What is elder health?

Overview

The health and functionality of the elderly can be highly variable, but the elderly differ from younger people in that the elderly are more likely to have chronic conditions, such as high blood pressure. The elderly are increasingly using complementary and alternative medicine (CAM), but they utilize it less than younger adults. Most elderly persons who use CAM do so as a complement to standard medicine, not as a substitute for (or an alternative to) CAM.

CAM use by elders is associated with poorer overall health, although people with life-threatening conditions do not appear more likely to use CAM. Prescription medications and surgery, the main conventional treatments, are often lifesaving but have special risks for elders because of their greater tendency to have multiple chronic conditions.

Because of their higher incidence of illness, seniors can especially benefit from evidence-based medicine (EBM) instead of CAM exclusively. More research on the effectiveness of both CAM and conventional medicine in the elderly is needed.

Why Seniors Are Different

Although many seniors are physically and mentally healthy, old age is the time
of life when people are most likely to suffer from chronic diseases such as
arthritis, heart disease, cancer, and
diabetes. Some people develop these diseases at earlier
ages, are successfully treated, and live full and productive lives. Their
illnesses are manageable or, in some instances, have been cured. Others have had
relatively little illness throughout their lives but develop chronic conditions as
they age. Some get older without having any serious conditions. Still others
develop debilitating illness at relatively young ages, do not improve much with
treatment or do not receive treatment, and reach their elder years already
disabled and with limited mobility and ability to handle daily activities.
Nonetheless, people who live to be age sixty-five and older (those who are
considered elderly) are frequently healthy.

Even for healthy seniors, physical changes occur. The organs are less
efficient. The kidneys take longer to filter waste from the blood, and lung
capacity decreases. The immune system weakens. Variation in
health among elders, however, is large. A person’s chronological age does not
necessarily indicate that person’s level of health or functionality. Still, the
elderly differ from younger people in that they are more likely to have chronic
conditions. Acute diseases, such as colds and influenza,
decline with age.

Using CAM

The elderly and the very young (children younger than age five years) use conventional medicine more than other age groups. It remains unclear what age group is most likely to use CAM. All age groups, however, are increasing their use of CAM, but older adults still appear somewhat less likely to use CAM. Estimates of CAM use by elders vary from 30 to 66 percent across surveys, in part because studies consider different CAM therapies. It is difficult to estimate CAM use by seniors because some research studies do not report age differences, while others use a variety of age cut-offs (such as fifty-two-plus, sixty-five-plus, and seventy-seven-plus) when studying older adults.

Seniors usually use CAM in addition to standard treatments. That is, they use
complementary
therapies in seeking to alleviate symptoms and pain, to
manage the side effects of conventional treatment, or for finding a cure. Most
seniors do not use alternative therapy alone; instead, they use alternative
therapy as a complement to standard medicine. This is true for most people,
regardless of age, in the United States and in other developed countries.

Demographics

A 2008 study of mostly U.S.-focused research examined the demographics of CAM users. The study found that CAM users are more educated than the general population but are not necessarily higher earners. This pattern also holds for seniors. One reason why seniors use CAM less often may be that many elders are less educated than younger adults. Educated persons are often informed consumers who also tend to seek information about topics with which they are unfamiliar. For many in the United States, CAM is little known.

The importance of income in determining CAM use is less clear, and it appears to play a role independent of education level. It is also not certain if elderly women are more likely to use CAM therapies than are elderly men, although CAM use is higher among younger women. CAM use based on one’s ethnicity also does not fall into a clear pattern.

CAM is often used by people with chronic conditions. Because the elderly frequently have such conditions, some will use CAM. CAM is also more likely to be used by people with multiple health problems, which many elderly experience too. CAM use is associated with poorer overall health, in all age groups, although people with life-threatening conditions do not appear more likely to use CAM. There is no strong evidence that, for example, people with cancer are more likely to use CAM. The elderly who use only CAM tend to be younger and healthier than those using only standard medicine or a combination of standard medicine and CAM. Elderly CAM users tend to be more health conscious, or more seriously ill, than non-CAM users.

Attitudes and one’s philosophy of life play only small parts in determining CAM use by the elderly, although these factors were found to be more significant for younger adults who use CAM. The elderly are more likely than younger adults to say that they want their doctors to make their health decisions. It appears that elders’ use of CAM is often a pragmatic decision based on health status and the desire to alleviate symptoms, rather than on philosophy and interest in cultural alternatives.

Evidence-Based Medicine

Evidence-based medicine (EBM) is a growing movement focused on the use of empirical, scientific standards to evaluate treatments. EBM encourages health professionals to use treatments that have been shown by careful study to be effective. At its best, EBM promises high-quality research of CAM modalities and conventional medicine. Because seniors have more health problems, are often taking multiple medications, and are more likely than other age groups to develop conditions for which surgery is the most common treatment, evidence-based research is especially important for this age group.

For many CAM modalities, evidence of effectiveness is limited. There is also
little evidence for the effectiveness of some conventional therapies. One example
is chronic back pain, which affects more seniors than younger adults.
Back
pain is one of the most common conditions for which seniors
use CAM (others conditions being arthritis, heart disease, allergy, and diabetes).
Recent research suggests that back surgery may be overused and that the more
invasive types of back surgery may be especially risky for seniors. Some research
exists on back pain and CAM.

