Complementary Medicine (CM) is a broad term used to describe a wide range of health care medicines and therapies that are presently considered as separate to conventional medicine. [1-5] These can be used together with or in place of conventional medicine. [2,5] Complementary medicine is used along with conventional medical therapies.  Alternative medicine is used in place of conventional medical treatment.  These may be brought together under the title Complementary and Alternative Medicine (CAM).
A review by Bauer and Rayner,  reports that older people (over the age of 65) in the West are substantial users of CAM, and this use continues to surge. In the USA and Canada, the prevalence of CAM use among older people has been reported to be between 41% and 87%. A US study  cited by Bauer and Rayner  reports CAM use to be as high as 92% among people aged 80 years or older. In the UK, CAM use among older people is somewhat lower than in North America, although still significant at between 28% and 42%.  In China and Japan, medicinal herbal medicines are mainstream health care, as is acupuncture, Tai Chi and Qigong.  Across EU countries, the prevalence of CAM use varies widely within and (0.3-86%).  CAM use is widely used for musculoskeletal problems and mainly by women.  The most common reason for CAM use was dissatisfaction with conventional care. 
In the USA and Australia, it is estimated that the number of visits to CAM practitioners is similar to the number of visits to general practitioners (GPs).  The most common forms of CAM used by older people are herbal medicine, chiropractic and massage, vitamins, and dietary supplements, acupuncture, spiritual healing or prayer, and meditation.  Self-medication with CAM is also reported to be high among the elderly, particularly with over-the-counter (OTC) vitamins and minerals, herbal products, and nutritional supplements.  Studies also suggest that older people’s satisfaction with CAM as an adjunct to conventional medical care is high and that CAM is seen to be beneficial in maintaining quality of life and well-being.  The potential for CAM to interact with conventional pharmaceutics and treatments is an important consideration in aged care. 
Up to 93 % of people report using some form of CAM during their cancer experience. 
Doctors, nurse practitioners, pharmacists and allied health professionals need to ask the question ‘Are you using any complementary or alternative medicine?’ and even ask specific questions regarding herbal and vitamin supplements as these can be contraindicated with some medications. [1,2,4,9-12] Health care professionals (HCP) can facilitate shared decision-making that is compatible with the individual’s values and goals regardless of stage of illness. [1,2,4,11,12]
Thirty-one systematic reviews and five non-systematic reviews were identified and have informed the creation of this evidence synthesis. Most of the systematic reviews were of high quality with the remainder acceptable. There is a paucity of reviews relating to aged care and palliative care. Of the reviews available, there is an even distribution between palliative and aged care and a slightly larger number of aged/dementia reviews. Most designed randomised control trials (RCTs) from the systematic reviews are of low quality due to small numbers, no consistency with population, study design, control groups, safety and adverse effects.
CM is grouped into five categories: body-based (e.g. chiropractic, massage), mind-body-based (e.g. meditation, relaxation), energy-based (e.g. acupuncture, Reiki), biological products (e.g. herbs, vitamins and minerals, natural health products), and whole systems (e.g. naturopathy, Traditional Chinese Medicine). [3,5] These categories are the basis of the structure of this evidence synthesis.
It is important to understand that there remains the need for large, well-designed RCTs to validate the benefits of these therapies in palliative care, aged care and palliative/aged care. Although the number of RCTs have increased in these therapies, contradictory results exist which makes it complex and challenging to understand the benefits, risks and safety of CAM. Some of these contradictory results will be mentioned below.
Body Based – Massage, physical exercise, Qigong
Older people in residential care often encounter complex issues commonly associated with cognitive impairment and dementia, which may lead to increased anxiety, depression and agitation. Massage presents a non-invasive, non-pharmacological integrative approach to complement mainstream healthcare practices for the older person. Touch is intended to provide a beneficial effect for the older person in the specific form of massage. 
McFeeters et al.,  Abraha et al.  and Moyle et al.  find evidence that massage can reduce anxiety-related behaviours, and agitated dementia behaviours including wandering, verbal agitation, physical agitation and resistance to care.
McFeeters et al.  also note that massage is effective in promoting comfort through reduction of pain. This appears particularly relevant for the cognitively impaired client whose ability to self-report may be limited.  Reduction of pain has the capacity to promote relaxation and induce sleep quality. 
