Complementary/Alternative Therapy Use in Older Women with Arthritis

275Research in Gerontological Nursing Vol. 5, No. 4, 2012

Empirical Research

Complementary/Alternative Therapy Use in Older Women with Arthritis

Corjena Cheung, PhD, RN

ABSTRACT

The purpose of this study was to describe the experiences of using complementary/alternative therapy

(C/AT) in community-dwelling older women with arthritis. A descriptive qualitative approach using focus

groups for data collection was conducted with a purposive sample of 27 older female C/AT users (mean

age = 77.8, range = 65 to 93). Content analysis was used to identify themes, which included (a) acceptance

of the incurable nature of arthritis, (b) high use of nutritional supplements, (c) use of multiple C/AT to man-

age symptoms, (d) physical symptoms and limited treatment options motivated C/AT use, (e) most C/AT

were perceived as effective, (f ) C/AT knowledge was limited among users, and (g) older women did not fully

disclose their C/AT use to their primary care physician. Findings revealed that older women are motivated

to use C/AT, particularly nutritional supplements, to manage arthritis symptoms without seeking medical

advice from their physician. Strategies are needed to improve communication between health care provid-

ers and older patients on C/AT use for optimal management of arthritis and prevention of adverse events.

At the time this article was written, Dr. Cheung was Associate Professor, Department of Nursing, St. Catherine University, St. Paul, Minnesota.

The author has disclosed no potential conflicts of interest, financial or otherwise. This project was funded by the National Institutes of Health-

Extramural Associates Research Development Award (EARDA) pilot research grant. The author thanks her mentors Dr. Jean Wyman and Dr. Cynthia

Peden-McAlpine for their guidance in the development and dissemination of this study, and to all of the activity directors from the community/

senior centers for their help in recruiting study participants. This article was originally submitted for the 10 Years of Geriatric Nursing Through the

BAGNC Program special issue, published in January 2012.

Address correspondence to Corjena Cheung, PhD, RN, Assistant Professor, School of Nursing, University of Minnesota, 5-135 Weaver-Densford

Hall, 308 Harvard Street SE, Minneapolis, MN 55455; e-mail: [email protected].

Received: May 17, 2011; Accepted: January 27, 2012; Posted: September 17, 2012

doi:10.3928/19404921-20120906-06

Arthritis is a highly prevalent chronic condition, with an estimated 50 million adults in the United States report-ing having some form of the condition (Centers for Dis-ease Control and Prevention, 2012). It encompasses more than 100 conditions that affect joints, the surrounding tis-sues, and other connective tissues. Rheumatoid arthritis (RA) and osteoarthritis (OA) are the two most common forms of arthritis and are the leading causes of disability among older adults (Arthritis Foundation, 2011).

The drug options for arthritis are limited. The medical approach currently offers no effective cure for arthritis; most provide only transient relief and do not modify the course of the disease. Side effects from pharmacological therapies remain a concern. General symptoms of arthritis include pain, swelling, limited joint function, fatigue, symptoms of distress by body part, and psychosocial issues. Acetamino-phen (e.g., Tylenol), a popular over-the-counter analgesic medication for arthritis pain, is associated with hepatic side

276 Copyright SLACK Incorporated

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effects (Zhang et al., 2010). Nonsteroidal anti-inflammatory drugs (NSAIDs), such as aspirin (e.g., Bayer), ibuprofen (e.g., Advil, Motrin), and naprosyn (e.g., Naproxen), are a mainstay of arthritis pain management but carry sig-nificant dose-related risks of adverse events such as reduced renal blood flow and renal toxicity (Barkin & Buvanendran, 2004). They are also associated with hypocoagulability, par-ticularly gastrointestinal bleeding, gastritis, peptic ulcers, and perforation in older adults (Hippisley-Cox, Coupland, & Logan, 2005). Rofecoxib (Vioxx), a type of NSAID, has been withdrawn from the marketplace since 2004 for seri-ous cardiovascular problems. Other NSAIDs, such as cele-coxib (Celebrex) and diclofenac (Voltaren), have been as-sociated with increased risk of stroke (Caughey, Roughead, Pratt, Killer, & Gilbert, 2011). Serious infections and con-gestive heart failure have also been linked with medications for RA and psoriatic arthritis, such as etanercept (Enbrel) (Donahue et al., 2008). In addition, older adults require spe-cial considerations when any pharmacological agent is used due to potential pharmacokinetic and pharmacodynamic interactions from age-related physiological changes and as-sociated comorbidities.

