Complementary Medicine - Synthesis
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Complementary Medicine - Synthesis

Introduction

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 alongside, combined with or in place of conventional medicine. [2,5] Complementary medicine is the term used when complementary practices are used alongside conventional medical therapies. [2] Alternative medicine is the term when complementary practices are used in place of conventional medical treatment. [2] These may be brought together under the title Complementary and Alternative Medicine (CAM), however these terms  can be used synonymously in the literature.

A review by Bauer and Rayner [6] 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 [7] cited by Bauer and Rayner [6] 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%. [6] In China and Japan, medicinal herbal medicines are mainstream health care, as is acupuncture, Tai Chi and Qigong. [6] Across EU countries, the prevalence of CAM use varies widely (0.3-86%). [8] CAM use is widely used for musculoskeletal problems and mainly by women. [8] The most common reason for CAM use was dissatisfaction with conventional care. [8]

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). [6] 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. [6] 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. [6] 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. [6] The potential for CAM to interact with conventional pharmaceutics and treatments is an important consideration in aged care. [6]

Up to 93% of people report using some form of CAM during their cancer experience. [4]

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]

Quality Statement

Forty-nine systematic reviews and six non-systematic reviews were identified and have informed the creation of this evidence synthesis. Most of the systematic reviews were of acceptable to high quality [4,13-49] with the remainder of low quality. [6,10,11,50-55] There is a paucity of reviews relating to aged care and palliative care.

Of the reviews available, there was a focus on palliative care in 16 reviews [4,15,21,22,26-28,31,34,35,39,41,44,45,50,55] with the various stages of cancer the focus of 19 reviews. [4,10,12,17,18,22,25,29,31,40-42,46,47,50-54]

Eight reviews focused on aged care [6,11,13,20,24,33,48,56] with nine focussing on dementia. [14,16,19,30,32,36,38,43,49]

Meta-analysis was conducted in 14 reviews. [22,24,26,28,30-33,37,39,40,42,43,47]

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.

Other sources were included to provide context. [1-3,5,7,9,12,56-59]

Evidence Synthesis

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 therapies – massage, physical exercise, Qigong

Massage

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. [13]

McFeeters et al., [13] Abraha et al. [14] and Moyle et al. [19] found 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. [13] also notes that massage is effective in promoting comfort through reduction of pain. This appears particularly relevant for the person with a cognitive impairment whose ability to self-report may be limited. [13] Reduction of pain has the capacity to promote relaxation and induce sleep quality. [13]

Falkensteiner et al. [15] 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. [15]

Contra-indications have been reported for the use of massage in certain conditions, including advanced heart disease, bony metastases, low platelet counts, kidney failure, pathological fractures, and malignant wounds. [58]

Physical exercise

Emerging evidence that physical exercise significantly benefits individuals living with a dementia in nursing homes is found in a review by Brett et al. [16] The authors note that further research is needed to explain the specific effects and what type of physical exercise is most beneficial. [16]

Findings in a review by Albrecht and Taylor [50] 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 people with progressing disease. [50] If used sensibly and sensitively, physical activity may assist adults with advanced-stage cancer to ‘live’. [50]

Qigong

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. [17] A review by Chan et al. [17] examined the effectiveness of qigong exercise in cancer care. Five of the eight RCT’s within the study suggested favourable effects of qigong exercise on the improvement of symptoms; inflammation, QoL, mood, and an increase in 5-year survival rate in people with cancer. However, there was a high degree of variability between all studies and high risk of bias. Therefore, the results should be interpreted cautiously and need to be supported by future research. [17]

Mind-body therapies – mindfulness, music therapy, art therapy, relaxation, sensory therapy, pet therapy, yoga, Tai Chi, hypnosis

Mindfulness

Mindfulness is defined in the literature as the engagement in formal and informal meditation, as well as a ‘state of awareness’. Mindfulness has been incorporated into several treatment approaches and is an emerging intervention in cancer care. [53] Findings by Shennan et al. [53] report significant benefits in psychological symptoms of anxiety and stress and indicate a positive effect on immune function and physiological arousal. [53] However, a recent review by de Oliveira Cruz Latorraca et al. [35] which looked at four low level RCT’s found no benefit for older people receiving palliative care. [35] More robust research is needed in this emerging area. [53]

