Older Patients—Knowing Where They’re Coming From

The quality of any encounter between a clinician and a patient from a different ethnic or cultural background depends on the clinician’s skill and sensitivity.¹

If the current Elder Boom doesn’t do for geriatrics what the Baby Boom did for pediatrics, it will be a surprise to everyone. For EMS, a booming elderly population requires a rethinking of the system, not only for the increased importance of Medicare reimbursement, but also for the increase in patients with multiple medical problems.

Now there’s another concern gaining ground in the geriatric field and that’s the fact that the population of first-generation ethnic minorities is aging just as rapidly as the general population. According to Hosam Kamel, MD, FACP, director of Geriatrics and Extended Care at St. Joseph’s Mercy Health Center in Hot Springs, AR, and co-editor of Doorway Thoughts: Cross-Cultural Health Care for Older Adults, “This segment is rapidly growing. EMS will be dealing with older people from minority groups more and more often.” The sub-group, expected to grow 9% over the next 25 years, is giving rise to the newer field of “ethnogeriatrics.”²

Implications for EMS

According to the authors and editors of Doorway Thoughts, a publication by the Ethnogeriatric Committee of the American Geriatrics Society, there are several issues to keep in mind, including varying levels of “acculturation” or assimilation to Western cultural lifestyles and mindset. The less acculturated, the more it will affect interactions between patient and provider, different expectations regarding behavior toward an elderly person, variations in trust in the treatment offered, cultural and religious interpretations for symptoms, as well as misunderstandings due to changes in language and literacy skills.

Kamel describes an older patient of his from Poland, who had been fluent in English for decades. “Then she got dementia and forgot all of it. Polish is suddenly the only language she speaks. When the recent memory goes,” a common condition in Alzheimer’s and other age-related brain disorders, “so does the second language.”

When does someone become “an elder”? Kamel says elderly is largely a political definition—some countries define their elderly as 60 years old, but here in the U.S., most healthcare systems place the line at 65, when Medicare starts paying benefits.

Still, health and cultural factors are more accurate signs to use when approaching an older adult with a different cultural background. Kamel warns providers not to make assumptions. “Start by being aware that there is diversity,” says Kamel. “Being aware that different people from different cultures might think differently from you is the key.”

Kamel urges EMS to incorporate “diversity training” into the system in order to better serve the changing communities EMS agencies serve. “When responders lack training,” he says, they report “feeling uncomfortable when going into the homes of minorities. Because they are concerned and they don’t want to hurt the feelings of their patients—they want to do the appropriate thing, but nobody’s told them what it is.” For better or worse, he says, it is not so much about your medical knowledge, but how you interact as a human being.

That’s why EMS should encourage diversity in their responders, he says. “It’s important to hire and train people from different cultures and backgrounds, people who can speak the different languages—because they know the community you serve.”

Knowing what cultural diversity might look like in an elderly patient, what different cultures might believe in and how their traditions affect the way they interface with typical North American medical practice is what Doorway Thoughts lays out. Issues to be aware of include:

Preferred terms for cultural identity: Be aware that the term you know may not be the preferred description for the individual you are treating. An elder’s sense of identity may even differ from his younger relatives’. Using the wrong term can put everyone off on a bad footing. For example, an older African-American might be more comfortable with black; the person you think of as Hispanic might consider himself Latino, Chicano, Cuban-American, Puerto Rican, etc. An elderly Native American might prefer the term Indian, or a more specific tribal association such as Lakota Sioux. A person with an Asian/Pacific Islander background may be insulted unless identified by nationality: Japanese, Korean or Chinese, for instance; “but never use the term ‘Oriental,’ ” often considered disparaging, says Kamel.

Respect your elder: “Be courteous, be formal, use last names, no loud voices—you don’t want to seem as if you’re telling them what to do—listen, and respect what they say,” says Kamel. This issue is so important in Native American culture, for example, he explains, that if either the patient or the family feels they have not been well treated, the news will spread, “and the entire group will lose trust in the system. You no longer have a one-person problem; now it’s a tribal problem.”

Culture-specific health risks: Every human population is at risk for coronary artery disease, but they may not tell you the same way. For example, a slight chest pain in a young-seeming Asian Indian male might signal an impending massive and potentially fatal MI. Additionally, different populations are at risk for a variety of health conditions, including but not limited to: diabetes—prevalent among Native Americans, African-Americans and Asian Indians; hypertension—high-risk for African-Americans; Pacific Asians are at risk for stomach, liver and other cancers, as well as depression, which is under-diagnosed and under-treated (e.g., Chinese women over 75 commit suicide seven times more often than other women).

The ethnogeriatricians who wrote Doorway Thoughts understand there is more to prehospital medicine than taking vitals, treating symptoms and transporting, adding that understanding a patient’s “different reality” can make effective treatment that much easier to achieve. These realities may also include “elephants in the room,” factors operating beneath the radar that affect your patient’s ability to trust medical personnel and procedures, including immigration status; gender roles; family dynamics and a history of discrimination, torture or trauma.

Cultural differences can also affect matters of disclosure, informed consent, end-of-life issues and approaches to decision-making in general. Both provider and patient bring attitudes and beliefs to the clinical encounter, but it remains the provider’s job to be sensitive to the patient’s needs, say the authors.

Kamel says it needn’t be that difficult. “When in doubt, just ask. Ask the patient what is okay. ‘Can I do this? Is it appropriate?’ This will relieve you from a lot.”

References

1. Adler RN, Kamel HK (Eds.). Doorway Thoughts: Cross-Cultural Health Care for Older Adults. Sudbury, MA: Jones and Bartlett Publishers, 2004.
2. www.americangeriatrics.org/publications/shop_publications/education__clinical_tools_for_health_care_providers.

Kathryn Robyn worked as an associate editor for EMS Magazine.