Although sex differences exist in both the prevalence of arthritis among older people and the rates of arthritis-based consequences and disability (Mili, Helmick, & Zack, 2002; Peek & Coward, 1999), there is limited literature on symp-tom experience and management by sex. Two phenom-enological studies on the experiences of older women and men managing fecal incontinence demonstrated vast differ-ences in experiences and symptom management between older women and men (Peden-McAlpine, Bliss, Becker, & Sherman, 2012; Peden-McAlpine, Bliss, & Hill, 2008). One survey reported that older women used a greater variety of C/AT to manage their health than their male counterparts (Cheung, Wyman, & Halcon, 2007). The current study will focus on older women, as the experiences of men and older women with arthritis using C/AT may be different.

BACKGROUNDArthritis was recently reported to be one of the most

common health conditions that is treated with C/AT (Cheung et al., 2007; Quandt et al., 2005; Sleath, Callahan, Devellis, & Beard, 2008). In this study, C/AT is defined as a group of health treatments or remedies that are used outside of, or in combination with, conventional medicine. C/AT has gained attention in the United States in the past decade because of its widespread use. Established by Con-gress in 1998, the National Center for Complementary and Alternative Medicine (http://nccam.nih.gov) was created

to conduct and sponsor C/AT research. With the incorpo-ration of C/AT in the covered services provided by some major health insurers and with complementary health care products such as herbal and nutritional supplements readily available at the supermarkets, these health care ap-proaches are more popular to the general public. Individu-als with arthritis are willing to explore unconventional in-terventions to relieve pain and improve physical function. The Arthritis Foundation (2011) noted that more than $3 billion is spent annually for unproven arthritis treatments.

Nonpharmacological arthritis treatments such as edu-cation about the disease; physical therapies; orthotic de-vices; and self-management strategies, including healthy life habits, weight control, regular physical activity, and ex-ercise, are commonly delivered by health care profession-als as part of arthritis care. C/AT such as herbal products, nutritional supplements, and movement-based and other mind-body interventions are not routinely prescribed by health care providers but are used extensively by patients for arthritis management (Ernst, 2008; Reid et al., 2008). Current knowledge on the use of C/AT for arthritis is mostly informed by efficacy studies. A systematic review of C/AT for arthritis-related pain reported that acupunc-ture; herbal remedies, including devils claw, avocado/soybean unsaponifiables, phytodolor, and capsaicin; and supplements including chondroitin, glucosamine, and S-adenosyl-L-methionine (SAMe) were effective in relieving the pain of OA, and gamma linolenic acid for RA (Soeken, 2004). However, knowledge and experience of using C/AT among older adults with arthritis has not been investigated.

LITERATURE REVIEWLiterature examining the use of C/AT for arthritis man-

agement in older adults is slowly on the rise. A secondary analysis from a large population-based survey (N = 30,785) reported that biologically based therapies (i.e., herb use, folk medicine, chelation therapy, special diets, or megavi-tamins) were the most frequently reported modalities used by older adults with arthritis (Quandt et al., 2005). Alter-native medical systems (i.e., Traditional Chinese Medicine, ayurveda, homeopathy, and naturopathy) were the least commonly used. Yoga, tai chi, and qigong was the specific category of C/AT that was used by the highest proportion of individuals for arthritis treatment. However, the study also found that most of the older adults used C/AT for condi-tions other than arthritis. It is unclear whether older adults with arthritis have more comorbidities or whether they are more proactive about their health than those without the condition. Pain and poor functional status were the most



common predictors of C/AT use (Quandt et al., 2005). Us-ing phenomenological analysis, Sale, Gignac, and Hawker (2006) also found that despite reports of pain, only 21% of older adults with OA take their pain medications and 95% reported using at least one herbal remedy for their arthritis. Two themes were generated from this study: Ad-herence to pain medication differs from other prescribed medications, and perceptions and attitudes toward pain play an integral role in adherence to pain medication.

One study focusing on the use of unconventional arthri-tis therapies in 219 rural adults (age range = 32 to 86) from North Carolina reported that religion and ointments were the most widely used remedies. Rural adults were skeptical about the effectiveness of almost all of the C/AT in the study, including religion, ointments, turpentine, special foods, whiskey, and special jewelry, except for special clothing, in-dicating that rejection of unconventional remedies that fail is widespread (Arcury, Gesler, & Cook, 1999).

