When considering the prospect of identifying Internet and web-based or digital (1) resources on complementary, alternative, and integrative medicine that are appropriate to use with older patients and their families, three questions often come to mind:
• Do elders really use the Internet to find information in the first place?
• Do their clinicians have the time and evaluation expertise to locate appropriate information?
• Is there actually reliable and appropriate Internet-based information on the topic anyway?
In 2015, the answer to all three questions is “yes.”
First, researchers at the highly regarded Pew Research Center noted in 2014 that “[o]verall, technology adoption among seniors has been increasing slowly but surely. Today, three quarters of seniors have a cell phone, six in ten use the internet, and almost half have broadband at home. Those still trail the national average, but they have been steadily increasing since we began tracking these metrics way back in 2000” (2). These scholars go on to posit that “[y]ounger, higher-income, and more highly educated seniors use the internet and broadband at rates approaching—or even exceeding—the general population; internet use and broadband adoption each drop off dramatically around age 75” (3). Recent research has also shown that while some seniors seek training for accessing digital information, and they trust what they find, others find that “[i]nformation seeking on the Internet is especially complex because it requires a general knowledge of the topic of interest, basic knowledge of hardware and software operations, information seeking skills (e.g., knowledge of how the Internet or a Web page is organized and how links, search boxes, and search histories work), and the ability to judge whether information sources are credible … ” (4).
Second, a number of studies have also shown that physician–patient communication about complementary, alternative, and integrative medicine, even in older populations, occurs successfully (5). Physician discomfort with discussions of CAIM (complementary, alternative, and integrative medicine) topics is diminishing (6). Specifically, investigators who looked at a population of older patients and their physicians noted that “[r]egardless of a physician’s stance or knowledge about CAM, she or he can help patients negotiate CAM treatment decisions … [and] providers do not have to possess extensive knowledge about specific CAM treatments to have meaningful discussions with patients and to give patients a framework for evaluating CAM treatment use” (7). Recent work indicates that CAIM services have even begun to be offered in the hospice setting, with benefits for older individuals at the end of life (8).
Finally, the Internet and the World Wide Web do have excellent sources of information for seniors and their clinicians on the topic of complementary, alternative, and integrative medicine in general, as well as specific information on mental health concerns. Caution is needed, however, when looking for, or choosing to use, the information that is dispensed widely via the Internet.
When looking for or using Internet-accessible materials with older people, there are helpful guidelines from major public health institutions. For instance, the World Health Organization (in a planning document for designing information for elders who are at risk in emergency and disaster situations), recommends that web-based information for elders should
• provide information about … resources in formats and communication channels that are accessible to older persons so they can make informed personal decisions; and
• provide information and public education to prepare for to meet health needs … in formats that are accessible to persons with less education and low literacy (9).
Other sources suggest that good websites for older users should
• avoid Internet or subject-specific jargon;
• have a reading level no higher than eighth grade;
• have pages that load quickly, even with a slow Internet connection;
• have pages that are accessible from both PCs and Macintosh/Apple computers;
• use formats that work on at least three common platforms (computers, tablets, cell phones); and
• create the feeling of a “trusted, knowledgeable friend” (10).
Furthermore, ideally, web-based information for the special population of older people needs to be
• specifically prepared for elders;
• culturally fluent for differing communities whether identified by race/ethnicity, faith tradition, disability status, or even generation; and
• easily printed.
Experts from the National Library of Medicine, working together with colleagues from the National Institute on Aging, created an excellent guide for designing “senior-friendly” websites. This tool is helpful as both a design aid and an evaluation guide for measuring the accessibility of web-based information for older people. Websites should also be created using the “plain language” guidelines familiar to health professionals who write and administer informed consent documents (11) (see Figure 20.1).
