Journal of Gerontological Nursing

COMPLEMENTARY AND ALTERNATIVE MEDICINE: USE IN AN OLDER POPULATION

Adam T Williamson, BA; Paula C Fletcher, PhD; Kimberley A Dawson, PhD

Abstract

ABSTRACT

The aging North American population validates increased research of complementary and alternative medicine (CAM) use by older adults. The purpose of this study was to examine older adults' attitudes and motivations toward CAM use in an attempt to explain its limited usage. Senior citizens (66 to 100 years) were qualitatively surveyed and interviewed to analyze trends in CAM use. Forty-two participants older than 65 completed a questionnaire and 10 of those same individuals participated in an interview session. Motivations for CAM use, prevalence of CAM use, knowledge of CAM, and physician attitudes were investigated. The results of the survey and interviews showed older adults' most prevalent motivations for using CAM were pain relief (54.8%), improved quality of life (45.2%), and maintenance of health and fitness (40.5%). Knowledge of CAM was extremely low across the entire sample, but a significant difference in knowledge level existed among CAM users and nonusers. The CAM therapies most commonly used by older adults were chiropractic (61.9%), herbal medicine (54.8%), massage therapy (35.7%), and acupuncture (33.3%). This sample of senior citizens perceived CAM treatments to be extremely beneficial. Increased education about CAM is needed for older adults and health professionals. Practitioners of CAM should try to understand older adults' motivations for using CAM therapies and be involved in educating older adults about CAM.

Abstract

ABSTRACT

The aging North American population validates increased research of complementary and alternative medicine (CAM) use by older adults. The purpose of this study was to examine older adults' attitudes and motivations toward CAM use in an attempt to explain its limited usage. Senior citizens (66 to 100 years) were qualitatively surveyed and interviewed to analyze trends in CAM use. Forty-two participants older than 65 completed a questionnaire and 10 of those same individuals participated in an interview session. Motivations for CAM use, prevalence of CAM use, knowledge of CAM, and physician attitudes were investigated. The results of the survey and interviews showed older adults' most prevalent motivations for using CAM were pain relief (54.8%), improved quality of life (45.2%), and maintenance of health and fitness (40.5%). Knowledge of CAM was extremely low across the entire sample, but a significant difference in knowledge level existed among CAM users and nonusers. The CAM therapies most commonly used by older adults were chiropractic (61.9%), herbal medicine (54.8%), massage therapy (35.7%), and acupuncture (33.3%). This sample of senior citizens perceived CAM treatments to be extremely beneficial. Increased education about CAM is needed for older adults and health professionals. Practitioners of CAM should try to understand older adults' motivations for using CAM therapies and be involved in educating older adults about CAM.

The perception and popularity of complementary and alternative medicine (CAM) has changed dramatically during the past decade. A recent study (Eisenberg et al., 1998) concluded that the percentage of Americans who used some form of alternative therapy during the past year had increased from 33.8% in 1990 to 42.1% in 1997. One of the most notable trends was observed among individuals older than 65 who were found to use alternative medicine the least of any of the other adult age cohorts (Eisenberg et al., 1998).

Results from the National Population Health Survey (NPHS), a Canadian survey designed to examine health-related data, also support this trend (Millar, 1997). Using the NPHS data, Millar (1997) concluded that approximately 17% of the population ages 25 to 64 consulted CAM practitioners during the past year, while only 10% of Canadian seniors had used these same services.

With the population aging, it is becoming increasingly important to research the health care practices of elderly individuals. It is estimated by the year 2011 a significant proportion of individuals born at the onset of the "baby boom" will reach 65. By 2031, the number of adults 65 and older will have grown two and a half times larger than the 1996 statistic of approximately 5,597,000. The impact these older individuals will have on all aspects of society, including health care, will be tremendous (Denton, Feaver, & Spenser, 1998). Further, the proportion of the population facing comorbidity and requiring multiple medications will increase the number of individuals seeking alternative means to improve their quality of life in its broadest sense: health, fitness, cognitive, emotional, economic, social, and recreation aspects. (For a more detailed discussion on quality of life refer to Spirduso [1995]).