As many C/AT are becoming more widely accepted, old-er patients are increasingly likely to be receiving care from physicians and using C/AT at the same time, often for treat-ing the same condition. It is critical for health care providers to better understand the experience of their C/AT use. Not only is arthritis a highly prevalent condition among older women, they tend to use herbal products as well as multiple prescribed and nonprescribed drugs as part of their health care practice (Yoon & Horne, 2004). This places them at risk for drug-herb interaction. Knowledge of C/AT use in older women with arthritis will be especially useful for health care professionals to deliver safer and more effective arthritis care. A descriptive qualitative approach was used to reveal the commonalities and differences in the experiences of older women using C/AT to manage arthritis.

The overall aim of the study was to understand the expe-riences of using C/AT in community-dwelling older women with arthritis. Other more specific aims were to explore: (a) the impact of arthritis on the lives of older women; (b) the types of C/AT used and factors that affect their decision to use C/AT; (c) the perception of effectiveness of different C/AT in managing arthritis; and (d) the level of knowledge related to benefits and risks associated with C/AT use.

METHODDesign

A descriptive qualitative approach using focus groups for data collection was selected for this study. Focus groups allow the researcher to get a group think perspective on the older womens experiences of arthritis using C/AT. In-stead of collecting isolated views from individual women,

focus groups invited members to open up, think deeply, and interact with each other to paint a portrait of a com-mon, combined shared perspective. Specific questions to answer the research aims were composed and asked in an interactive group setting where older women felt free to interact with other group members. A total of four focus group sessions with different older women in each group were held between June and August 2007. Five to 9 par-ticipants were in each group, which is the recommended number for focus groups, as suggested by Morgan (1997).

Ethical ConsiderationsThis study was approved by the Institutional Review

Board of the participating university. Potential participants were contacted via telephone by a research team member after recruitment indicating interest in the study. At that time the participants eligibility for participation in the study using the inclusion criteria was confirmed, demographic in-formation was collected, and the informed consent process, as well as all of the rights guaranteed to participants, were explained. Any questions the participants had about the in-formed consent process were answered by the investigator. Written consent was obtained from each older woman be-fore every focus group meeting began. The participants were informed that they did not have to answer any question and could withdraw from the study at any time. Any reference to names and places were removed during transcription, and transcripts were given a numerical code to maintain confi-dentiality. Transcripts were locked in the researchers office and only the researchers had access to the transcripts. Each participant was provided an honorarium of $25.

Sampling and RecruitmentA purposive sample of 27 community-dwelling older

women who volunteered and met the inclusion criteria par-ticipated in the study. Participants were recruited from Min-neapolis/St. Paul, Minnesota via flyers explaining the study that were posted at various community locations including health food stores, senior high-rise apartment buildings, a convent, and churches. The flyers included instructions to contact the researcher if they were interested in the study. Another method of recruitment included referral from em-ployees at senior community centers, senior programs, and senior gatherings. The designated employee read the flyer to potential participants who were then asked to provide con-tact information to the employee if they were interested in participating in the study. In an effort to recruit older women from diverse racial and ethnic backgrounds, the majority of recruitment took place in inner cities and the metropolitan


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area. The following inclusion criteria were used for selection of a purposive sample: women who (a) were 65 and older; (b) were community dwelling (non-institutionalized indi-viduals who have access to C/AT and are able to make health care choices); (c) had been diagnosed with arthritis for at least 1 year; (d) reported symptoms and experiences related to their arthritis such as pain, disability, and decreased social activities; and (e) were using at least one form of C/AT to manage their arthritis symptoms.

Data Collection The literature and the research teams knowledge of older

womens experiences of arthritis were used to develop the fo-cus group questions. Because older adults are more familiar with the term alternative medicine, this term was used instead of C/AT in the focus group questions. Examples of the ques-tions included: What is it like living with arthritis? Which alternative medicine(s) have you used to manage arthritis? What made you decide to use alternative medicine? How did you get information about alternative medicine? Did you talk to your physician about your alternative medicine use?

A research assistant contacted potential participants by telephone 1 week before and also 1 day prior to the focus group meeting to confirm the date, time, and place of the fo-cus group. At that time, potential participants were instructed to reflect on their experience of using C/AT to manage arthri-tis. Each focus group lasted approximately 1 to 1.5 hours. An official welcome and a brief introduction to the study were offered at the beginning of each meeting. Two audiorecording devices at each end of the table were used to record the meet-ing process. Each older woman was given a name tag with her first name printed to facilitate member discussion.

The moderator of the focus groups used the focus group questions outlined above to initiate open-ended discussions on issues related to the older womens experience and percep-tions of arthritis, factors that influenced their C/AT use, as well as the experience of using C/AT in managing arthritis. The principal investigator (PI, C.C.), who has background and experience in gerontology and focus group methodology, served as the moderator for all groups. She maintained the groups focus by asking the same guiding questions and ask-ing other questions for the purpose of clarifying information. To avoid educating the focus group participants during the sessions, the moderator maintained a nonbiased position and clarified terms only to facilitate discussion.

