Use of complementary and alternative therapies to promote sleep in critically ill patients.

BY BELLERUTH NAPARSTEK IN HEALTHY SLEEP

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03 Nov
A new review from the Central Arkansas Veterans Healthcare System examines which complementary and
alternative therapies are most effective at helping critically ill patients sleep better.
Researchers at Central Arkansas Veterans Healthcare System reviewed seven studies that examined the effect of
complementary and alternative therapies on sleep promotion in critically ill patients. The research shows that
massage, music therapy and therapeutic touch promote relaxation and comfort in critically ill patients, which likely
leads to improved sleep.
The review concluded with the following conclusions and recommendations:
Massage, music therapy and therapeutic touch are safe for critically ill patients and should be routinely applied by ICU
nurses who have received training on how to provide these interventions.
Environmental interventions, such as reducing noise, playing white noise such as ocean sounds, and decreasing
interruptions to sleep for care, also are safe and logical interventions that ICU nurses should use to help patients
sleep.
Progressive muscle relaxation has been shown to be helpful for improving sleep in patients with insomnia, but
because it requires that they consciously attend to relaxing specific muscle groups and practice these techniques, this
may be difficult and impractical for critically ill patients.
Aromatherapy and alternative sedatives, such as valerian and melatonin, are not recommended because the safety of
these substances is unclear.
Citation: Richards K, Nagel C, Markie M, Elwell J, Barone C. Use of complementary and alternative therapies
to promote sleep in critically ill patients. Critical Care Nursing Clinics of North America. 2003 Sep;15 (3): pp.
329-40. richardskathyc@uams.edu
- See more at: http://blog.healthjourneys.com/healthy-sleep/use-of-complementary-and-alternative-therapies-topromote-sleep-in-critically-ill-patients.html#sthash.5W1oN7T4.dpuf

The Role of Complementary and

Alternative Medicine in End-of-Life
Care
Julia Dorfman, MD, PhD; Sandeep Denduluri, MD; Kathryn Walseman, MD; Benjamin Bregman, MD

Psychiatric Annals

April 2012 - Volume 42 Issue 4: 150-155

DOI: 10.3928/00485713-20120323-09

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References
In the early part of the 20th century, people often died at home where family, community, and clergy
assisted them with the dying process. As the century progressed, dying began taking place in hospitals.
Consequently, the physicians role in end-of-life care changed as well.

Today, the physician has a special responsibility for meeting patients needs and desires at the end
of life.1,2 Despite this responsibility, little research is available into patients needs and preferences at
the end of life; many physicians still struggle to understand what constitutes a good death for their
patients and how to assist them in this final transition.1,2
In an attempt to shed light on what constitutes a good death, Karen Steinhouser and her research
team conducted focus groups and in-depth interviews of patients, families, and health care
providers.1 Their results reiterated four previously identified themes of palliative medicine: the
importance of pain and symptom management; clear communication and decision-making;
preparation for death; and completion, which refers to the process of life review, resolving conflicts,
spending time with family and friends and saying goodbye.1

As patients work through the process of completion, it is especially important for them to be treated
and seen as unique individuals and whole persons, not only as diseases or cases. 1 Therefore,
physicians focus on death as a purely physiologic event that needs to be fought with the aid of
biomedical technology often results in patients and physicians not being on the same page with
regards to the goals of treatment toward the end of life.
Patients and physicians may look to complementary and alternative medicine (CAM) as adjuncts to
conventional therapies at the end of life. It has been estimated that among adult cancer patients
participating in clinical trials, 63% used at least one complementary therapy and 60% to 70% of
hospices offer complementary therapy services.35
This article focuses on three domains of CAM as they might be applicable to palliative and end-of-life
care. First discussed are herbal medicines, as they are the most commonly used modality of CAM.
Then we will address the growing evidence base for the efficacy of massage therapy in reducing
pain and distress. Finally, the role of animal-assisted therapy at the end of life is discussed. Animalassisted therapy is not traditionally thought of as a complementary medicine modality; however, it
has been used successfully to improve mood, reduce pain, and alleviate loneliness in certain
populations.

