As the cultural diversity of older adults in the United States grows, clinicians are very likely to encounter older patients from a wide range of ethnic groups. The purpose of the Geriatrics Cultural Navigator is to provide cross-cultural assistance to clinicians with older patients from minority groups. The Geriatrics Cultural Navigator outlines factors for the practitioner to reflect upon before interacting with a patient.
Doorway Thoughts
- Inquire about preferred language or dialect, e.g., Mandarin, Cantonese, Taiwanese, etc.
- Inquire about need for interpretation services
- Although the Chinese language has many dialects, there is a common written language that is understood by all who are literate
- English language deficiency, especially among women
- 46% of Chinese Americans have limited English proficiency
- 30% of Chinese American households are linguistically isolated
- Older immigrants often less educated than more recent arrivals
- Acculturation level typically corresponds to health literacy
- Prefer Chinese-language media
- Relationship with healthcare providers:
- In traditional Chinese culture, physicians are socially respected due to the humanitarian nature of the career and the asymmetry of medical knowledge between physicians and patients
- Chinese older patients tend to exhibit respectful and submissive communication style with doctors
- Occasions to avoid speaking about illnesses as they are considered “bad luck”:
- Lunar New Year
- Birthday
- Birth of baby
- Chinese winter solstice (Dongzhi Festival)
Preferred Cultural Terms
- Chinese, Chinese American, or Asian
- Avoid the term “Oriental”
Formality of Address
- Older adults, physicians are respected
- Initially formal: Dr., Rev., Mr., Mrs., etc., + surname
- Later, more informal first name at patient’s discretion
Effective Communication
- Tradition of politeness
- Use interpretation as a sign of respect
- Smiling, nodding, may conceal lack of understanding
- Recommend speaking 2 sentences, ask for Teach back
- Ask for questions, or ask patient to repeat information in own words
Tradition and Health Beliefs
- Harmony is sought in body (eg: yin/yang) and environment (feng shui); disease caused by yin/yang or qi (vital force) imbalance
- Concept of ‘cold’ and ‘hot’ foods or supplements linked to physiological conditions
- ‘Hot’ foods: pungent spices (ex: chili, turmeric), pepper, ginger, oily foods
- ‘Cold’ foods: watermelon, strawberries, lettuce, kale, bitter herbs
- Mental illness caused by emotional imbalance or spirits; history of cultural trauma may play a role
- Common for older Chinese patient to assume the “sick role” in which the older adult will allow family members take over and provide care as an expression of filial piety and respect
- Fears about blood being drawn, surgery
- Blood is perceived to be valuable
- When in the hospital, Chinese older patients may prefer Chinese food options; encourage food from home
- Common Superstitions
- Numbers – lucky #s like 7, 8 (8 rhymes with prosperity); unlucky 4 (rhymes with death)
Culture-Specific Health Risks
- Higher risk for:
- Infectious disease
- Hepatitis B
- Active tuberculosis
- Cardiovascular complications
- Hypertension
- High cholesterol
- Diabetes
- Stroke
- Vascular dementia
- Cancer
- Breast
- Gastric
- Liver
- Lung
- Nasopharyngeal
- Others
- Glucose-6-dehydrogenase deficiency
- Alcohol flush syndrome
- Thalassemia
- Lupus
- Infectious disease
- Depression is under-detected and under-treated
- Stems from the cultural perception of admitting to a mental health problem as being weak and frowned upon
- Pressure to save face
- Stems from the cultural perception of admitting to a mental health problem as being weak and frowned upon
- High suicide risk especially in older women; no warning
Practices and Health
- In Chinese culture as adults age, more value is placed on exercise and physical health, including tai chi which has been proven to improve balance and reduce falls
- Many Chinese elders value life-long learning
- Proverb: “Live till Old Age, Learn till Old Age”
- Traditional remedies usually used alongside Western approaches
- May prefer using TCM (Traditional Chinese Medicine) or herbal meds over Western medicine
- Important to regularly screen for TCM use as certain herbs may have adverse drug-herb interactions
- Combining treatments in TCM with allopathic medicine, hospice and/or palliative care modalities may boost patient comfort
- Acupuncture, tai chi, cupping, tui na
- May prefer using TCM (Traditional Chinese Medicine) or herbal meds over Western medicine