Improving health status, and more importantly, quality of life has become an increasingly important goal of many North Americans, thus fuelling interest in CAM. Many CAM practitioners include health promotion and disease prevention in their treatments and work to develop a more holistic approach than traditional medicine. The CAM philosophies incorporate not only the physical body to attain a higher sense of wellness, but also mental and spiritual aspects (Altshuler, 1999; Lorenzi, 1999). It is this approach, combined with the added awareness of CAM health practices, which is contributing to the increased use of these therapies.

Complementary and Alternative Medicine Defined

When examining the current literature related to the use of CAM therapies, an extremely wide range of treatments are found. Millar (1997) reported 15% of the Canadian population had used alternative therapies in the past year, whereas researchers from other countries have found that the use of CAM therapies in the past year varies from 10% to 49% (Eisenberg et al., 1998; MacLennan, Wilson, & Taylor, 1996). This significant variability can be partially attributed to the different health care philosophies other cultures embrace, different methodologies used in each study, and the variations in the definition of CAM. There is no single clear definition of CAM, and this lack of standardization makes it extremely difficult for comparison among studies.

Some researchers have developed their own lists of practices they consider CAM. Others use the definition as practices neither taught widely in North American medical schools nor generally available in North American hospitals (Eisenberg et al., 1998). A third definition includes therapies administered by a health practitioner who does not possess recognized authority to prescribe medications (Montbriand, 2000). A universal definition is not available because of the rapidly changing criteria. Many of the practices that would have been included on the list of alternative therapies 10 years ago have now gained recognition and moved into the "gray area" between alternative and mainstream medicine. Eskinazi (1998) proposed a definition of CAM based on societal beliefs, defining CAM as:

A broad set of health care practices (i.e., akeady available to the public) not readily integrated into the dominant health care model, because they pose challenges to diverse societal beliefs and practices (cultural, economic, scientific, medical and educational) (p. 1622).

The list of therapies that can be included in Eskinazi's (1998) definition include well-known alternative therapies, such as acupuncture, chiropractic, homeopathy, hypnosis, relaxation techniques, herbal remedies, nutrition therapies, naturopathy, vitamins, and massage. It also includes lesser known therapies, such as color therapy, music therapy, therapeutic touch, oxygen therapy, and organotherapy. Eskinazi's description offers a solid definition for the present study, and allows for revisions based on changing societal belief s and practices.

The purpose of this investigation was to examine the attitudes of elderly individuals toward CAM ?? an attempt to explain the decreased usage by the senior citizen population as observed in previous literature (Eisenberg et al., 1998; Millar, 1997). A further purpose was to describe the different ways in which elderly individuals use CAM, and their attitudes and knowledge related to CAM therapies.

METHODS

Study Design

A questionnaire examining sociodemographic information, general health status, and the health practices of those older than 65 was developed and distributed to 42 senior citizens. The questionnaire was composed of 21 items, including open-ended, multiple choice, and forced choice questions, and a Likert scale question. The surveys were distributed within retirement facilities, senior centers, community programs, and chiropractic offices in Central Ontario, Canada. The end of the questionnaire included a section in which participants could volunteer to take part in the second part of the research, involving an in-depth interview with the researcher to further examine trends in CAM usage. (Questionnaire available from the authors upon request.)

The interview consisted of nine questions generated from analysis of the questionnaires and focused on issues deemed significant. The interview questions are listed in the Sidebar on page 23.

Statistical Analysis

The responses from the questionnaires were coded and a descriptive analysis of the data was completed using the Statistical Package for the Social Sciences (SPSS Inc., Chicago, IL). Analysis included univariate distributions, percentages, means, and a t test The personal interviews and open-ended questions within the questionnaire were qualitatively analyzed. Both the questionnaire and the interviews were analyzed for recurring trends.

Study Participants

Forty-two participants completed the questionnaire. Thirty of the participants were women and 12 were men. The mean age of the sample population was 77.9 (+/- 7.4). Participants were asked to classify themselves as CAM users or nonusers by indicating whether or not they used any of the following CAM therapies:

* Acupuncture.

* Chiropractic.

* Herbal medicine.

* Homeopathy.

* Hypnosis.

* Massage.

* Meditation.