Falkensteiner et al.  reviewed the effectiveness of massage therapy for adults receiving palliative oncological care. Their findings demonstrate that massage therapy can reduce the perception of pain and the symptoms of anxiety and depression. 
Emerging evidence that physical exercise significantly benefits individuals living with a dementia in nursing homes is found in a review by Brett et al.  The authors note that further research is needed to explain the specific effects and what type of physical exercise is most beneficial. 
Findings in a review by Albrecht and Taylor  support the use of physical activity as a safe and feasible intervention in adults with advanced-stage cancer. It also has the potential to improve health-related quality of life particularly delaying functional decline and alleviating many common side effects experienced
by patients with progressing disease.  If used sensibly and sensitively, physical activity may assist adults with advanced-stage cancer to ‘live’. 
Qigong, a form of traditional Chinese medicine (TCM) practice, involves the use of movements, meditation, and control of breathing pattern to achieve a harmonious flow of energy (qi) in the body.  A review by Chan et al.  examines the effectiveness of qigong exercise in cancer care. The suggested favourable effects of qigong exercise on the improvement of symptoms, inflammation, QoL, mood, and the increase of the 5-year survival rate in cancer patients, need to be supported by future research with robust methodology. 
Mind-body – Mindfulness, relaxation, yoga, music therapy, sensory, pet therapy, art therapy, Tai Chi
Mindfulness approaches are an emerging and promising intervention in cancer care.  Findings in a review by Shennan et al.  report significant benefits in psychological symptoms of anxiety and stress and indicate a positive effect on immune function and physiological arousal.  The authors caution more robust research is needed in this is emerging area. 
A review by Wood et al.  finds that art therapy can be associated with improvements in psychological and spiritual distress, and QoL and coping in cancer patients. Art therapy may empower cancer patients to recalibrate their sense of self and strengthen their involvement in symptom management and self-care. The authors caution more robust research is needed in this is emerging area. 
A review by Klainin-Yobas et al.  indicates that relaxation interventions can be beneficial for elderly people. As such, the relaxation interventions could be used as primary prevention and/or adjunctive therapy for depression and anxiety. As an example, yoga could be taught to older adults living in community facilities or residential facilities. 
In music therapy, recipients can be actively engaged in making music and singing, which is defined as “interactive” method usually led by a music therapist, or they can listen to music that a therapist plays or sings, which is considered a “passive” method.  Livingstone et al. note that agitation decreased in residents with structured music therapy, and when carrying out pleasant activities.  Watson et al.  report that music therapy has a significant effect in reducing physical aggressive agitation.
A review by Zhang et al.  supports the use of music therapy in the treatment of disruptive behaviour and anxiety and of cognitive function, depression and quality of life. The authors suggest that older people living with dementia could be encouraged to accept music therapy, especially interactive. 
A review by Zhao et al.,  suggests that music therapy when added to standard treatment has statistical significance in reducing depressive symptoms among older adults. However, when compared with standard treatments, music therapy was not effective in reducing depressive symptoms in older adults. Music therapy can be used to decrease depressive symptoms for elders with depression, but no support for the use of music therapy as a treatment to reduce depressive symptoms for elders with dementia. 
Araha et al.  report evidence of music played in residential dining rooms during meal-time significantly decreasing agitation in older adults with dementia immediately following the intervention and one-hour post-intervention. Dance therapy results were insignificant. 
McConnell et al.  found in their review that music therapy may be effective for reducing pain in the palliative care setting however this is based on studies with a high risk of bias.
Gerdner and Buckwalter  translated an evidence-based protocol into an educational tool, a picture book Musical Memories for children with a grandparent or parent living with dementia. The book provides a new model of support to help children cope with the challenging behaviours associated with Alzheimer’s. Song titles and performers that stimulate remote memory and elicit positive feelings to prevent or alleviate agitation are included in the book. Individualised music serves as a catalyst to unveil personhood, promote communication, elicit positive memories, reduce anxiety, and alleviate agitation. 
Livingston et al.  review sensory therapy activities and structured music therapies used to reduce agitation for older residents with dementia living. Sensory intervention reduced agitation decreased in residents also useful for clinically significant agitation.  This review also includes the cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia.
There is little evidence, of low a standard, to make recommendations about the use of pet therapy for agitation in palliative care. 
