ASSISTED LIVING COLUMN
Ethel Mitty Sandi Flores
Complementary and Alternative Medicine (CAM)
Barbara Moquin, PhD, APRN, BC-P, Marc R. Blackman, MD, Ethel Mitty, EdD, RN, and Sandi Flores, RN
The use of complementary and alternative
medicine (CAM) appears to be on the rise in
all adult age groups, including the elderly pop-
ulation. Many herbal and biologic prepara-
tions offer promise, but they are largely of
unproven benefit. The content(s) are unregu-
lated by government agencies, such as the
Food and Drug Administration, making their
use problematic to recommend and guide.
Use of CAM modalities in assisted living com-
munities (ALCs) is by and large a hidden prac-
tice, but it is estimated that 5%9% of residents
ingest some kind of herbal remedy. Belief sys-
tems among residents and their familiesfor
example, that a certain kind of tea is a cure
for dementiacan be persuasive. Responsible
for resident well-being, assisted living nurses
are caught in the middle. Nurse licensure con-
siders herbals as medications, yet physicians
refuse to prescribe them, and nurses (or certi-
fied med techs) cannot administer them. In
some states, alternative practitioners are
not viewed as legal prescribers. Undaunted,
residents (or their families) purchase alterna-
tive medicines that are contraindicated by
their traditional medical regimen. Secreted in
their room, nurses are unaware of the stash
and the self-administrating practice. This arti-
cle describes the state of the science regarding
the efficacy and safety of CAM modalities and
actions that ALC nurses might undertake to
collaborate with residents to address their
CAM interest and use respectfully. (Geriatr
Nurs 2009;30:196-203)
Complementary and alternative medicine
(CAM), also known as integrative medicine, re-
fers to a group of diverse medical and health
care systems, practices, and products that are
not presently considered to be part of conven-
tional medicine.1 It is suggested that the term
complementary medicine speaks to modalities
196
used in concert with conventional or traditional
medicine, whereas the term alternative medi-
cine applies when a CAM modality is used
instead of conventional medicine.2 Although
some scientific evidence exists regarding certain
CAM therapies, key questions with regard to their
effectiveness and safety are yet to be answered
through well-designed research studies.
The hundreds of CAM modalities include:
 Mind-body interventions that use systems of
thought such as meditation, prayer, yoga, tai chi,
biofeedback, relaxation, and art, dance and music
therapies
 Biologically based therapies, such as herbal prepa-
rations, botanicals, and dietary supplements
 Manipulative and body-based methods, such as
chiropractic, therapeutic massage, and osteopathic
manipulation
 Energy therapies such as Reiki, therapeutic touch,
and bioelectromagnetic-based therapies
 Whole medical systems, such as traditional Chinese
medicine, Ayurvedic medicine, homeopathy, and
naturopathic medicine, which incorporate many or
all of the above-noted therapies1,2
Use of CAM is widespread. Among a nationally
representative sample of more than 31,000 U.S.
adults, 62% reported some use of 27 CAM modal-
ities in the previous 12 months; at the time of the
study, CAM was defined as including prayer for
health reasons.3 At least 30% of those aged 65
and older used at least 1 CAM modality compared
with those younger than 65 years.3 Most CAM use
is complementarythat is, it is used in addition
to mainstream interventions. Only a minority of
CAM use serves as an alternative to conventional
or traditional treatment. More than half of Alz-
heimers disease caregivers report having tried
at least 1 CAM modality to improve the memory
of the dementia sufferer.4 The most commonly
used CAM modalities among older adults are chi-
ropractic (used as much as younger adults),
Geriatric Nursing, Volume 30, Number 3
herbals, relaxation techniques, massage, high-
dose or mega vitamins, and religious or spiritual
healing.4 Interestingly, older adults with a pri-
mary health care provider are more likely to use
CAM than older adults who do not have a primary
provider.4 This certainly speaks to assisted living
community (ALC) residents, all of whom must
have a physician or nurse practitioner provider.
Older adults who see their physician frequently
are more likely to use CAM than older adults
who do not see their physician as frequently.4
One wonders if this is because they are not get-
ting the comfort they need from traditional thera-
pies or if the user is seeking to access all possible
resources (or is an overuser).4 It is also interest-
ing to note that older adults with several years of
college education and a comfortable income are
likely CAM users.5
Approximately 60% of CAM users in the United
States do not discuss their use of CAM modalities
with their health care providers.4 Of these indi-
viduals, 6% are using herbals and prescription
medications. This is of particular concern in the
care of older adults because of the increased
risk for adverse interactions between conven-
tional drugs and various CAM biologic agents
due to age-related changes in drug metabolism,
pharmacodynamics, and pharmacokinetics. Age-
related alterations in hepatic and renal function
contribute importantly to these phenomena, in
both the absence and presence of disease.