Two research assistants took field notes during all focus group meetings to identify speakers and their behaviors dur-ing the focus groups. The notes included the following impor-tant components: participant characteristics, phrases or words

used by the older women as they discussed the key question, enthusiasm, body language, and the overall mood of the dis-cussion. The moderator and research assistants compared notes, shared observations, and talked about the older wom-ens responses to key questions at the end of each meeting.

Because qualitative research is an interactive process, focus group questions were modified slightly after each fo-cus group with some changes in emphasis on the questions being introduced to explore issues that surfaced in prior focus groups. The audiorecorded sessions were transcribed verbatim by the two research assistants. The transcripts were checked by the PI for accuracy against the recordings.

Data AnalysisThe focus group analysis used the content analysis tech-

niques suggested by Krueger and Casey (2009). The ana-lytic process was essentially inductive in nature, with codes and categories emerging from the languages and ideas of the focus group participants. The focus of the analysis was on group responses rather than responses of individuals. Data collection and analysis were performed simultane-ously and continuously. The content analysis approach included the following steps, which included the PI along with both research assistants: l Independently read all transcripts reflecting the entire

description of the experience to get a sense of the whole and identified transitions and possible codes.

l After discussion of the codes, the team collapsed codes into common categories within and across groups in re-sponse to the key questions (experience of living with arthritis, types of C/AT used, reasons for C/AT usage, knowledge about C/AT) (e.g., the different C/AT modal-ities such as fish oil, massage, or acupuncture were iden-tified and coded). After merging all redundant codes (e.g., "heat" and "hot pack"), links were used to connect to codes that represent purposes. They were then col-lapsed into the type of C/AT used category.

l More abstract themes were then identified from com-mon categories, and descriptors were written to convey the meaning of each theme.

l Text exemplifying the common experience of the older women was isolated to illustrate each theme.

Considerations of RigorIn this study, methods to increase the trustworthiness

and credibility of the work included:l Two experienced researchers in National Institutes of

Health-funded C/AT and qualitative studies served as consultants in the study.



l Guided questions were developed and used in each fo-cus group.

l The same experienced moderator was used in all four focus group sessions.

l The transcribed sessions from the four groups were sim-ilar in character.

l The steps used in the identification of codes, categories, and themes were recorded to enable the research team to retrace the trail of the analysis.

l The assumptions and biases of the research team mem-bers, including the prevalence of C/AT use and personal experiences with certain modalities, were examined and considered throughout the analysis process.

FINDINGS A total of 27 older women participated in the study. The

mean age of the women was 77.8 (SD = 8.2 years, age range = 65 to 93). The sample included White/Caucasian (n = 23) and Black/African American women (n = 4), with a major-ity having a high school (n = 16) or college (n = 9) educa-tion. Most were widowed (n = 23) and living alone (n = 18). The annual household income levels ranged from


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stickler on everything at home, you knowclean. Now when I drop something, I just leave it there.

Type of C/AT Used and Influencing Factors A wide variety of C/AT nutritional supplements in

particularwas reported being used for arthritis by older women in all groups (Table). Nutritional supplements, es-pecially glucosamine, were used by older women in all four focus groups for improving joint health. Other self-help modalities, including plant-based creams and ointments, were most commonly used for pain relief and mobility improvement. Occasional visits were made to chiroprac-tors, acupuncturists, and massage therapists for arthritis and musculoskeletal problems. A majority of participants reported using a combination of C/AT at the same time.

Having symptoms, particularly pain, was frequently mentioned as the influencing factor for using C/AT. Other factors included limited treatment options, side effects of drugs, and a desire to stay active and independent. The older women discussed a preference for a combination of alternative with traditional therapies to treat their arthritis: l When you are having pain, you want to do something

about it.l Because the medications didnt really do anything for

me but make my stomach upset.l My body doesnt like [medication], I take it only when

the pain gets really bad.l I wish my doctor would go a bit more on the alternative

side [alternative therapies]. Combining the two medi-cines would be great. The group of older women from a convent and two church-

es (Group 2) reported using the greatest variety of C/AT, in particular mind-body interventions such as prayer, guided im-agery, and meditation for arthritis symptoms. Only one of the four focus groups included older women from a diverse ethnic background (Group 3). All four Black/African American old-er women in that group mentioned using plant-based creams and rubs for their arthritis symptoms. One of them reported using a product that contains mineral spirits and petroleum gas to lubricate the joints. The group of older women who belonged to a healthy senior program (Group 4) used a variety of C/AT for arthritis as well as for general health (Table).