Music therapy

Music therapy is now one of the most researched and utilised CM in palliative care. [26] In music therapy, recipients can be actively engaged in making music and singing, which is defined as an “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” or “receptive” method. [32,43] Livingstone et al. noted that agitation decreased in residents with structured music therapy, and when carrying out pleasant activities. [49] Watson et al. [48] reported that music therapy had a significant effect in reducing physical aggressive agitation. Tsoi et al. [32] found receptive music therapy had the greatest effect on the reduction of agitation, behavioural problems and anxiety in older people with dementia.

A review by Zhang et al. [43] 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. [43]

A meta-analysis by Zhao et al. [33] suggests that music therapy when added to standard treatment has statistical significance in reducing depressive symptoms among older adults. However, for music therapy alone compared with standard treatments, music therapy was not effective in reducing depressive symptoms in older adults. Zhao et al. [33] also examined the use of music therapy for depression in older adults with or without dementia. Music therapy can be used to decrease depressive symptoms for older adults with depression, but no support was found for the use of music therapy as a treatment to reduce depressive symptoms for older people with dementia. [33]

Abraha et al. [14] report evidence of music played in residential dining rooms during mealtime significantly decreased agitation in older adults with dementia immediately following the intervention and one-hour post-intervention. Dance therapy results were insignificant. [14]

Two reviews found that music therapy may be effective for reducing pain in the palliative care setting. [26,28] However, high risk of bias was reported in one study [28], and the other study looked at the effects from only one or two sessions. [26]

Gerdner and Buckwalter [57] translated an evidence-based protocol into an educational tool, a picture book of ‘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. [57]

Art therapy

A review by Wood et al. [18] found that art therapy can be associated with improvements in psychological and spiritual distress, QoL and coping in people with cancer. Art therapy may empower people with cancer to recalibrate their sense of self and strengthen their involvement in symptom management and self-care. However, studies looking at art therapy for older people with dementia, have shown insufficient evidence for its efficacy. [36] More robust research is needed in this emerging area. [18]

Relaxation

A review by Klainin-Yobas et al. [20] 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. [20]

Sensory therapy

Livingston et al. [49] reviewed sensory therapy activities and structured music therapies used to reduce agitation for older residents living with dementia. Sensory intervention which included massage, ‘therapeutic touch’ and multisensory stimulation, reduced agitation during treatment in residents and was also found to be useful for clinically significant agitation. [49] This review also includes the cost-effectiveness of sensory, psychological, and behavioural interventions for managing agitation in older adults with dementia.

Animal-assisted therapy

While a paucity of evidence exists for animal assisted therapy (AAT), a review which included 2 studies of low sample sizes (n=20), suggested AAT for people receiving palliative care may be positively linked to mood and symptom burden. [27] Due to the limited sample size and poor methodology more research is required into the impact and effectiveness of animals as an adjunct to therapy in palliative care settings. [27]

Yoga

Patel et al. [30] recommend yoga for older adults with careful observation and monitoring of side effects. Danhauer et al. [51] 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. Consideration needs to be given to the design of programs to accommodate treatment related symptoms. [51]

Tai Chi

A review and meta-analysis by Du et al. [24] reports that Tai Chi exercise may improve self-rated sleep quality in older adults, while another review found positive short-term effects on cancer-related fatigue. [47] Positive effects were also seen in older people with Parkinson’s Disease in relation to balance and wellbeing; however, this review contained small sample sizes and low-quality studies. [23]

Hypnosis

There is very limited research into the use of hypnotherapy for symptom management at end of life, with no research identified specific to older people receiving palliative care. [46,55] 

Energy-based therapies – acupuncture

Acupuncture/acupressure

While acupuncture/acupressure is one of the most used forms of CM, the strongest evidence for its use is for the treatment of chemotherapy induced nausea and vomiting. [58,59] These findings are supported in a review by Towler et al. [31] who identified potential benefits of acupuncture for people with cancer-related symptoms, included pain, nausea, and vomiting. Towler et al. [31] also found positive indications that acupuncture may be useful for symptoms where treatment is currently limited, such as hot flushes, [52] xerostomia (dry mouth syndrome), fatigue and dyspnoea. The treatment of dyspnoea was also investigated in a recent review in older people with chronic obstructive pulmonary disease (COPD) and advanced cancer, and while this study supported Towler et al. [31] findings for the improvement of dyspnoea symptoms [39], a further review investigating dyspnoea, QoL and anxiety in older people with COPD found no effect. [37]