- Medications that Chinese American older adults may be more susceptible to side effects or require lower doses
- Based on cytochrome P450 polymorphisms which reduce CYP2D6 enzymatic activity, thus potentially increasing drug levels in Chinese population
- Warfarin
- Tamoxifen
- Allopurinol
- Carbamazepine
- Oxcarbazepine
- Phenytoin
- SSRIs
- Tricylic depressants
- Thiopurines
- Voriconazole
- Rosuvastatin
- Based on alleles that result in poor metabolism of CYP2C19 and subsequently cause absent or reduced drug metabolism
- Clopidogrel (recommended to prescribe dual antiplatelet therapy in combination with aspirin to prevent vascular occlusive events)
- Based on cytochrome P450 polymorphisms which reduce CYP2D6 enzymatic activity, thus potentially increasing drug levels in Chinese population
- Home care for Chinese Elders
- Chinese older adults generally accept home care
- Respectful to take off shoes at the door when entering a Chinese household
- Elder abuse in Chinese community
- More likely to experience elder mistreatment if they:
- Are comparatively older
- Have higher levels of education
- Have fewer children
- Have poorer health
- Are of female gender
- Are of lower socioeconomic status
- More likely to experience elder mistreatment if they:
- Dietary Intake
- Greater acculturation to American society is associated with:
- An increase in intake of:
- Meats
- Dairy
- Breads
- Fast foods
- A decrease in intake of:
- Dark green vegetables
- Grains cooked from dry (ex: rice)
- An increase in intake of:
- Consumption of sweets, dairy, coffee, fried noodles, dumplings, rice, and meat are associated with some adverse cardiovascular patterns
- However, consumption of vegetables, fruit, tofu, and nuts are associated with an improved cardiovascular risk profile
- Greater acculturation to American society is associated with:
Approaches to Health Decision-Making
- Decisions usually made by family, rather than patient
- Family members may request physician to dilute the severity of the disease
- Family may filter the information the patient receives
- Older males may take primary role
Informed Consent
- Ask patient who should be told of serious diagnosis
- Patient may assume that the physician implicitly understands. Hard information may only be accessible from family members
- Impolite to burden patient with details of illness
- Patients traditionally shielded from diagnosis of cancer
- Patients may wish to know diagnosis but families often disagree – from China study of 150 cancer patients and their families
- More Chinese older patients today hope their doctor tells them the truth even if they have been diagnosed with cancer
Gender Issues
- Wife becomes part of husband’s family at marriage
- Patriarchal society
- Older males may prefer male physicians
End-of-Life Care
- Chinese patients under-utilize hospice care
- Lack of knowledge; poor translation of terms
- Critically ill patients often hospitalized, even if beyond treatment
- Speaking about death may be considered bad luck
- Avoid saying death /”si”, say end of life, last stage of life
- Use common proverbs to normalize life cycle
- “Sheng lao bing si” – to be born, to grow old, to get sick and to die
- Use nonverbal communication effectively
- Bow to show respect
- Nod to express support, agreement, and harmony
- When handing documents, use two hands in addition to bowing
- Ask for permission to sit down
- When discussing bad news or if family members are in emotional distress, it is ok to touch them on shoulder to show empathy
- Presence of adult children increases likelihood of staying at home
- Oral DNR orders may be preferred to avoid bad luck of written consent
- No need to sign if patient/family is in distress; legally accepted
- Patients may prefer that physician decide or make medical recommendations
- Important to properly explain what palliative care/hospice is to Chinese patient especially since meaning can be severely misunderstood in translation
- Back translation of palliative care is “do nothing care”
- Preferred translation: “huan he zhi liao” or “gentler/kinder approach to care”
- Back translation of hospice is “last minute care”
- Preferred translation: “An ning zhao gu” or “comfort and peace oriented care”
- Back translation of palliative care is “do nothing care”
- Attitudes are diverse: consult each patient
- Belief that death at home could lead to difficulty in selling or renting the property
- If elderly passes away at over 90 yo, it is considered a good death
- Death by natural causes are tolerable but murders and suicides bring “bad luck”