Integrative Medicine Older Adults Evie Kalmar MD MS

Integrative Medicine & Older Adults Evie Kalmar, MD, MS UCSF Geriatrics & Palliative Medicine Fellow 10/24/2019

I have no disclosures.

Objectives 1. Define Integrative Medicine and discuss its potential to improve the health and well‐ being of older adults 2. Describe Integrative Medicine practices, including nutrition, mind‐body, and exercise 3. List resources to learn more about Integrative Medicine

Roadmap 1. Overview of Integrative Medicine 2. Integrative Medicine Practices 3. How to apply Integrative Medicine to common symptoms 4. Summary & Resources

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 therapeutic relationship between practitioner and patient, is informed by evidence, and makes use of all appropriate therapies. ” https: //integrativemedicine. arizona. edu/about/definition. html

1. What is Integrative Medicine? https: //dukeintegrativemedicine. org/patient‐care/wheel‐of‐health/

Terminology Alternative Medicine = replaces conventional medicine Complementary Medicine = complements conventional medicine Integrative Medicine = complementary + conventional Medicine

Who uses Integrative Medicine? 33. 2% of U. S. adults use complementary health approaches Most common complementary approach natural used products by 17. 7% of adults https: //nccih. nih. gov/research/statistics/NHIS/2012/key‐findings

Who uses Integrative Medicine? 33. 2% of U. S. adults use complementary health approaches Most common complementary approach natural used products by 17. 7% of adults Natural products: dietary supplements other than vitamins and minerals https: //nccih. nih. gov/research/statistics/NHIS/2012/key‐findings

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 https: //nccih. nih. gov/research/statistics/NHIS/2012/key‐findings

Why do people use Integrative Medicine? https: //nccih. nih. gov/news/camstats/2010/findings 2. htm

Why do people use Integrative Medicine? Prevent illness & For general wellness Reduce pain Treat specific health condition Supplement conventional medicine https: //nccih. nih. gov/news/camstats/2010/findings 2. htm

2. Integrative Medicine Practices 1. Overview of Integrative Medicine 2. Integrative Medicine Practices 3. How to apply Integrative Medicine to common diseases 4. Summary & Resources

What are common Integrative Medicine Practices? 1. Natural Products 2. Deep Breathing 3. Meditation 4. Chiropractic & Osteopathic 5. Massage 6. Yoga 7. Diet‐Based Therapies 8. Progressive Relaxation 9. Guided Imagery 10. Homeopathic Treatment https: //nccih. nih. gov/news/camstats/2010/findings 2. htm

What are common Integrative Medicine Practices? https: //nccih. nih. gov/news/camstats/2010/findings 2. htm 1. Natural Products 2. Deep Breathing 3. Meditation 4. Chiropractic & Osteopathic 5. Massage 6. Yoga 7. Diet‐Based Therapies 8. Progressive Relaxation 9. Guided Imagery 10. Homeopathic Treatment 11. Exercise

What are common Integrative Medicine Practices? Nutrition B. Mind body C. Exercise A.

A. Nutrition ‐ Barriers Dentition Access Malabsorption

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. https: //nccih. nih. gov/research/statistics /NHIS/2012/key‐findings https: //nccih. nih. gov/news/camstats/2 010/findings 2. htm use of fish oil, probiotics, and melatonin in recent years. ↑

A. Nutrition ‐ 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

A. Nutrition ‐ Foods that cause inflammation Refined sugar & sweetener Foods that reduce inflammation 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

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 Kogan, 2017

A. Nutrition ‐ Medications can impair absorption of nutrition Diuretics deplete nutrients like potassium, magnesium, calcium Proton‐pump block inhibitor absorption of nutrients like vitamin B 12

B. Mind body Yoga Chiropractic Manipulation Meditation https: //nccih. nih. gov/research/statistics/NHIS/2012/key‐findings Massage Therapy

B. Mind Body ‐ Trends

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. https: //nccih. nih. gov/research/statistics/NHIS/2012/key ‐findings

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

C. Exercise ‐ Types Aerobic Exercise Resistance Training Balance Training Flexibility Training Lifestyle Modifications Kogan, 2017

C. Exercise ‐ Benefits Improves blood pressure, heart failure, cholesterol Decreases Improves fall risk, maintains healthy bones depression, sleep, cognition Decreases risk of obesity, diabetes, improves symptoms of hot flashes Decreases mortality Kogan, 2017

4‐ 7‐ 8 Breathing Empty lungs Inhale through nose for 4 seconds Hold breath for 7 seconds Exhale through mouth for 8 seconds

3. How to apply Integrative Medicine to common diseases 1. Overview of Integrative Medicine 1. Integrative Medicine Practices 2. How to apply Integrative Medicine to common diseases 3. Summary & Resources

Which conditions inspire use of Integrative Medicine? https: //nccih. nih. gov/news/camstats/2010/findings 2. htm 1. Back pain 2. Neck pain 3. Joint pain 4. Arthritis 5. Cholesterol 6. Cold 7. Other Musculoskeletal 8. Severe headache 9. Insomnia

Which conditions inspire use of Integrative Medicine? https: //nccih. nih. gov/news/camstats/2010/findings 2. htm 1. Back pain 2. Neck pain 3. Joint pain 4. Arthritis 5. Cholesterol 6. Cold 7. Other Musculoskeletal 8. Severe headache 9. Insomnia