Background
The aging of the baby-boomer generation and
influx of older people from other countries and
ethnicities is contributing growing numbers to
what was already the largest group of health
care consumers: older adults (i.e., those aged
over 65 years). Among them, the most common
health challenges in men are diseases of the circu-
latory, musculoskeletal, and connective tissue
and of the genitourinary system. In women, the
most common health challenges are musculoskel-
etal, circulatory, and mental health disorders.6
Demographic indicators suggest that an expand-
ing aging population with continuing need for
medical services will continue to increase. As
such, it is reasonable to predict that specific inter-
est in and use of CAM modalities will expand as
well. (Use of CAM modalities among those aged
over 85 years is lowest among all age groups.3)
Geriatric Nursing, Volume 30, Number 3
The use of CAM by older adults is beginning to
be more closely studied, in part to help design
safer and more efficacious treatments specific
to the needs of this population. CAM use can
vary, depending on a particular geographic region
(i.e., availability of specific practitioners) as well
as ethnic group.7 Among more Hispanic than
black or white individuals (and few Asians), the
most widely used CAMs are herbal teas, fish oil,
massage, other, and acupuncture. Differing so-
ciocultural beliefs influence the frequency and
pattern of CAM use. For example, among African
Americans, CAM use is a combination of Euro-
pean, Native American, and African customs. In
addition, Native American and black American
groups also view spirituality as integral to the
prevention of illness and maintenance of health.
A study of CAM use for 3 specific medical
conditionsinsomnia, back pain, and colds
demonstrated the influence of race and ethnicity
on this decision among older adults.7 Being His-
panic, African American, and female is a good
predictor of CAM use. Hispanic users are more
likely than African Americans and Caucasians
to use herbals to self-treat colds and insomnia
and are more likely than Caucasians to self-treat
back pain.
Safety and Efficacy of CAM Use
A wide variety of CAM modalities in the United
States are available from practitioners or as self-
care practices. They range from indigenous
health practices that are centuries old to modali-
ties that are licensed and provided by a trained
practitioner (e.g., acupuncture, Reiki). However,
most CAM practices are not regulated; licensure
and certification can vary among practices within
and between geographic locations. Echinacea,
Gingko biloba, and garlic supplements are
reported to be the most commonly used herbals.3
Many of the biologically based CAM modalities
are regulated under the Dietary Supplemental
and Education Act of 1994 but are not required
to be tested for purity, safety, or efficacy.2
Despite numerous anecdotal reports or claims
of the efficacy and safety of diverse CAM modal-
ities, there is a general lack of product and prac-
tice standardization and a dearth of credible
scientific information supporting these practices.
The potential for adverse reactions with the use
of herbal preparations and of botanical and
197
dietary supplements in older adults is shown in
the Table 1. Nonetheless, most users are satisfied,
given that few malpractice or wrongful injury
lawsuits are filed.
CAM Use for Managing Illness in
Older Adults
In the normal course of time, CAM modalities
are most often used for back pain and problems,
head or chest colds, neck pain or problems, joint
pain or stiffness, anxiety, or depression.3 Given
how debilitating and distressing these conditions
can be, particularly affecting quality of life, inter-
est in CAM modalities is not surprising. Use with
regard to specific medical conditions is discussed
in this section.
Musculoskeletal Disorders
Osteoporosis. Phytoestrogen is a naturally oc-
curring substance found in soy and red clover
that the body converts to the hormones estrogen
and testosterone. Increasingly used to prevent or
treat osteoporosis in postmenopausal women,
there is little evidence confirming their benefits.
Dehydroepiandrosterone (DHEA), a widely
used dietary supplement, is the most abundant
adrenal steroid in humans. Levels decline pro-
gressively with age. Small-scale trials of DHEA
supplementation in older persons have produced
conflicting results regarding its effects on bone
density. Further studies are necessary to deter-
mine its utility in preventing or treating osteopo-
rosis in older people. It can also be risky for
women with a history of estrogen-sensitive
breast cancer (discussed later).
