High	63	—	5	3
6	Metropolitan	Public	Low/high	120	—	4	—

Study Participants

The study used a self-selected convenience sample of participants from the different groups of interest (residents, families, staff, managers, and doctors), and recruitment at each site was undertaken with the assistance of the facility manager. Inclusion criteria included having experience with using CM, being able to read and comprehend English, and the ability to provide written consent. Flyers advertising the study were displayed in prominent areas in each facility so that residents, families, and staff were familiar with the project and its purpose. The flyers also contained the proposed date and time for each focus group, allowing participants to self-select participation. The researchers visited each site before each focus group to provide information and answer any questions. The manager provided a list of medical doctors at each site who were individually invited to participate.

Participants included 26 residents (21 women and five men), five family members (a son, three daughters, and a wife), and 27 staff (two enrolled nurses [Licensed Practical Nurses] and 25 personal care assistants) of whom all bar two were women; as well as 13 key informants comprising four doctors (two men and two women), three managers, four registered nurses (RNs), an activity coordinator, and a CM therapist all of whom were women (see Table 1).

Procedures

Focus groups were used as an effective method of obtaining a wide range of views and provide rich data that impart insights into topics which are not well understood (Morgan, 1996). Residents, family members, and care staff were invited to participate in focus groups conducted at each facility. A total of 10 focus groups were conducted across the six facilities—four with residents and family members together and six with care staff. Resident and family focus groups were conducted separately to those with staff as the presence of staff may have prevented free discussion and the disclosure of information. Semistructured key informant interviews were also conducted to understand philosophical, practical, or structural issues, highlighted in previous work (Rayner, Willis, & Pirotta, 2011), which may impact on CM use in this setting. The interviews with the doctors were conducted via the telephone at their request; all other interviews were conducted face-to-face at the facilities for the convenience of participants.

The interview and focus group questions included personal and professional views and experiences of CM, in particular what is used; suitability, safety, and efficacy of CM in this setting; who determines CM use and who administers CM (see Table 2).

Table 2.

Theme List for Interviews and Focus Groups.

Questions	Prompts
Tell me a little about yourself and your experience with CM	Ever used?
	Multiple modalities?
	What used and why?
	Personal use?
	Professional use (key informants)?
	What other aspects of your health would you use CM for?
Tell me what you know about CM?	What is CM?
Tell me what you know about CM?	Vitamins, herbal, yoga, massage, Tai Chi, Chiro, Traditional Chinese Medicine, homeopathy, naturopathy, aromatherapy, osteopathy, other?
What are your beliefs about CM use?	Treatment of chronic illness?
What are your beliefs about CM use?	Safety and efficacy?
	Costs?
	Evidence?
What has been you experience of CM?	Personal, professional, clients lead (key informants)
	How do you use CM?
	Effectiveness?
	Side effects?
	Use with conventional medicine?
	What factors were important in your decision to use CAM?
What CM is available in the aged-care facility?	Vitamins, herbal, yoga, massage, Tai Chi, Chiro, Traditional Chinese Medicine, homeopathy, naturopathy, aromatherapy, osteopathy, other?
	Who determines?
	How delivered?
Practical issues	How do you purchase?
	Where from?
	Who administers?
	Referrals?
What factors are important to your continuing with CAM?	Cost?
What factors are important to your continuing with CAM?	Relationship with therapists?Effectiveness?

Note. CM = complementary medicine; CAM = complementary and alternative medicine.

Analysis

The interviews and focus groups were digitally audio-recorded and transcribed verbatim. All names of individuals and organizations were removed from the transcripts to maintain anonymity, and residents were give pseudonyms. As this was an exploratory study, thematic analysis was used. Thematic analysis involves inductive identification and description of implicit and explicit themes emerging from the data (Daly, Kellehear, & Gliksman, 1997).

A thematic conceptual network was used to connect basic codes into organizing categories, which were then grouped into global themes (Attride-Stirling, 2001). Transcripts were analyzed individually, and a list of 25 basic codes emerged that reflected participants’ experiences of CM. All transcripts were reread before the codes were merged into five broader organizational categories, some of which were over lapping. Each transcript was then systematically checked using these categories, and theoretical analysis of the organization categories produced three global themes. Direct quotes were retrieved from the transcripts to illustrate the findings. Strategies used to establish rigor included checking of transcripts against recordings for transcription errors and omissions, and analysis by both the researchers (Guba & Lincoln, 1989).

Results

The diversity of participants provided rich data about CM use in residential aged-care facilities, as well as barriers and enablers for older people in this setting. Knowledge about CM varied among the participants, and there was some uncertainty about what was included under the umbrella term complementary medicine. Supplements were not viewed as CM by most participants, nor was Tai Chi, which residents referred to as a leisure activity.

