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Are there any alternative medicine treatments that might be useful for your geriatric patients? A rigorous review looking at evidence for efficacy might be welcome.
Hi! Jim Phelps here for the Psychopharmacology Institute. Let’s examine a review from Drs. Sarah Nguyen and Helen Lavretsky, both of whom are faculty at the University of California Los Angeles. Theirs is a rigorous review of the evidence base for complementary and integrated medicine techniques for geriatric populations, and they endorsed 2 approaches while largely tossing out a third very common one. The article is divided into an examination of diet, diet supplements, and mind–body or mindfulness-based therapies and activities. Diet and these latter activities survived the examination in this review, but nutritional and herbal supplements did not. This is a review article and therefore subject to selection bias and spin. If you hear a result that you find hard to swallow, dig into the references. And I’ll show you some examples of that as we go.
For vitamin E, no benefits have been found regarding dementia prevention or memory preservation. The B vitamins—including folic acid, vitamin B6, and B12—have also shown no benefit in these geriatric issues nor did they prevent depression or anxiety in healthy but at-risk individuals. One study showed that B vitamins slowed the rate of brain atrophy but only in participants who already had minimal cognitive impairment and high homocysteine levels. So, the conclusion here is that if you’re looking for ways to lower risk in patients with very strong risk of Alzheimer’s dementia, and if you would consider treating with folic acid, B6, and B12 together, first measure serum homocysteine levels. For now, evidence supports vitamin B only in patients with hyperhomocysteinemia.
How about ginkgo biloba? A 2016 meta-analysis found ginkgo biloba to be potentially beneficial for the improvement of cognitive function and activities of daily living in patients with mild cognitive impairment or Alzheimer’s dementia. However, a closer look at this study reveals multiple caveats, and a 2009 Cochrane review found that the positive studies of ginkgo were “inconsistent and unreliable.” Moreover, ginkgo has serious drug interactions with common geriatric medications, including risk for bleeding when combined with warfarin, inhibition of thiazide diuretics, and risk for coma when combined with trazodone. So, without better evidence for efficacy, ginkgo doesn’t appear justified for the prevention or treatment of dementia.
St. John’s wort has clearly shown efficacy for depression and anxiety, which are common geriatric issues, but it also has multiple serious drug interactions, which Nguyen and Lavretsky detail. Their conclusion is that preclinical and clinical evidence but no randomized trials were found for kava, valerian, pennywort, hops, chamomile, passionflower, ashwagandha, skullcap, and lemon balm. Not mentioned in their review is low- or micro-dose lithium, the evidence for which in this context I’ve examined in another recent Quick Take. I’m surprised at this omission, as I think that microdosing with quantities found in drinking water ought to be considered in this context, but perhaps lithium is too pharmacologic for Nguyen and Lavretsky’s review.
In contrast with the nutraceuticals, a Mediterranean diet has more substantial evidence for protection of cognitive function, although there is some variation in that support. Since this dietary approach has well-documented cardiovascular benefits as well, there’s really little reason to hold back from a resounding endorsement of plant-based foods as well as consumption of berries and green leafy vegetables, while limiting animal foods and saturated fats.
Finally, mind–body therapies, including meditation, yoga, tai chi and qigong, and mindfulness-based therapies, such as mindfulness-based stress reduction and mindfulness-based cognitive therapy, were examined for the management of mood, anxiety, and cognition in seniors. And the authors’ enthusiasm for these techniques is unmistakable. They note, for example, that in contrast to pharmacologic approaches, these therapies “aim to teach patients lifelong skills that may continue to confer benefits long after formal training has ended.” However, the data amassed in this review do not seem to fully support their enthusiasm.
Regarding cognition, for example, the authors cite a review that found 6 relevant studies, most of which had a high risk of bias and small sample sizes, and only 1 study with a low risk of bias, a large sample size, and an active control group, which reported no significant findings. Evidence for geriatric depression is somewhat better, and for anxiety, including PTSD, the evidence is somewhat mixed. Hence, whether you conclude that mind–body and mindfulness-based therapies should be first line for older patients targeting depression, anxiety, or preservation of cognition may depend on other factors, such as the availability of these techniques in your area and your patient’s willingness to utilize them.
For more on all this, have a look at Nguyen and Lavretsky’s extensive tables summarizing the studies that they reviewed, which is linked here at Psychopharmacology Institute.
Abstract
Emerging Complementary and Integrative Therapies for Geriatric Mental Health
Sarah A Nguyen, Helen LAvretsky
Purpose: The use of complementary and integrative medicine (CIM) is on the rise among diverse populations of older adults in the USA. CIM is commonly perceived as safer, less expensive, and more culturally acceptable. There is a growing body of evidence to support the use of CIM, especially mind-body therapies, diet and nutritional supplements used for mental disorders of aging.
Recent findings: We summarize the results of the recent clinical trials and meta-analyses that provide the evidence for the role of CIM in treating older adults with mood or cognitive disorders that includes the use of diet and supplements, and mind-body therapies.
Summary: Dietary and mind-body therapies have become increasingly popular and show the strongest evidence of efficacy for mood and cognitive disorders. Although the use of vitamins and supplements is the most popular CIM practice, only mixed evidence supports their use with additional concerns for herb (supplement)-drug interactions. Despite increasing use of CIM by the general population, information to guide clinicians providing care for older adults remains limited with variable scientific rigor of the available RCTs for a large number of commonly used CIM interventions for the mental health of older adults.
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Reference
Nguyen, S. A., & LAvretsky, H. (2020). Emerging complementary and integrative therapies for geriatric mental health. Current Treatment Options in Psychiatry, 7(4), 447-470.