Osteoarthritis is among the most common
chronic diseases affecting older adults, and al-
most half (47%) of older adults with osteoarthritis
report using some CAM modality. Techniques
specifically focused to provide stress relief,
such as relaxation breathing and music therapy,
may be of benefit as adjunctive therapy in ad-
dressing the experience of suffering that often ac-
companies pain. Gentle movement and stretching
techniques, such as those in yoga, tai chi, and
warm-water aquatics, are an alternative to more
vigorous exercise regimens. Other CAM modali-
ties include acupuncture, massage, chiropractic
manipulation, glucosamine supplements, Reiki,
and prayer. Herbal preparations, including capsa-
icin cream and Phytodolor, are thought to exert
198
effects mechanistically in much the same way
as conventional nonsteroidal anti-inflammatory
treatments.
Lower back pain is among the most difficult
health challenges for which CAM modalities are
widely used. In particular, therapeutic massage,
acupuncture, mind-body relaxation, and energy
modalities are often used for lower back pain.
The combined use of massage, self-care relaxation,
and acupuncture may be more effective than the
use of any of these modalities separately. A meta-
analysis of randomized trials of acupuncture for
lower back pain found it to be superior to various
control modalities, but a significant placebo effect
was found, thus confounding the results.6 Chiro-
practic, specifically spinal manipulation, is be-
lieved safe for older adults and is recommended
as a treatment for low back pain.
Cardiovascular Disorders
A heart-healthy diet and aerobic exercise are
the first recommendations to manage high blood
pressure and dyslipidemia. The diet includes lim-
iting sodium intake, refined sugar, and saturated
fat while increasing amounts of complex carbo-
hydrates, fruits, and vegetables. In the Dietary
Approach to Stop Hypertension (DASH) trial,
nearly 70% of participants following the heart-
healthy diet decreased both systolic and diastolic
blood-pressure measurements.8 Recent studies
suggest that diets including essential fatty acids
may lower blood pressure, increase levels of
high-density lipoproteins (i.e., the good choles-
terol), and lower levels of triglycerides and low-
density lipoproteins. Examples of essential fatty
acids are omega-3 (found in fresh deep-water
fish and in flaxseed oil) and omega-6 linoleic
acid (found in raw nuts and seeds). Stress-
management techniques, such as relaxation
breathing, music therapy, and meditation, may re-
duce blood pressure in hypertensive older adults
and improve sleep quality.
Neurologic and Emotional Disorders
Depression is among the most common and
debilitating major public health problems; inci-
dence increases with advancing age. Although de-
pression is more common in women, increasing
attention is focused on men, in whom it is more
often unrecognized or untreated. (There is an
alarming prevalence of depression and suicide
Geriatric Nursing, Volume 30, Number 3
Geriatric Nursing, Volume 30, Number 3

Table 1.
Potential Adverse Effects Associated with CAM Supplements and Medications

CAM Supplement Adverse Effects Interactions

Coenzyme Q10 Relatively infrequent: headache, nausea, vomiting, Warfarin (Coumadin)

epigastric pain
.300 mg/day is associated with increased liver
transaminase
Dehydroepiandrosterone Women: weight gain, voice change, facial hair, headache Calcium channel blockers, sildenafil
(DHEA) Men: prostatic hypertrophy
Echinacea Allergic reactions, hepatitis, asthma, vertigo Immunosuppressants
Gingko biloba All rare: serious bleeding, seizure, headache, dizziness Anticoagulants
Glucosamine Nausea, diarrhea, heartburn Reduces effectiveness of hypoglycemic drugs
Omega-3 fatty acids Belching, halitosis, blood glucose elevation Antiplatelets, anticoagulants, antihypertensives
S-adenosylmethionine Nausea, vomiting, diarrhea, anxiety, restlessness Tricyclics and SSRIs
(SAM-e)
Saw palmetto All rare: constipation, diarrhea, decreased libido, headache, None described
hypertension, urine retention
St. Johns wort Nausea, allergic reaction, dizziness, headache, Anticoagulants, antiretrovirals, SSRIs,
photosensitivity (rare) immunosuppressants, and
chemotherapeutic drugs
CAM 5 complementary and alternative medicine; SSRI 5 selective serotonin reuptake inhibitor.
From Geriatric Nursing Review Syllabus 2. New York: American Geriatrics Society.
199
in widowed men aged 70 years and older.) A CAM
modality might help manage mild to moderate
depression. However, adequate treatment of
severe depression may involve psychotherapy
and psychotropic medication to prevent further
morbidity and mortality.
