1. Integrative Medicine & Older Adults
Evie Kalmar, MD, MS
UCSF Geriatrics & Palliative Medicine Fellow
10/24/2019
Good afternoon. I’m excited to be here and talk to you about integrative medicine in older adults. My name is Evie Kalmar, and I’m currently a geriatrics and palliative care fellow at UCSF.

2. I have no disclosures.
I don’t have any disclosures.

3. Objectives
Define Integrative Medicine and discuss its potential to improve the health and well- being of older adults
Describe Integrative Medicine practices, including nutrition, mind-body, and exercise
List resources to learn more about Integrative Medicine
What is it?
Here’s how it applies to patients
Here’s where to go to learn more
My hope is that, by the end of this talk, you’ll be able to 1) define IM and discuss its potential benefits, 2) describe a few integrative medicine practices, focusing on nutrition, mind-body, and exercise, and 3) Have access to a list of resources if you’re interested in learning more about IM.

4. Roadmap Overview of Integrative Medicine
Integrative Medicine Practices
How to apply Integrative Medicine to common symptoms
Summary & Resources
Here’s a brief overview of how we’ll meet those objectives. The talk will be broken up into four main sections. First, I’ll give you an overview of IM. Second, we’ll discuss some common practices. Third, we will see how it applies to common disease. Lastly, we’ll summarize what we’ve discussed and give you resources for further reading.

6. 1. What is Integrative Medicine?
“Integrative Medicine is healing-oriented medicine that takes account of the whole person, including all aspects of lifestyle. It emphasizes the therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies.”
I want to start by getting us all on the same page. “What is integrative medicine?” Ok to call out words. There are many definitions but here is one I like: (read). What I like about this one is the focus on looking at the whole person, all aspects of lifestyle and ***.
Think about what do I want people to take away, use simple language  would I recommend to my patients?
Think about different cases, what will help things stick in mind? 1) repetition 2) repeating structure 3) give breaks (case, photo, etc)

7. 1. What is Integrative Medicine?
Do you look at this and think apply to older adults? They all do. See people of all backgrounds and ages. Medicine comes last. Majority of it is people in their life in community -- that is more central. Value things that are central to health. Unlike medicine that treat one thing, these fundamental address many things simultaneously.
This image helps to describe that emphasis on the whole
Integrative health care often brings conventional and complementary approaches together in a coordinated way. It emphasizes a holistic, patient-focused approach to health care and wellness—often including mental, emotional, functional, spiritual, social, and community aspects—and treating the whole person rather than, for example, one organ system. It aims for well-coordinated care between different providers and institutions.  

8. Alternative Medicine = replaces conventional medicine
Terminology
Alternative Medicine = replaces conventional medicine
Complementary Medicine = complements conventional medicine
Integrative Medicine = complementary + conventional Medicine
There’s a lot of terminology and so I want to take a minute to define some terms. Raise your hand if you’ve heard of complementary medicine.
When describing approaches that are not typically part of conventional medical care or that may have origins outside of usual Western practice, people often use “alternative” and “complementary” interchangeably, but the two terms refer to different concepts:  
If a non-mainstream practice is used together with conventional medicine, it’s considered “complementary.” 
If a non-mainstream practice is used in place of conventional medicine, it’s considered “alternative.” 
Mention CAM and TCM

9. Who uses Integrative Medicine?
33.2% of U.S. adults use complementary health approaches
Most common complementary approach
natural products
used by 17.7% of adults
Statistics from 2012
That means 1 out of 3 people

10. Who uses Integrative Medicine?
33.2% of U.S. adults use complementary health approaches
Most common complementary approach
natural products
used by 17.7% of adults
Statistics from 2012
Natural products:
dietary supplements other than vitamins and minerals

11. How Big is Integrative Medicine?
~ 59 million Americans spend money out-of-pocket on complementary health
Total annual spending is $30.2 billion
Out-of-pocket spending for complementary health represents 1.1% of total health care spending
Statistics from 2012
We’re always talking about how healthcare costs so much money. 59 million people are spending even MORE on their health with complementary approaches. We spend so much and yet many people still feel like they need more.
Out-of-pocket spending for complementary health represents:
9.2% of all out-of-pocket spending on health care

12. Why do people use Integrative Medicine?
Ask question and then give the information.

13. Why do people use Integrative Medicine?
Prevent illness & For general wellness
Reduce pain
Treat specific health condition
Ask question and then give the information.
Supplement conventional medicine

14. 2. Integrative Medicine Practices
Overview of Integrative Medicine
Integrative Medicine Practices
How to apply Integrative Medicine to common diseases
Summary & Resources
So far, we’ve talked about what Integrative Medicine is, how often it’s used, and why people use it. In this next section, we’ll talk in more detail about specific practices.