While the results for the treatment of pain, dyspnoea, fatigue, and hot flushes are promising, there is currently not enough high-quality evidence to make firm conclusions for its efficacy. [58]

Biological products – aromatherapy, herbal supplements

Aromatherapy

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. [48] 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. [38] found inconsistent effects of aromatherapy on agitation, behavioural symptoms, activities of daily living (ADL) and QoL for people with dementia. Several other reviews also investigated the use of aromatherapy and found no significant short-term effects on the reduction of anxiety, [45] pain or QoL for people receiving palliative care. [34] However, a review investigating the perceived benefits of using aromatherapy, massage, or reflexology by older people receiving palliative care, found they were considered beneficial in enabling an ‘escape’ from their disease. [21]

Herbal supplements and other natural products

De Souza Silva et al. [11] 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 [56] 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’s receiving palliative care.

The role of vitamins, minerals, and proteins in the treatment of cachexia in people with cancer was investigated for the development of clinical practice guidelines for the European Palliative Care Research Centre. While no serious adverse effects were seen with the use of controlled dosages, and positive results were indicated for the use of Vitamin C for the treatment of fatigue, appetite loss and nausea, further research is recommended before its use in cancer treatment can be supported. [29] Vitamin E has also shown some effect in the treatment of oral mucositis in people with head and neck cancer however as the research base was small, guideline recommendations are currently not supported. [54]

The use of cannabinoids has been the subject of increased research in the management of common symptoms in palliative care such as chronic pain, weight, appetite, nausea, and vomiting. While not specific to older adults, a high-level study (overview of systematic reviews) identified inadequate evidence for the recommendation of its use as a treatment option for these symptoms in people with advanced cancer and HIV/AIDS. [44]

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. [12] They are popular among people affected by cancer. [12] They may also be used in the context of palliative care. [12] 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. [12]

A meta-analysis by Yan et al. [40] provides insufficient evidence that the external application of TCM can relieve pain in bone cancer. A review by Yanju et al. [42] 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 people with gastric cancer in China. [41] A Cochrane Review by Yang et al. [41] 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. [41]

A review by Chung et al. [22] includes RCTs conducted and published in China investigating the effectiveness of CHM for the management of pain, constipation, fatigue, and anorexia among people with advanced cancer. The evidence is inconsistent.

Indigenous medicine

Research into traditional indigenous medicines is a developing field with traditional medicine currently utilised by 20 to 50 per cent of indigenous communities, including indigenous Australians, around the world. While not specific to older adults, a key finding of a recent review was the direct influence of health professional attitude on a person’s disclosure of use. Like other CM, failure to disclose use of traditional indigenous medicine could have potential implications for both care and medication interactions. [25]

Evidence Gaps

  • 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.
  • Many included systematic reviews cite methodological shortcomings of the included studies: small sample size, lack of consistency across study design, population and outcomes, use of validated instruments, with little mention of risks and safety issues.
  • There is a paucity of research and evidence in both animal assisted therapy and hypnotherapy.