Close to half the residents (n = 12) were current or prior users of CM. Residents used supplements, predominantly fish oil, and over-the-counter gels and creams, covertly, for pain relief and well-being. In some facilities, supplement use had to be “prescribed by the doctor.” Most other participants reported either current or prior use of CM. The views expressed by residents in this study were grounded in the reality of their current situation—living in aged-care facilities and compromised by pain and immobility related to chronic illness.

Three global themes depicting CM use in the six residential aged-care facilities emerged from the analysis: “having no choice,” “the cost of CM,” and “therapeutic control.”

Having No Choice

Some residents and family members (on a resident’s behalf) reported long-term CM use as a health care option prior to moving into residential aged-care, and a few continued their use once they moved in:

I was married to a naturopath, and she has always looked after me. My doctor is not into things like that. I’ve always had cod liver oil tablets, and yet I’m still riddled with arthritis, so it must help some way to be able to be involved in Tai Chi. (Bob, Resident Site 2)

She [mother], will be 90 in a few weeks, was always interested in vitamins. She had a cupboard full well before Vitamin E and fish oils became part of the everyday usage. She was very much a vitamin person. (Family, Site 4)

One resident reported enquiring about the possibility of using CM on admission to a private metropolitan facility because she wanted to continue using it, and once living in the facility, many residents continued to use self-prescribed CM, sometimes covertly, for pain relief:

I’ve got magnesium tablets in my cupboard. I take one occasionally. Sometimes when you move your legs they lock. (Esther, Resident Site 2)

I use homeopathy and naturopathy. Homeopathy is based on the 12 tissue salts that the body has in balance. One of them Calciphosforum [sic] I carry with me at all times. (Betty, Resident Site 1)

Much of the CM used by residents was nonpharmaceutical oils and gels for pain management, to aid mobility and improve quality of life. “Ruby” uses Elmer Oil,⁴ which her family purchases, for pain in her left leg which she reports “is very good and seems to help me exercise,” and a staff member reported that another resident uses Goanna Oil⁵ for pain relief. “Thea” has been rubbing Emu Oil⁶ into her knees for a long time and “gets a lot of [pain] relief,” and “Doris” uses a gel prepared for horses, for her arthritic back and knees, which she reports “is great for the pain and better for me than popping pills.”

Most residents said they would like the opportunity to have a massage or at least have a CM therapist available rather than have to ask their families to organize this as “extra,” but there was no discussion about the possibility of CM use, as “Mavis” reported, “Just because we’re old they think we don’t need it.” Some residents and family members stressed that doctors were in the best position to make informed decisions about appropriate care, and were resigned to no longer using CM accepting the doctors’ emphasis on the importance of maintaining medication regimes for the management of chronic illness. Others were simply unsure why their use of CM had discontinued as the following discussion demonstrates:

I took fish oil for years. I never took it here. I don’t know really why I stopped. I would take it now for my back. It seems to be an only thing. I found them very good for um . . . pain. (John, Resident Site 1)

I get osteoarthritis in my foot. I probably wouldn’t have it now if I had continued using fish oil. (Leonie, Resident Site 1)

A few residents like “Anna” were indignant about the loss of choice as they had used CM for pain relief, while others, like “Marie” and “Sylvia,” reported that CM was no longer a helpful option for them:

Acupuncture for my back did me good. I got pain relief. (Anna, Resident Site 1)

I used them [supplements] for the heart before I came in here. I’m on medication now and the doctor asked me to stop. (Marie, Resident Site 3)

In the earlier days I had chiropractic care. It was helpful, but it [disease] got to the stage where it [chiropractic] wasn’t helpful. (Sylvia, Resident Site 4)

Care staff reported that they offered Tai Chi and hand massage to residents, although these were generally referred to as lifestyle activities and used for leisure or relaxation rather than as a health care option:

We do a hand massage. We put a bit of lavender oil in Vitamin E cream. There is one particular lady that suffers with a bad neck, so when we rub her neck. She says it relieves the pain. (Care Staff, Site 2)

Residents were enthusiastic about being offered these options, as “Doug” indicated, “Tai Chi relieves the boredom that, that you’re here doing nothing . . . well we don’t do much,” but like the care staff, as the quotes suggests, thought of CM as leisure activities rather than health care.