* Naturopathic medicine.

* Spiritual healing.

* Therapeutic touch.

* Traditional Chinese medicine.

* Yoga.

The researcher confirmed this categorization by asking participants to list the specific therapies they were using currendy or had used in the past, and the frequency of use. Based on standardized frequency criteria developed by the researchers, 31 of the participants were classified users and 11 were categorized as non-users.

For the personal interview section, 10 of the 31 CAM users were randomly selected and interviewed. The mean age of these participants was 75.2 (+/5.2). Because the purpose of the interview was to further inquire about CAM use, only participants categorized as CAM users were included in the random selection process.

RESULTS

Questionnaire Results

Participant Characteristics. The characteristics of the participants completing the general questionnaire are provided in Table 1. As indicated, the majority of the sample were women between the ages of 70 and 84 (71.4%) who lived independendy, were fairly educated (i.e., secondary school or higher, 81%), and used CAM.

The individuals completing the general questionnaire can be broadly classified as a "healthy" sample of the population. The most notable conditions affecting this group of older adults were high blood pressure and arthritis - conditions not uncommon to this age group (Table 2). The majority of these individuals were living independently and able to perform activities of daily living. The two most prevalent medications used were vitamins and aspirin (Table 3). These are not medications required to sustain life, but rather to maintain quality of life and reduce pain.

Table

TABLE 1PARTICIPANT INFORMATION

TABLE 1

PARTICIPANT INFORMATION

Table

TABLE 2CHRONIC HEALTH CONDITIONS EXPERIENCED

TABLE 2

CHRONIC HEALTH CONDITIONS EXPERIENCED

Table

TABLE 3MEDICATION USE

TABLE 3

MEDICATION USE

Participants were asked a series of questions related to their health and health practices. Three (7.1%) of the participants stated that they had not visited their physician, 21 (50%) stated they made one visit, 17 (40.5%) indicated they made two or three visits, and one participant (2.4%) reported making between four and six visits within the past 3 months. Twentyseven participants (64.3%) used a physician as their primary health care provider, 12 (28.6%) used a chiropractor, 2 (4.8%) used a naturopath, and 1 (2.4%) used a physiotherapist.

Prevalence of CAM Treatments. The usage of the different forms of CAM therapies was obtained through two questions on the survey, the first of which was, "Check beside the forms of therapies that you use or have ever used." The second was, "How many visits have you made to each health practitioner in the past 6 months?" (Table 4). The four CAM therapies most commonly being used or had been used in the past were:

* Chiropractic.

* Herbal medicine.

* Massage.

* Acupuncture.

The CAM therapies that were used the least within this sample were:

* Hypnosis.

* Traditional Chinese medicine.

* Homeopathy.

* Yoga.

The participants' motivations for using CAM therapies were also examined. The individuals categorizing themselves as CAM users were asked why they used CAM therapies. Of the responses:

* 23 (54.8%) used CAM for pain relief.

* 19 (45.2%) used CAM to improve quality of life.

* 17 (40.5%) used CAM to maintain health and fitness.

* 14 (33.3%) used CAM for prevention.

* 6 (14.3%) used CAM because they were referred by their physician.

* 5(1 1.9%) used CAM for stress relief.

Knowledge of CAM. Knowledge of CAM therapies was first determined by asking participants to categorize a list of therapies into one of four groups. The different categories were "Alternative," "Complementary," "Mainstream," and "Don't Know." Complete results are presented in Table 5. The three CAM therapies participants knew the most about and were able to classify into either the Alternative, Complementary, or Mainstream groups were chiropractic, massage, and acupuncture. The CAM therapies participants most often classified as "Don't Know" were traditional Chinese medicine, hypnosis, yoga, meditation, spiritual healing, and therapeutic touch.

An independent t test was completed to examine the participants' perceived knowledge of CAM. A 7point Likert scale with anchors of 1 "not very knowledgeable" and 7 "extremely knowledgeable" was used to compare the perceived knowledge of CAM between users and non-users. This statistic revealed a perceived knowledge rating mean of 3.7 (SD = 1.7) for CAM users and 1.5 (SD = 1.6) for non-users. This was a statistically significant difference (p = .000), with users perceiving themselves more knowledgeable than non-users.

