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.  Alternative medicine is the term when complementary practices are used in place of conventional medical treatment.  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  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 (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]
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]
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
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.  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.  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.  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. 
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. 
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 people 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.  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. 
Mind-body therapies – mindfulness, music therapy, art therapy, relaxation, sensory therapy, pet therapy, yoga, Tai Chi, hypnosis
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.  Findings 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.  However, a recent review by de Oliveira Cruz Latorraca et al.  which looked at four low level RCT’s found no benefit for older people receiving palliative care.  More robust research is needed in this emerging area. 
Music therapy is now one of the most researched and utilised CM in palliative care.  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.  Watson et al.  reported that music therapy had a significant effect in reducing physical aggressive agitation. Tsoi et al.  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.  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 meta-analysis by Zhao et al.  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.  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. 
Abraha et al.  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. 
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 , and the other study looked at the effects from only one or two sessions. 
Gerdner and Buckwalter  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. 
A review by Wood et al.  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.  More robust research is needed in this 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. 
Livingston et al.  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.  This review also includes the cost-effectiveness of sensory, psychological, and behavioural interventions for managing agitation in older adults with dementia.
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.  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. 
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. Consideration needs to be given to the design of programs to accommodate treatment related symptoms. 
A review and meta-analysis by Du et al.  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.  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. 
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
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.  who identified potential benefits of acupuncture for people with cancer-related symptoms, included pain, nausea, and vomiting. Towler et al.  also found positive indications that acupuncture may be useful for symptoms where treatment is currently limited, such as hot flushes,  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.  findings for the improvement of dyspnoea symptoms , a further review investigating dyspnoea, QoL and anxiety in older people with COPD found no effect. 
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. 
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 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,  pain or QoL for people receiving palliative care.  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. 
Herbal supplements and other natural products
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’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.  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. 
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. 
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 people with gastric cancer 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 people with advanced cancer. The evidence is inconsistent.
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. 
- 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