Patel et al.  recommend yoga for older adults with careful observation and monitoring of side effects. Danhauer et al.  support the incorporation of yoga alongside conventional cancer treatment for women with breast cancer. This review cites studies suggesting that yoga can lead to improvements in, or buffer, treatment-related changes in mental health, fatigue, sleep quality, and other aspects of quality of life. Very little has been reported about potential adverse events.
A review and meta-analysis by Du et al.  reports that Tai Chi exercise may improve self-rated sleep quality in older adults.
Energy-based - Acupuncture
Most acupuncture treatments or combination therapies with analgesics exhibited favourable effects compared with conventional treatments in individual studies. However, a meta-analysis suggested that acupuncture was no better than opioids. The comparison between acupuncture plus opioids and opioids alone demonstrated a significant difference in favour of the combination therapy. 
Acupuncture can be considered as a treatment option for troublesome hot flushes for adults with breast or prostate cancer. 
A review by Towler et al.  identifies potential benefit of acupuncture for people with cancer-related symptoms, including pain, nausea and vomiting. There was also a positive indication that acupuncture may be useful for symptoms where treatment is currently limited, such as hot flushes, xerostomia (dry mouth syndrome), fatigue and dyspnoea.
Biological products – Aromatherapy, herbal supplements
Aromatherapy has become a popular complementary therapy with an increased use in hospices and aged care facilities to decrease anxiety, agitation and provide a more relaxing and appealing healing environment. Watson et al.  report that aromatherapy has a significant effect in reducing physical aggressive agitation in older people living permanently in a residential aged care facility.
A Cochrane Review by Forrester et al.  found inconsistent effects of aromatherapy on agitation, behavioural symptoms, activities of daily living (ADL) and quality of life (QoL) for people with dementia.
De Souza Silva et al.  report that herbal supplements are commonly used by older adults. The two most common supplements were gingko and garlic among elderly living in the community. These supplements have the potential to interact with anticoagulants and produce bruising or bleeding problems. Garlic can slow blood clotting when used concomitantly with non-steroidal anti-inflammatory drugs (e.g. naproxen, and diclofenac) and anticoagulants (e.g. warfarin) thus increasing the chances of bruising and bleeding.
A review by Kasper  reports that three herbal treatments may be effective in older adults: oral capsules of lavender oil (Silexan) for anxiety, Hypericum extract for major depression, and Ginkgo biloba extract in older adults living with dementia.
The above-mentioned supplements may not reflect current CM use of older Australian receiving palliative care.
Whole systems - Traditional Chinese Medicine (TCM)
Traditional Chinese Medicine (TCM)
Chinese herbal medicines (CHM) have become increasingly widespread for issues such as disease prevention, immunity boosting, and symptom control.  They are popular among people affected by cancer.  They may also be used in the context of palliative care.  Integration of TCM and Western medicine in care practices may provide benefits to people affected by cancer in the palliative care period if healthcare professionals are fully aware of adjuvant/complementary medicines being used and their potential benefits, risks and side effects. 
A meta-analysis by Yan et al.  provides insufficient evidence that the external application of TCM can relieve pain in bone cancer. A review by Yanju et al.  provides insufficient evidence that Kushen injections can relieve bone pain. Both reviews note that the results are from a small number with poor methodological quality.
CHM have been used as an alternative therapeutic measure to treat many gastric cancer patients in China.  A Cochrane Review by Yang et al.  provides weak evidence for Huachansu, Aidi, Fufangkushen, and Shenqifuzheng in the improvement of leukopenia when used together with chemotherapy and Huachansu, Aidi, and Fufangkushen for adverse events in the digestive system caused by chemotherapy. Most of the included studies were of low quality and valid comparisons were scarce, meaning that more trials are needed for meta-analysis to draw definite conclusions. 
A review by Chung et al.  includes RCTs conducted and published in China investigating the effectiveness of CHM for the management of pain, constipation, fatigue, and anorexia among cancer patients. The evidence is inconsistent.
- Evidence is lacking regarding the use, benefits, risks, safety and effectiveness of complementary medicine for older people and older people receiving palliative care.
- The evidence is limited for use of CM in residential aged care.
- All included systematic reviews cite methodological shortcomings of the included studies: small sample size, lack of consistency across study design, population and outcomes with little mention of risks and safety issues.
Updated 04 September 2019