Roland Hart, PhD
(Wyoming Geriatric Education Center
as the contact)
Impact of Historical
Events

 Unique relationship between AI/AN(s) and federal
government
 Intergenerational grief and anger – boarding schools,
other key events (see table on next slide)
 Intergenerational acceptance and survival
 Native American patients and their families will
have more distress
Cohort Experiences

1900-1920
1920-1940
1940-1960
1960-1980
1980-Present
Reservations Citizenship
World War II Vietnam War
Service
Education of
Professionals
“Vanishing
America”
Adoption of
Indian
Children by
Whites
Relocation by Indian
BIA to Urban Activism
Areas
Litigation
Forced
Boarding
Schools
Loss of Land Forced
by
Assimilation
Allotment
System
Law Banned Boarding
Spiritual
Schools
Practices
Urbanization Urban Panfor Education Indianism
& Jobs
Reservation
Gaming
Interactions with
Healthcare Providers

 Be aware that there will be lower levels of trust from
Native American patients and their families
 Knowing historical events and context will help
establish trust
 However, do not assume any particular cultural
knowledge or practice by the older Native American
Conflicting Expectations

 American Indian and Euro-American values often differ
 These values affect the patients’ behavior, attitudes, and
beliefs about health care and treatment
 Also affect the expectations of the health care provider
 Increasing your understanding of conflict in value
systems will enhance ability to collaborate successfully
 Treatment planning and health care should be culturally
congruent and respectful
Values & Beliefs
American Indian
Euro-American
Cooperation
Competition
Group harmony
Individual achievement
Modesty & humility
Overt identification of
achievements
Physical modesty
Physical exhibition
Non-interference
Advice giving, directiveness,
counseling, educating
Silence is valued; ability to
listen and wait
Rapid responses; decision
making; problem solving
Generosity & sharing;
material possessions given
away
Individual ownership; amassed
material property
Culturally Appropriate
Geriatric Care

 Listening valued over talking by many elders
 Calmness and humility valued over speed and
directiveness
 Avoid “invisible elder” syndrome
 Incorporate elder’s understanding of the situation
 Use this understanding to inform treatment planning
Communication

 Verbal communication
 Elders often report English speakers “talk too fast”
 Silence is valued
 Interruption is extremely rude, especially interruption of an
elder
 Non-verbal communication





Physical distance
Eye contact
Emotional expressiveness
Body movements
Touch – not usually acceptable except for a handshake
Language Assessment

 Many speak English, but some may be monolingual
 Literacy level should be assessed
 What grade level of English do they understand?
 May need to keep words simple
 Older adults often need time to translate concepts
into Indian language or thought and then back to
English/Western thought before answering
Domains of Ethnogeriatric
Assessment

 Ethnogeriatrics: considers the “influence of ethnicity,
and culture on the health and well-being of older
adults." (American Geriatric Society)
 Assessment should include many components
including:
 Background
 Clinical Domains
 Health History
 Physical Exam
 Cognitive and Affective Status
Assessment

Background:
 World view
 Life experience
 Exposure to traditional Indian beliefs and practices
 Inter-tribal marriages
 Military service
 Status of health care benefits
 Medicare, Medicaid, HMO, HIS
Physical Exam:
 Modesty and privacy valued
 Make requests in quiet and pleasant manner
 Asking permission is important
 Take care to keep the body covered
Assessment: Cognitive and
Affective Status

 Memory loss often minimized by family & community
 Culturally modified Mini-Mental Status Exam
 Functional Status
 Assess appropriateness of common ADL and IADL scales
 Home & Family Assessment
 Typical home safety
 Also, family care patterns, gender taboos, feelings about
outsider assistance
 Gender Roles – vary greatly between tribes
 Family willingness and knowledge base
Assessment

 Advanced directives and end-of-life preferences
 Assess when appropriate
 Not until a relationship with some trust has developed
 Problem/Condition Specific Information
 Problem-oriented format may be offensive and
patronizing to elders
 Implies a power differential between health care
provider and the “person with the problems”
Explanatory Models of Illness

 Very important to explore beliefs concerning the causes of
and treatment for illness
 Many culturally-mediated beliefs for the cause of
dementia and other conditions
 Ask questions such as:






What do you think has caused you to experience __ ?
Why do you think it started?
What do you call it?
How does it work?
Does anyone else need to be consulted?
What type of treatment do you think you should receive?
Explanatory Models of Illness

