Treating American Indians/Alaskan Native Elders
By Melvina McCabe, M.D.
| Geriatric Times |
 |
November/December 2001 |
|
Vol. II |
|
Issue 6 |
The American Indian/Alaskan Native (AI/AN) elder population is rapidly
expanding. According to U.S. Census rates between 1980 and 1998, the American
Indian/Eskimo/Aleut population aged 65 and older increased by 33% compared to
an increase of 9% in the same-aged white elder population (U.S. Census Bureau,
1999). This increase does not include those aged 45 to 65, considered as elders
by many AI/AN populations. In addition, many AI/ANs aged 55 to 65 have the same
number of chronic diseases and complications as do whites aged 65 and older
(National Indian Council on Aging, 1981). Following recommendations to include
those 55 and over in programs serving AI/AN elders, a review was conducted on
the issue of redefining elders based on chronological age versus functional
status (Indian Health Service [IHS], 1995). This review noted that tribes
differ in their definition of elder. Health care professionals should be
cognizant of cultural age-appropriateness in order to identify those at risk
and to provide the best quality care (see Table).
One factor explaining the expansion of this segment of the AI/AN population
is the increasing life expectancy (see Figure 1).
The life expectancy for AI/ANs born between 1972 and 1974 was 63.5 years,
compared to 71.1 years for those born between 1992 and 1994 (IHS, 1997). There
has been a corresponding increase in the number of chronic diseases and rates
of disability for AI/AN elders. According to 1997 IHS data, the top five
leading causes of death among AI/ANs between the ages of 55 to 64 are diseases
of the heart, malignant neoplasms, cerebrovascular diseases, diabetes mellitus,
and pneumonia and influenza (see Figure 2).
It is critical to recognize the heterogeneity between and within the 500 to
600 tribal groups, which is manifested in the epidemiology of disease and the
cultural values and beliefs of each group. For example, while the overall
leading causes of death among AI/ANs are diseases of the heart, in the Alaska,
Navajo and Albuquerque areas they are accidents and adverse effects (IHS,
1998-1999). One must avoid the tendency to generalize the following findings,
discussion and recommendations to all tribal groups and villages.
Epidemiology of Disease
According to results from the Strong Heart Study, a prospective
epidemiologic study of AIs in Arizona, Oklahoma, North Dakota and South Dakota
between 1989 and 1995, the coronary vascular disease (CVD) incidence rates for
AIs aged 45 to 74 was approximately two times higher than in a similar study of
whites and African-Americans, and the CVD rates for AIs appeared to be
increasing (Howard et al., 1999). In this same study, stroke rates for AI women
were similar to other U.S. populations, but rates for AI men were lower.
Diabetes, which continues to increase in AI/AN populations, had a significant
independent effect on CVD rates in this population. In the Strong Heart Study,
diabetes prevalence rates ranged from 32.4% to 70.9%, with higher prevalence
rates and higher rates of central adiposity and unfavorable lipoprotein changes
in women compared to men (Howard et al., 1998).
An interesting diabetes aside is a study that found a greater difference in
the prevalence rate of diabetes among the AI geriatric population (age 55 to
74) -- but not among those 45 to 54-using the newer American Diabetes
Association diagnostic criteria compared to the World Health Organization
criteria (Lee et al., 2000).
Among AI/AN men, lung, prostate, colon, stomach and liver cancers are the
top five leading causes of cancer deaths, while among AI/AN women, lung,
breast, colon, ovarian and pancreatic cancers head the list (IHS, 1997).
Palliative care for these and other cancers is an area of cancer therapy that
is relatively underdeveloped in AI/AN communities. Vaccination rates as low as
49% for influenza and 22% for pneumococcus were found in an urban AI population
(Buchwald et al., 2001).
Chronic liver disease and cirrhosis compose the ninth leading cause of death
among AI/AN elders (IHS, 1997). The medical complications of cirrhosis and
liver failure from alcoholism are well-known. In addition, alcoholism accounts
for a portion of the high mortality rates from accidents and injuries, the
seventh leading cause of death among AI/AN elders. In one study that looked
specifically at an urban Indian elder population, the proportion of AI/AN heavy
drinkers was no different from that of the general population, but the
age-specific (age 65 to 74) alcohol death rate was higher than in a similar
white population (Barker and Kramer, 1996). There are, however, regional
variations. In a substudy of the Strong Heart Study on the Cheyenne population
(age 45 to 76), more elder men (71%) than women (28%) used alcohol heavily
(Lowe et al., 1997). Participants in this study were asked if they ever drank
heavily, but there was no quantified amount to define heavy drinking. Men were
more likely to be current drinkers, binge drinkers and to have a positive
screen for alcoholism using the Short Michigan Alcoholism Screening Test
(SMAST). Women who were heavy drinkers were more likely to show signs of
depression.
Treatment Needs
There is much to learn about and to determine for AI/AN communities, whose
cultural values and beliefs may not be congruent with those of Western society
and medicine. Organ transplantation and advanced directives are ethical areas
not clearly defined for this population.
In 1991, the federal Patient Self-Determination Act requiring health care
facilities to inform patients of their right to accept or reject any medical
therapy was enacted. Since that time, it has become evident that discussion
methods may need to be revised when dealing with AI/AN elders. For example, in
a sample of Navajo patients (mean age=60), it was found that discussing matters
concerning death and dying may bring them to reality (Carrese and Rhodes,
1995). Their recommended approach for such discussions included: a) making an
assessment of the patient's willingness to discuss this information; b)
preparing for such discussions by establishing a trusting relationship,
involving family, making it clear that no ill will is intended and involving
traditional healers if desired; c) the discussion must be positive, not
hurried, and third-person reference is preferred; and d) discussion follow-up
must reveal actions by the providers that relay hope (Carrese and Rhodes,
2000).
A similar approach may be used for other AI/AN tribes and villages, but it
must be individually tailored. The timing of the discussion of advanced
directives also may vary within AI/AN communities compared to the white
population. Western medicine recommends that advanced directives discussions be
conducted in an elective situation such as a clinic, as opposed to an acute
emergency situation. Within some AI communities, however, the discussion seemed
most successful when conducted in the acute situation (Hepburn and Reed,
1995).
Another obvious factor is the educational level of the patient, particularly
if the information is delivered in writing. Providers must determine the
patient's first language. If the AI/AN language is primarily spoken-and this is
likely with the elder population-then effective medical translators must be
employed who understand the medical terms that are used, are aware of the
limits of the communication process (i.e., the translator must not interpose
their own words/beliefs into the communication) and understand the ethics of
translation. Knowledge of the race and cultural beliefs of the translator are
also critical. For example, there may be a taboo against using a Navajo
translator to enhance communication around death and dying issues, as the
translator may be accused by the patient of wishing death upon them. Several
studies have supported the concept that effective communication between health
care provider and patient is enhanced by the use of medically trained
interpreters and by the provider's knowledge of the patient's culture
(D'Avanzo, 1992; Haffner, 1992; Wardin, 1996).
Very little is known about palliative care approaches and treatment among
AI/ANs. This should prompt health care providers to pay particular attention to
this area of medicine, as AI/AN communities do find this an important issue.
Providers must also realize that the current Western paradigm of palliative
care may need to be tailored to the unique needs of AI/AN communities.
In all interventions, the most important criterion is respect for the
patient. With respect comes the acknowledgement and acceptance of the patient
and their culture, enhanced communication -- the building stone for the
development of trust -- and equality in the patient/physician relationship.
Dr. McCabe is associate professor in the department of family and
community medicine at University of New Mexico School of Medicine. A Navajo
physician, she chairs the geriatric section of her department.
References
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