Table

TABLE 4USAGE PATTERNS OF COMPLEMENTARY AND ALTERNATIVE MEDICINES

TABLE 4

USAGE PATTERNS OF COMPLEMENTARY AND ALTERNATIVE MEDICINES

Table

TABLE 5CLASSIFICATION OF COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES

TABLE 5

CLASSIFICATION OF COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES

Participants were also asked to give a short definition of what they considered complementary or alternative medicine. The answers obtained from the participants were diverse in nature and individual, and one unifying answer was provided. Of the participants, 19 (45.2%; 13 users, 6 non-users) stated they knew little about CAM or did not provide a definition. The most prevalent answer (7 responses or 16.7%; 5 users, 2 non-users) given by those who were able to provide a definition was that alternative medicine was that not prescribed by a physician and complementary medicine was treatment advised by a physician. An example of one such definition was, "Alternative - medical apart from doctor. Complementary - with doctor's advice." Only 3 participants (7.1%; all users) were able to provide a more comprehensive definition such as, "Any therapy administered by a professional other than those in so-called mainline medicine (e.g., chiropractors, massage therapists, chiropodists, naturopaths, and more questionable practitioners of aroma therapy, shiatsu, reflexology, homeopathy, acupuncture, therapeutic touch and yoga)." The remaining 13 participants (11 users, 2 non-users) provided very unique responses or listed only examples of therapies.

Table

TABLE 6GENERAL PRACTITIONER KNOWLEDGE AND SUPPORT (USERS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE, n = 31)

TABLE 6

GENERAL PRACTITIONER KNOWLEDGE AND SUPPORT (USERS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE, n = 31)

General Practitioner Knowledge and Support. The final portion of the questionnaire examined the participants' physician knowledge and support of use of CAM (Table 6). Questions were posed to gain an understanding of the relationship existing between patients and their physicians in relation to CAM use. Within this sample of the participants' physicians, 64.5% were aware of their patient's CAM use, 41.9% were not supportive, and 58.1% did not recommend CAM use.

Interview Results

All 10 participants interviewed had been using CAM for a minimum of 10 years. When asked about their motivations for using CAM therapies, the majority reported using CAM for pain relief (80%), or for prevention of disease or debilitation (70%). Five participants indicated they learned about CAM therapies from family and friends - an observation also reflected within the general questionnaire. All 10 participants interviewed indicated their use of CAM had been beneficial and improved their overall well being. When asked if cost had a significant influence on their use of CAM, all participants indicated that if the therapy was needed, cost would not deter them from using CAM. However, participants did indicate that cost would affect the amount or frequency of use. One of the interviewed participants said the following regarding the relationship between cost and CAM:

Cost is definitely a problem. If people can get drugs and therapy for free from their doctor as opposed to paying for (CAM), it doesn't become a decision of what they believe will work better, but what is cheaper and more accessible. When people have to start paying for more of their health care, as they will in the future, they will begin to actively consider the different forms of therapy more based upon their personal opinions of whether they work and their feelings toward the philosophies behind the therapies.

DISCUSSION

The findings of this study indicate increased education related to CAM should be a priority. It is evident that older adults need to be further educated about the different options available to meet their health needs. The finding that users know significantly more about CAM than non-users is not unexpected; however, that users rate their perceived knowledge of CAM as a 3.7 on a 7-point scale is surprising. It is noteworthy that even those individuals using CAM remedies do not perceive themselves very knowledgeable about CAM treatments, and non-users were even less aware of treatment specifics (i.e., 1.5 on 7-point scale).

This research supports the notion that elderly individuals need to take a more proactive approach to their health and increase their understanding of treatments they receive. One way to achieve this is through further education. Past research (Eisenberg et al., 1998; Maiga & Aboubacar, 1997) has established the correlation between a higher education level and increased use of CAM. The findings of this article suggest that education level may not be the sole factor, but specific knowledge of CAM also might affect usage patterns.

