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Correspondence: Address correspondence to Jose Ness, MD, Assistant Professor, Department of Internal Medicine, University of Iowa Carver College of Medicine, SE624GH, 200 Hawkins Drive, Iowa City, IA 52242. E-mail: jose-ness{at}uiowa.edu
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Key Words: Complementary therapies • Alternative medicine • Chiropractic • Dietary supplements
Both definitions encompass numerous therapies, often clustered into five major domains: alternative medical systems (e.g., acupuncture, homeopathy, naturopathy, and Ayurveda), mind–body interventions (e.g., meditation, mental healing), biologically based therapies (e.g., herbal products, nonherbal dietary supplements), manipulative methods (e.g., chiropractic, massage therapy) and energy therapies (e.g., Reiki, therapeutic touch, and electromagnetic fields; see National Center for Complementary and Alternative Medicine [NCCAM], 2002). CAM practices have become increasingly popular among Americans. In a landmark, nationally representative survey of 2,055 American adults, use of CAM in the previous year was reported by 42.1% of respondents (Eisenberg et al., 1998). The 2002 National Health Interview Survey revealed that 62% of American adults used some form of CAM therapy in the preceding year (Barnes, Powell-Griner, McFann, & Nahin, 2004). Among 16,068 Americans surveyed on their utilization of CAM practitioners, 8.3% had visited such professionals in 1996 (Druss & Rosenheck, 1999).
Less is known about CAM use among older adults. To our knowledge, the only nationally representative analysis of CAM use focusing on older adults in the United States was conducted by Eisenberg and colleagues in 1997 (Eisenberg et al., 1998) and included 311 elderly respondents, 30% of whom had received at least one CAM intervention in the preceding year (Foster, Phillips, Hamel, & Eisenberg, 2000). Other national surveys, such as the 2002 National Health Interview Survey, have addressed elders as part of their study population but have not focused on this demographic group (Barnes et al., 2004). Regional surveys of older adults have been published. In a study of 1,597 Medicare enrollees residing in California, 41% of respondents reported use of a CAM modality (Astin, Pelletier, Marie, & Haskell, 2000).
Surveys also have been conducted on older adults suffering from specific medical conditions, such as Alzheimer's disease (NCCAM, 2002; Howes, Perry, & Houghton 2003). For example, caregivers of patients with Alzheimer's disease report frequent use of CAM interventions to help with the patients' memory and cognition (Coleman, Fowler, & Williams, 1995). Among 699 older adults with the diagnosis of cancer, 33% used complementary medicine (Wyatt, Friedman, Given, Given, & Beckrow, 1999). A population-based telephone survey of 480 elderly patients with arthritis revealed that 66% used at least one CAM modality and 28% sought the care of CAM providers (Kaboli, Doebbeling, Saag, & Rosenthal, 2001).
The popularity of CAM has triggered the development of courses on the subject in some medical schools (Wetzel, Eisenberg, & Kaptchuk, 1998) and the reevaluation of health insurance coverage provided by insurance carriers (Pelletier, Marie, Krasner, & Haskell, 1997), as billions of dollars are spent on these interventions on a yearly basis in the United States alone (Neal, 2001). Past surveys have identified being a perimenopausal woman, having a higher income, attaining higher education, and experiencing chronic illnesses as correlates of increased CAM use in the general population (Eisenberg et al., 1998). Older individuals must be specifically considered in understanding CAM use, as they tend to have more morbidity, more physical dysfunction, more health care utilization, and less disposable income than middle-aged adults. Thus, it is imperative to have comprehensive and detailed information on the patterns of use of complementary medicine by older Americans.
In order to formulate a coherent approach toward the emerging reality of CAM, recommendations for the coordination of research efforts in the field have been articulated at a federal level. Among other goals, policy efforts are being directed at the following: (a) supporting research on CAM approaches designed to improve self-care and wellness-promoting behaviors; (b) supporting new and innovative CAM research that could aid in expanding our knowledge about health and disease; and (c) strengthening the dialogue among CAM and conventional medical practitioners, researchers and research institutions, governmental funding and regulatory agencies, the private and nonprofit sectors, and the public. In order to streamline such efforts, there is a need for ongoing epidemiological studies addressing which CAM interventions are most commonly used, the correlates that define population subgroups most likely to use CAM, and the socioeconomic framework within which such use occurs (WHCCAMP, 2003). This holds particularly true for older adults who are not only frequent CAM users but also major health care consumers who may be particularly vulnerable to the biological, functional, and economic repercussions of health care interventions.