Key informants generally acknowledged older people in residential aged-care were not big users of CM, being reliant on conventional medicine and accepting of what doctors’ prescribed or recommended. This, however, was expected to change with “the baby boomer” generation of aged-care residents who are considered to be more active participants in their own health care and high users of CM, and more demanding of choice:

I would expect that when you get some of your “baby boomers” coming through they will probably express a particular therapy that they will want. (Manager, Site 1)

I think when the “baby boomers” go through we will see the demand for Tai Chi or acupuncture, those kind of things. (Doctor, Site 5)

I think it will probably be the next generation that will be asking about those things. (Doctor, Site 3)

The Cost of CM

Residents were open to the idea of trying different types of health care options, but the cost of CM was cited as being prohibitive by many. Comments below from Robert and Esther indicate a massage therapist sometimes visited two of the facilities. While these residents thought a massage would be beneficial, they reported that the cost was too expensive, and most residents were of the view that CM should be provided at little or no cost:

There is a masseur who comes in. A half an hour session costs you $32, so that is more than a dollar a minute. (Robert, Resident Site 5)

A massage therapist who comes in charges $7 a minute, which is extortion. (Esther, Resident Site 2)

I think for old people it should be free. We’ve worked very hard, we’ve paid for everything, and now we should be given it free. (Doris, Resident Site 5)

The cost of CM for people on limited incomes living in residential aged-care was also raised by key informants, care staff, and families. Families believe CM to be a legitimate health care option which should be offered in residential aged-care and moreover should be subsidized through Medicare. The cost of CM was borne by the families who have to take responsibility for taking their relative to a therapist if requested and the staff and key informants also commented on the high costs of using CM:

Cost is an obstacle because they [residents] may not have a lot of money. People say to me . . . Oh how much is it going to cost me for a massage? (Activity Therapist, Site 1)

Well some sort of subsidized or concessional rate that would make it [CM] affordable for ongoing care. (Family, Site 4)

A lot of residents are pensioners who can’t afford it. A lot of them are taking fish oils but it’s expensive so unless they can afford it, they’re not going to take it. (Doctor, Site 4)

Facility care staff, nurses, and managers would like to offer CM to residents but are limited by facility polices, the need for medical approval, and cost. At the health service level, CM is not subsidized or supported by health care funding and individual facility policies that curtail CM use. Key informants were of the view that funding arrangements in the residential aged-care sector certainly limited their ability to offer CM:

Its resources! We’ve got a program with the aged-care funding initiative for anyone in low care but it’s limited to allied health so osteopaths or masseuses are not on it. In high care facilities, they have to fund everything. (Doctor, Site 2)

Cost is a big thing because some of the complementary things are not PBS⁷ listed or covered. (Doctor, Site 5)

I know myself how expensive CM is. I’d promote it more if it was subsidized. (Manager, Site 4)

Therapeutic Control

Three of the doctors reported personal use of CM and were accepting of individual residents’ use of CM. However, all four doctors were reluctant to support CM use in this setting. Older age, multiple chronicity, and polypharmacy were reported as reasons to be cautious with CM, and like facility managers, doctors reported the potential of interactions between CM and conventional medicine and cited the lack of evidence of safety and efficacy.

The use of CM in aged-care facilities, either by individual residents or as directed by facility staff, was governed by the doctors’ approval, and by facility policies. Doctors exercise considerable control over the health care choices of older people living in residential facilities:

The doctor has to initiate, has to oversee [use of supplements]. Even though they [residents] can buy it themselves, the doctor has to be aware of it on the primary medication chart. (Care Staff, Site 6)

If people are on vitamins and natural products and I don’t think it is going to interact with anything we are giving them, as far as I can tell, then I’d be happy for them to stay on it. (Doctor, Site 4)

Any sort of care has to be authorized. So, doctors really can make it or mar it [CM use] with their attitude. (Family, Site 2)

All the doctors were generally skeptical of the benefit of CM for older people. One doctor acknowledged that “lots of people are on fish oil and multivitamins, particularly vitamins B and D”; however, all reported that they would not initiate or recommend CM in aged-care settings:

I’ve got one person who uses acupuncture to manage pain. It’s client lead. I wouldn’t recommend it. (Doctor, Site 2)

I probably wouldn’t initiate it too much CM. (Doctor, Site 5)

The doctors cited a lack of evidence of efficacy for CM and the potential for interactions with conventional medications for being wary of its use:

I don’t have any strong objections if they’re not interfering with other medications. Like Tai Chi and reflexology. I don’t know if they’d do any good. People that use them have found that it works, but otherwise, no, no scientific basis. (Doctor, Site 1)

Something either works and there’s evidence for it or it doesn’t work. In aged-care . . . the super-old, with multiple co-morbidities . . . certainly there is the worry of interactions with the other drugs that they may be on. How are you going to know, there is no research done. (Doctor, Site 2)

There were also different policies governing the use of CM in the participating residential aged-care facilities. Managers and care staff spoke about the desire to offer residents less invasive modalities such as aromatherapy and massage, but added that any therapeutic intervention had to be sanctioned by the visiting doctors, and there were also facility guidelines that had to be adhered to:

Technically, we have to have a certified aromatherapist to come here to do an assessment on every resident who would like to use aromatherapy. They write a care plan and mix the oils and then we can use them. So for us to just set up in our little bit of lavender in a tissue, we are not allowed to do that. It is really difficult to use things like aromatherapy, there are healthcare guidelines. (Manager, Site 2)

I guess staff get the relatives or the patient to sign a waiver or a permission form, or they will get the doctor to sign a permission form saying, it is ok for them to have aromatherapy or acupuncture—someone else taking responsibility for it. (Doctor, Site 1)

Discussion

Older people in the community largely participate in their health care and self-manage the symptoms of chronic diseases through the use of CM (Arcury et al., 2012; Callahan et al., 2009; Closs, Staples, Reid, Bennett, & Briggs, 2007). While many CM used in chronic disease management have no evidence of effectiveness, users report they are helpful in managing the symptoms of chronic illnesses and the side-effects of conventional medications (Lin et al., 2014).

The findings of this research suggest that older Australians in residential aged-care facilities would like to be active participants in their own health care but are a unique group in respect of choice. Once living in facilities, they are largely dependent on others for the provision of their health care, which is typically limited to conventional medicine, and they have little choice or control in decision making. Despite this, some use CM covertly, in the form of supplements, gels, and creams, in conjunction with conventional treatments to manage the pain associated with chronic illness. These residents have been prior users of CM and use CM in the facility with family assistance. The use of CM as “covert caring for the self” in chronic illness has been defined as the need for autonomy, control, and consultation in health care (Lindsey, 1997, p. 234).

Cost coupled with the control exercised by doctors and the constraints imposed by facility policies are significant barriers to CM use in residential aged-care. Most residents do not have the disposable income to support CM use and are dependent on families to assist them financially. Cost is also reported by older people living in the community as a barrier to CM use (Adams, Lui, et al., 2009; Spinks et al., 2013; Walkom et al., 2013). While CM used in conjunction with conventional medicine is increasing acceptable in palliative and hospice settings for pain management (Berger, Tavares, & Berger, 2013; Nelson, 2006; Running, Shreffler-Grant, & Andrews, 2008), the barriers to CM use in residential aged-care settings found in this study have also been reported in these settings, in particular the costs of use for individuals and organizations (Demmer, 2004; Running et al., 2008).

Views of CM found among the doctors in this study reflect those found in the Australian medical literature (Pirotta et al., 2010). There is considerable debate about a lack of evidence to support CM use (Dwyer, 2011) and discussion about the deficiencies in the regulation of CM products and therapists (Harvey, Kozczak, Marron, & Newgreen, 2008) in the medical literature and the popular press. Older people are likely to be using CM and conventional medication concomitantly (Sarris et al., 2010; Zhang et al., 2007) and may not disclose their use to doctors (Lin et al., 2014; Spinks et al., 2013; Zhang et al., 2007). Interactions between commonly used conventional medications and self-prescribed CM have been reported (Abebe, 2002; Mora, Ciocon, & Galindo, 2014; Ulbricht et al., 2008), and while most CM used by residents in this study were gels or creams, dermal absorption of active ingredients could still be of clinical relevance. The literature suggests older people would like to openly discuss their CM use with doctors (Lin et al., 2014); however, doctors may not have sufficient knowledge to give meaningful advice (Koenig, Ho, Yadegar, & Tarn, 2012) or feel confident to do so (Mitchell, Brown, Erikssen, & Tiemann, 2008).

Why do older people in aged-care facilities not have the same health care choices available to community-dwelling older people or people in palliative and hospice care settings? Choice, the freedom to make one’s own decisions and a marker of autonomous adulthood, has driven health care policy over recent years (J. Clarke, Smith, & Vidler, 2006) and is a cornerstone of patient centered-care (Coulter, 2002). Despite critiques of “choice” (Fotaki et al., 2008; Mol, 2008) that show people cannot or do not always want or utilize health care options when available, there is general support for the idea that people should be included in discussions about health care and involved in decision making. Having some control, or even perceptions of control, is an important determinant of positive self-related health status among older people (Schoellgen, Huxhold, Schuz, & Tesch-Romer, 2011), and well-being has been shown to be enhanced by respectful care and social interactions which strengthen a sense of personal control (O’Connor & St. Pierre, 2004).

The findings of this study may reflect unconscious stereotyping of older people by the health professionals and institutional structures of the aged-care facilities. Stereotyping of older people occurs widely in contemporary Australia, at the individual and institutional level, and is perpetuated by exposure to negative depictions of older people in the media (Australian Human Rights Commission, 2013). Ageism is a form of age discrimination which leads to false assumptions about the needs and capacities of older people. Ageism is reflected in attitudes, practices, and relationships where age is used to determine the provision services; where older people are not afforded the same choice as younger people; when there is a failure to consider the older person’s context, experiences, and desires; and where “stereotypical” assumptions are made about the dependency of the elderly (Sargent, 2011).