Page updated 09 July 2021

  • References

  1. Australian Medical Association Limited (AMA). AMA Position Statement: Complementary Medicine - 2018. Canberra: AMA: 2018.
  2. National Health and Medical Research Council (NHMRC). Talking with your patients about Complementary Medicine - a Resource for Clinicians. Canberra: NHMRC; 2014.
  3. National Health and Medical Research Council (NHMRC). Complementary medicines [Internet]. 2018 [cited 2018 Oct 5].
  4. Truant TL, Porcino AJ, Ross BC, Wong ME, Hilario CT. Complementary and alternative medicine (CAM) use in advanced cancer: a systematic review. J Support Oncol. 2013 Sep;11(3):105-13.
  5. National Center for Complementary and Integrative Health (NCCIH). Complementary, Alternative, or Integrative Health: What’s In a Name? [Internet]. 2018 [updated 2018 Jul; cited 2020 Jul 7].
  6. Bauer M, Rayner JA. Use of complementary and alternative medicine in residential aged care. J Altern Complement Med. 2012 Nov;18(11):989-93. doi: 10.1089/acm.2011.0582. Epub 2012 Aug 21.
  7. Ness J, Cirillo DJ, Weir DR, Nisly NL, Wallace RB. Use of complementary medicine in older Americans: results from the Health and Retirement Study. Gerontologist. 2005 Aug;45(4):516-24.
  8. Eardley S, Bishop FL, Prescott P, Cardini F, Brinkhaus B, Santos-Rey K, et al. A systematic literature review of complementary and alternative medicine prevalence in EU. Forsch Komplementmed. 2012;19 Suppl 2:18-28. doi: 10.1159/000342708.
  9. Therapeutic Guidelines Limited. Therapeutic guidelines: palliative care. Version 4. Melbourne: Therapeutic Guidelines Limited; 2016.
  10. Weeks L, Balneaves LG, Paterson C, Verhoef M. Decision-making about complementary and alternative medicine by cancer patients: integrative literature review. Open Med. 2014 Apr 15;8(2):e54-66. eCollection 2014.
  11. de Souza Silva JE, Santos Souza CA, da Silva TB, Gomes IA, Brito Gde C, de Souza Araujo AA, et al. Use of herbal medicines by elderly patients: A systematic review. Arch Gerontol Geriatr. 2014 Sep-Oct;59(2):227-33. doi: 10.1016/j.archger.2014.06.002. Epub 2014 Jul 9.
  12. Peters MDJ. Cancer: Traditional Asian Medicines and Palliative Care. Adelaide: The Joanna Briggs Institute; 2016.
  13. McFeeters S, Pront L, Cuthbertson L, King L. Massage, a complementary therapy effectively promoting the health and well-being of older people in residential care settings: a review of the literature. Int J Older People Nurs. 2016 Dec;11(4):266-283. doi: 10.1111/opn.12115. Epub 2016 Feb 15.
  14. Abraha I, Rimland JM, Trotta FM, Dell'Aquila G, Cruz-Jentoft A, Petrovic M, et al. Systematic review of systematic reviews of non-pharmacological interventions to treat behavioural disturbances in older patients with dementia. BMJ Open. 2017 Mar 16;7(3):e012759. doi: 10.1136/bmjopen-2016-012759.
  15. Falkensteiner M, Mantovan F, Muller I, Them C. The use of massage therapy for reducing pain, anxiety, and depression in oncological palliative care patients: a narrative review of the literature. ISRN Nurs. 2011;2011:929868. doi: 10.5402/2011/929868. Epub 2011 Aug 23.
  16. Brett L, Traynor V, Stapley P. Effects of Physical Exercise on Health and Well-Being of Individuals Living With a Dementia in Nursing Homes: A Systematic Review. J Am Med Dir Assoc. 2016 Feb;17(2):104-16. doi: 10.1016/j.jamda.2015.08.016. Epub 2015 Oct 1.
  17. Chan CL, Wang CW, Ho RT, Ng SM, Chan JS, Ziea ET, et al. A systematic review of the effectiveness of qigong exercise in supportive cancer care. Support Care Cancer. 2012 Jun;20(6):1121-33. doi: 10.1007/s00520-011-1378-3. Epub 2012 Jan 19.
