PRACTICAL INTEGRATIVE MEDICINE IN GERIATRIC HEALTHCARE NW GWEC Spring 2019 Geriatric Healthcare Series June 4, 2019 Lianne Hirano, MD Clinical Assistant Professor Div. Gerontology & Geriatric Medicine UW School of Medicine No disclosures to report. Integrative Medicine (Hirano), NW GWEC Spring 2019 1
21
Embed
PRACTICAL INTEGRATIVE MEDICINE IN GERIATRIC HEALTHCARE€¦ · •Dietary Supplements • Herbs “botanicals” (St. John’s Wort, Garlic, Ginseng) • Vitamins and minerals (Calcium,
This document is posted to help you gain knowledge. Please leave a comment to let me know what you think about it! Share it to your friends and learn new things together.
Transcript
PRACTICAL INTEGRATIVE MEDICINE IN GERIATRIC HEALTHCARENW GWEC Spring 2019 Geriatric Healthcare SeriesJune 4, 2019
Lianne Hirano, MDClinical Assistant ProfessorDiv. Gerontology & Geriatric MedicineUW School of Medicine
No disclosures to report.
Integrative Medicine (Hirano), NW GWEC Spring 2019 1
Case #1:87 yo woman “told to come” to Senior Care Clinic by
ENT. She is accompanied by her daughter/caregiver who lives with her.
On her intake questionnaire she lists “advancing age!”as her most important health problem.
She was seeing ENT for tx of SCC of her R cheek and maxillary sinus (for which she had undergone surgery w/ flap and reconstruction) and was now undergoing XRT.
Case #1 Cont:
She has had several falls within the past year and endorses balance and strength problems on ROS.
She denies having any other medical problems or PMHx.
Her MMSE score was 15/30 (-3 orientation, -3 registration, -5 calculation and attention, -3 recall). She believes her memory is "not as good as it used to be" but attributes this to advancing age.
Integrative Medicine (Hirano), NW GWEC Spring 2019 2
MedicationsEfudex 5% topical BIDFolic Acid 1ml injection qweekCyanocobalamin 2ml injection qweekCoQ10 100mg po qdVit C 1000mg po tidFish Oil 1 tsp po qdayFlax Oil 1 Tbsp po qdayCalcium/Mag/Zinc 1cap po tid"Vision Essentials" Vitamin 4 caps po qd (Vit C, Vit A, Zinc, Copper)
Medications Nutritional Yeast 1 Tbsp po tid Rhodiola Rosea 50mg po qday Taurine 600mg po qdayQuercelin 300mg po qday Carrot Powder 260mg po qday N-acetyl-L-cystiene 260mg po qday Schisandra (berry) 160mg po qday Eyebright Laerial Part 60mg po qday Bilberry Extract 320mg po qdayGingko Extract (Leaf) 60mg po qday L-Glutamic Acid HCl 60mg po qdayGlycine 60mg po qday Alpha Lipoic Acid 10mg po qday Lutein (from Marigold Flower) 15mg po
qday Lycopene 3mg po qday Zeaxanthine 2mg po qday Astaxanthin (from algea) 1mg po qday
• Betaine HCl 648mg po tid• Pepsin (1:10,000) 130mg po tid• Amylase 10,000DU po tid• Protease 30,000 HUT po tid• Lipase 200 FCCLU po tid• Invertase 400 SU po tid• Malt Dictase 200 DP po tid• Lactase 300 ALU po tid• Cellulase 100 CU po tid
Integrative Medicine (Hirano), NW GWEC Spring 2019 3
Questions:
Where to begin?
How do we address the use of complementary, alternative, and integrative treatments and practices?
Why do our patients turn to these treatments and practices?
Efficacy? Harm? Evidence? Regulation?
Definitions:
• Conventional Medicine
• Complementary• Care that may have origins outside of usual conventional “Western
Medicine”
• Non-mainstream practice is used together with conventional medicine
• Alternative• Non-mainstream practice is used in place of conventional medicine
• Integrative • Incorporating complementary approaches into mainstream health
care
• “Functional Medicine”, Naturopathy
Integrative Medicine (Hirano), NW GWEC Spring 2019 4
• Majority of adults in the US take one or more dietary supplements either every day or occasionally
Natural Products
Integrative Medicine (Hirano), NW GWEC Spring 2019 6
• 1994 – Congress passes the Dietary Supplement Health and Education Act (DSHEA)
• Defines herbal medicines as “dietary supplements”, neither food nor drugs.
• Labels are required to state: “this product is not intended to diagnose, treat, cure, or prevent any disease.”