To expand the information currently available in the literature on the use of CAM by older Americans and obtain much-needed sociodemographic and functional data in the field, we administered a module on alternative medicine to a subsample of participants of the Year 2000 wave of interviews of the Health and Retirement Study (HRS). The HRS is a representative national sample of the American population born in 1947 or earlier. It was designed to obtain detailed information regarding the dynamics of retirement and how it interacts with health, health insurance, and economic well-being. The HRS provides comprehensive and detailed information on a wide range of domains such as demographics, health status, housing, family structure, employment history, disability, and net worth, painting a biosocioeconomic picture of the cohort under study (Health and Retirement Study, 2005). Over 20,000 individuals within 7,600 households have been followed for more than a decade, with biennial interviews collecting a vast amount of pertinent data. The comprehensive and multifaceted data set provided by the HRS allowed us to explore important correlates of CAM use that are often not present in population surveys (Juster & Suzman, 1995).
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Within the survey, we divided alternative medicine interventions into alternative services (e.g., chiropractic, massage therapy, and acupuncture), dietary supplements (e.g., multivitamins, and specific vitamins and minerals), herbal supplements (e.g., garlic, Echinacea, and gingko biloba), and personal practices (e.g., breathing exercises, meditation). We determined the selection of these service clusters by considerations pertaining to validity, thoroughness, and the need to conform to the logistic constraints and limitations imposed by the fact that our module was an add-on component of the lengthier HRS baseline survey. Respondents were queried as to whether they had ever used an alternative practitioner or personal practice and as to whether they were regularly taking a dietary supplement. Participants could report more than one service or supplement used. Personal practices, dietary supplements, and herbal supplements were based on current use; alternative practitioner use was reported as lifetime prevalence. We defined "any CAM use" as meeting the criteria for any of the specific interventions based on the time period for the original question. A number of potential correlates were available from the core instrument, including demographic information, income, current smoking status, current alcohol consumption, insurance coverage, hospitalizations and doctor visits over the previous 2 years, self-reports of a number of specific chronic health conditions (e.g., hypertension, diabetes, and arthritis), and limitations in activities of daily living (ADL) or instrumental activities of daily living (IADL). We measured out-of-pocket medical expenses by direct questioning regarding money spent on medications and payments to health care providers. The cost of prescription drugs was reported on the basis of average month expenditure over the previous 2 years. Participants also were asked to report the total amount spent on dietary supplements and herbal supplements separately in the past 12 months. The HRS was reviewed by the University of Michigan Institutional Review Board, and the full questionnaire is available online at http://hrsonline.isr.umich.edu/.
Statistical Analysis
We tested associations between categorical demographic variables and dichotomous outcomes by using a chi-square test or Fisher's Exact Test. We weighted prevalence estimates for the study sampling design. We treated annual out-of-pocket medical expenses and out-of-pocket drug expenses as continuous variables and tested them for associations with CAM modalities by using simple linear regression with expenditures as the dependent variable. We entered variables that were tested as potential correlates of CAM use into multiple logistic regression models to predict each CAM modality. We treated the number of chronic conditions as a continuous variable summed from nine chronic conditions. We treated all other variables as categorical variables. We categorized age as 52–64, 65–79, and 80 years and older, and we categorized annual household income into quartiles. We asked respondents the number of times they saw a medical doctor in the previous 2 years, and we categorized these visits as 0–4, 5–9, 10–19, or 20 or more. We categorized ADL limitations as none, mild (one ADL activity limited), or severe (at least two ADL activities limited). Linear and logistic regression models used the study sample weights, normalized to the total study size.
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Nevertheless, in the particular case of dietary supplements, the use of a less rigorous definition for the category may have played a fundamental role in our survey results. For instance, whereas we considered all multivitamins as CAM, other authors have limited the category to "high-dose or megavitamins" (Eisenberg et al., 1993). We considered dietary calcium supplements as CAM in our study, even though their use has proven benefits for bone health. Appropriate calcium supplementation among elders and postmenopausal women is part of the current standard of care in the prevention and management of osteoporosis (National Institutes of Health Consensus Development Conference, 2000).
Herbal supplement use, although not as common as nonherbal dietary supplements, was still prevalent among older adults. The most commonly used herbs in our survey include garlic, echinacea, ginkgo biloba, and ginseng. Of note, herbal use was substantially lower among respondents 80 years of age and older, and it approximated use rates found in other surveys. The reasons for lower use rates with increasing age are unclear, especially when use of other CAM interventions remained popular. Cohort effects and differential access to herbs are possible explanations. Another possibility is that the sample size was too small to yield stable estimates of herbal use among those in this age group.
Higher age was associated with increased utilization of nonherbal dietary supplements. As previously discussed, multivitamin use played a considerable role in comprising these rates. However, at higher ages, there were fewer reports of alternative practitioner use. This could reflect cultural beliefs inherent to a specific cohort, lower income, less mobility, and thus less access to practitioners out of the home or lack of insurance coverage for potentially expensive health care interventions. The latter has been shown to play a significant role in profiling the population that seeks CAM providers (Wolsko, Eisenberg, Davis, Ettner, & Phillips, 2002).
