1. The Use of Herbs and Supplements Copyright © 2016 by Elsevier, Inc. All rights reserved.

2. 2 * Older adults use a variety of complimentary and alternative therapies, including herbs and supplements * In fact, 38% of American adults (mostly age 50- 59) spend 14.8 billion on these products * Popular examples include fish oil/omega 3 fatty acids, glucosamine, chondroitin, melatonin, echinacea, flax seed, ginseng, ginkgo, and garlic being the most commonly used

3. Copyright © 2016 by Elsevier, Inc. All rights reserved. 3 * Standards in Manufacturing * Regulated by Dietary Supplement Health and Education Act * Herbal manufacturers label herbs as foods * NOT regulated by FDA like “medications” * Good Manufacturing Practices required since 2007 * Preparation and storage, product identification, purity, strength, composition

4. Copyright © 2016 by Elsevier, Inc. All rights reserved. 4 * Different parts of herbs may have uses and actions that are unrelated * Manufactured in several forms * Capsules, extracts, oils, tablets, salves, teas, tinctures * Efficacy varies depending on the form of the parts used and how it is prepared

5. Copyright © 2016 by Elsevier, Inc. All rights reserved. 5 * Teas * Teas are both foods (regulated) and herbs (not regulated) * Research shows that green tea may be beneficial for its antioxidant properties * Consumption of more than recommended amounts of certain teas may cause illness or death

6. Copyright © 2016 by Elsevier, Inc. All rights reserved. 6 * Chamomile * Usually taken in tea form * Primary uses: antiinflammatory and antispasmodic * Promote sleep * Reduce anxiety

7. Copyright © 2016 by Elsevier, Inc. All rights reserved. 7 The teas, herbs, and supplements listed on the following slides are considered to affect coagulation and therefore pose a significant risk, since they are commonly used by older adults

8. Copyright © 2016 by Elsevier, Inc. All rights reserved. 8 * Echinacea * Available commercially as capsules, tea, juice, extract, and tincture * Shown to be effective for the prevention of upper respiratory infections or decreasing their duration by 1-2 days * Adverse reactions include fever, sore throat, diarrhea, nausea and vomiting, abdominal pain, and dry eyes * Persons with human immunodeficiency virus (HIV) or autoimmune disease should use with caution

9. Copyright © 2016 by Elsevier, Inc. All rights reserved. 9 * Garlic * Composed of more than 200 chemicals * Primary active ingredient is a sulfur called allicin * Reported benefits include decreased blood clots and reduced total serum cholesterol and low-density lipoprotein * Possible adverse reactions include severe allergic reactions, increased flatulence, and upper gastrointestinal (GI) irritation with nausea and heartburn

10. Copyright © 2016 by Elsevier, Inc. All rights reserved. 10 * Ginkgo biloba * Prepared as capsules, extracts, and tablets * May benefit cognitive function in dementia; however, there is no scientific evidence that ginkgo impacted cognitive impairment, memory, attention, language, visual-spatial ability, executive functions, or reduced prevalence of dementia and Alzheimer’s disease * Major serious side effect is bleeding

11. Copyright © 2016 by Elsevier, Inc. All rights reserved. 11 The teas, herbs, and supplements listed on the following slides are not associated with bleeding.

12. Copyright © 2016 by Elsevier, Inc. All rights reserved. 12 * Ginseng * Capsules, extracts, tinctures * Improves well-being and helps with stress adaptation * Enhances immunity * Decreases cellular oxidation * Potential side effects (Box 10-1)

13. Copyright © 2016 by Elsevier, Inc. All rights reserved. 13 * Glucosamine and Chondroitin Sulfate * Support cartilage and connective tissue * Typically used for osteoarthritis * Mild antiinflammatory effects * Use with caution in persons with shellfish allergies, diabetes, and asthma

14. Copyright © 2016 by Elsevier, Inc. All rights reserved. 14 * Hawthorn * Extracts, teas, capsules * Used in the treatment of heart disease, digestive, and kidney problems * Reported to increase cardiac output * Antispasmodic and antianxiety effects * Antiinflammatory, reduces lipids, and has diuretic and sedating effects

15. Copyright © 2016 by Elsevier, Inc. All rights reserved. 15  Melatonin  Used as an alternative or adjuvant to sleep medications to promote sleep  Low levels during the day and high during the night improve the quality of sleep and morning wakefulness  May be helpful with jet lag  Available in immediate and extended-release forms  Use with caution in persons taking other medications that can cause drowsiness