Other useful tools for assessing the quality of health-related sites are available through the MedlinePlus® portal, including two web pages with patient-friendly language, entitled a “MedlinePlus Guide to Healthy Web Surfing, and Evaluating Health Information”; the NLM has also created a helpful web-based instructional tool for people who may experience low literacy or low health literacy, entitled “Evaluating Internet Health Information: A Tutorial” (12).
Several other NIH institutes have also created excellent guides for assessing the quality of Internet-accessible and web-based information. Two useful examples come from the National Cancer Institute and the newly renamed National Center for Complementary and Integrative Health (NCCIH). The NCI’s web page, entitled “Evaluating Online Sources of Health Information: How can you be careful about cancer information on websites, Twitter, YouTube, blogs, Facebook, and e-mail?” is particularly timely in that it advises health consumers about a variety of approaches to evaluating health information, including social media (13). The NCCIH site, entitled “Finding and Evaluating Online Resources on Complementary Health Approaches,” is one of the few NIH sites that specifically address consumer and health professional concerns about web-based and Internet-accessible information in the realm of CAIM (14) (see Figure 20.2).
When specifically looking for tools and materials that focus on the needs and concerns of older individuals, the National Institute on Aging plays a leading role. The Institute includes a helpful guide to “Online Health Information: Can You Trust It?” as one of its long-standing AgePage series; the material is freely available as a print brochure or as an online tool (15) (see Figure 20.3).
In the NIA’s major web tool, known as NIH SeniorHealth: Built with You in Mind, and created cooperatively with the National Library of Medicine, there is a very full section entitled “Complementary Health Approaches” with content covering clinical and research issues, and tips for being an informed consumer and on communicating with the healthcare team (16). This site is particularly useful, as it offers the capability to resize the type, can be seen in a high-contrast mode, and can be printed as a handout—all features that are specifically targeted to older users. The NIH Senior Health materials can also be readily shared via a single click to many social media tools, which makes the information widely available for family members who may be at a distance from their elders (see Figure 20.4).
If the need is to locate focused mental health information in an Internet-accessible or web-based format, the materials from the National Institute of Mental Health and several national associations for mental health professionals who care for older adults are key. The NIMH web-based resources found at their page on “Older Adults and Mental Health” are targeted to depression and Alzheimer’s disease (17). More specific information on a wider range of topics is available from the Geriatric Mental Health Foundation (associated with the American Association for Geriatric Psychiatry), which has a large array of consumer- and family-focussed materials at their website; their Internet-accessible brochures are listed under the tab entitled “Consumer/Patient Information,” and include web-accessible and printable brochures on alcohol/drug abuse/misuse, substance abuse and misuse, alcohol and aging, Alzheimer’s disease, anxiety, caregiving, dementia, depression, disaster preparedness, healthy aging, and sleep (18). The Health in Aging Foundation, created by the American Geriatrics Society, also offers materials on a variety of general mental health issues experienced by elders with their A-to-Z section and their “tip sheets,” including one short entry in the A-to-Z section for “Alternative Remedies” (19). None of these sites, however, offers much information about CAIM-specific approaches for geriatric mental health.
However, the National Center for Complementary and Integrative Health (NCCIH; the NIH Institute formerly known as NCCAM) clearly focuses on CAIM-oriented web-based information, with one page specifically entitled “Aging,” and another page entitled “Seniors or Older Adults or Elderly Information” (20). Those seeking additional NCCIH information specifically on geriatric mental health will have to find it by searching the NCCIH website for topics, diagnoses, and concerns typically found in an older population. For example, there are full entries and patient education “tip sheets” for CAIM materials on subjects such as Alzheimer’s disease, arthritis, cognitive function, dementia, depression, hospice care, insomnia, menopausal symptoms, neurodegenerative diseases, osteoarthritis, pain, Parkinson’s disease, sleep disorders, and stroke—all areas of interest for older people and their family and professional caregivers. Health professionals can also use the NCCIH tools to access continuously updated PubMed MEDLINE searches, with active links that identify and, in many cases, provide full-text access to current systematic reviews, meta-analyses, and reports of randomized controlled trials on CAIM and aging, and CAIM and Alzheimer’s disease (21). Health professionals—clinicians and researchers alike—will also find that the NCCIH page on CAIM research entitled “Spotlighted Research Results—Aging” includes information useful for older populations; a recent issue of the NCCIH Clinical Digest, a monthly e-newsletter for health professionals, offered evidence-based information on CAIM approaches on the use of dietary supplements and cognitive function and dementia (22).