Women have been noted to make more frequent use of CAM (Eisenberg et al., 1998), and we found this in our sample as well. Ethnicity also has been found to be an independent predictor of CAM use, usually with Caucasians making more frequent use of CAM than other races (Eisenberg et al., 1998; Ni, Simile, & Hardy, 2002). Both these findings were corroborated by our survey. An exception was noted for personal practices, which were more commonly reported by African Americans and Hispanics than by Caucasians.
Greater educational attainment was associated with more frequent dietary supplement use and personal practices, but with fewer chiropractic visits. Education has been previously linked to CAM utilization ( Ni et al., 2002). In our survey, this pattern persisted even after adjustment for income levels. These data corroborate other findings in the available CAM literature that point to an overall relationship between income and increased CAM utilization (Eisenberg et al., 1998), although the trend was clearer in the utilization of alternative practitioners. The association between dietary supplements and CAM use was greatest among those in the quartile above the median income, and the association with chiropractic use was greatest among those in the quartile below the median income. Income and education may simply be markers of socioeconomic status in these findings, but these associations also could reflect differences in knowledge about the health effects of CAM modalities as well as differences in the amount of discretionary income that can be allocated to CAM services and products.
Out-of-pocket expenses on medical services and prescription drugs incurred by CAM users were significantly higher than those of non-CAM users, especially for those using alternative practitioners and dietary supplements. This finding, if correct, may have several explanations. It may reflect the fact that CAM users may have more chronic illnesses or more severe illnesses than nonusers, although this was not seen in our sample. It also may reflect an orientation toward CAM use for perceived health-promotional purposes. Finally, it may reflect respondent attribution of CAM expenses as part of their general health care expenses. This is quite possible because health insurance coverage frequently excludes many CAM interventions. This may change if private and government-funded insurance plans begin to adopt broader coverage plans for CAM modalities (Pelletier & Astin, 2002; Steyer, Freed, & Lantz, 2002). CAM-related expenses have grown considerably over the past decade and will certainly become a major public health issue in the future (Eisenberg et al., 1998; MacLennan, Wilson, & Taylor, 2002; Thomas, Nicholl, & Coleman, 2001).
Frequent visits to a physician in the preceding 2 years correlated positively with alternative services utilization. This confirms previous survey findings indicating that CAM users were more likely to use conventional medical services as well (Foster et al., 2000; Ni et al., 2002), and it suggests that this subset of patients may seek complementary modalities as a means of treating conditions not relieved by conventional care, or as an additional pathway for preventive care (Astin, 1998; Sirois & Gick, 2002), but not as a substitute for allopathic care. Conventional and complementary interventions have been shown to be frequent partners in patients' perceptions of health care (Eisenberg et al., 2001). Of interest, having any type of health insurance was not associated with CAM use overall or with more frequent use of any CAM category. In fact, those with health insurance were less likely to use herbs or personal practices. Although this finding conflicts with previous data on CAM practices (Wolsko et al., 2002), it may reflect the heterogeneous nature of CAM-related coverage offered by different health insurance programs (Cleary-Guida, Okvat, Oz, & Ting, 2001).
Having one impairment, but not more than one, in the ability to perform ADLs was independently associated with increased overall CAM use and, in particular, with alternative practitioner utilization. Thus, functional limitation, at least when present to a modest degree, did not reduce the acceptance of most CAM modalities among older adults. However, with higher levels of physical impairment, CAM use was lower, possibly reflecting more severe disability and lesser access to some CAM modalities. This finding lends some support to the association between chronic illness burden and CAM use noted in previous studies (Eisenberg et al., 1998) and may indicate that CAM modalities retain their appeal in the face of some functional performance decrements. Whether such appeal arises from the patient's own beliefs, caregiver pressure, or a combination of both remains to be investigated. We did not observe a significant association between the number of chronic conditions and CAM use, although the number of comorbid conditions may itself be related to functional limitations.
Cigarette smoking was associated with less CAM use, especially when dietary supplements were considered. This association corroborates the results of various nutritional surveys (Lyle, Mares-Perlman, Klein, Klein, & Greger, 1998; Phillips et al., 2000) that show that using dietary supplements correlates with a higher likelihood of health-promoting behaviors such as physical activity, healthier eating habits, and abstinence from tobacco use. Although this could explain our findings to a certain degree, the inverse relationship of smoking with overall CAM use merits further attention.