 Use gathered information to plan culturally acceptable
intervention and treatment
 Collaborative relationship with American Indian elders
and their families most effective
 Explanation for Dementia in some cultures:
 Someone has bad will against individual or their family and
has used bad medicine on the person with dementia.
 Likely seek medicine man on his/her own
 Important that patient knows how western medicine can
help
 Can use in conjunction with traditional health or medicine
man
Culturally Appropriate
Prevention and Treatment

 Depend upon elder’s tribal affiliation, level of
traditional beliefs, belief in Western biomedical
health care system
 Most Native American’s have some exposure
through IHS, military, or urban clinics
 Emphasize importance of obtaining detailed history
 Elders’ experiences will be quite varied
 A detailed history helps provider begin to
understand influence of tribal and cohort influences
Issues in Treatment:
Informed Consent

 Literacy should be assessed
 Is an interpreter necessary?
 Give ample time for consideration and consultation with
others
 May consult leaders, matriarchs, patriarchs, religious
leaders, medicine persons
 Medical procedures may only be appropriate on certain
dates, determined through consultation with native
healers
 After slow and deliberate consideration of treatment
options, an elder may not choose to accept the treatment
Issues in Treatment:
Advanced Directives

 Elders may be less likely to have written Advanced
Directives, due to:
 Historical misuse of signed documents
 Distrust of the dominant system
 Belief families will take care of decision making and
know preferences
Native Americans and
Dementia

 NA appear to have lower frequency of dementia
than other populations
 Less likely to be institutionalized
 Orientation to present time, taking life as it comes
 General acceptance of physical and cognitive decline
as part of aging
Native Americans and
Dementia

 Memory loss not often presenting complaint
 Most common problems reported include
understanding instructions and recognizing people
they know
 Least common behaviors were wandering and
exhibiting dangerousness (John, Henessey, Roy &
Salvini, 1996)
 Behavior of individual with dementia is accepted
without social stigma
Dementia and Caregiving

 One person is likely to feel the obligation of
caregiving
 Heavy mental burden, depression
 Little recognition that caregiving is burdensome
 Extended family is central to NA culture
 Family should distribute caregiving burden
 Family meetings are needed for discussing nursing
home placement
 Nursing homes are not consistent with Native values
Native American
Caregivers

 Concept of caregiver burden is often unacceptable
 Cultural respect of elders may not allow for expression of
burnout, anger, etc.
 Caregiver burnout may be increased by cultural values of:




Non-interference
Individual freedom
Non-directive communication
Respect for elders
 Caregivers – use of “passive forbearance” as coping
strategy, not common among white caregivers
Native American
Caregivers

 Strength: NA caregivers do not expect to control the
situation of caring for cognitively impaired elder,
which white caregivers do
 Best to offer culturally appropriate support systems
 Educate NA about how outside providers can help
keep elder safe
Need & Utilization of
Services

 High level of need among elderly NA, but relatively
low level of services available
 Barriers include:
 Availability
 Use of non-IHS services (VA, private)
 Long-term care is a primary concern of NA elders
 IHS has no program for long-term care
 Long-term care often given by family, clan, kin
 Tribes typically responsible for LTC
Acceptability of Services







Culturally incongruent treatments
Cultural differences in concepts of modesty & propriety
Perceived lack of respect
Long clinic waits
Staff turnover
Fatalistic attitude toward health
Promoting Acceptability:





It helps IHS if they sign up, including local IHS clinic
Are provided insurance
Family can encourage use of services
Access to specialty services
Able to seek services in town
References

 Hendrix, L.R. Ethnogeriatric Curriculum Module: Health and Health Care
of American Indian and Alaskan Native Elders. Stanford Geriatric
Education Center.
http://www.stanford.edu/group/ethnoger/americanindian.html
 Hendrix, L. (1998). American Indian elders. In G. Yeo, N. Hikoyeda, M.
McBride, S.-Y. Chin, M. Edmunds, & L. R. Hendrix (Eds.), Cohort analysis
as a tool in ethnogeriatrics: Historical profiles of elders from eight ethnic
populations in the United States. Working Paper Series No.12. Stanford
Geriatric Education Center, Palo Alto, CA. (650) 494-3986.
 John, R., Hennessy, C. H., Roy, L. C., & Salvini, M. L. (1996). Caring for
cognitively impaired American Indian elders: Difficult situations, few
options. In G. Yeo & D. Gallagher-Thompson (Eds.), Ethnicity & the
dementias (chap.16, pp. 187-206). Washington, DC: Taylor & Francis.