15. What are common Integrative Medicine Practices?
Natural Products
Deep Breathing
Meditation
Chiropractic & Osteopathic
Massage
Yoga
Diet-Based Therapies
Progressive Relaxation
Guided Imagery
Homeopathic Treatment
These are the top ten most commonly used CAM therapies in There has been an increase in use of deep breathing, meditation, and yoga in recent years.

16. What are common Integrative Medicine Practices?
Natural Products
Deep Breathing
Meditation
Chiropractic & Osteopathic
Massage
Yoga
Diet-Based Therapies
Progressive Relaxation
Guided Imagery
Homeopathic Treatment
Exercise
These are the top ten most commonly used CAM therapies in There has been an increase in use of deep breathing, meditation, and yoga in recent years.

17. What are common Integrative Medicine Practices?
Nutrition
Mind body
Exercise
We will focus on these three modalities, but I want to note that this list is not exhaustive.

18. A. Nutrition - Barriers Dentition Access Malabsorption Dentition
Access to food (mobility, ability to cook, $)
malabsorption
Dentition
Access
Malabsorption

19. A. Nutrition - Supplements
Americans spend $12.8 billion on natural products per year.
Fish oil was the #1 natural product among adults, with 7.8% using it in 2012.
↑ use of fish oil, probiotics, and melatonin in recent years.
Lack of adequate regulation by FDA for supplements and herbs
Include reminder to tell doctors about OTC supplements, reminder to docs to ask
most commonly used, but maybe shouldn't be. I think it's worth noting that these don't address some of the main problems.

20. A. Nutrition - Food Foods that cause inflammation
Refined sugar & sweetener
White sugar, corn syrup, agave nectar, rice syrup, aspartame
Processed foods
Refined carbs, trans fat
Food additives and chemicals
Artificial colors, chemical preservatives, additives like carrageenan
Kogan, 2017
Kogan, 2017

21. A. Nutrition - Food Foods that cause inflammation
Foods that reduce inflammation
Refined sugar & sweetener
Clean protein
White sugar, corn syrup, agave nectar, rice syrup, aspartame
100% grass-fed animal protein, wild-caught seafood, nuts, seeds, legumes
Processed foods
Fruit & vegetables
Refined carbs, trans fat
Fresh or frozen
Food additives and chemicals
Healthy fats
Artificial colors, chemical preservatives, additives like carrageenan
Nuts, seeds, avocados, olive oil, coconut oil, flax oil
Kogan, 2017
Kogan, 2017

22. A. Nutrition – Therapeutic Diets
High blood pressure
Dietary Approaches to Stop Hypertension (DASH)
Slow cognitive decline
Mediterranean-DASH Intervention for Neurodegenerative Delay (MIND)
Irritable Bowel Syndrome
Low FODMAP diet
Have any of you heard of therapeutic diets? Call out if you know of any. Many different diets for different target populations. These are just a sample of many diets for specific health conditions.
Kogan, 2017

23. A. Nutrition - Medications
Medications can impair absorption of nutrition
Diuretics
deplete nutrients like potassium, magnesium, calcium
Proton-pump inhibitor
block absorption of nutrients like vitamin B12
Old people are on tons of medications. In conventional medicine, we’re often working counter to
People can get addicted to PPIs.
There are alternatives: Deglycerinated licorice is used for reflux.

24. B. Mind body Massage Therapy Yoga Chiropractic Manipulation Meditation
Mind-body practices involve using the mind & body in intentional ways. The mind and body approaches most commonly used by adults include yoga, chiropractic or osteopathic manipulation, meditation, and massage therapy.
Massage Therapy
Yoga
Chiropractic Manipulation
Meditation

25. B. Mind Body - Trends
The percentage of adults who practice yoga has increased substantially, from 5.1% in 2002 to 9.5% in 2012.