Some argue that the “biomedicalisation” of aging (Estes & Binney, 1989) has contributed to ageism and promotes paternalism among health care professionals, who in turn treat older people differently to younger people (Gullette, 2011). Research has found stereotyping and negative attitudes to older people among health care professionals including RNs (Gething et al., 2002; Higgins, Slater, Van der Riet, & Peek, 2007) and doctors (L. H. Clarke, Bennett, & Korotchenko, 2014) irrespective of the care setting (Gallagher, Bennett, & Halford, 2006). The organizational structures of many aged-care facilities, which includes lines of authority, work practices, leadership styles, and care planning, can also stereotype residents by denying them choice and decision making in their care provision. The quotes in this article from participating residents exemplify the lack of control many of them feel.

The findings of the study should be considered in light of the small sample and the self-selected nature of participants which have the potential to introduce selection and positive response biases. Recruitment was dependent on the assistance of facility staff and misunderstandings or gatekeeping by some staff who do not appreciate the need for research is a major barrier and a potential source of bias (Felsen, Shaw, Ferante, Lacroix, & Crabtrees, 2010; Renert, Russel-Mayhew, & Arthur, 2013; Watson, Lumley, Rayner, & Potter, 2008). In addition, despite our best efforts, we were unable to recruit residents to participate at two sites. The increasing frailty and the large proportion of residents who have dementia (Australian Institute of Health and Welfare, 2012b) may be a possible explanation. Thirty-two doctors who provide medical management in the six residential aged-care facilities involved in the study were invited to participate. Recruitment of doctors as research participants is known to be difficult (Johnston, Leung, Wong, Ho, & Fielding, 2002; van Geest, Johnson, & Welch, 2007), especially when the research is qualitative and concerns CM (Rayner, Forster, McLachlan, Kealy, & Pirotta, 2010). Although we cannot say that the views expressed by the participating doctors are representative of all doctors providing medical management in residential aged-care, they do correspond with the prevailing Australian literature on CM use (Easthope, Tranter, & Gill, 2000; Pirotta et al., 2010).

Conclusion

These findings may have particular relevance for the large number of CM using “baby-boomers” as they age, who are better informed about health issues, and likely to expect to be offered choice, and to be involved in health care decisions. The self-prescribed use of CM by older people in residential facilities mirrors use among community-dwelling older people, especially in relation pain management in chronic illness. Given that individuals entering residential aged-care settings are increasingly older, have more chronicity, and are likely to die in the facility, it would seem that the provision of CM as part of health care needs to be considered. Choice in health care should not diminish in institutional settings and support for the appropriate and effective use of CM by older people in all settings, especially for the management of chronic conditions associated with aging, needs consideration.

Footnotes

Acknowledgements

The authors thank all participants.

Declaration of Conflicting Interests

The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.

Funding

The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: The authors acknowledge funding from a Faculty of Health Sciences, La Trobe University Grant and the administrative support provided by Sandra Cowen.

Notes

Author Biographies

Jo-Anne Rayner, PhD, is a senior research fellow at the Australian Centre for Evidence-Based Aged Care, La Trobe University, and has a doctorate in public health. An experienced qualitative researcher, she has expertise is in the use of complementary and alternative medicine as a health care options and her research focuses on the care of older adults, especially those with dementia.

Michael Bauer, PhD, is a senior research fellow at the Australian Centre for Evidence-Based Aged Care, La Trobe University. He holds a doctorate in health sciences and a master’s in gerontology. His research aims to enhance the lives of older people through improved service delivery. His interests include decision making and dementia, sexuality, CAM, staff-family relationships, and hospital transition.

References

Abebe

(2002). Herbal medications potential for adverse interactions with analgesic drugs. Journal of Clinical Pharmacology, 27, 391-401.

Access Economics. (2010). Cost effectiveness of complementary medicines. Report to the National Institute of Complementary Medicine. Sydney, Australia: Author.

Adams

Lui

C.-W.

McLaughlin

(2009). The use of complementary and alternative medicine in later life. Reviews in Clinical Gerontology, 19, 227-236.

Adams

Sibbritt

Young

A. F.

(2009). A longitudinal analysis of older Australian women’s consultations with complementary and alternative medicine (CAM) practitioners, 1996-2005. Age and Ageing, 38, 93-99.

Andrews

(2002). Private complementary and alternative medicine and older people: Service use and user empowerment. Ageing & Society, 22, 343-368.

