Aging & Mental Health

Vol. 15, No. 2, March 2011, 267271

Vitamin and herbal extracts use in patients diagnosed with dementia: What do health
professionals know and think?
Naji Tabetab*, Rummana Khanb and Helen Idleb
a

Institute of Postgraduate Medicine, Brighton and Sussex Medical School, University of Brighton,
Mayfield House, Falmer, Brighton BN1 9PH, UK; bCognitive Treatment and Research Unit,
Sussex Partnership NHS Foundation Trust, Brighton, Sussex, UK
(Received 13 January 2010; final version received 28 June 2010)

Objectives: Vitamins and herbal extracts are associated with various side effects, potential serious drug
interactions and mostly unproven efficacy. Yet, research has shown that nearly half of dementia patients are
receiving such medication. Health professionals caring for older people with dementia are central to the safe
management of this practice. Therefore, the aim of this study was to assess the views, knowledge and practices of
professionals in relation to this issue. Such information is essential to identify potential problems and to inform
targeted intervention strategies.
Method: Cross-sectional survey carried out across East Sussex in the UK based on a self-administered postal
questionnaire.
Results: Out of 350 questionnaires sent, 200 responded (57%). Health professionals greatly underestimated the
prevalence of over-the-counter medication use (68% believed that less than 10% of patients receive such
medication) when compared to published data. A considerable minority (38.7%) reported that vitamins and
herbal extracts should be recommended for individuals at risk of developing dementia, despite lack of evidence to
support such use. Further, only 24.4% always or often discussed potential side effects/interactions of these
supplements with their patients.
Conclusion: The views and practices of many health professionals are inconsistent with current best practice.
Many professionals do not appear to enquire routinely about non-prescribed medicinal products and adequate
advice may not be given to patients/carers. The data highlights a significant issue and calls for urgent action
through targeted educational interventions directed not only at dementia patients and their carers, but at health
professionals as well.
Keywords: Alzheimer; dementia; over-the-counter medication; older people; vitamins; herbal extracts

Introduction
Dementia disorders are very common among older
people worldwide and their prevalence is expected to
increase further over the next few decades (Kalaria
et al., 2008). Currently, there is no available cure
although several drugs have been licensed for the
symptomatic treatment of Alzheimers disease (AD)
and other dementias (Emre, Cummings, & Lane, 2007;
Farlow, Miller, & Pejovic, 2008). As a result of the lack
of a curative treatment, a variety of alternative therapies have been used to aid in the management of these
disorders (Gray et al., 2008; Kelley & Knopman, 2008).
In many instances, the proposed therapies have not
been based on evidence-based data established through
randomised controlled trials (RCTs). Nevertheless, in
the recent years there has been a worldwide increased
interest in a variety of vitamins, herbal extracts and
other over-the-counter agents for dementia disorders
and for a host of human ailments. Many of these have
been used in response to the live longer and healthier
messages which associated these substances with health,
longevity and improved memory.
Available evidence supporting a role for vitamins
and herbal extracts in dementia has for the most part
*Corresponding author. Email: n.t.tabet@brighton.ac.uk
ISSN 13607863 print/ISSN 13646915 online
2011 Taylor & Francis
DOI: 10.1080/13607863.2010.513040
http://www.informaworld.com

been based on case reports, observational studies, nonRCTs or very small single-centre RCTs. However,
enthusiasm for the use of these agents in dementia or in
the prevention of cognitive decline has not been
supported by recent studies and systematic reviews
(Birks & Grimley Evans, 2007; Dodge, Zitzelberger,
Oken, Howieson, & Kaye, 2008; Isaac, Quinn, &
Tabet, 2008; Tabet, Birks, & Grimley Evans, 2000).
Further, many of these agents may be associated with
significant side effects (Bjelakovic, Nikolova, Gluud,
Simonetti, & Gluud, 2007; Dodge et al., 2008).
Despite the lack of clear evidence and the potential
for serious side effects, several vitamins and herbal
extracts have been widely used among older people with
dementia. Studies in some countries have already shown
that nearly half of all patients with dementia may be
receiving alternative therapy including a variety of
vitamins and herbal extracts (Coleman, Fowler, &
Williams, 1995; Hogan & Elby, 1996; Landin,
Frolich, & Schwarz, 2008). Health professionals
caring for older people with dementia are best placed
to safely manage such a practice. However, their views
and knowledge have not been clearly established in
relation to the use of over-the-counter medication