Only 3 of the 27 older women used solely herbal and nutritional supplements to manage their arthritis and oth-er health problems. These three reported having negative experiences with conventional care in the past but found success using supplements in managing their arthritis and health. The rest of the older women used C/AT in conjunc-tion with traditional Western medicine approaches.

Perception of Effectiveness of Most C/AT in Managing Arthritis

A majority of older women were satisfied with their C/AT use and believed that they were convenient and ef-fective, as evidenced by the following quotes:l Its just cream but it works. It doesnt stop the pain right

away but pretty soon you know its like, hey, I dont hurt anymore.

l I get most of my supplements from a catalog and some from a drug store when they are on sale.

l Ive been taking herbs for many years and I think thats really kind of helped the whole situation.Many older women reported using C/AT inconsistent-

ly. Some expressed concerns with the cost and accessibility of using C/AT, especially those that required an alternative medical practitioner and that were not covered by insur-ance, such as massage therapy, chiropractic medicine, or acupuncture. Older women reported they could only use these C/AT on an as-needed basis. Others were skeptical about the effectiveness of some C/AT such as herbal sup-plements, aromatherapy, and magnets: I dont know, its like when they say this is helpful, howd you know, youd have to eliminate everything else to know it was beneficial. Change of insurance, cost, being impatient, feeling better, or having other health problems were reported to be relat-ed to their inconsistent C/AT use: I thought, well, maybe this isnt working and it costs a lot, so I quit.

Despite the popular use of glucosamine in arthritis management among the older women, 2 participants ex-pressed experiencing serious side effects while taking the supplement. One complained of dizziness, and the other experienced elevated blood pressure. As a result, both par-ticipants stopped taking any kind of glucosamine.

Level of Knowledge Related to Benefits and Risks Associated with C/AT Use

In general, many older women were uncertain if over-the-counter nonprescription drugs, such as Aleve (naproxen), were C/AT: I take Aleve every day, is that al-ternative medicine? Many did not know much about the benefits and risks associated with their choice of C/AT, say-ing I dont know what is in this cream, it works and I dont think itll hurt to try. Many participants did not seek any medical advice before experimenting and used C/AT based on the recommendations of family and friends, stat-ing, My friend told me WD-40 works, so I tried it [topi-cally] to help loosen my joints and My son told me to take it [herbal supplement] for my arthritis, cholesterol, and everything. The low level of knowledge also applied



to older womens medication use: Ive got a whole list of them [medications] that I cant pronounce half of them.

The primary source of C/AT information was from family and friends. It is noteworthy that although many older women did not seek medical advice before experi-menting with C/AT, some received C/AT information from their physicians/nurses who were supportive of C/AT use. Advertisements from television commercials, health literature, and catalogs were other information sources about C/AT reported by participants.

A small number of participants were knowledgeable about their C/AT use, especially the three older women who only used C/AT for their arthritis. Most of the participants in one of the focus groups who were highly educated offered the most information about their C/AT use during the discussion: The jade rollers apply pressure to the acupressure points to unlock meridians to increase energy. They follow the natural curva-ture of the spine. Many older women were surprised to learn about the different C/AT that were discussed during the focus group meetings and were willing to experiment with them. Almost everyone in one of the focus groups tried the herbal cream that was brought to the meeting by one participant for show and tell.

Most participants did not discuss their C/AT use with their primary care physician unless they were taking both oral supplements and medications: Youre supposed to get your doctors permission if you take anything. Some expressed concerns with their physicians limited interest/knowledge of C/AT and disapproval of their C/AT use. Therefore, they pur-posely did not bring it up during clinic visits, stating, I dont tell my doctor because he would not go for any of this stuff, he isnt interested and He would laugh if I told him I pray for my arthritis. Some thought the limited time spent with their phy-sicians was a barrier to discussing their C/AT use: You know they are squashed into those little small increments, I dont al-ways remember to tell him everything when I am there.