26. B. Mind Body - Yoga
> 85 % of U.S. adults who practice yoga felt ↓ stress.
6 in 10 people motivated to exercise more regularly.
4 in 10 motivated to eat healthier.
More likely to report feeling better emotionally than users of dietary supplements or spinal manipulation.

27. C. Mind Body - Meditation
Use of meditation is increasing.
14.2% of adults practiced it in 2017.
Involves:
quiet location
specific, comfortable posture
focus of attention
open attitude
Benefits – pain, blood pressure, anxiety, irritable bowel syndrome
Charles, 2018

28. C. Exercise - Types Aerobic Exercise Resistance Training
Flexibility Training
Ask: What are the different exercise types we should do? There are many types of exercise that people can engage in. The goal for most of these types of 2-3 times per week. Aerobic exercise is repetitive activity of large muscle groups that sustains an elevated heart rate. Resistance training is moving limbs against resistance such as body weight, bands, or weights. Flexibility training involves moving a joint through its complete range of motion. Balance training is exercise that prevents falls by maintaining stability during physical activity. Lifestyle modifications involve making changes to existing daily routines to increase physical activity, like taking stairs or parking at the back of a parking lot.
Balance Training
Lifestyle Modifications
Kogan, 2017

29. C. Exercise - Benefits
Improves blood pressure, heart failure, cholesterol
Decreases fall risk, maintains healthy bones
Improves depression, sleep, cognition
Decreases risk of obesity, diabetes, improves symptoms of hot flashes
Decreases mortality
Numerous benefits to exercise. Kogan page 52-53
Add slide of efficacy of exercise
People feel better
Yoga, tai chi, chi gong – low impact, adaptive (can be done by people in all function groups from wheelchair bound to healthy), also very functional and use many muscle groups (hands over head – good for brushing hair, hands behind back – good for dressing, touch your toes – good for putting on socks)
Kogan, 2017

30. 4-7-8 Breathing Empty lungs Inhale through nose for 4 seconds
Hold breath for 7 seconds
Exhale through mouth for 8 seconds
Now we’ve gone over what is IM and three modalities that can be applied to different groups
Now we’re going to talk about three things that we can apply to different conditions, and then we’ll be done

31. 3. How to apply Integrative Medicine to common diseases
Overview of Integrative Medicine
Integrative Medicine Practices
How to apply Integrative Medicine to common diseases
Summary & Resources

32. Which conditions inspire use of Integrative Medicine?
Back pain
Neck pain
Joint pain
Arthritis
Cholesterol
Cold
Other Musculoskeletal
Severe headache
Insomnia
Do you notice trends in the conditions that inspire use of IM?

33. Which conditions inspire use of Integrative Medicine?
Back pain
Neck pain
Joint pain
Arthritis
Cholesterol
Cold
Other Musculoskeletal
Severe headache
Insomnia
What do you notice about these conditions? Pain is a huge reason people seek out integrative medicine.

34. Symptom-specific approaches
Pain
Insomnia
Use same structure of: nutrition, exercise, mind body for each of these

35. Pain
Who here has ever had pain?

36. Pain 11.2% of adults have daily pain Common causes: Arthritis
Bone and joint diseases
Chronic pain conditions
Focus on osteoarthritis given prevalence
~ 25 million adults (11.2%) have daily pain
Jama study - highest reason for suicide without depression is arthritis
particular important because no one is prescribing opioids
this is for all adults, must be higher in older adults. Look for pain stats in older adults.

37. Pain is associated with
Worse health
Depression
Anxiety
Social isolation
Sleep disturbance
Impaired mobility & disability
↑ health care utilization and $
Focus on osteoarthritis given prevalence

38. Pain - Nutrition
Minimal evidence to support though low risk side effects
Supplements with potential benefit
SAMe (S-Adenosylmethionine)
Glucosamine
Chondroitin
Oral herbal therapies
Boswellia
Tumeric + Black Pepper
SAMe (S-Adenosylmethionine) – effect on both pain and function may be potentially clinically relevant for arthritis
Glucosamine – depends on formulation, meta-analysis of it showed improvement in pain and function in OA with Rotta brand compared to placebo
Oral herbal therapies: : boswellia, avocado-soyabean unsaponifiables (ASU)
Towheed  T, 2005

39. Pain - Nutrition Dr. Weil Anti-Inflammatory Diet Aim for variety.
Include as much fresh food as possible.
Minimize consumption of processed foods and fast food.
Eat an abundance of fruits and vegetables.