Similarly, major websites from well-known clinical providers often provide information about complementary and integrative modalities, but they rarely mention specific mental health or geriatric topics. Typical examples come from the Mayo Clinic (23), the Cleveland Clinic (24), and Stanford HealthCare (25), all of which contain positive information about a wide range of CAIM approaches, but none of which focuses specifically on the needs or concerns of an older population. The UPMC Center for Integrative Health in Pittsburgh includes information about a number of mental health conditions for which integrative treatment is offered, but none is specifically or uniquely geriatric (26). The International Network of Integrative Mental Health, a “global organization dedicated to advancing an integrative whole person approach to mental health,” with a website rich with links to web-based and Internet-accessible mental health resources, does not have a specific section for older persons’ mental health (27).
The clinician or consumer seeking web-based, Internet-accessible, digital information about complementary, integrative, and/or alternative approaches to dealing with mental health issues and older patients or family members is left with sifting the information from various, sometimes dubious, sites. Beginning with a Google® or Yahoo® or a Wikipedia® search is not recommended, as the first stops on the information journey should be the NIH SeniorHealth site or the NCCIH site.
If, however, web surfing or “googling” is undertaken, then using the tools for assessing quality from the NCCIH, MedlinePlus, and the National Institute on Aging will arm the searcher with skills to filter and choose wisely from the flood of material that is dumped out by the search engines. Learning a simple rubric or mnemonic for measuring quality is useful; the Trust It or Trash It model (28), developed by the genetic disease community as a tool for consumers searching for digital information on complex medical problems, is helpful. Additionally, looking for the HON Code symbol prominently displayed on a health website is also useful; this mark, assigned by the long-standing and highly regarded Health On the Net Foundation only to those sites that have been vetted and approved by their expert staff, is an international quality marker (29) (see Figure 20.5).
If there is web-accessible, Internet-accessible CAIM information that is available from websites other than those associated with NIH institutes, professional associations, and/or major medical centers, there are several points to remember when assessing the quality of these materials. As one physician blogger put it in 2014, there are five questions to ask:
1. Does the website claim to cure everything?
2. Are they trying to sell you something?
3. Has this treatment already worked for thousands of anonymous people?
4. Is this the “medical secret” doctors don’t want you to know about?
5. Are there any peer-reviewed medical studies that can support their claims?
If the answer to any two of these questions is “yes,” then one should be very skeptical of those web resources (30).
Finally, seeking out the services of a trained consumer health information specialist may also be an option. Hospital and medical center libraries, and some larger public libraries, may have personnel who are especially trained in consumer health information services; each of the eight Regional Medical Libraries of the National Network of Libraries of Medicine has a staff member with responsibility for consumer health materials as well (31). These colleagues may be helpful in identifying consumer health materials that are locally produced or distributed.
Ellen Gay Detlefsen DLS has no conflicts to disclose as of January 2015.
1. A note of clarification: The terms Internet and Web are often used interchangeably, but in fact the two terms are not synonymous. The “Internet” is a massive network of networks, which connects millions of computers so that any computer can communicate with any other computer as long as they are both connected to the network known as the Internet. The “World Wide Web,” or the “Web,” is a way of accessing information over the Internet that uses common protocols for communication in order to share information. You may want to think of the Internet as the way the content moves around, and the Web as the software that lets you use the content. It is probably more accurate to use terms like “web-accessible information” and “Internet-delivered information.” Digital information is a newer term used to describe the information that is shared via the Web, and across the Internet. In practice, however, most laypeople simply use the words Internet, web, and even digital, to mean the same thing—the information that is obtained by a search with a computer that is connected to the worldwide network known as the Internet. There is a very friendly explanation of these terms and concepts on the website of the Computer History Museum, in Mountain View, CA, at http://www.computerhistory.org/revolution/networking/19.