16. Copyright © 2016 by Elsevier, Inc. All rights reserved. 16 * Red Yeast Rice * Chemically equivalent and as effective as statins and may be a potential alternative for patients who cannot tolerate statins * Be aware of a contaminant called “citinin,” which can cause kidney failure

17. Copyright © 2016 by Elsevier, Inc. All rights reserved. 17 * St. John’s Wort * Used to treat mild or moderate depression and seasonal affective disorder, anxiety, pain * Metabolized through the cytochrome P450 3A4 enzyme; use with caution if person is on drugs metabolized using the same pathways * Contraindicated with other antidepressant use, especially selective serotonin reuptake inhibitors (SSRIs) * Wait 2 weeks after discontinuing St. John’s wort before beginning an antidepressant

18. Copyright © 2016 by Elsevier, Inc. All rights reserved. 18 * Saw Palmetto * Offers mild to modest symptom improvement for benign prostatic hyperplasia (BPH) * Don’t use with other drugs being used to treat BPH or prostate cancer

19. Copyright © 2016 by Elsevier, Inc. All rights reserved. 19 * Hypertension * Hawthorn used as treatment for hypertension * Caution is urged when erectile dysfunction drugs are used concomitantly with hawthorn because hypotension may result * Dietary calcium in enriched low-fat dairy products taken three times daily may lower blood pressure in moderate hypertension

20. Copyright © 2016 by Elsevier, Inc. All rights reserved. 20 * HIV * Persons with HIV-related symptoms are known to use alternative therapies, including herbs, to assist with symptoms * Use herbals with caution; some products may lower therapeutic drug levels or alter metabolism of antiretrovirals * For example, St. John’s wort may help with depression but lowers blood level of antiretroviral medication

21. Copyright © 2016 by Elsevier, Inc. All rights reserved. 21 * GI Disorders * Chinese have used herbal therapies for thousands of years to treat irritable bowel syndrome * Popular herbals for GI disorders include psyllium, calcium, cranberry, and probiotics * Chronic alcohol-induced and fulminate hepatitis have both been positively affected by the use of milk thistle

22. Copyright © 2016 by Elsevier, Inc. All rights reserved. 22 * Alzheimer's Disease * Ginkgo used by older persons with dementia because it increases blood supply to brain * Improves memory and attention * According to the Alzheimer’s Association, moderate physical activity, drinking tea one to four times a day, and maintaining normal serum vitamin D levels decrease the risk of cognitive decline

23. Copyright © 2016 by Elsevier, Inc. All rights reserved. 23 * Diabetes * Herbal approaches to diabetes management in place before discovery of insulin in 1921 * Approximately 400 different plants affect blood glucose; many still in use * Overall there is not enough evidence to support the use of herbal supplements to treat diabetes

24. Copyright © 2016 by Elsevier, Inc. All rights reserved. 24 * Many herb and supplement products interact with prescription or over-the-counter medications, foods, and/or other herbs and supplements * The more herbs and other drugs that the client is taking, the more likely it is that an interaction will occur

25. Copyright © 2016 by Elsevier, Inc. All rights reserved. 25  Perioperative Assessment * Hypertension, excessive and prolonged bleeding, and increased chance for interactions between herb and other drugs may occur * Herbs that affect bleeding and clotting time, such as garlic, ginger, ginkgo, and ginseng, should be especially noted and reported to surgical team * Select herbs and the perioperative patient (Table 10-1)

26. Copyright © 2016 by Elsevier, Inc. All rights reserved. 26 * Interventions * Education * Check for side effects, adverse reactions, and interactions among herbs, supplements, medications, foods, and illness * Urge discontinuance of possibly harmful products * Provide relevant information and correct use of product as indicated * Refer to person’s usual health care provider

27. Copyright © 2016 by Elsevier, Inc. All rights reserved. 27 * Education * Help elders understand the importance of reporting herb and supplement use * Review aspects of product safety * Discontinue if side effects occur

28. Copyright © 2016 by Elsevier, Inc. All rights reserved. 28 The National Health and Nutrition Examination Survey indicates that the highest use of herbals and supplements were among: a. African Americans. b. Asians. c. White Caucasian. d. Hispanic.

29. Copyright © 2016 by Elsevier, Inc. All rights reserved. 29 Which of the following is chemically equivalent to the statins? a. Saw palmetto b. Hawthorn c. Echinacea d. Red yeast rice