Arcury

T. A.

Grzywacz

J. G.

Neilberg

R. H.

Lang

Nguyen

Altizer

K. P.

. . . Quandt

S. A.

(2012). Older adults’ self-management of daily symptoms: Complementary therapies, self-care, and medical care. Journal of Aging & Health, 24, 569-597.

Armstrong

Thiebout

Brown

Nepal

(2011). Australian adults use of complementary and alternative medicine in the treatment of chronic illness: A national study. Australian and New Zealand Journal of Public Health, 35, 384-390.

Attride-Stirling

(2001). Thematic networks: An analytic tool for qualitative research. Qualitative Research, 1, 385-405.

Australian Human Rights Commission. (2013). Fact or fiction? Stereotypes of older Australians. Sydney: Author.

10.

Australian Institute of Health and Welfare. (2008). Australia’s health 2008 (Cat. no. AUS 99). Canberra: Author.

11.

Australian Institute of Health and Welfare. (2012a). Australia’s health 2012 (No. 13. Cat. no. AUS 156). Canberra: Author.

12.

Australian Institute of Health and Welfare. (2012b). Dementia in Australia (Cat. no. AGE 70). Canberra: Author.

13.

Bailey

Gahche

Miller

Thonas

Dwyer

(2013). Why U.S. adults use dietary supplements. JAMA Internal Medicine, 173, 355-361.

14.

Bauer

Rayner

J. A.

(2012). Use of complementary and alternative medicine in residential aged care: A review of the literature. Journal of Alternative and Complementary Medicine, 18, 989-993.

15.

Berger

Tavares

Berger

(2013). A Canadian experience of integrating complementary therapy in a hospital palliative care unit. Journal of Palliative Medicine, 16, 1294-1298.

16.

Callahan

Wiley-Exley

Mielenz

Xiao

Currey

Sleath

. . . Sniezek

(2009). Use of complementary and alternative medicine among patients with arthritis. Preventing Chronic Disease, 6(2), 44.

17.

Cartwright

(2007). “Getting on with life”: The experiences of older people using complementary health care. Social Science & Medicine, 64, 1692-1703.

18.

Cheung

C. K.

Wyman

J. F.

Halcon

L. L.

(2007). Use of complementary and alternative therapies in community-dwelling older adults. Journal of Alternative and Complementary Medicine, 13, 997-1006.

19.

Clarke

Smith

Vidler

(2006). The indeterminacy of choice: Political, policy and organisational implications. Social Policy and Society, 5, 327-336.

20.

Clarke

L. H.

Bennett

E. V.

Korotchenko

(2014). Negotiating vulnerabilities: How older adults with multiple chronic conditions interact with physicians. Canadian Journal of Aging, 33(1), 26-37.

21.

Closs

Staples

Reid

Bennett

Briggs

(2007). Managing the symptoms of neuropathic pain: An exploration of patient’s experiences. Journal of Pain and Symptom Management, 34, 422-433.

22.

Coulter

(2002). After Bristol: Putting patients at the centre. British Medical Journal, 324, 648-651.

23.

Daly

Kellehear

Gliksman

(1997). The public health researcher: A methodological approach. Melbourne, Australia: Oxford University Press.

24.

Demmer

(2004). A survey of complementary therapies services provided by hospices. Journal of Palliative Medicine, 7, 510-516.

25.

Dwyer

J. M.

(2011). Is it ethical for medical practitioners to prescribe alternative and complementary treatments?—No. Medical Journal of Australia, 195(2), 79.

26.

Easthope

Tranter

Gill

(2000). General practitioners’ attitudes toward complementary therapies. Social Science & Medicine, 51, 1555-1561.

27.

Estes

C. L.

Binney

E. A.

(1989). The biomedicalization of aging: Dangers and dilemmas. The Gerontologist, 29, 587-596.

28.

Evans

Vihstadt

Westrom

Baldwin

(2015). Complementary and integrative healthcare in a long-term care facility. Global Advances in Health and Medicine, 4(1), 18-27.

29.

Felsen

Shaw

Ferante

Lacroix

Crabtrees

(2010). Strategies for in-person recruitment: Lessons learned from a New Jersey primary care research network study. Journal of the American Board of Family Medicine, 23, 523-533.

30.

Fotaki

Roland

Boyd

McDonald

Scheaff

Smith

(2008). What benefits will choice bring to patients? Literature review and assessment of implications. Journal of Health Services Research & Policy, 13, 178-184.

31.

Gallagher

Bennett

Halford

(2006). A comparison of acute and long-term health-care personnel’s attitudes towards older adults. International Journal of Nursing Practice, 12, 273-279.

32.

Gething

Fethney

McKee

Churchward

Goff

Matthews

(2002). Knowledge, stereotyping and attitudes towards self ageing. Australasian Journal on Ageing, 21, 74-79.

33.