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N. Tabet et al.

by dementia patients. Therefore, the aim of this study

was to determine whether limitations and shortcomings
existed to professionals practice and to patientprofessional interactions. Understanding current knowledge
and practice of health professionals is essential to
inform health messages and educational approaches.

Methods
The study was carried out across East Sussex, in the
United Kingdom. Health professionals eligible to take
part in the study practiced in East Sussex and were
from professions with responsibility of care for older
people with dementia. These included general practitioners, old age psychiatrists and older people mental
health nurses. Health professionals were sent an
invitation letter, a self-administered questionnaire
and a self-addressed and stamped envelope.
Professionals who did not return the questionnaire
were not sent a subsequent reminder.
The self-administered questionnaire was specifically designed to examine the knowledge and practices
of health professionals. The questionnaire was piloted
among a small group of professionals. The questionnaire comprised of a combination of close-ended and
Likert scale-type questions. The aim was to elicit as
much as possible information about participants
views, knowledge and practice in relation to the use
of vitamins and herbal extracts among people diagnosed with dementia. The chi-square test was used to
statistically assess differences between the responses of
doctors and nurses. The study was approved by the
local research Ethics Committee and the Trust
Research and Development Department.

Results
Three hundred and fifty questionnaires were sent to
health professionals and 200 responded (response rate
of 57%). Responding professionals included 129
doctors and 71 nurses. Out of all responding professionals, 42.9% (n 85) personally believed in the use of
vitamins and herbal extracts for dementia patients
while the rest did not believe in their use or were
unsure. Professionals greatly underestimated the
number of patients taking vitamins and herbal extracts
(Figure 1) when compared to available evidence on the
issue from several previous publications. The majority
45
40
35
30
25
20
15
10
5
0
<5%

510%

1130%

3150%

>50%

Figure 1. Percentage of patients who the professionals

believe are taking vitamins and herbal extracts.

of professionals (68%, n 136) believed that less than

10% of their patients receive such medication.
Meanwhile, only about a quarter (24.4%, n 49) of
professionals stated that they always or often discuss
possible adverse events or interactions for these substances with their patients. A sample of the views,
knowledge and attitudes of the health professionals
caring for older people are presented in Table 1. The
views of professionals regarding the use of these
substances in relation to specific common dementia
disorders are presented in Table 2.
Although significantly more nurses than doctors
personally believed in the use of vitamins and herbal
extracts for dementia (55.7% and 35.9%, respectively;
2 16.02, df 2, p 5 0.01), both groups did not differ
significantly on whether they personally have recommended these substances to patients (nurses 34.2% and
doctors 32.0%; 2 0.10, df 1, p 0.44). More
doctors always or often discussed possible adverse
events with patients (27.6%) compared to nurses
(18.1%). However, still the vast majority of doctors
did not discuss side effects with patients. In contrast,
slightly more nurses (60%) than doctors (54.3%)
agreed or strongly agreed that vitamins and herbal
extracts can cause serious drug interactions.