DISCUSSIONArthritis is a common chronic health condition that

has no simple cure. This study adds to the growing body of knowledge on the widespread use of nutritional supple-ments as well as multiple C/AT use to manage symptoms in a small group of older women. Findings from this focus group study reveal that participants accepted the debilitat-ing and incurable nature of arthritis and yet were motivated to experiment with different C/AT strategies and resources to help manage and improve their condition. The finding of high use of nutritional supplements confirms the results of other studies showing that older adults, particularly older

women, use dietary supplements more than other segments of the U.S. population (Kishiyama et al., 2005). Many older women considered cost a barrier to C/AT use. Income level predicted C/AT use in many previous studies (Ryan, Wilson, Taylor, & Greenfield, 2009). People with higher incomes are more frequent C/AT users, particularly in income brackets above $50,000 per year. Although many C/AT products, such as supplements and creams, are cheaper than regular medications, these products, as well as therapies received from C/AT practitioners, are generally not covered by insur-ance. Many older women have limited household income; therefore, it is not surprising that participants in this study found cost a barrier to C/AT use.

Findings from this study show that even though older women were proactive about their health care and a wide variety of C/AT were used by older women for managing arthritis, many C/AT had not been well researched. Their knowledge of C/AT, especially the benefits and risks associ-ated with their choice of C/AT, was far from adequate. The limited treatment options and the desire to be free from pain motivated older women to experiment with different C/AT for arthritis management before medical advice was sought. Consistent with another C/AT study whose pur-pose was to understand patients perceptions about C/AT (Rao, Arick, Mihaliak, & Weinberger, 1998), older women in all focus groups mentioned that, other than physicians and nurses, family and friends were important sources of information about C/AT. This may explain the low level of C/AT knowledge among the older women in this study because family and friends are not trained to offer compre-hensive or evidence-based C/AT information.

The level of C/AT knowledge is highly associated with the individuals educational level and her exposure to C/AT information. Older women from one particular group were individuals with a higher educational level (at least 16 years of education). Increasing educational levels have been found to correlate with higher C/AT use in older adult samples (Arcury, Quandt, Bell, & Vitolins, 2002). Some of the older women were members of the citys healthy senior program and received health information via meetings and newsletters on a regular basis. The focus group consisting of older women from the most diverse backgrounds re-ported higher use of C/AT, which is consistent with a re-cent review reporting that C/AT is commonly used among racial and ethnic minorities (Struthers & Nichols, 2004).

IMPLICATIONS FOR PRACTICE In the current study, participants reported high percep-

tions of effectiveness associated with C/AT use, which is


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consistent with findings from other C/AT studies (Cheung et al., 2007; Oldendick et al., 2000). However, most old-er women did not abandon Western medicine for C/AT alone, in keeping with two large-scale population studies that found a majority of patients continue to seek a balance between Western medicine care and select C/AT (Astin, Pelletier, Marie, & Haskell, 2000; Eisenberg et al., 1998). Studies also found that adult C/AT users believe that C/AT combined with conventional medical treatments would help (Barnes, Powell-Griner, McFann, & Nahin, 2004). Research indicated that patients with arthritis wanted the health care staff to adopt a holistic approach to their care and to see the whole person behind the disease and not only the disease (McPherson, Brander, Taylor, & McNaughton, 2001). This perspective is consistent with the philosophy that many of the older women in this study adopted. The multifactorial symptoms of arthritis warrant further exploration of C/AT using a holistic approach to disease management.

Most participants stated that their physician was not fully aware of their use of C/AT unless they were taking both oral supplements and medications. It is noteworthy that even though this may lessen the concern about poten-tial drug-herb adverse interactions, the issue of not being fully aware of what patients were using for self-treatment and the possibility of patients using unproven C/AT pose some major concerns for health care providers.

Many older women in this study expressed that their health care providers do not have the time or interest in hearing about their C/AT use. Simply showing an interest in what patients are doing for self-care by asking specific questions related to C/AT use can be a first step toward developing an open and trusting relationship, thus fostering collaboration and possibly more integrative use of health care services. Another area in which health care providers can increase their competency in arthritis management is to become educated on the C/AT strategies older women use, so that they can more accurately inform patients of the benefits and risks of C/AT.

Findings from this study indicate that there is a need for improved arthritis care and communication about C/AT use between health care professionals and their older patients. The use of C/AT in older women reflects an opportunity for nurses to be better prepared in addressing issues related to safe C/AT use. The need for health care providers to offer informa-tion on safe C/AT and options on how to manage arthritis effectively with C/AT is urgent and driven by consumers.

IMPLICATIONS FOR FUTURE RESEARCH Future research is needed to further explore the role of

C/AT in arthritis management, barriers to C/AT informa-

tion, and the benefits and risks of various C/AT modalities. The differences across groups regarding the specific type of C/AT used warrant further in-depth exploration. Older women in this studys focus groups indicated that they per-ceived benefits from being in a group setting and sharing with each other their arthritis condition and strategies used. Thus, future studies examining the effects of socioemotional outcomes of arthritis support groups are indicated.