Guba

E. G.

Lincoln

Y. S.

(1989). Fourth generation evaluation. Newbury Park, CA: SAGE.

34.

Gullette

(2011). Agewise: Fighting the New Ageism in America. Chicago, IL: The University of Chicago Press.

35.

Harvey

K. J.

Kozczak

V. S.

Marron

L. J.

Newgreen

D. B.

(2008). Commercialism, choice and consumer protection: Regulation of complementary medicines in Australia. Medical Journal of Australia, 188, 21-25.

36.

Higgins

Slater

Van der Riet

Peek

(2007). The negative attitudes of nurses towards older patients in the acute hospital setting: A qualitative descriptive study. Contemporary Nurse, 26, 225-237.

37.

Iedema

Velijanova

I. C.

(2013). Lifestyle science: Self-healing, co-production and DIY. Health Sociology Review, 22, 2-7.

38.

Johannessen

Garvik

(2015). Experiences with the use of complementary and alternative medicine in nursing homes: A focus group study. Complementary Therapies in Clinical Practice. Advance online publication. doi:10.1016/j.ctcp.2015.1004.1003

39.

Johnston

Leung

Wong

Fielding

(2002). Physicians’ attitudes towards the computerization of clinical practice in Hong Kong: A population study. International Journal of Medical Informatics, 65, 41-49.

40.

Kirby

Broom

Sibbritt

Refshauge

Adams

(2015). Suffering, recognition and reframing: Healthcare choices and plural care pathways for women with chronic back pain. Current Sociology, 63, 652-668.

41.

Koenig

Yadegar

Tarn

(2012). Negotiating complementary and alternative medicine use in primary care visits with older patients. Patient Education & Counseling, 89, 368-373.

42.

Lin

Canaway

Carter

(2014). Interface, interaction and integration: How people with chronic disease in Australia manage CAM and conventional medical services. Health Expectations, 18, 2651-2665.

43.

Lindsey

(1997). Experiences of the chronically ill: A covert caring for the self. Journal of Holistic Nursing, 15, 227-242.

44.

McLachlan

Lui

C.-W.

Adams

J. A.

(2012). Complementary and alternative medicine use among older Australian women—A qualitative analysis. BMC Complementary & Alternative Medicine, 12, 35.

45.

Mitchell

Brown

Erikssen

Tiemann

(2008). Multidisciplinary care planning in the primary care management of completed stroke: A systematic review. Medical Journal of Australia, 188, S61-S64.

46.

Mol

(2008). The logic of care: Health and the problem of choice. London, England: Routledge.

47.

Mora

Ciocon

Galindo

(2014). Extreme complementary alternative medicine: A case of over-the-counter polypharmacy. Consultant, 53, 349-353.

48.

Morgan

D. L.

(1996). Focus groups. Annual Review of Sociology, 22, 129-152.

49.

Moses

(2005). Complementary and alternative medicine use in the elderly. Geriatric Therapeutics, 35(1), 63-68.

50.

Nahin

R. L.

Pecha

Welmerink

D. B.

Sink

DeKosky

S. T.

Fitzpatrick

A. L.

(2009). Concomitant use of prescription drugs and dietary supplements in ambulatory elderly people. Journal of American Geriatric Society, 57, 1197-1205.

51.

Nelson

(2006). Being in tune with life. Complementary therapy use and well-being in residential hospice residents. Journal of Holistic Nursing, 24, 152-161.

52.

Ness

Grillo

D. J.

Weir

D. R.

Nisly

N. L.

Wallace

R. B.

(2005). Use of complementary medicine in older Americans: Results from the health and retirement study. The Gerontologist, 45, 516-524.

53.

O’Connor

B. P.

St Pierre

E. S.

(2004). Older persons’ perceptions of the frequency and meaning of elderspeak from family, friends and service workers. International Journal of Aging & Human Development, 58, 197-221.

54.

Ortiiz

Ammann

Gross

Schnabel

Walbaum

Binting

. . . Brinkhaus

(2014). Complementary medicine in nursing homes—Results of a mixed methods pilot study. BMC Complementary & Alternative Medicine, 14, Article 443.

55.

Pirotta

Kotsirilos

Brown

Adams

Morgan

Williamson

(2010). Complementary medicine in general practice—A national survey of GP attitudes and knowledge. Australian Family Physician, 39, 946-950.

56.

Rayner

Forster

McLachlan

Kealy

Pirotta

(2010). Women’s use of complementary medicine to enhance fertility: The views of fertility specialists in Victoria, Australia. Australian and New Zealand Journal of Obstetrics and Gynaecology, 50, 305. doi:10.1111/j.1479-828X.2010.01160.x

57.

Rayner

Willis

Pirotta

(2011). What’s in a name? Integrative medicine or simply good medical practice? Family Practice, 28, 655-660.

