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Christine McKibbin, PhD & Catherine Carrico, PhD Wyoming Geriatric Education Center.

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Presentation on theme: "Christine McKibbin, PhD & Catherine Carrico, PhD Wyoming Geriatric Education Center."— Presentation transcript:

1 Christine McKibbin, PhD & Catherine Carrico, PhD Wyoming Geriatric Education Center

2   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 Impact of Historical Events

3  1900-19201920-19401940-19601960-19801980-Present ReservationsCitizenshipWorld War II Service Vietnam WarEducation of Professionals “Vanishing America” Adoption of Indian Children by Whites Relocation by BIA to Urban Areas Indian Activism Litigation Forced Boarding Schools Loss of Land by Allotment System Forced Assimilation Urbanization for Education & Jobs Urban Pan- Indianism Law Banned Spiritual Practices Boarding Schools Reservation Gaming Cohort Experiences

4   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 Interactions with Healthcare Providers

5   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 Conflicting Expectations

6 Values & Beliefs American IndianEuro-American CooperationCompetition Group harmonyIndividual achievement Modesty & humilityOvert identification of achievements Physical modestyPhysical exhibition Non-interferenceAdvice 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

7  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

8   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 Communication

9   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 Language Assessment

10   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 Domains of Ethnogeriatric Assessment

11   World view  Life experience  Exposure to traditional Indian beliefs and practices  Inter-tribal marriages  Military service  Status of health care benefits  Medicare, Medicaid, HMO, IHS Assessment: Background

12   Modesty and privacy valued  Make requests in quiet and pleasant manner  Asking permission is important  Take care to keep the body covered Assessment: Physical Exam

13   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: Cognitive and Affective Status

14   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” Assessment

15   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

16   Use gathered information to plan culturally acceptable intervention and treatment  Collaborative relationship with American Indian elders and their families most effective  Explanation for Dementia on Wind River:  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 Explanatory Models of Illness

17   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 Culturally Appropriate Prevention and Treatment

18   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: Informed Consent

19   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 Issues in Treatment: Advanced Directives

20   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

21   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 Native Americans and Dementia

22   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 Dementia and Caregiving

23   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

24   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 Native American Caregivers

25   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 my family, clan, kin  Tribes typically responsible for LTC Need & Utilization of Services

26   Culturally incongruent treatments  Cultural differences in concepts of modesty & propriety  Perceived lack of respect  Long clinic waits  Staff turnover  Fatalistic attitude toward health Acceptability of Services

27   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 Promoting Acceptability

28   Hendrix, L.R. Ethnogeriatric Curriculum Module: Health and Health Care of American Indian and Alaskan Native Elders. Stanford Geriatric Education Center.  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. References

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