Symptom‐specific approaches Pain 2. Insomnia 1. https: //nccih. nih. gov/news/camstats/2010/findings 2. htm

Pain

Pain 11. 2% of adults have daily pain Common causes: Arthritis Bone and joint diseases Chronic pain conditions https: //nccih. nih. gov/research/statistics/NHIS/2012/key‐findings

Pain is associated with Worse health Depression Anxiety Social isolation Sleep disturbance Impaired ↑ mobility & disability health care utilization and $ https: //nccih. nih. gov/research/statistics/NHIS/2012/key ‐findings

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 Towheed T, 2005

Pain ‐ Nutrition Dr. Weil Anti‐Inflammatory Diet 1. Aim for variety. 2. Include as much fresh food as possible. 3. Minimize consumption of processed foods and fast food. 4. Eat an abundance of fruits and vegetables. www. drweil. com

Pain – Mind‐body Acupuncture Small but statistically significant benefit Ice massage ↑ ROM, function, and knee strength Meditation Yoga Tai chi Manheimer, 2018

Pain ‐ Exercise Can reduce pain and improve physical function Fransen, 2005 & Fransen, 2014

Insomnia

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.

Insomnia ‐ Nutrition Limited evidence for supplements Melatonin Valerian root Matheson, 2017 Bent, 2006

Insomnia – Mind‐Body Cognitive behavioral therapy ‐ mild effect Listening to music ‐ may support sleep Acupuncture – no evidence to support Guided imagery Meditation Cheuk, 2012 Jespersen, 2015 Montgomery, 2003

Insomnia ‐ Exercise Regular brisk walking and moderate weight training Improvement in total sleep duration, sleep onset latency and global sleep quality Kogan, 2017 Montgomery, 2002

4. List Resources 1. Overview of Integrative Medicine 2. Integrative Medicine Practices 3. How to apply Integrative Medicine to common diseases 4. Summary & Resources

Summary Integrative Medicine

Summary Integrative Medicine Practices

Summary Integrative Medicine Practices Symptoms

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 https: //imconsortium. org/resourcesjournal/resou rces/

Resources Alzheimer’s Association. ”Facts and Figures. ” https: //www. alz. org/alzheimers‐dementia/facts‐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), 10. 1016/j. amjmed. 2006. 026 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. 2018. Cheuk DKL, Yeung WF, Chung KF, Wong V. Acupuncture for insomnia. Cochrane Database of Systematic Reviews 2012, Issue 9. Art. No. : CD 005472. DOI: 10. 1002/14651858. CD 005472. pub 3. https: //www. drweil. com/diet‐nutrition/anti‐inflammatory‐diet‐pyramid/dr‐weils‐anti‐inflammatory‐food‐pyramid/ 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 006489. DOI: 10. 1002/14651858. CD 006489. pub 4. Fransen M, Mc. Connell S, Hernandez‐Molina G, Reichenbach S. Exercise for osteoarthritis of the hip. Cochrane Database of Systematic Reviews 2014, Issue 4. Art. No. : CD 007912. DOI: 10. 1002/14651858. CD 007912. pub 2. Fransen M, Mc. Connell 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 004376. DOI: 10. 1002/14651858. CD 004376. pub 3. https: //nccih. nih. gov/health/aging https: //nccih. nih. gov/news/camstats/2010/introduction. htm https: //nccih. nih. gov/research/statistics/NHIS/2012/key‐findings https: //nccih. nih. gov/research/statistics/2007/camsurvey_fs 1. htm https: //www. nia. nih. gov/health/vitamins‐and‐minerals https: //integrativemedicine. arizona. edu/about/definition. html

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 010459. DOI: 10. 1002/14651858. CD 010459. pub 2. 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 013010. DOI: 10. 1002/14651858. CD 013010. Matheson, E. , Hainer, BL. Insomnia: Pharmacologic Therapy. American Family Physician. July 2017, Volume 96, Number 1. Mikhail Kogan, Stephanie Cheng, Seema Rao, Sharon De. Mocker, Mariatu Koroma Nelson. Integrative Medicine for Geriatric and Palliative Care Medical Clinics of North America, Volume 101, Issue 5, 2017, Pages 1005‐ 1029. https: //doi. org/10. 1016/j. mcna. 2017. 04. 013. Montgomery P, Dennis JA. Physical exercise for sleep problems in adults aged 60+. Cochrane Database of Systematic Reviews 2002, Issue 4. Art. No. : CD 003404. DOI: 10. 1002/14651858. CD 003404. 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 003161. DOI: 10. 1002/14651858. CD 003161. 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 002946. DOI: 10. 1002/14651858. CD 002946. pub 2. 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. 2014; 62(1): 25‐ 39.

Thanks! Louise Aronson, MD, MFA

Alzheimer’s Disease

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 Herbert, 2013 www. alz. org

Alzheimer’s Disease No disease‐modifying treatments Focus on prevention Kogan, 2017

Alzheimer’s Disease ‐ Nutrition Mediterranean diet MIND diet = Mediterranean diet + DASH diet Kogan, 2017

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 Kogan, 2017

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 exercise Tai chi Yoga of Forbes, 2015 Wayne, 2014