A healthy diet can be one of the first recom-
mendations to assist in improving mood. Dietary
intake that includes complex carbohydrates can
improve serotonin levels. Increasing essential
fatty acids and protein intake may increase alert-
ness and mood. Of equal importance is discontin-
uing excess alcohol, caffeine, and tobacco, which
can contribute to depression and irritability. Aer-
obic exercise (e.g., swimming, brisk walking) is
also recommended for mild to moderate depres-
sion. Exercise in combination with antidepres-
sants can yield faster, more lasting results, than
either alone.
The botanical known as St. Johns wort has re-
ceived considerable attention and is widely used,
although a large multicenter study failed to show
the efficacy of this agent in patients with major
depression of mild to moderate degree. The
adverse effects and potential harmful interaction
of St. Johns wort with many significant medica-
tions are shown in the Table 1.
S-adenosylmethionine (SAM-e), a naturally
occurring compound that is necessary for the
brain to produce sufficient dopamine and seroto-
nin, is currently marketed as an antidepressant.
Adverse interactions with other drugs have not
been described.9
Dementia. Some, but not all, studies investigat-
ing the use of supplements for treatment of
dementia demonstrate that Ginkgo biloba extract
has some benefit in improving cognitive ability
and memory impairment in Alzheimers patients.
Brain tissue studies and spinal fluid abnormali-
ties found in Alzheimers patients provide a rea-
sonable rationale for supplementing with
various antioxidants, including vitamins A, C,
and E and selenium, although evidence of their
effect has yet to be demonstrated in clinical trials.
Parkinsons disease patients have reduced
brain levels of glutathione, an antioxidant in-
volved in neuroprotective functions, and of coen-
zyme Q10. Also known as ubiquinone, coenzyme
Q10 is necessary for basic cell function; it has
also been implicated in blood pressure reduc-
tion.10 In very small, unblinded clinical trials, sup-
plementation with these 2 naturally occurring
substances slows the progression of disease
200
and reduces the severity of symptoms. Patients
with Parkinsons disease may also benefit from
a combination of dietary food additions contain-
ing higher amounts of coenzyme Q10, as found
in salmon, sardines, and mackerel. Acupuncture,
music therapy, and physical therapy are used by
Parkinsons patients to attempt to reduce disabil-
ities and improve cognitive, emotional, and social
functioning, but evidence about their effective-
ness is lacking.
Sleep disorders are common in older adults,
affecting both sleep quality and quantity. Studies
suggest that abnormalities in slow-wave and
rapid-eye-movement (REM) sleep may also be
linked to psychological, endocrine-metabolic,
and immune system dysfunctions. Approaches
to ameliorate sleep disorders include biologic
compounds (e.g., valerian, melatonin), mind-
body therapy, and manipulation. Nutritional and
exercise modifications are among the safest rec-
ommendations when working with older adults
who have sleep disturbance problems. Milk con-
tains tryptophan, a precursor of serotonin. Hav-
ing warm milk before bedtime or eating other
tryptophan-containing foods such as bananas,
brown rice, and turkey may be helpful in relieving
depression-associated sleep difficulties. Chamo-
mile, an herbal tea, is also known for its relaxing
properties.
Melatonin, a hormone produced by the pineal
gland, apparently significantly influences the cir-
cadian sleep-wake cycle. Evidence suggests that
melatonin may promote improved sleep quality
or efficiency and thereby reduce excessive day-
time sleepiness.2 Age-related changes, certain
medications (e.g., beta-blockers, nonsteroidal
anti-inflammatories), and some comorbid condi-
tions (e.g., persistent pain, acute myocardial
infarction) can reduce melatonin levels.2 The
effectiveness of melatonin in treatment of insom-
nia has not been empirically demonstrated.