  18. Wood MJM, Molassiotis A, Payne S. What research evidence is there for the use of art therapy in the management of symptoms in adults with cancer? A systematic review. Psychooncology. 2011 Feb;20(2):135-45. doi: 10.1002/pon.1722.
  19. Moyle W, Murfield JE, O'Dwyer S, Van Wyk S. The effect of massage on agitated behaviours in older people with dementia: a literature review. J Clin Nurs. 2013 Mar;22(5-6):601-10. doi: 10.1111/j.1365-2702.2012.04234.x. Epub 2012 Nov 20.
  20. Klainin-Yobas P, Oo WN, Suzanne Yew PY, Lau Y. Effects of relaxation interventions on depression and anxiety among older adults: a systematic review. Aging Ment Health. 2015;19(12):1043-55. doi: 10.1080/13607863.2014.997191. Epub 2015 Jan 9.
  21. Armstrong M, Flemming K, Kupeli N, Stone P, Wilkinson S, Candy B. Aromatherapy, massage and reflexology: A systematic review and thematic synthesis of the perspectives from people with palliative care needs. Palliat Med. 2019 Jul;33(7):757-769. doi: 10.1177/0269216319846440. Epub 2019 May 6.
  22. Chung VC, Wu X, Lu P, Hui EP, Zhang Y, Zhang AL, et al. Chinese Herbal Medicine for Symptom Management in Cancer Palliative Care: Systematic Review And Meta-analysis. Medicine (Baltimore). 2016 Feb;95(7):e2793. doi: 10.1097/MD.0000000000002793.
  23. Cwiekała-Lewis KJ, Gallek M, Taylor-Piliae RE. The effects of Tai Chi on physical function and well-being among persons with Parkinson's Disease: A systematic review. J Bodyw Mov Ther. 2017 Apr;21(2):414-421. doi: 10.1016/j.jbmt.2016.06.007. Epub 2016 Jun 16.
  24. Du S, Dong J, Zhang H, Jin S, Xu G, Liu Z, et al. Taichi exercise for self-rated sleep quality in older people: a systematic review and meta-analysis. Int J Nurs Stud. 2015 Jan;52(1):368-79. doi: 10.1016/j.ijnurstu.2014.05.009. Epub 2014 May 28.
  25. Gall A, Leske S, Adams J, Matthews V, Anderson K, Lawler S, Garvey G. Traditional and Complementary Medicine Use Among Indigenous Cancer Patients in Australia, Canada, New Zealand, and the United States: A Systematic Review. Integr Cancer Ther. 2018 Sep;17(3):568-581. doi: 10.1177/1534735418775821. Epub 2018 May 21.
  26. Gao Y, Wei Y, Yang W, Jiang L, Li X, Ding J, Ding G. The Effectiveness of Music Therapy for Terminally Ill Patients: A Meta-Analysis and Systematic Review. J Pain Symptom Manage. 2019 Feb;57(2):319-329. doi: 10.1016/j.jpainsymman.2018.10.504. Epub 2018 Oct 30.
  27. MacDonald JM, Barrett D. Companion animals and well-being in palliative care nursing: a literature review. J Clin Nurs. 2016 Feb;25(3-4):300-10. doi: 10.1111/jocn.13022. Epub 2015 Nov 1.
  28. McConnell T, Scott D, Porter S. Music therapy for end-of-life care: An updated systematic review. Palliat Med. 2016 Oct;30(9):877-83. doi: 10.1177/0269216316635387. Epub 2016 Mar 4.
  29. Mochamat, Cuhls H, Marinova M, Kaasa S, Stieber C, Conrad R, Radbruch L, Mücke M. A systematic review on the role of vitamins, minerals, proteins, and other supplements for the treatment of cachexia in cancer: a European Palliative Care Research Centre cachexia project. J Cachexia Sarcopenia Muscle. 2017 Feb;8(1):25-39. doi: 10.1002/jcsm.12127. Epub 2016 Jul 20.
  30. Patel NK, Newstead AH, Ferrer RL. The effects of yoga on physical functioning and health related quality of life in older adults: a systematic review and meta-analysis. J Altern Complement Med. 2012 Oct;18(10):902-17. doi: 10.1089/acm.2011.0473. Epub 2012 Aug 21.