A 2003 study evaluated the best available evidence on several CAM treatments of
back pain, finding that massage had positive outcomes. Spinal
manipulation (including chiropractic) was moderately helpful.
The quality of the studies on acupuncture was poor, but acupuncture
appeared to be more effective than no treatment or “sham treatment” (in which a
doctor simulated acupuncture treatment). The risks of all three CAM treatments for
back pain were relatively low.

Another CAM modality that has received initial though inadequate study is
homeopathy. A 2009 study of persons with chronic low back
pain who were followed for two years found that the subjects showed significant
improvement and decreased use of prescription medications. Because the elderly are
more likely to have low back pain than younger persons, continued research on
various treatment modalities for this health problem might have benefits for this
age group.

EBM is still relatively new and sometimes meets with resistance from both conventional and CAM practitioners. The latter sometimes argue that CAM therapies are not taken seriously by conventional doctors, even when evidence of their effectiveness exists. A 2005 article on chiropractic practices suggests that EBM is mostly used to justify the use of conventional medicine. The process of determining what treatment modalities are effective can be expected to continue slowly and contentiously.

Careful evaluation of the evidence for treatment is nonetheless superior to giving treatment for which little or no evidence of effectiveness exists. The greater incidence of illness and treatment of older adults means they will especially benefit from the further development of EBM.

Treatment Types

The main conventional treatments for all persons are prescription medications and surgery. Both are often lifesaving, but each treatment modality has some special risks for the elderly. CAM could prove to be one way to address these risks.

Because they have more illnesses, the elderly are more likely to be taking
multiple medications, the interactions of which are often unknown, even if there
have been good studies of the individual drugs. Conventional drugs often are not
tested on seniors, even though they take more of them. Thus, evidence on
prescription drugs that is specific to seniors is sparse. The need for
evidence-based CAM is especially important in the case of the elderly who take
many medications, because CAM can reduce the chances of drug
interactions, such as when massage is used instead of
medication for back pain. Some CAM treatments, however, may themselves interact
with conventional medications. One example is St. John’s
wort, an herbal preparation that is often used to treat
depression. This preparation can interact with antidepressants such as alprazolam (Xanax).

The elderly are also more likely than younger adults to have conditions that are surgically treated. Surgical technologies and methods have improved significantly in a short time, increasing the chance that surgery will benefit seniors. Even the very old are increasingly considered candidates for surgical treatment.

Surgery, however, is always risky, and the elderly are at greater risk than younger people. Chronic high blood pressure, multiple chronic conditions, and a weaker immune system can make surgery more dangerous for an elderly person and can lead to a longer recuperation time. Alternatives to surgery would be of special benefit to seniors. Less healthy seniors have increased risk of complications and morbidity from surgery. The possibility of cognitive decline in seniors who are surgically treated also remains a concern, though a 2009 study indicates that surgery does not contribute to long-term cognitive decline in seniors. This issue requires further study. The effect of CAM in aiding postsurgical healing also deserves increased research.

Evidence on all medical modalities, CAM and conventional, is particularly inadequate for the elderly. The aging of the U.S. population and in societies across the world underscores the critical need for continued research.

Bibliography

Aleccia, JoNel. “Surgery in the Super Old: Success at What Price?” Available at http://www.msnbc.msn.com/id/28282424. Article looking at the pros and cons of surgery on very old persons.

American Society of Anesthesiologists. “Surgery, Illness Do Not Increase Cognitive Decline for Older Patients.” Available at http://www.medicalnewstoday.com/articles/168756.php. Article summarizing a study with a control group showing that surgery does not contribute to long-term cognitive decline in seniors.

Bishop, Felicity L., and G. T. Lewith. “Who Uses CAM? A Narrative Review of Demographic Characteristics and Health Factors Associated with CAM Use.” Evidence-Based Complementary and Alternative Medicine 7, no. 1 (2008): 11-28. Available at http://ecam.oxfordjournals.org/cgi/content/full/7/1/11. Peer-reviewed article providing an overview of demographic and health factors of CAM users.

Cherkin, Daniel C., et al. “A Review of the Evidence for the Effectiveness, Safety, and Cost of Acupuncture, Massage Therapy, and Spinal Manipulation for Back Pain.” Annals of Internal Medicine 138 (2003): 898-906. Peer-reviewed article summarizing reviews of randomized, controlled trials from research published since 1995 on massage therapy, spinal manipulation, and acupuncture as treatments for nonspecific back pain.

Cherniak, Paul, and Neil S. Cherniack. Alternative Medicine for the Elderly. New York: Springer, 2003. Book giving balanced, detailed, critical evaluation of CAM treatments for seniors.

Napoli, Maryann. “Is Back Surgery Worth It? An Interview with a Leading Researcher.” HealthFacts 32 (2007): 1-3. Interview of Richard A. Deyo, a preeminent researcher on back pain treatment, which includes his comments on back surgery for seniors.

Villanueva-Russell, Yvonne. “Evidence-Based Medicine and Its Implications for the Profession of Chiropractic.” Social Science and Medicine 60 (2005): 545-561. Peer-reviewed article examining the limitations of evidence-based medicine while supporting the development of new methodologies to evaluate the effectiveness of chiropractic and other CAM treatments.

Witt, Claudia M. “Homeopathic Treatment of Patients with Chronic Low Back Pain.” Clinical Journal of Pain 25 (2009): 334-339. Peer-reviewed article evaluating the effect of homeopathic treatment for persons with low back pain.