2. Pew Research Center. Older adults and technology use, 2014. http://www.pewinternet.org/2014/04/03/older-adults-and-technology-use/.
3. Pew Research Center Internet Project. Seniors continue to lag in tech adoption, 2014. http://pewinternet.tumblr.com/post/81584916842/technology-adoption-among-seniors-has-been.
4. Xie B. Improving older adults’ e-health literacy through computer training using NIH online resources. Library Information Sci Res 2012;34:63–74 (2012)CrossRefWeb of Science; Zulman DM, Kirch M, Zheng K, An LC. Trust in the Internet as a health resource among older adults: analysis of data from a nationally representative survey. J Med Internet Res 2011 Feb 16;13(1):e19, http://www.jmir.org/2011/1/e19/CrossRefMedlineWeb of Science; Czaja SJ. Aging, e-health tools, and health literacy, in Centers for Disease Control and Prevention, Improving health literacy for older adults: expert panel report 2009. Atlanta: US Department of Health and Human Services; 2009.
5. AARP [and] National Center for Complementary and Integrative Health. Complementary and alternative medicine: what people aged 50 and older discuss with their health care providers. Consumer Survey Report. https://nccih.nih.gov/news/camstats/2010.
6. Shelley BM, Sussman AL, Williams RL, Segal AR, Crabtree BF. “They don’t ask me so I don’t tell them”: patient-clinician communication about traditional, complementary, and alternative medicine. Ann Fam Med. 2009 Mar–Apr;7(2):139–147CrossRefMedlineWeb of Science; Corbin Winslow L, Shapiro H. Physicians want education about complementary and alternative medicine to enhance communication with their patients. Arch Intern Med. 2002 May 27;162(10):1176–1181.CrossRefMedlineWeb of Science
7. Koenig CJ, Ho EY, Yadegar V, Tarn DM. Negotiating complementary and alternative medicine use in primary care visits with older patients. Patient Educ Couns. 2012 Dec;89(3):368–373CrossRefWeb of Science; Sleath B, Rubin RH, Campbell W, Gwyther L, Clark T. Ethnicity and physician-older patient communication about alternative therapies. J Altern Complement Med. 2001 Aug;7(4):329–335.CrossRefMedlineWeb of Science
8. Helwick C. Few hospices providing CAM services to patients. Medscape Medical News. May 23, 2014. http://www.medscape.com/viewarticle/825676#vp_2.Find this resource:
9. Older persons in emergencies: an active ageing perspective. Geneva: World Health Organization, 2008. http://www.who.int/ageing/publications/EmergenciesEnglish13August.pdf.
10. Devlin M. Network librarians conclude outreach projects. Part III: Health information for elders. Dragonfly 2003;34(4). http://nnlm.gov/pnr/news/200310/devlin.html.Find this resource:
11. National Library of Medicine & National Institute on Aging. Making your website senior friendly. http://www.nia.nih.gov/health/publication/making-your-website-senior-friendly; http://www.nlm.nih.gov/pubs/staffpubs/od/ocpl/agingchecklist.html; Hart TA, Chaparro BS, Halcomb CG. Evaluating websites for older adults: adherence to “senior-friendly” guidelines and end-user performance. Behav Inform Technol 2008 May;27(3):191–199CrossRefWeb of Science; Plain Language Action and Information Network. Federal plain language guidelines. http://www.plainlanguage.gov/howto/guidelines/FederalPLGuidelines/TOC.cfm.