Herbal Medicines
For centuries, herbal medicines were the primary source of medical treatment for the worlds
population. Currently, the use of herbal supplements in the US is exceedingly common and has been
steadily increasing.
It was estimated that in 1997, American consumers spent $5.1 billion on herbal medicines and more
people visited alternative medicine practitioners than primary care physicians. 6 The use of herbal
supplements may be even higher in certain populations, such as cancer patients and cancer
survivors. In 2008, the prevalence of nutritional supplements or vitamin use among a sample of
4,139 cancer survivors was 40.1%.7
Many herbal medications contain bioactive compounds that can be helpful in the treatment of
multiple medical conditions. Also, multiple commonly used medications were developed from plant
compounds. For example, the antiarrhythmic medication digitalis was purified from the foxglove
flower; aspirin from the willow tree; morphine from opium poppy; and vincristine from rosy
periwinkle.8
However, the increasing popularity of over-the-counter (OTC) herbal preparations presents a unique
set of problems, such as toxicities due to contamination, and interactions with mainstream
medications. Furthermore, patients reluctance to disclose their use of herbal supplements to their
physicians or pharmacists increases their risk for herb-drug interactions. 9,10

Drug-Herb Interactions
As an illustration of the complexity of potential interactions and its relevance to psychiatry, it is useful
to focus on the pharmacokinetic and pharmacodynamic properties of the commonly used herbal
antidepressant St. Johns wort.9,10

Due to its common use, multiple interactions with other pharmacological compounds have been
uncovered and reported. Of particular concern are the potentially lethal pharmacokinetic interactions
of St. Johns wort with the anticoagulant warfarin; the anti-arrhythmic medication digoxin; the
immunosuppressant cyclosporine; and the protease inhibitor indinavir.
The likely mechanism by which St. Johns wort lowers the plasma levels of these medications is
through the induction of hepatic p450 enzymes. Additionally, St. Johns wort interacts
pharmacodynamically with serotonergic compounds. One of its components acts as a serotonin
reuptake inhibitor and therefore can increase the risk of serotonin syndrome when used
concomitantly with antidepressant medications.9,10

Contaminated Herbs
Another common problem encountered with the use of herbal medicines is contamination. For
example, contamination with heavy metals is common in Chinese and Ayurvedic herbal medicine;
multiple case reports and case series have described this problem.11,12
Other contaminants can also be found in herbal medicine preparations. Californian officials
discovered that 7% of the 251 products they tested contained undeclared pharmaceuticals such as
ephedrine, chlorpheniramine, methyltestosterone, and phenacetin.11 Moreover, contaminations with
herbicides, pesticides, bacteria or mycotoxins, and undeclared herbal constituents are well
documented and can be life-threatening. In Belgium, traditional Chinese medicines contaminated
with plants from the Aristolochia species caused an epidemic of subacute interstitial nephropathy
with multiple patients requiring kidney transplantation.11
As more research is done into the efficacy and safety of various herbal remedies, some myths are
dispelled while new treatments are also emerging. Several herbal therapies were recently shown to
be beneficial in randomized controlled trials for symptoms that contribute to significant morbidity for
many palliative care patients. Glutamine was shown to be beneficial for mucositis, fish oil for
cachexia, and milk thistle for hepatotoxicity.1316
Considering the uncertain risk-benefit ratio of many herbal supplements, they should be used with
caution, especially by patients at the end of life who might be taking multiple conventional medicines,
such as chemotherapy, highly active antiretroviral therapy (HAART), immunosuppresants,
anticoagulants, and antiarrhythmics.
Stricter regulation of ingredients, mandated reporting of toxicities and side effects, as well as
additional randomized controlled efficacy studies can improve the safety profile of herbal medicines
and allow them to be used with more confidence.