Current alcohol use was linked to more alternative practitioner and dietary supplement use, but less personal practices use. In a cohort of more than 80,000 people aged 50 to 76 years, women using moderate amounts of alcohol (3–6 drinks/week) made use of certain nonherbal dietary supplements more commonly than those consuming less or more alcohol (1–2 drinks/week or more than 7 drinks/week, respectively; see White et al., 2004). Similar findings were identified in a Japanese cohort of more than 78,000 people aged 45 to 74 (Ishihara, Sobue, Yamamoto, Sasaki, & Tsugane, 2003). Our findings regarding CAM and alcohol use may be explained by the fact that moderate alcohol drinkers appear to use more dietary supplements and, possibly, resort to other CAM modalities more frequently as well. As moderate alcohol use is often perceived as a healthy lifestyle intervention, this correlation, as well as the one previously described for smoking, could suggest that certain CAM use may be a marker for a healthier lifestyle in general. The relationship between lifestyle habits and complementary medicine use clearly warrants further attention.
There are some potential limitations to our study. Institutionalized elderly patients were not interviewed. The data gathered in our study reflect self-reports and corroborating records were not accessed. Cross-sectional data analyses carry the intrinsic inability to establish a definite causation relationship, indicating the need for longitudinal research in order to further our understanding of these findings. The HRS offers this capacity. Finally, our data, albeit nationally representative, include a relatively small number of non-White respondents, and such minorities might warrant surveying in greater depth.
However, on the basis of our findings and those of others, we may conclude that the use of CAM remains widespread. This applies as well to the oldest old, who make frequent use of alternative modalities, especially chiropractic and dietary supplements. CAM users report more out-of-pocket health expenses than non-CAM users. Although age-use associations are dependent on the CAM modality, we did find that being of the female gender, being of Caucasian ethnicity, having a higher educational level, making frequent visits to the doctor, and experiencing mild functional limitation were among the factors that predicted a higher prevalence of CAM use in this nationally representative population. Further research is needed to understand in greater depth why older adults seek certain alternative practices more often and to determine the impact of CAM use on a range of important health outcomes.
Potential research avenues that could be explored based on data yielded by our study include studies on the efficacy and safety of chiropractic as it pertains to older adults and, in particular, the oldest old; an assessment of the reasons given by older adults to use some of the most popular herbal and nonherbal dietary supplements, followed by comprehensive and methodologically strict evaluations of their efficacy and safety; qualitative research into the relationship between personal practices and physical and psychological well-being and follow-up studies addressing the feasibility and outcomes of transposing such practices into the conventional health care environment; and further epidemiological studies looking at a possible role for CAM as a marker of a healthy lifestyle. Finally, as insurance coverage for CAM interventions grows in popularity and scope, studies addressing the impact of such coverage on CAM patterns of utilization and outcomes would be of great relevance.
The study results also bear significant implications for medical practice. Physicians and other providers involved in the care of older adults should be cognizant of how prevalent the use of CAM therapies is among elders and should ask their patients routinely about such use. Patients will often neglect to mention or opt not to discuss CAM with their usual providers (Cohen, Ek, & Pan, 2002), and this information gap could lead to potentially detrimental consequences. Certain dietary supplements have been recently banned from the market because they have hazardous side effects (Rados, 2004). Adverse interactions between dietary supplements and conventional pharmacological agents have been frequently described (Fugh-Berman, 2000; Fugh-Berman & Ernst, 2002) and are of particular concern with older adults who commonly make use of numerous prescription and over-the-counter drugs. Chiropractic has been linked to stroke and other adverse vascular events, albeit unusually (Kapral & Bondy, 2001). Expenses related to CAM may curtail many patients' ability to afford other medications, leading to difficulties with compliance not fully understood by the primary care provider.
From a health care policy standpoint, the widespread use of CAM documented in our study suggests the need for ongoing educational efforts aimed at enhancing the awareness of patients and health providers regarding the implications, benefits, and risks of CAM therapies. The development of appropriate educational venues for CAM should be accompanied by the implementation of credentialing protocols for the less well-regulated CAM modalities, the delineation of a quality control program for herbs and other dietary supplements that would ensure that these products meet standards of consistency and safety, and the establishment of routine postmarketing surveillance for adverse effects and interactions associated with dietary supplements (Eisenberg et al., 1998; WHCCAMP, 2003). Finally, as more evidence comes to light illustrating the benefits or lack thereof of specific CAM approaches, consideration should be given to broader health insurance coverage for those interventions proved to be effective and safe through rigorous clinical trials and comprehensive safety assessments.
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1 Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City.
2 Department of Epidemiology, University of Iowa College of Public Health, Iowa City.
3 Institute for Social Research, University of Michigan, Ann Arbor.
Decision Editor: Linda S. Noelker, PhD
Received for publication June 7, 2004. Accepted for publication December 30, 2004.
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  F. L. Bishop and G. T. Lewith Who Uses CAM? A Narrative Review of Demographic Characteristics and Health Factors Associated with CAM Use Evid. Based Complement. Altern. Med., March 13, 2008; (2008) nen023v1. [Abstract] [Full Text] [PDF]
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