40. Pain – Mind-body Acupuncture
Small but statistically significant benefit
Ice massage
↑ ROM, function, and knee strength
Meditation
Yoga
Tai chi
(meditation & chronic pain)
Define cognitive studies - guideded imagery, meditation
MBSR
Cold packs – decreased swelling, didn’t change pain
Evidence for yoga and chronic lower back pain, not arthritis
Manheimer, 2018

41. Pain - Exercise Can reduce pain and improve physical function
hip OA, similar studies for knee OA
Can reduce pain and improve physical function
Fransen, 2005 & Fransen, 2014

42. Insomnia
Who here has ever had trouble falling asleep?

43. Insomnia Occurs in up to 30% of older adults.
Can impair mood, energy, performance, quality of life.
May lead to depression, cognitive impairment, caregiver stress, and increased healthcare costs.
Most common treatment for insomnia is medication.

44. Insomnia - Nutrition Melatonin Valerian root
Limited evidence for supplements
Melatonin
Valerian root
Melatonin – may do nothing or may help tremendously. Start at 1 mg. If not doing anything after one week, take 3 mg. There is mixed data and not great evidence.
– debate (some people believe mg is more effective, other people think higher dose more effective, don’t go above 5 in older adults)
The available evidence suggests that valerian might improve sleep quality without producing side effects.
Matheson, 2017
Bent, 2006

45. Insomnia – Mind-Body Cognitive behavioral therapy - mild effect
Listening to music - may support sleep
Acupuncture – no evidence to support
Guided imagery
Meditation
Lack of evidence for acupuncture related to diversity and poor quality of studies
CBT Aims to improve sleep by changing poor sleep habits and by challenging negative thoughts, attitudes and beliefs about sleep. , best demonstrated for sleep maintenance insomnia
Cheuk, 2012
Jespersen, 2015
Montgomery, 2003

46. Insomnia - Exercise Regular brisk walking and moderate weight training
Improvement in total sleep duration, sleep onset latency and global sleep quality
Total sleep duration, sleep onset latency and scores on a scale of global sleep quality showed significant improvement.
Kogan, 2017
Montgomery, 2002

47. 4. List Resources Overview of Integrative Medicine
Integrative Medicine Practices
How to apply Integrative Medicine to common diseases
Summary & Resources

48. Summary Integrative Medicine
Here are all of the modalities (add image) – I focused on these three to give you a taste
Integrative
Medicine

49. Summary Integrative Medicine Practices
Here are all of the modalities (add image) – I focused on these three to give you a taste
Integrative
Medicine
Practices

50. Summary Integrative Medicine Practices Symptoms
Here are all of the modalities (add image) – I focused on these three to give you a taste
Integrative
Medicine
Practices
Symptoms

51. Resources for Integrative Medicine
The National Center for Integrative Primary Healthcare
The Office of Cancer Complimentary and Alternative Medicine
The National Center for Complementary and Integrative Health
Cochrane Complementary Medicine
rces/
Osher Collaborative – same as IM consortium?
Key textbook – by david reikel
IM4US – integrative medicine for underserved populations

52. Resources
Alzheimer’s Association.”Facts and Figures.” Last accessed 9/10/2019.
Bent, S., Padula, A, Moore, D, Patterson, M., Mehling, W. Valerian for sleep: a systematic review and meta-analysis Am. J. Med. (2006),  /j.amjmed
Clarke TC, Barnes PM, Black LI, Stussman BJ, Nahin RL. Use of yoga, meditation, and chiropractors among U.S. adults aged 18 and older. NCHS Data Brief, no 325. Hyattsville, MD: National Center for Health Statistics
Cheuk  DKL, Yeung  WF, Chung  KF, Wong  V. Acupuncture for insomnia. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No.: CD DOI: / CD pub3.
Forbes  D, Forbes  SC, Blake  CM, Thiessen  EJ, Forbes  S. Exercise programs for people with dementia. Cochrane Database of Systematic Reviews 2015, Issue 4. Art. No.: CD DOI: / CD pub4.
Fransen  M, McConnell  S, Hernandez‐Molina  G, Reichenbach  S. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No.: CD DOI: / CD pub2.
Fransen  M, McConnell  S, Harmer  AR, Van der Esch  M, Simic  M, Bennell  KL. Exercise for osteoarthritis of the knee. Cochrane Database of Systematic Reviews 2015, Issue 1. Art. No.: CD DOI: / CD pub3.