Massage
According to the 2007 National Health Interview Survey (NHIS), chiropractic manipulation and
massage were among the top 10 CAM therapies used by adults and children, with 8.3% of adults
and 1% of children reporting they used massage. In a survey of hospice programs, massage was
the most common complementary modality offered; 60% of participating hospice agencies reported
offering it.4

Massage is theorized to interrupt the cycles of distress through therapist intentionality (presence,
communication, and desire to produce a therapeutic response); induction of the relaxation response;
increased blood and lymphatic circulation; potentiation of analgesic side effects; decreased
inflammation and edema; manual release of muscle spasms; increased endogenous endorphin
release; and inducing sensory stimuli that override pain symptoms. 17
Massage therapy includes many different modalities such as Swedish massage, Reiki, and several
other modalities less-studied in Western medicine, but which are used across the Mediterranean,
India, China, and Southeast Asia.
The physiological basis for the benefits of massage is currently under active investigation. It appears
that moderate pressure massage activates the parasympathetic nervous system as measured by
heart rate variability changes on EKG, which reflect increased vagal efferent activity after massage. 18
A randomized controlled trial of the benefits of massage in women with breast cancer demonstrated
that massage helps to lower systolic blood pressure and heart rate, consistent with activation of the
parasympathetic nervous system.19Moreover, massage therapy boosted the immune system by
decreasing the radiation therapy-induced deterioration of NK cell activity.19
A preliminary study that compared a single session of massage therapy with light touch control
showed that massage causes a large decrease in serum vasopressin, a small decrease in serum
cortisol, an increased number of circulating lymphocytes (CD25+, CD 56+, CD4+ and CD8+), and
decreased numbers of pro-inflammatory cytokines such as IL-4, IL-5A, IL-10, and IL-13 relative to
controls, suggesting a beneficial effect on the immune system.20
A small randomized controlled trial of 39 hematological oncology patients undergoing chemotherapy
found that massage therapy significantly reduced serum cortisol levels with associated
improvements in symptoms of anxiety and depression.21 However, a comprehensive quantitative
review of the literature did not find statistically significant effects of massage on cortisol levels,
concluding that other mechanisms, some of which might still need to be discovered, are responsible
for the well-documented clinical benefits of massage. 22
Clinically, massage therapy and touch were compared to each other in a randomized controlled trial
for their ability to improve pain and mood in patients with advanced cancer.17 In this study, 380
randomly assigned participants received up to six treatments over a 3-week period. The massage
intervention was performed by a licensed therapist who had at least 6 months of experience treating
advanced cancer or hospice patients. In contrast, the control treatment was provided by practitioners
without prior knowledge of any type of body work and consisted of light and constant pressure, with
no side-to-side hand movement.
Both treatment arms showed statistically significant improvements in immediate and sustained pain
scores, with massage being statistically but not clinically superior to simple touch for immediate pain
scores. Moreover, both groups showed improvement in physical and emotional distress scores, as
well as in quality-of-life assessments over the weeks of treatment. Even though this study showed
only limited superiority of massage over touch, it supports the overall importance of touch in
improving quality of life, mood, and reducing distress in patients with terminal illness.

Meta-analysis of massage therapy attempted to address the question of whether massage therapy
can reduce the level of pain, anxiety, and depression in patients receiving palliative oncological
care.23 More than 69 articles were found, but only six studies met sufficient criteria for stringency, with
four studies corresponding to evidence level I and two to evidence level III. A total sample of 1,558
adult oncological patients receiving palliative care was analyzed. The patients participating in the
different studies mainly received a full body massage, but two of the studies evaluated foot massage
and one of the studies only administered a hand massage.
Overall, in this population of patients, massage therapy was shown to provide a statistically
significant reduction in the subjectively perceived symptoms of pain, lasting as long as 18 hours after
the completion of massage. Massage also helped to reduce symptoms of anxiety and depression,
especially in socially isolated patients. No negative side effects of massage therapy were identified
in the six main articles analyzed.23