12. National Library of Medicine. MedlinePlus guide to healthy web surfing. http://www.nlm.nih.gov/medlineplus/healthywebsurfing.html; National Library of Medicine. Evaluating health information. http://www.nlm.nih.gov/medlineplus/evaluatinghealthinformation.html; National Library of Medicine. Evaluating Internet health information: a tutorial from the National Library of Medicine. http://www.nlm.nih.gov/medlineplus/webeval/webeval.html.
13. National Cancer Institute. Evaluating online sources of health information: how can you be careful about cancer information on websites, Twitter, YouTube, blogs, Facebook, and e-mail? http://www.cancer.gov/cancertopics/cancerlibrary/health-info-online.
14. National Center for Complementary and Integrative Health. Finding and evaluating online resources on complementary health approaches. https://nccih.nih.gov/health/webresources.
15. National Institute on Aging. Online health information: can you trust it? http://www.nia.nih.gov/sites/default/files/online_health_information_can_you_trust_it_1.pdf.
16. National Library of Medicine & National Institute on Aging. Complementary health approaches. http://nihseniorhealth.gov/complementaryhealthapproaches/whatarecomplementaryhealthapproaches/01.html.
17. National Institute of Mental Health. Older adults and mental health. http://www.nimh.nih.gov/health/topics/older-adults-and-mental-health/index.shtml.
18. Geriatric Mental Health Foundation. Consumer/patient materials. http://www.gmhfonline.org/.
19. Health in Aging Foundation. Aging and health A-to-Z [and] tip sheets. http://www.healthinaging.org/aging-and-health-a-to-z/; http://www.healthinaging.org/news/tip-sheets/; http://www.healthinaging.org/aging-and-health-a-to-z/topic:alternative-remedies/.
20. National Center for Complementary and Integrative Health. Aging https://nccih.nih.gov/health/aging; Seniors or older adults or elderly information https://nccih.nih.gov/taxonomy/term/506; Time to talk tips. https://nccih.nih.gov/health/tips.
21. National Center for Complementary and Integrative Health. Evidence-based medicine: literature reviews. https://nccih.nih.gov/health/providers/litreviews.htm.
22. National Center for Complementary and Integrative Health. Spotlighted research results—aging. https://nccih.nih.gov/health/50/research; NCCIH Clinical Digest. Dietary supplements and cognitive function, dementia, and Alzheimer’s disease. https://nccih.nih.gov/health/providers/digest/alzheimers.htm.
23. Mayo Clinic. Complementary and integrative medicine. http://www.mayoclinic.org/departments-centers/general-internal-medicine/minnesota/overview/specialty-groups/complementary-integrative-medicinehttp://www.mayo.edu/research/centers-programs/complementary-integrative-medicine/complementary-integrative-medicine-program/overview
24. Cleveland Clinic. About integrative and lifestyle medicine. http://my.clevelandclinic.org/services/wellness/integrative-medicine/abouthttp://my.clevelandclinic.org/services/wellness/integrative-medicine/treatments-services/brainhealthandwellness
25. Stanford Health Care. Integrative medicine center. https://stanfordhealthcare.org/medical-clinics/integrative-medicine-center/conditions.html.
26. UPMC Center for Integrative Medicine. Conditions we treat. http://upmc.com/Services/integrative-medicine/Pages/conditions.aspx.
27. The International Network of Integrative Mental Health. http://www.inimh.org/index.asp.
28.Trust it or trash ithttp://www.trustortrash.org/ . ; Genetic Alliance. Trust it or trash it? creating & assessing genetic health information. Washington, DC: Genetic Alliance; 2010. .Find this resource:
29. Health On the Net Foundation. http://www.hon.ch/Global/HON_mission.html.
30. Baum N. Health information on the Internet: 5 questions to ask. http://www.kevinmd.com/blog/2014/10/health-information-internet-5-questions-ask.html.
31. National Network of Libraries of Medicine. Health information on the Web. http://nnlm.gov/hip//