Various studies report melatonin interference
with calcium channel blockers and immunosup-
pressants, but the data are limited. Valerian has
few side effects and appears to be useful for
mild insomnia and for treatment of sleep disrup-
tion associated with cancer and rheumatoid
arthritis.2
Aerobic, but not strenuous, exercise in the
early (not late) evening can contribute to im-
proved sleep quality. Tai chi, a combination of
low impact exercise and meditation, might im-
prove sleep onset and quality as well as reduce
Geriatric Nursing, Volume 30, Number 3
daytime sleepiness. Acupuncture, by virtue of its
ability to reduce pain as a result of release of neu-
rotransmitters (e.g., endorphins, serotonin) and
facilitate dopamine utilization, can be an effec-
tive modality. Acupressurestimulation of me-
ridian or acupoints using finger pressurecan
reduce sleep disruption, improve sleep efficiency
and quality, and reduce agitation.2 This treatment
can be given by nursing staff (or by a family mem-
ber). Mind-body interventions such as guided
imagery and meditation, are purportedly effec-
tive CAM modalities to improve sleep patterns
but require further empiric demonstration. Yoga
reduces anxiety levels and as such, has been rec-
ommended to improve sleep quality. Other CAM
modalities for improving sleep used by older
adults include aromatherapy (e.g., lavender),
a warm bath, and relaxing music.
Urogynecologic Disorders
Menopause lends itself to the use of behav-
ioral, nutritional, and exercise interventions as
well as nonpharmacologic supplements to man-
age some of the symptoms associated with it.
More than 30% of menopausal women report
using 1 or more CAM modalities, such as acupunc-
ture, natural and plant estrogens, and other herbal
preparations, despite a lack of scientific evidence
of efficacy.11 This number is likely to increase be-
cause of the expanding population of older adult
women and increasing concerns about the long-
term safety of estrogen or hormone replacement
therapy (reported in 2002 by the Womens Health
Initiative study). It is particularly important to use
caution when recommending phytoestrogen to
women with hormone-dependent cancers. Phy-
toestrogen has yet to be proven conclusively to
be an agonist or antagonist of the estrogen recep-
tor. There is no evidence that DHEA has any pos-
itive effect on hot flashes. Women at risk for
diseases or conditions affected by hormones
(e.g., breast, ovarian, or uterine cancer; fibroids)
or those on tamoxifen (a selective estrogen recep-
tor modulator taken by some women with a his-
tory of breast cancer) are advised to use these
products with extreme caution.11
The herb ginseng has shown some benefit for
managing mood disturbances, sleep disorders,
and improving the sense of well-being.11 How-
ever, it appears to have no effect on hot flashes.
The evidence about soy use is mixed; long-term
use is associated with increasing the thickness
Geriatric Nursing, Volume 30, Number 3
of the lining of the uterus. Aerobic exercise and
mind-body relaxation techniques are helpful in
decreasing irritability, restlessness, and anxiety
associated with menopause.
Symptomatic benign prostatic hyperpla-
sia (BPH) affects more than 40% of men aged
70 and older. Men are increasingly self-treating
this condition with the herbal compound known
as saw palmetto, the fifth leading medicinal
herb consumed in the United States.12 Saw pal-
metto and other supplements (e.g., pygeum)
have been studied but require more rigorous sci-
entific investigation to confirm initial claims that
its efficacy exceeded that of placebo treatment
and was similar to that of standard pharmaco-
logic treatment.12
Diabetes
Normal aging is associated with increased
insulin resistance and glucose intolerance and in-
creased risk of developing type 2 diabetes. Type 2
diabetes mellitus is associated with increased in-
cidence of obesity, hypertension, dyslipidemia,
and macro- and microvascular disease. Approxi-
mately 50%60% of diabetic patients report using
CAM interventions, including folk remedies in
ethnic populations. There is considerable scien-
tific interest in examining the potential benefit
of using various CAM biologic agents (e.g., chro-
mium, vitamin C, other dietary antioxidants such
as green tea) or other modalities (e.g., stress-
reduction techniques) in combination with die-
tary modifications, exercise, and weight manage-
ment.13 Acupuncture has shown some benefit in
managing the pain associated with diabetic
neuropathy.
Cancer
Approximately 30%50% of cancer patients in
one survey noted that they were using CAM inter-
ventions to manage their specific cancer. Cancer
CAM therapies purportedly can be used to
strengthen the bodys immune system as well as
to manage the adverse effects of conventional
treatments, such as chemotherapy and radiation.
Many cancer patients who use CAM modalities
report feeling more empowered while dealing
with the challenges of cancer. This has been sub-
stantiated by numerous studies examining vari-
ous indices of health-related quality of life.14
The CAM therapies most frequently used are
201
herbal preparations, exercise, and spiritual and
energy modalities (such as qi gong, therapeutic
touch, Reiki, polarity, healing touch, or Johrei).