Discussion
Health professionals in this study appear to greatly
underestimate the percentage of patients receiving
over-the-counter medication. To date, research has
consistently shown that nearly half of all dementia
patients receive such therapy. This clearly supports the
prevailing view that professionals are not actively
seeking such information from patients and their carers
during consultations. This result is in line with those
reported earlier about health professionals rarely
asking patients about the use of complementary and
alternative therapies (Brown et al., 2007). This apparent lack of communication with patients and carers
about the use of over-the-counter substances may carry
identifiable risk especially in view of the recognised
side effects and drug interactions associated with these
agents. It is also likely that many patients do not
volunteer information about their use of over-thecounter medication to their health professionals. One
reason for this may be that many patients and carers
do not associate over-the-counter substances with
medicinal drugs. Others may totally depend on nonmedical sources for information about alternative
medicine. It is suspected that people place a great
emphasis on media reports as a primary source of
information in relation to alternative medicinal products. The overall positive coverage in the mass media
about some alternative treatments is, in part at least,
related to the relative lack of reporting on issues such
as safety and side effects (Weeks & Strudsholm, 2008).
The last few years have witnessed an increase in the
use of alternative medicine across age groups and

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Aging & Mental Health

Table 1. Views and knowledge of 200 professionals who responded to the questionnaire.

These drugs may cause serious interactions with

other prescribed drugs
Use of these drugs should influence which acetylcholinestrase inhibitors to use
Use of some of these should be influenced by already
prescribed anticoagulants including aspirin
These drugs should be recommended to individuals
who are at risk of developing dementia in future
Vitamins/herbal extracts have an important role as
an adjunct to other agent in treatment of
dementias
Vitamins/herbal extracts have been mainly used
because of their antioxidant properties
There is strong clinical evidence supporting the use of
antioxidants in the treatment of dementia

Strongly
agree

Agree

Neither agree
nor disagree

Disagree

Strongly
disagree

9.1 (18)

47.5 (95)

26.3 (53)

17.2 (34)

2.6 (5)

13.9 (28)

68.6 (137)

12.9 (26)

2.1 (4)

8.8 (18)

42.0 (84)

43.5 (87)

4.7 (9)

1.0 (2)

7.1 (14)

31.6 (63)

51.0 (102)

8.3 (17)

2.0 (4)

7.1 (14)

40.9 (82)

41.9 (84)

8.6 (17)

1.5 (3)

7.6 (15)

41.4 (83)

46.5 (93)

3.5 (7)

1.0 (2)

2.0 (4)

26.4 (53)

48.7 (97)

17.3 (35)

5.6 (11)

Note: Data represents the percentage as well as the actual number of professionals (in parentheses).

Table 2. Vitamins and herbal extracts are helpful in which of the following according to the 200 professionals who
responded to the questionnaires.
Strongly
agree
Alzheimers dementia
Vascular dementia
Dementia with Lewy bodies
Frontotemporal dementia

2
29.1
16.3
15.8

(4)
(58)
(33)
(32)

Neither agree
nor disagree

Agree
33.3
56.6
74.5
74.5

(67)
(113)
(149)
(149)

56.6
12.8
8.2
8.7

(113)
(26)
(16)
(17)

Disagree
7.1
1.5
1
1

(14)
(3)
(2)
(2)

Strongly
disagree
1 (2)
0
0
0

Note: Data represent the percentage as well as the actual number of professionals (in parentheses).

settings (Greenfield, Pattison, & Jolly, 2008; Schwarz,

Knorr, Geiger, & Flachenecker, 2008; Sprague et al.,
2007). Recent research, in particular, has shown that
complementary and alternative medicine use is
common among older people either to maintain
health or to treat a specific health condition (Cheung,
Wyman, & Halcon, 2007). Ritchie (2007) proposed
that the increased use of such treatments in general has
occurred as a result of promotions through media and
health programmes and change in public attitudes. The
findings of this study highlight the need for professionals to be proactive during consultations to elicit
information about the use of alternative treatments.
In a previous survey of doctors and nurses attitudes
and practices regarding alternative and complimentary
therapies, it was reported that professionals have
limited experience and knowledge in this area.
Interestingly and importantly, they were found to be
uncomfortable in discussing such treatments with their
patients (Brown et al., 2007).
In this study, health professionals overall showed
significant discrepancy in their knowledge and practice
in relation to the use of vitamins and herbal extracts.
No clear trend emerged regarding the views of professionals in areas such as the efficacy, the role and the
mode of action of these agents in the management of