  31. Towler P, Molassiotis A, Brearley SG. What is the evidence for the use of acupuncture as an intervention for symptom management in cancer supportive and palliative care: an integrative overview of reviews. Support Care Cancer. 2013 Oct;21(10):2913-23. doi: 10.1007/s00520-013-1882-8. Epub 2013 Jul 19.
  32. Tsoi KKF, Chan JYC, Ng YM, Lee MMY, Kwok TCY, Wong SYS. Receptive Music Therapy Is More Effective than Interactive Music Therapy to Relieve Behavioral and Psychological Symptoms of Dementia: A Systematic Review and Meta-Analysis. J Am Med Dir Assoc. 2018 Jul;19(7):568-576.e3. doi: 10.1016/j.jamda.2017.12.009. Epub 2018 Feb 1.
  33. Zhao K, Bai ZG, Bo A, Chi I. A systematic review and meta-analysis of music therapy for the older adults with depression. Int J Geriatr Psychiatry. 2016 Nov;31(11):1188-1198. doi: 10.1002/gps.4494. Epub 2016 Apr 19.
  34. Candy B, Armstrong M, Flemming K, Kupeli N, Stone P, Vickerstaff V, Wilkinson S. The effectiveness of aromatherapy, massage and reflexology in people with palliative care needs: A systematic review. Palliat Med. 2020 Feb;34(2):179-194. doi: 10.1177/0269216319884198. Epub 2019 Oct 29.
  35. Latorraca COC, Martimbianco ALC, Pachito DV, Pacheco RL, Riera R. Mindfulness for palliative care patients. Systematic review. Int J Clin Pract. 2017 Dec;71(12). doi: 10.1111/ijcp.13034. Epub 2017 Nov 6.
  36. Deshmukh SR, Holmes J, Cardno A. Art therapy for people with dementia. Cochrane Database Syst Rev. 2018 Sep 13;9(9):CD011073. doi: 10.1002/14651858.CD011073.pub2.
  37. Fernández-Jané C, Vilaró J, Fei Y, Wang C, Liu J, Huang N, et al. Acupuncture techniques for COPD: a systematic review. BMC Complement Med Ther. 2020 May 6;20(1):138. doi: 10.1186/s12906-020-02899-3.
  38. Forrester LT, Maayan N, Orrell M, Spector AE, Buchan LD, Soares-Weiser K. Aromatherapy for dementia. Cochrane Database Syst Rev. 2014 Feb 25;(2):CD003150. doi: 10.1002/14651858.CD003150.pub2.
  39. von Trott P, Oei SL, Ramsenthaler C. Acupuncture for Breathlessness in Advanced Diseases: A Systematic Review and Meta-analysis. J Pain Symptom Manage. 2020 Feb;59(2):327-338.e3. doi: 10.1016/j.jpainsymman.2019.09.007. Epub 2019 Sep 18.
  40. Yan X, Yan Z, Liu W, Ding H, Qiao S, Chen G, et al. External application of traditional Chinese medicine in the treatment of bone cancer pain: a meta-analysis. Support Care Cancer. 2016 Jan;24(1):11-7. doi: 10.1007/s00520-015-2737-2. Epub 2015 Apr 19.
  41. Yang J, Zhu L, Wu Z, Wang Y. Chinese herbal medicines for induction of remission in advanced or late gastric cancer. Cochrane Database Syst Rev. 2013 Apr 30;(4):CD005096. doi: 10.1002/14651858.CD005096.pub4.
  42. Yanju B, Yang L, Hua B, Hou W, Shi Z, Li W, et al. A systematic review and meta-analysis on the use of traditional Chinese medicine compound kushen injection for bone cancer pain. Support Care Cancer. 2014 Mar;22(3):825-36. doi: 10.1007/s00520-013-2063-5. Epub 2013 Nov 26.
  43. Zhang Y, Cai J, An L, Hui F, Ren T, Ma H, et al. Does music therapy enhance behavioral and cognitive function in elderly dementia patients? A systematic review and meta-analysis. Ageing Res Rev. 2017 May;35:1-11. doi: 10.1016/j.arr.2016.12.003. Epub 2016 Dec 23.
  44. Hauser W, Fitzcharles MA, Radbruch L, Petzke F. Cannabinoids in Pain Management and Palliative Medicine - An Overview of Systematic Reviews and Prospective Observational Studies. Dtsch Arztebl Int. 2017 Sep 22;114(38):627-634. doi: 10.3238/arztebl.2017.0627.