LIMITATIONSA few study limitations should be noted. First, because

a number of older women were not certain of the specific type of arthritis they haveand quite a few had both RA and OAthis study included two different diseases, which may limit the usefulness of the findings. Second, despite the spe-cial efforts that were made to recruit diverse older women, only 4 participants were from a non-White/Caucasian back-ground, limiting transferability of the findings across ethnic groups. Third, the findings should be interpreted in light of the limited geographic scope of the study because older women were recruited from a single mid-Western metro-politan area. It is possible that older women from rural areas might offer new insights. Further, this study only examined the experiences of older women, and the experiences and management in arthritis of older men may be very different.

CONCLUSIONThe number of older women in the United States with

arthritis and its associated disabilities is expected to rise substantially in the years to come, resulting in a significant impact not only on individuals but the health care system as a whole. Because arthritis is such a common reason for clinic visits, it is important for health care providers treating these patients to be aware of C/AT use. Older women are motivated to use different C/AT to manage arthritis symp-toms without seeking professional medical advice. Although some C/AT are probably safe and may provide benefits, oth-ers can interact adversely with prescribed therapies. Strate-gies are needed to improve communication between health care providers and older patients on C/AT use. Understand-ing C/AT use in older women with arthritis is essential for providing safe and effective arthritis care.

REFERENCESArcury, T.A., Gesler, W.M., & Cook, H.L. (1999). Meaning in the use

of unconventional arthritis therapies. American Journal of Health Promotion, 14, 7-15. doi:10.4278/0890-1171-14.1.7

Arcury, T.A., Quandt, S.A., Bell, R.A., & Vitolins, M.Z. (2002). Com-plementary and alternative medicine use among rural older adults. Journal of Evidence-Based Complementary & Alternative Medicine, 7, 167-186. doi:10.1177/153321010200700302



Arthritis Foundation. (2011). The heavy burden of arthritis in the U.S. Retrieved from http://www.arthritis.org/facts.php

Astin, J.A., Pelletier, K.R., Marie, A., & Haskell, W.L. (2000). Comple-mentary and alternative medicine use among the elderly persons: One-year analysis of a Blue Shield Medicare supplement. Journals of Gerontology. Series A, Biological Sciences and Medical Sciences, 55, M4-M9. doi:10.1093/gerona/55.1.M4

Barkin, R.L., & Buvanendran, A. (2004). Focus on the COX-1 and COX-2 agents: Renal events of nonsteroidal and anti-inflammatory drugs-NSAIDs. American Journal of Therapeutics, 11, 124- 129.

Barnes, P.M., Powell-Griner, E., McFann, K., & Nahin, R.L. (2004, May 27). Complementary and alternative medicine use among adults: United States, 2002. Advance Data from Vital Health Sta-tistics, Issue 343. Retrieved from http://www.cdc.gov/nchs/data/ad/ad343.pdf

Caughey, G.E., Roughead, E.E., Pratt, N., Killer, G., & Gilbert, A.L. (2011). Stroke risk and NSAIDs: An Australian population-based study. Medical Journal of Australia, 195, 525-529. doi:10.5694/mja11.10055

Centers for Disease Control and Prevention. (2012). ArthritisMeeting the challenge of living well: At a glance 2012. Retrieved from http://www.cdc.gov/nccdphp/publications/aag/arthritis.htm

Cheung, C.K., Wyman, J.F., & Halcon, L.L. (2007). Use of comple-mentary and alternative therapies in community-dwelling older adults. Journal of Alternative and Complementary Medicine, 13, 997-1006.

Donahue, K.E., Gartlehner, G., Jonas, D.E., Lux, L.J., Thieda, P., Jo-nas, B.L.,Lohr, K.N. (2008). Systematic review: Comparative effectiveness and harms of disease-modifying medications for rheumatoid arthritis. Annals of Internal Medicine, 148 , 124-134.

Eisenberg, D.M., Davis, R.B., Ettner, S.L., Appel, S., Wilkey, S., Van Rom-pay, M., & Kessler, R.C. (1998). Trends in alternative medicine use in the United States, 1990-1997: Results of a follow-up national survey. Journal of the American Medical Association, 280, 1569-1575.

Ernst, E. (2008). Complementary treatments in rheumatic diseases. Rheumatic Diseases Clinics of North America, 34, 455-467.