Animal-Assisted Therapy
Animal-assisted therapy (AAT) is defined as a goal-directed intervention between a human and a
trained therapy animal that draws from this human-animal bond, designed to promote improvement
in human physical, social, emotional, and cognitive functions.24
There is a growing appreciation of the healing properties of the human-animal bond. Studies have
demonstrated that when compared with non-owners, pet owners are often better able to tolerate
stressful situations, as evidenced by a lowered heart rate and systolic and diastolic blood pressures
when engaged in mental arithmetic tasks.25,26 Other data have shown that the rates of depression
among those with AIDS is lower in pet owners compared with non-owners. 27
Over the past several decades, the benefits of the human-animal bond have been recognized not
only in pet ownership, but also with transient interactions between humans and animals. Odendaal
found a significant decrease in blood pressure along with an increase in blood levels of oxytocin,
beta-endorphin, prolactin, and dopamine after just 5 to 24 minutes of positive interaction with a dog. 28
Although there has been little research on the direct effects that AAT has specifically on end-of-life
care, the effects of AAT on various domains that are significant in palliative care patients, such as
pain, social isolation, stress, and anxiety, have been addressed in the AAT literature with other
patient populations.
A large study looking specifically at the effects of AAT on an outpatient pain management clinic
population found that adults with chronic pain who received brief therapy dog visits had significantly
lower reports of pain and emotional distress as compared with those who did not visit with a therapy
dog.29 Similar results have been observed among children whose perceived pain was significantly
reduced when they participated in AAT after surgery.30
Social isolation and loneliness are common end-of-life issues. AAT has been shown to decrease
loneliness and facilitate social interactions among certain populations. Specifically, in a study among
elderly residents of long-term care facilities, AAT was shown to be effective in reducing the burden of
loneliness among elderly adults.31

In acute-care settings, it has been observed that AAT serves to increase social interactions with both
patients and families.32 Additionally, multiple studies have looked at socialization among those with
dementia and found that AAT increases social behavior and decreases agitation among these
individuals.33,34
Alleviating stress and anxiety through both pharmacologic and non-pharmacologic methods at the
end of life is a common practice among palliative care patients and physicians. Several studies have
shown a reduction in stress and anxiety in response to AAT, suggesting that AAT could offer an
alternative to some of the more traditional pharmacological and nonpharmacological methods of
anxiety reduction. Among hospitalized psychiatric patients, AAT lessened patients anxiety to a
significant degree compared with routine therapeutic recreation.35
AAT in patients hospitalized with heart failure resulted in lower levels of stress hormones,
epinephrine, and norepinephrine, as well as lower levels of anxiety compared with control
groups.36 Additional studies have demonstrated a reduction in state-anxiety among non-clinical
individuals who may or may not have pets, which occurs simply from petting animals. 37, 38
Johnson et al write, AAT meets the National Institute of Health (NIH) definition of Mind-Body
Intervention CAM techniques as a process that may facilitate the minds capacity to affect bodily
function and symptoms.39 Indeed, research over the years has demonstrated the physiological and
psychosocial benefits of human-animal interactions among both medical and psychiatric patients.
Although AAT with end-of-life patients remains underrepresented in the literature, issues that are
common to this and other patient populations have been successfully addressed with AAT.

Conclusion
As psychiatrists, we are aware that a choice of medication, as well as issues of compliance, are
often very personal and carry significant transferential component that is often indicative of the
quality of therapeutic relationship. As such, the fact that more patients are currently seeing
alternative medicine practitioners than primary care providers could be a sign of their dissatisfaction
with the quality of their relationship with allopathic practitioners.6

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Authors
All authors are with The George Washington University, Department of Psychiatry and Behavioral
Sciences. Julia Dorfman, MD, PhD; Sandeep Denduluri, MD; Kathryn Walseman, MD; and Benjamin
Bregman, MD, are Resident Physicians.
Drs. Dorfman, Denduluri, Walseman, Bregman, and Norris have disclosed no relevant financial
relationships.
Address correspondence to: Julia Dorfman, MD, PhD, The George Washington University,
Department of Psychiatry and Behavioral Sciences, 2150 Pennsylvania Ave., NW, 8th Floor,
Washington, DC, 20037; fax: 202-741-2891; email: .dorfman.julia@gmail.com
10.3928/00485713-20120323-09