53. Resources
Herbert LE, Weuve J, Scherr PA, Evans DA. Alzheimer disease in the United States (2010 – 2050) estimated using the 2010 census. Neurology 2013; 80:1778.
Jespersen  KV, Koenig  J, Jennum  P, Vuust  P. Music for insomnia in adults. Cochrane Database of Systematic Reviews 2015, Issue 8. Art. No.: CD DOI: / CD pub2.
Manheimer  E, Cheng  K, Wieland  LS, Shen  X, Lao  L, Guo  M, Berman  BM. Acupuncture for hip osteoarthritis. Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD DOI: / CD
Matheson, E., Hainer, BL. Insomnia: Pharmacologic Therapy. American Family Physician. July 2017, Volume 96, Number 1.
Mikhail Kogan, Stephanie Cheng, Seema Rao, Sharon DeMocker, Mariatu Koroma Nelson. Integrative Medicine for Geriatric and Palliative Care Medical Clinics of North America, Volume 101, Issue 5, 2017, Pages
Montgomery  P, Dennis  JA. Physical exercise for sleep problems in adults aged 60+. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No.: CD DOI: / CD
Montgomery  P, Dennis  JA. Cognitive behavioural interventions for sleep problems in adults aged 60+. Cochrane Database of Systematic Reviews 2003, Issue 1. Art. No.: CD DOI: / CD
Towheed  T, Maxwell  L, Anastassiades  TP, Shea  B, Houpt  JB, Welch  V, Hochberg  MC, Wells  GA. Glucosamine therapy for treating osteoarthritis. Cochrane Database of Systematic Reviews 2005, Issue 2. Art. No.: CD DOI: / CD pub2.
Wayne PM, Walsh JN, Taylor-Piliae RE, et al. Effect of tai chi on cognitive performance in older adults: Systematic review and meta-analysis. J Am Geriatr Soc ;62(1):25-39.

54. Thanks!
Louise Aronson, MD, MFA

56. Alzheimer’s Disease

57. Alzheimer’s Disease 5.8 million people in US have Alzheimer’s Disease
1 in 10 people older than 65 have Alzheimer’s Dementia
Someone develops Alzheimer’s Disease every 65 seconds
In 2010, there were estimated to be 4.7 million individuals aged 65 years or older with AD dementia. As you can see, the number of people with AD increases with age. The total number of people with AD dementia in 2050 is projected to be 13.8 million, with 7.0 million aged 85 years or older.
Herbert, 2013

58. Alzheimer’s Disease No disease-modifying treatments
Focus on prevention
Kogan, 2017

59. Alzheimer’s Disease - Nutrition
Mediterranean diet
MIND diet = Mediterranean diet + DASH diet
DASH = Dietary Approaches to Stop Hypertension
Kogan, 2017

60. Alzheimer’s Disease - Nutrition
Low glycemic index
↓ pro-inflammatory foods (red meat, dairy, sugar, trans fats, processed foods)
↑ fresh fruits and vegetables
↑ foods high in antioxidants (berries, turmeric, green tea)
↑ foods rich in omega-3 fatty acids (seafood, nuts, seeds)
Overnight fasting to promote ketogenesis
Some people may really believe in this literature. We have some suggestive evidence, but not necessarily proven by highest evidence standards. This will be helpful for ****. Can I guarantee it will help with you Alzheimer’s? I cannot.
Kogan, 2017

61. Alzheimer’s disease - Exercise
Positive effect on cognition
Improves ability to maintain activities of daily living and function
↓ advanced complications (i.e., falls, sarcopenia, and contractures)
Examples of exercise
Tai chi
Yoga
Exercise has been shown to have a positive effect on cogntion, both in mild cognitive impairment as well as Alzheimer’s disease.
By focusing on strength, balance, flexibility, people can decrease complications of advanced dementia complications such as falls, muscle decrease, and contractures
Forbes, 2015
Wayne, 2014