Natural Safe
Don't forget about our high quality herbal supplements. At GNC we pride ourselves on having natural products to help you treat yourself naturally.
GNC herbs have been used to treat arthritis, boost immune function, improve mental clarity, or just relax and relieve the stresses of the day. What ever your need you will be able to find the right product.
GNC.com
• No oversight of contents, efficacy, or safety of herbal medicines. JAMA 2003;289:1568-70.
• In vitro or animal studies are not required prior to human trials because of belief that traditional use implies efficacy and proof of safety. Ann Intern Med 2002;136:616-618.
• Direct to consumer marketing without need for FDA approval (no incentive to conduct RCTs)
• DSHEA initially did not require reporting of adverse events to FDA!
DSHEA
Integrative Medicine (Hirano), NW GWEC Spring 2019 7
http://well.blogs.nytimes.com/2015/02/03/new-york-attorney-general-targets-supplements-at-major-retailers/ February 3, 2015
Herbal MedicationsHerbals may be adulterated w/ contaminants and/or prescription medications.Herbals are NOT required to pass preliminary safety studies so adverse events may not be noted until many pts have used the product over many years.Most adverse events are reported to Poison Control Centers rather than to the FDA.
Integrative Medicine (Hirano), NW GWEC Spring 2019 8
• Exercise caution, start low and go slow
• Older persons may be more vulnerable to herb-drug interactions due to age-related changes in pharmacokinetics.
• Risk of poly-herbacy and herb-herb interactions.
• Herbal medications can cause delirium and increase pill burden
“Benefits are equivocal. It is important to note there were several methodological difficulties with the included studies. More well-designed, large-scale randomized controlled trials are needed before clear conclusions can be drawn regarding [insert complementary therapy for particular elderly condition here]”
Integrative Medicine (Hirano), NW GWEC Spring 2019 11
• Poor standardization of therapies
• Difficult to create appropriate control group (music therapy vs usual care, light therapy vs usual care)
• Not many studies in elderly
• Small sample sizes
• Bias
Research Issues
• Healing touch, therapeutic touch, Reiki
• Reflexology
• Music therapy
• Art therapy
• Biofeedback
• Meditation
What doesn’t cause harm?
Integrative Medicine (Hirano), NW GWEC Spring 2019 12
• CBD may increase levels of SSRIs, TCAs, antipsychotics, Beta blockers, opioids
Integrative Medicine (Hirano), NW GWEC Spring 2019 18
How to have the talk
• Open up the conversation
• Ask pts specifically if they are using cannabis, or even considering it (especially if they have symptoms that have been challenging to manage)
• Ask caregivers (like adult children)
• Share that you are open and willing to discuss how cannabis might fit into their medical care
• Do not discuss all risks upfront; appearing too negative immediately may push pts to assume you will judge them for considering and/or using cannabis
Cannabis Considerations
• Think of cannabis as a supplement (similarly unregulated, unknown effects, don’t know what might be in it)
• Visit a dispensary (I did!)
• Consider having a dispensary in mind to recommend to a pt who is set on trying cannabis (harm reduction)
Integrative Medicine (Hirano), NW GWEC Spring 2019 19
Advice for Our Patients (Harm Reduction)
• DO NOT buy products from the internet, on the street, or synthetic products from gas station stores!
• Same approach as to medication: Start low, go slow (try 1/4-1/2 of “recommended dose”)
• There has been research done on cannabis and some of it is promising (seizures in children, pain, nausea/ vomiting) but most studies have not included older folks
• Recommend topical/transdermal products > oral
• Recommend products w/ CBD > THC concentration, or pure CBD
Advice for Our Patients
• Recommend against smoking/inhaling if immune-compromised
• Try new product on a day you’re not going to drive, go out, or make important decisions and have a caregiver or family member nearby just in case of adverse effects (particularly w/ oral route cannabis)
• Unfortunately, cannabis products are not tested, regulated, or quality-controlled
Integrative Medicine (Hirano), NW GWEC Spring 2019 20
Advice for Our Patients
• Be aware that products are expensive! And only cash is accepted (most dispensaries have ATMs inside)
• Try to go with a friend/in a group, during the day.
• Remember: Cannabis is not legal in all states, and definitely not in most other countries (consideration for travel)
• Don’t forget: cannabis remains a controlled substance.
• If you work, review your job’s policy on cannabis/drug testing.
• Lock it up! Especially if you have grandchildren who visit or live with you.
• Cochrane Reviews
• https://nccih.nih.gov/health
Sources cited throughout, in addition:
Integrative Medicine (Hirano), NW GWEC Spring 2019 21