  45. Hsu CH, Chi CC, Chen PS, Wang SH, Tung TH, Wu SC. The effects of aromatherapy massage on improvement of anxiety among patients receiving palliative care: A systematic review of randomized controlled trials. Medicine (Baltimore). 2019 Mar;98(9):e14720. doi: 10.1097/MD.0000000000014720.
  46. Montgomery GH, Sucala M, Baum T, Schnur JB. Hypnosis for Symptom Control in Cancer Patients at the End-of-Life: A Systematic Review. Int J Clin Exp Hypn. 2017 Jul-Sep;65(3):296-307. doi: 10.1080/00207144.2017.1314728.
  47. Song S, Yu J, Ruan Y, Liu X, Xiu L, Yue X. Ameliorative effects of Tai Chi on cancer-related fatigue: a meta-analysis of randomized controlled trials. Support Care Cancer. 2018 Jul;26(7):2091-2102. doi: 10.1007/s00520-018-4136-y. Epub 2018 Mar 21.
  48. Watson K, Chang E, Johnson A. The efficacy of complementary therapies for agitation among older people in residential care facilities: a systematic review. JBI Libr Syst Rev. 2012;10(53):3414-3486.
  49. Livingston G, Kelly L, Lewis-Holmes E, Baio G, Morris S, Patel N, et al. A systematic review of the clinical effectiveness and cost-effectiveness of sensory, psychological and behavioural interventions for managing agitation in older adults with dementia. Health Technol Assess. 2014 Jun;18(39):1-226, v-vi. doi: 10.3310/hta18390.
  50. Albrecht TA, Taylor AG. Physical activity in patients with advanced-stage cancer: a systematic review of the literature. Clin J Oncol Nurs. 2012 Jun 1;16(3):293-300. doi: 10.1188/12.CJON.293-300.
  51. Danhauer SC, Addington EL, Sohl SJ, Chaoul A, Cohen L. Review of yoga therapy during cancer treatment. Support Care Cancer. 2017 Apr;25(4):1357-1372. doi: 10.1007/s00520-016-3556-9. Epub 2017 Jan 7.
  52. Frisk JW, Hammar ML, Ingvar M, Spetz Holm AC. How long do the effects of acupuncture on hot flashes persist in cancer patients? Support Care Cancer. 2014 May;22(5):1409-15. doi: 10.1007/s00520-014-2126-2. Epub 2014 Jan 30.
  53. Shennan C, Payne S, Fenlon D. What is the evidence for the use of mindfulness-based interventions in cancer care? A review. Psychooncology. 2011 Jul;20(7):681-97. doi: 10.1002/pon.1819. Epub 2010 Aug 4.
  54. Yarom N, Hovan A, Bossi P, Ariyawardana A, Jensen SB, Gobbo M, et al. Systematic review of natural and miscellaneous agents for the management of oral mucositis in cancer patients and clinical practice guidelines-part 1: vitamins, minerals, and nutritional supplements. Support Care Cancer. 2019 Oct;27(10):3997-4010. doi: 10.1007/s00520-019-04887-x. Epub 2019 Jul 8. Erratum in: Support Care Cancer. 2021 Jul;29(7):4175-4176.
  55. Zeng YS, Wang C, Ward KE, Hume AL. Complementary and Alternative Medicine in Hospice and Palliative Care: A Systematic Review. J Pain Symptom Manage. 2018 Nov;56(5):781-794.e4. doi: 10.1016/j.jpainsymman.2018.07.016. Epub 2018 Aug 2.
  56. Kasper S. Phytopharmaceutical treatment of anxiety, depression, and dementia in the elderly: evidence from randomized, controlled clinical trials. Wien Med Wochenschr. 2015 Jun;165(11-12):217-28. doi: 10.1007/s10354-015-0360-y. Epub 2015 Jun 20.
  57. Gerdner LA, Buckwalter KC. Musical Memories: translating evidence-based gerontological nursing into a children's picture book. J Gerontol Nurs. 2013 Jan;39(1):32-41. doi: 10.3928/00989134-20121204-01. Epub 2012 Dec 13.
  58. Watson MS, Ward S, Vallath N, Wells J, Campbell R, editors. Oxford handbook of palliative care. 3rd ed. New York: Oxford University Press; 2019.
  59. Kogan M, Cheng S, Rao S, DeMocker S, Koroma Nelson M. Integrative Medicine for Geriatric and Palliative Care. Med Clin North Am. 2017 Sep;101(5):1005-1029. doi: 10.1016/j.mcna.2017.04.013.