dementia patients. A significant minority of professionals (one-third) either prescribed or recommended

vitamins and herbal extracts at some point in the past.
Forty percent of respondents also personally believed
that such treatments may be effective. In fact, studies
indicate that physicians in general tend to have a
positive attitude regarding complimentary and alternative medicine (Furlow, Patel, Sen, & Liu, 2008).
However, an interesting finding in this study was that
only a minority of health profession agreed or strongly
agreed that vitamins and herbal extracts were helpful
in AD. In contrast, the majority either agreed or
strongly agreed that these agents are useful in conditions such as vascular dementia, dementia with Lewy
bodies and frontotemporal dementia. In this context,
it is likely that the attitude towards alternative therapies is more positive for conditions where no current
licensed treatments exist or where knowledge about
aetiology and pathogenesis is not clear.
Over-the-counter agents such as vitamins and
herbal extracts used may have significant side effects
or interactions with other prescribed medication.
Gingko biloba, for example, is a widely used alternative therapy to help memory. Although it is safe
overall, side effects (some serious) have been reported
including intracerebral haemorrhage, gastrointestinal

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N. Tabet et al.

disturbances, headache, dizziness and allergic skin

reactions (Mahadevan & Park, 2008). It can also
cause bleeding when combined with warfarin or aspirin
(Hu et al., 2005), raised blood pressure when combined
a thiazide diuretic and coma when combined with
trazodone (Izzo & Ernst, 2001). Significantly, in this
study 50% of professionals did not appear to be aware
of these interactions especially as many dementia
patients are also prescribed aspirin or warfarin.
Bjelakovic et al. (2007) carried out a meta-analysis
on randomised trials of antioxidant supplements (beta
carotene, vitamin A, vitamin C, vitamin E and
selenium) enrolling more than 230,000 subjects. The
authors reported increased mortality in relation to beta
carotene, vitamin A and vitamin C compared to
placebo or no treatment.
A limitation of this study which needs to be
considered when interpreting the results relates to the
use of cross-sectional surveys in general. Postal questionnaires are widely used in health care settings,
however non-response reduces the effective sample size
and can introduce bias (Edwards et al., 2007). Handout
surveys may have higher response rate compared to
postal surveys (Gribble & Haupt, 2005), but will take
longer to recruit participants. Likewise, face-to-face
interviews may be more appropriate for certain groups,
including patients, but again this is much more time
consuming to carry out and it is likely that it would not
have had an effect on the response obtained from
health professionals.
The study indicates that many health professionals
underestimate the prevalence of over-the-counter medication use among patients with dementia. It seems
professionals are failing to actively enquire about the
use of alternative therapies such as vitamins and herbal
extracts among their patients. The knowledge of health
professionals in relation to the uses, efficacy, side
effects and drug interaction profile of vitamins and
herbals extracts for dementia is at best variable and
uncertain, indicating low knowledge base about such
widely used medication. Results presented in this study
are for all health professionals as distinction is not
particularly useful in current day practice. Many
community based patients are followed up by community nurses who tend to spend much more time with
patients and carers. Hence, the obtained data here shed
light on a significant problem and call for urgent action
to address it through educational programmes targeted
at all professionals (doctors, nurses and others) caring
for older people with dementia. Interventions need to
emphasise the potential for side effects and interactions
of vitamins and herbal extracts. The enquiry about the
use of such agents to patients should form part of the
routine history taking by health professionals.
Doctors, in particular, should possess some relevant
information about this topic to be able to give an upto-date advice to patients and carers about best
available current evidence in relation to some of the
most widely used alternative treatments. In addition to
educating health professionals, a critical target for

education about the potential interactions/problems of

over-the-counter is the caregivers who know what
medication the patient is taking and, importantly, may
be able to influence what is taken. The caregivers will
also be able to inform health providers about such
medication.

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