Hippisley-Cox, J., Coupland, C., & Logan, R. (2005). Risk of adverse gastrointestinal outcomes in patients taking cyclo-oxygenase-2 inhibitors or conventional non-steroidal anti-inflammatory drugs: Population based nested case-control analysis. BMJ, 331, 1310-1316. doi:10.1136/bmj.331.7528.1310

Kishiyama, S.S., Leahy, M.J., Zitzelberger, T.A., Guariglia, R., Zajdel, D.P., Calvert, J.F., Jr.,...Oken, B. (2005). Patterns of dietary supple-ment usage in demographically diverse older people. Alternative Therapies in Health and Medicine, 11, 48-53.

Krueger, R., & Casey, M.A. (2009). Focus groups: A practical guide for applied research (4th ed.). Thousand Oak, CA: Sage.

McPherson, K.M., Brander, P., Taylor, W.J., & McNaughton, H.K. (2001). Living with arthritisWhat is important? Disability and Rehabilitation, 23, 706-721.

Mili, F., Helmick, C.G., & Zack, M.M. (2002). Prevalence of arthritis: Analysis of data from the U.S. Behavioral Risk Factor Surveil-lance System, 1996-99. Journal of Rheumatology, 29, 1981-1988.

Morgan, D.L. (1997). Focus groups as qualitative research (2nd ed.). Newbury Park, CA: Sage.

Oldendick, R., Coker, A.L., Wieland, D., Raymond, J.I., Probst, J.C., Schell, B.J., & Stoskopf, C.H. (2000). Population-based survey of complementary and alternative medicine usage, patient satisfac-tion, and physician involvement. Southern Medical Journal, 93, 375-381.

Peden-McAlpine, C., Bliss, D., Becker, B., & Sherman, S. (2012). The experience of community-living men managing fecal incon-tinence. Rehabilitation Nursing. Advance online publication. doi:10.1002/rnj.38

Peden-McAlpine, C., Bliss, D., & Hill, J. (2008). The experi-ence of community-living women managing fecal incon-tinence. Western Journal of Nursing Research, 30, 817-835. doi:10.1177/0193945907312974

Peek, M.K., & Coward, R.T. (1999). Gender differences in the risk of developing disability among older adults with arthritis. Journal of Aging and Health, 11, 131-150. doi:10.1177/089826439901199201

Quandt, S.A., Chen, H., Grzywacz, J.G., Bell, R.A., Lang, W., & Arcury, T.A. (2005). Use of complementary and alternative medicine by persons with arthritis: Results of the National Health Interview Survey. Arthritis and Rheumatism, 53, 748-755.

Rao, J.K., Arick, R., Mihaliak, K., & Weinberger, M. (1998). Us-ing focus groups to understand arthritis patients perceptions about unconventional therapy. Arthritis Care and Research, 11, 253-260.

Reid, M.C., Papaleontiou, M., Ong, A., Breckman, R., Wething-ton, E., & Pillemer, K. (2008). Self-management strategies to reduce pain and improve function among older adults in com-munity settings: A review of the evidence. Pain Medicine, 9, 409-424.

Ryan, A., Wilson, S., Taylor, A., & Greenfield, S. (2009). Factors as-sociation with self-care activities among adults in the United Kingdom: A systematic review. BMC Public Health, 9. Re-trieved from http://www.biomedcentral.com/1471-2458/9/96/ doi:10.1186/1471-2458-9-96

Sale, J.E., Gignac, M., & Hawker, G.A. (2006). How bad does the pain have to be? A qualitative study examining adherence to pain medication in older adults with osteoarthritis. Arthritis and Rheumatism, 55, 272-278.

Sleath, B., Callahan, L.F., Devellis, R.F., & Beard, A. (2008). Arthritis patients perceptions of rheumatologists participatory decision-making style and communication about complementary and al-ternative medicine. Arthritis and Rheumatism, 59, 416-421.

Soeken, K.L. (2004). Selected CAM therapies for arthritis-related pain: The evidence from systematic reviews. The Clinical Journal of Pain, 20, 13-18.

Struthers, R., & Nichols, L.A. (2004). Utilization of complementary and alternative medicine among racial and ethnic minority pop-ulations: Implications for reducing health disparities. Annual Re-view of Nursing Research, 22, 285-313.

Yoon, S.L., & Horne, C.H. (2004). Perceived health promotion prac-tice by older women: Use of herbal products. Journal of Geronto-logical Nursing, 30(7), 7-15.

Zhang, W., Nuki, G., Moskowitz, R., Abramson, S., Altman, R., Arden, N.K.,Tugwell, P. (2010). OARSI recommenda-tions for the management of hip and knee osteoarthritis: Part III. Osteoarthritis and Cartilage, 18, 476-499. doi:10.1016/j.joca.2010.01.013

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Complementary/Alternative Therapy Use in Older Women with Arthritis

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