Controversy persists regarding the role of diet
as a possible risk factor for developing breast
cancer. There appears to be a link between obe-
sity and increased estrogen levels that may con-
tribute to de novo breast cancer and recurrence
after early-stage disease. High-fiber, low-fat diets
with fruits, vegetables, whole grains, fish, and le-
gumes are associated with decreased risk of
breast cancer. Biologic agents, herbal prepara-
tions, and vitamins have all been tried, but their
efficacy has not been scientifically evaluated.
Lifestyle changes that include exercise and stress
management are helpful in managing mood and
energy changes associated with breast cancer.
Prostate cancer usually develops slowly in
older men. Use of CAM in combination with con-
ventional treatment is reported to reduce associ-
ated discomfort and improve the quality of life.14
In fact, risk of death in this population is higher
from heart disease than from prostate cancer.
The botanical mixture known as PC-SPES had
been used as a CAM dietary supplement that in
early small-scale trials showed a decrease in
serum prostate-specific antigen (PSA) levels
and pain, as well as improved quality of life.
However, in June 2002 several lots of PC-SPES
were found to be adulterated with diethylstilbes-
trol, warfarin, and other undeclared prescription
ingredients, and as a result, it was removed from
the market. At present, exercise and healthy diet
remain the safest CAM recommendations to
assist with the management of side effects and
improvement of quality of life in these patients.
Lung cancer has been linked not only to smok-
ing but also to excesses in dietary intake of dairy
products, red meats, and saturated fats, although
these associations have been questioned. In addi-
tion, preliminary research suggests that ingestion
of vitamin A by those who smoke may be harmful,
whereas vitamin A intake in those who do not
smoke may be beneficial. Dietary changes as
well as mind-body interventions may assist lung
cancer patients to manage emotional distress
and the adverse effects of treatment. Cancer
patients using relaxation and stress-management
techniques have been able to manage cravings
when pursuing tobacco cessation.14
There are no herbal preparations or botanic
supplements that appear to be useful in the pre-
vention or management of patients with colon
202
cancer at the present time. A fiber-rich diet has
been postulated possibly to prevent the onset of
colon cancer; however, studies are inconclusive.
Lutein, which is present in broccoli, carrots, or-
anges, and spinach, was found in one study to
be beneficial for colon cancer prevention. The
National Cancer Institute and the National Center
for Complementary Alternative Medicine (i.e.,
NCI, and NCCAM, respectively) are co-spon-
soring several studies, among which are the use
of acupuncture to reduce symptoms of colorectal
cancer, a comparison of chemotherapy and
administration of pancreatic enzyme for treat-
ment of pancreatic cancer, and the use of mistle-
toe extract and chemotherapy for solid tumor
treatment.14
Assisted Living Nursing and CAM
Modality Safety
Older adults erroneously assume that dietary
supplements and related biologic products
among the most popular CAM therapiesare
both safe and effective because these products
are characterized as natural. The Food and
Drug Administration does not have the authority
to evaluate or regulate dietary supplements. In ad-
dition, the industry is not required to prove that
the advertised ingredients actually provide the
health benefits or safety they claim. Studies have
found that dietary supplements often can contain
little, none, or more of what the product labels
claim, as well as contaminants or adulterants
with unlisted products and prescription drugs.
There is little information related to possible
differences in the pharmacokinetics and pharma-
codynamics of various CAM biologic agents in
older adults; as a result, proper dosage adjust-
ments for these compounds are unknown. Cou-
pled with the increased likelihood of older
adults taking several potent medications, there
is an increased risk for adverse herbal-drug inter-
actions. Without knowledge of what these
products contain in their entirety, or the conse-
quences of their use, residents and ALC health
care professionals need to talk with each other.
It is imperative to ask new (and continuing
stay) residents specifically about their use of
dietary supplements and biologic products and
look at the ingredients in those supplements.
Make inquiries about the use of CAM modali-
ties (particularly the ingestibles) part of the
Geriatric Nursing, Volume 30, Number 3
admission and annual assessment. Consider ask-
ing about CAM use when the resident has an
unexpected medical or functional event (e.g.,
exacerbation of a previously well-controlled con-
dition; fall). Gently probe tea drinking habits by
having a cup of tea with a resident or two, and
while sitting there, say My this cup of tea hits
the spot. (pause) What kind of tea do you like
to drink? (black, green, other).