The finding that the majority of participants obtained their information about CAM from family and friends is supported by Montbriand (1993), who found that seniors were obtaining information about alternative therapies from lay sources, media, and social groups. This could partially account for why some seniors have unfavourable views or misinformation related to CAM. A quote provided within one of the questionnaires when asked to define CAM illustrates this point, "Touch therapy, massage, aroma therapy and chiropractic. I know little about these therapies but do not favor them." This individual admits to having little knowledge about CAM, but has predetermined that these therapies do not work and did not support them.

The medical profession must also be further educated about how CAM can be integrated into the present health care system. The finding that more than 40% of the physicians within this study were aware of their patients' use of CAM and not supportive demonstrates this point. This attitude is reflected in the following participant's statement:

My family doctor is aware that I am using these therapies, but he definitely does not endorse them or recommend them. He sarcastically says if it works, use it.

By neglecting the potential benefits associated with CAM, health care professionals may be dissuading their patients from using treatments that could be advantageous to their health status.

Another important conclusion that can be made from this research is that increased support from professionals Ln the health field is necessary. The majority of the participants within this study indicated their physicians were either unaware of their CAM use or not supportive of their CAM use. This finding is somewhat contradictory to the findings presented by Berman et al. (1995) and Boucher and Lenz (1998), who concluded that physicians reported high levels of interest and referrals for CAM therapies to their patients. If health care providers are not knowledgeable about how CAM can help their patients attain a higher level of wellness, they may not be able to answer their patients' questions or concerns accurately. Montbriand (1993) concluded that 97% of healthprofessionals, including physicians, pharmacists and nurses, believed they did not possess adequate information about alternative therapies. Lack of knowledge may translate to a lack of CAM therapy prescription when they may, indeed, be helpful.

Another important factor to consider is the possibility of problematic interactions among treatments if health care providers are not aware of their patients' CAM use (e.g., complications from using traditional medications and herbal remedies together). Montbriand (2000) found that the majority of health care professionals felt their patients told them about their alternative therapy use, when in actuality, fewer than 50% of senior citizens talked about the alternative therapies they were using. The lack of open communication between senior citizens and physicians noted in the present study confirms the findings of Montbriand (1993).

Complementary and alternative medicine practitioners themselves are also responsible for becoming more educated about the specific needs of the elderly population and motivations for using these therapies. This study found that seniors were using CAM for pain relief, to increase quality of life, to maintain health and fitness, and for disease prevention. Knowledge in geriatrics will assist them to more effectively market their services and actually improve the quality of life of seniors.

The researchers of this study suggest it is important to inform elderly adults about CAM and increase the opportunities for them to learn about and experience CAM therapies. The results of this study indicate that all of the individuals who initiated CAM use continued to use these therapies because they were extremely satisfied with the results. Conversely, those who did not use CAM had never experienced any of the therapies and were discouraged against trying CAM therapies by physicians, family, or friends. Again, it is the responsibility of CAM practitioners to develop new ways to educate senior citizens about the benefits of CAM services.

Nursing Implications

One way to attain further education and integration is by changing the curriculum in North American health-oriented schools (e.g., nursing school, medical school). If health care providers are educated about CAM, they will have a better understanding of how CAM may be a beneficial tool. They will also be more aware of possible treatment interactions and can further aid in the integration of CAM into the current health care system. Perhaps, if the medical and nursing communities are not willing to accept the reality and popularity of CAM from the public, they will listen to their own future health care providers.

Duggan, Verhoef, and Hilsden (1999) found 65% of first-year medical students at a Canadian medical school wanted a course in CAM. More important, because health care funding and resources continue to be cut, nurses provide patients with information concerning health promotion efforts, such as use of CAM. As such, it is equally, if not more, important that nursing professionals become knowledgeable in the area of CAM so they may provide the best possible care to their patients. Perhaps pressure from within the medical community and society at large will motivate curriculum change.

LIMITATIONS

The results of this study are limited by a number of factors that must be considered when interpreting the results. First, the sample obtained for the purposes of this study may not represent the entire population of elderly adults. Participants had high socioeconomic status and education levels and tended to be in better health and generally more active than the average community-based senior citizen. One group not represented in this sample was socially isolated senior citizens. These older adults are, typically, an extremely difficult portion of the population to access for research purposes.