58.

Renert

Russel-Mayhew

Arthur

(2013). Recruiting ethnically diverse participants into qualitative health research: Lessons learned. The Qualitative Report, 18(23), 1-3.

59.

Roy Morgan Research. (2015a). Checking the health of Australia’s vitamin market (Article No. 6465). Available from www.roymorgan.com

60.

Roy Morgan Research. (2015b). Taking it as a complement: Most alternative health consumers also visit the doctor (Article No. 6463). Retrieved from http://www.roymorgan.com/findings/6434-complementary-medicine-alternative-health-services-and-doctors-june-2015-201509010506

61.

Running

Shreffler-Grant

Andrews

(2008). A survey of hospices use of complementary therapy. Journal of Hospice and Palliative Nursing, 10, 304-312.

62.

Sargent

(2011). Age discrimination: Ageism in employment and service provision. Surrey, UK: Gower.

63.

Sarris

Robins Wahlin

T. B.

Goncalves

D. C.

Byrne

G. J.

(2010). Comparative use of complementary medicine, allied health, and manual therapies by middle-aged and older Australian women. Journal of Women & Aging, 22, 273-282.

64.

Schnabel

Binting

Witt

C. M.

Teut

(2014). Use of complementary and alternative medicine by older adults—A cross-sectional survey. BMC Geriatrics, 14, Article 38. doi:10.1186/1471-2318-14-38

65.

Schoellgen

Huxhold

Schuz

Tesch-Romer

(2011). Resources for health: Differential effects of optimistic self-beliefs and social support according to socioeconomic status. Health Psychology, 30, 326-335.

66.

Spinks

Hollingsworth

Manderson

Lin

Canaway

(2013). Costs and drivers of complementary and alternative medicine (CAM) use in people with type 2 diabetes or cardiovascular disease. European Journal of Integrative Medicine, 5, 44-53.

67.

Stoelwinder

J. U.

(2002). The price of choice: Private health insurance in Australia. Australian Health Review, 25(6), 42-49.

68.

Ulbricht

Chao

Costa

Rusie-Seamon

Weissner

Woods

(2008). Clinical evidence of herb-drug interactions: A systematic review by the National Standard of Research Collaboration. Current Drugs and Metabolism, 19, 1063-1120.

69.

van Geest

Johnson

Welch

. (2007). Methodologies for improving response rates in surveys of physicians: A systematic review. Evaluation & the Health Professions, 30, 303-321.

70.

Walkom

Loxton

Robertson

(2013). Costs of medicines and health care: A concern for Australian women across the ages. BMC Health Services Research, 13, Article 484.

71.

Watson

L. F.

Lumley

Rayner

Potter

(2008). Recruitment to research studies in maternity hospitals: An example from the Early Births Study. Midwifery, 24, 509-520.

72.

Wieland

L. S.

Manheimer

Berman

B. M.

(2011). Development and classification of an operational definition of complementary and alternative medicine for the Cochrane Collaboration. Alternative Therapies in Health and Medicine, 17(2), 50-59.

73.

Wilkinson

J. M.

Jelinek

H. F.

(2009). Complementary medicine use among attendees at a rural health screening clinic. Complementary Therapies in Clinical Practice, 15, 80-84.

74.

Willis

K. F.

Rayner

J. A.

(2015). The nexus between the social and the medical: How can we understand the proliferation of complementary and alternative medicines for enhancing fertility and treating infertility? In Gale

N. K.

McHale

J. V.

(Eds.), The Routledge handbook of complementary and alternative medicine: Perspectives from social science and law (pp. 110-125). London, England: Routledge.

75.

Xue

C. C.

Zhang

A. L.

Lin

da Costa

Story

D. F.

(2007). Complementary and alternative medicine use in Australia: A national population-based survey. The Journal of Alternative and Complementary Medicine, 13, 643-650.

76.

Xue

C. C.

Zhang

A. L.

Lin

Myers

Polus

Story

D. F.

(2008). Acupuncture, chiropractic, and osteopathy use in Australia: A national population survey. BMC Public Health, 8, Article 105.

77.

Yen

Jowsy

McRae

I. S.

(2013). Consultations with complementary and alternative medicine practitioners by older Australians: Results from a national survey. BMC Complementary & Alternative Medicine, 13, Article 73.

78.

Zhang

A. L.

Story

D. F.

Lin

Vitetta

Xue

C. C.

(2008). A population survey on the use of 24 common medicinal herbs in Australia. Pharmacoepidemiology & Drug Safety, 17, 1006-1013.

79.

Zhang

A. L.

Xue

C. C.

Lin

Story

D. F.

(2007). Complementary and alternative medicine use by older Australians. Annals of the New York Academy of Sciences, 1114, 204-215.