Few older adults escape significant challenges
to their well-being or health. As a health care
professional, you are likely helping your resi-
dents view their treatment options. There is no
risk in asking, Have you thought about using
an herbal remedy or XX for your pain? You can
then say something such as, In considering
your options, you probably should think about:
 the benefits that can be expected with (the CAM)
approach/option;
 the risks and burdens associated with (the CAM)
option (This is the classic risk/benefit/burden
discussion);
 possible side effects with each CAM option; and
 the possible interference of one treatment regimen
with another.
References
1. National Center for Complementary and Alternative
Medicine, National Institutes of Health. What is
complementary and alternative medicine? Available at
http://nccam.nih.gov/health/whatiscam. Cited Feb. 20,
2009.
2. Gooneratne NS. 2008. Complementary and alternative
medicine for sleep disturbances in older adults. Clin
Geriatr Med 2008;24:121-38.
3. Barnes PM, Powell-Griner E, McFann K, et al.
Complementary and alternative medicine use among
adults: United States, 2002. Advance data from the Vital
and Health Statistics; No. 343. Hyattsville, MD: National
Center for Health Statistics; 2004.
4. Foster DF, Phillips RS, Hamel MB, et al. Alternative
medicine use in older Americans. J Am Geriatr Soc 2000;
48:1560-5.
5. American Association of Retired Persons.
Complementary alternative medicine research report.
Available at http://aarp.org/research/health/prevention/
cam_2007.html. January 2007. Cited February 16, 2009.
6. Wertkin AD, Cizza G, Blackman MR. Complementary and
alternative medicine in aging. In: Hazzard WR, Blass JP,
Geriatric Nursing, Volume 30, Number 3
Halter JB, eds. Principles of geriatric medicine and
gerontology. 5th ed. New York: McGraw-Hill; 2003. p.
231-42.
7. Cherniack EP, Ceron-Fuentes J, Florez H, et al. 2008.
Influence of race and ethnicity on alternative medicine as
a self-treatment preference for common medical
conditions in a population of multi-ethnic urban elderly.
Complement Ther Clini Pract 2008;14:116-23.
8. Appel LJ, Moore TJ, Obarzanek E, et al. A clinical trial of
the effects of dietary patterns on blood pressure. N Engl J
Med 1997;336:1117-24.
9. Wong, C. SAM-e. Updated January 23, 2008. Available at
http://altmedicine.about.com/od/treatmentsfromatod/a/
SAMe.htm. Cited February 16, 2009.
10. MayoClinic.com. Coenzyme Q10. March 1, 2008.
Available at www.mayoclinic.com/health/
coenzyme-q10/NS_patient-coenzymeq10. Cited
February 16, 2009.
11. National Center for Complementary and Alternative
Medicine, National Institutes of Health. Menopausal
symptoms and CAM. Updated February 2009. Available
at http://nccam.nih.gov/health/menopause/D406.pdf.
Cited February 16, 2009.
12. MayoClinic.com. Saw palmetto (Serenoa repens
[Bartram] Small). February 1, 2008. Available at www.
mayoclinic.com/health/saw-palmetto/
NS_patient-sawpalmetto. Cited February 16, 2009.
13. National Center for Complementary and Alternative
Medicine, National Institutes of Health. CAM and
diabetes: a focus on dietary supplements. June 2008.
Available at http://nccam.nih.gov/health/diabetes/
CAM-and-diabetes.htm. Cited February 16, 2009.
14. National Cancer Institute. Complementary and
alternative medicine in cancer treatment: questions and
answers. Available at www.cancer.gov/cancertopics/
factsheet/Therapy/CAM. Cited February 16, 2009.
BARBARA E. MOQUIN, PhD, APRN, BC-P, is a senior nurse
specialist (research) at the National Center for Comple-
mentary and Alternative Medicine (NCCAM), a component
of the National Institutes of Health (NIH), Bethesda, MD.
MARC R. BLACKMAN, MD, is affiliated with the Division of
Intramural Research of NCCAM, a component of the NIH;
and an adjunct professor at the University of Maryland,
School of Medicine, Baltimore, MD. ETHEL MITTY, EdD, RN,
is an adjunct clinical professor of nursing at the College of
Nursing, New York University, John A. Hartford Institute
for Geriatric Nursing, New York University, New York, NY.
SANDI FLORES, RN, C, is the executive director of the
American Assisted Living Nurses Association and the edu-
cation director of Community Education, LLC (www.
communityed.com), San Marcos, CA.
0197-4572/09/$ - see front matter
2009 Mosby, Inc. All rights reserved.
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