A second limitation of the study was the relatively small sample size. This lack of power further limits the generalizability of the study findings. Limitations aside, the area of geriatric use of CAM is understudied. This descriptive pilot study of CAM provides valuable information which can be built on through future research to gain a more comprehensive understanding of this important issue.

CONCLUSION

Future research is needed to gain a more complete understanding of CAM and how elderly individuals use these therapies. However, the most notable gap in the area of CAM is the lack oí scientifically based research concerning CAM therapies. For the medical community to actively support CAM and begin to fully integrate its use into the health care system, strong methodological research must be completed. Also, the researchers must conduct their research using a more representative sample of senior citizens to examine whether trends remain consistent. Lastly, an examination of CAM knowledge among different age groups in longitudinal and cross-sectional studies is extremely important in determining whether or not the decreased knowledge seen within this sample is:

* The result of a cohort effect.

* Because CAM was not as popular when older adults were learning about health care.

* Caused by actual age changes associated with usage.

Given the changing demographics, treatments - whether allopathic or alternative - will be paramount in improving the health and quality of life of senior citizens.

REFERENCES

  • Alishuler, L.H. (1999). Alternative medicine: What is the physician's role? Journal of the Oklahoma State Medical Association, 92(5), 219-226.
  • Berman, B.M., Singh B.K., Lao, L., Singh, B.B., Ferentz, K.S., & Hartnoll, S.M. (1995). Journal of American Board of Family Practitioners, 8(5), 361-366.
  • Boucher, TJV., & Lenz, S.K. (1998). An organizational survey of physicians' attitudes about and practice of complementary and alternative medicine. Alternative Therapies, 4(6), 59-65.
  • Denton, F.T., Feaver, C.H., & Spenser, B.G. (1998). The future population of Canada, its age distribution and dependency relations. Canadian Journal on Aging, 77(1), 83-109.
  • Duggan, K., Verhoef, M.J., & Hilsden, RJ. (1999). First-year medical students and complementary and alternative medicine: Attitudes, iknowledge and experiences. Annals Royal College of Physicians and Surgeons Canada, 32, 157-160.
  • Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wllkey, S-, Van Rompay, M., & Kessler, R.C. (1998). Trends in alternative medicine use in the United States, 19901997: Results of a follow-up national survey. JAMA, 280(18), 1569-1575.
  • Eskinazi, D.P. (J 998). Factors that shape alternative medicine. JAMA, 280(U), 1569-1575.
  • Lorenzi, E-A. (1999). Complementary/alternative therapies: So many choices. Geriatric Nursing, 20(3), 125-133.
  • MacLennan, A.H., Wilson, D.H., & Taylor, A.W. (1996). Prevalence and cost of alternative medicine in Australia. The Lancet, 347, 569-573.
  • Maiga, A., & Aboubacar, A. (1997). How different are users and non-users of alternative medicine? Canadian Journal of Public Health, 88(3), 159-162.
  • Millar, WJ. (1997). Use of alternative health care practitioners by Canadians. The Canadian Journal of Public Health, 88(3), 154-158.
  • Montbriand, M.J. (1993). Freedom of choice: An issue concerning alternste therapies chosen by patients with cancer. Oncology Nursing Forum, 20(8), 1195-1201.
  • Montbriand, M.J. (2000). Senior and healthprofessionals' perceptions and communication about prescriptions and alternative therapies. Canadian Journal on Aging, 19(1), 35-56.
  • Spirduso, WW. (1995). Physical dimensions of aging. Champaign, IL: Human Kinetics.

TABLE 1

PARTICIPANT INFORMATION

TABLE 2

CHRONIC HEALTH CONDITIONS EXPERIENCED

TABLE 3

MEDICATION USE

TABLE 4

USAGE PATTERNS OF COMPLEMENTARY AND ALTERNATIVE MEDICINES

TABLE 5

CLASSIFICATION OF COMPLEMENTARY AND ALTERNATIVE MEDICINE THERAPIES

TABLE 6

GENERAL PRACTITIONER KNOWLEDGE AND SUPPORT (USERS OF COMPLEMENTARY AND ALTERNATIVE MEDICINE, n = 31)

10.3928/0098-9134-20030501-06

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