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
- 1 in 5 Asian Americans are Asian Indians
- Individual beliefs and practices will vary given Indias diversity (e.g., 28 states, 22 national languages, 6 major religions)
- Respect for older adults, multi-generational families
- Do not misinterpret acculturated appearances (e.g., behavior, attire) to mean the absence of cultural values
- Immigration has increased exponentially since 1980s
Preferred Cultural Terms
- Acceptable terms: Indian American, Indian, Asian Indian
- Avoid the term “desi” (meaning “from our country”) as it may come off as inauthentic if speaker is not of Asian Indian origin
Formality of Address
- Use formal titles (e.g, Dr., Rev., Mr., Mrs., etc.) until permission is given for first name basis. It is likely that older adults will prefer use of formal titles indefinitely
- For Hindi speakers, adding “-ji” indicates respect (e.g. Laxmanji, Geetaji)
- Accompanying family members may have different preferences of how to be addressed.
Effective Communication
- Patients may be accustomed to clinicians having greater decision-making responsibility in India and therefore unaccustomed to having greater autonomy here in the United States
- Clinicians should clarify with older adults how much medical information they prefer to receive versus deferring to their family members.
- If family members prefer information to be withheld, explore why
- Establish expectations for duration of clinic visits to avoid misunderstandings at subsequent visits
- Medical interpreter preferred for older adults with limited English proficiency to reduce the likelihood of miscommunication, unless there a medical interpreter is unavailable
Tradition and Health Beliefs
- Older adults may prefer holistic forms of treatment through traditional forms of medicine (eg, Ayurveda,) which include dietary modifications, herbal supplements, fasting, meditation practices.
- Religious attire or symbols should not be removed without first asking for permission
- tupi/kufi, a religious cap worn by Muslim men
- hijab, a head covering worn by Muslim women
- mangalsutra, a necklace worn by married Hindu women
- sacred threads, worn by Hindu men and women
- turban, a head covering worn by Sikh men
- kara,steel bracelet worn by Sikh men who have undergone the Amrit ceremony to become a Khalsa (purified) Sikh
- Religion influences perception of illness and death but may not feel comfortable disclosing
- May be unaccustomed to counseling as a therapeutic modality.
Culture-Specific Health Risks
- Cardiovascular disease (e.g., CAD, diabetes, dyslipidemia, obesity): leading cause of mortality
- Most common cancers
- Women: breast, gynecologic, colorectal
- Men: prostate, lung, colorectal
- History of chewing pan tobacco increases risk for head & neck cancers and other related disorders
- Older adults originally from India living with their families in the US may struggle with loneliness and isolation
Practices and Health
- Rice or various breads (roti/naan/paratha) are common staples of diet
- Tea or coffee with milk is usually consumed one or more times per day
- Washing hands prior to meals and eating with hand (usually right hand) is common and should be accommodated while hospitalized
- A detailed history of diet and supplements is important
- Dietary restrictions may vary even among vegetarians (e.g., fish, eggs, onion, garlic, alcohol)
- Clarify if food (jello) or medications with animal derivatives are acceptable (e.g. gelatin capsules, porcine heparin)
- May prefer home-cooked meals over hospital food
- Older adults may prefer to schedule procedures around auspicious times based on the lunar calendar
- Older adults may have a lower threshold to stop new medications based on how they feel
- To confirm a diagnosis, a therapeutic trial may be preferred over an extensive workup if patients are accustomed to an inexpensive approach
- Ghee, a type of clarified butter that contains conjugated linoleic acid and anti-oxidants, is commonly used in foods and can be beneficial in moderation
Approaches to Health Decision-Making
- Identify older adults preferences for medical decision-making, particularly if family members prefer to be involved
- May prefer relatives or friends with more health literacy and/or English proficiency to communicate with clinicians
Informed Consent
- Verify preferences for receiving medical information, particularly for serious news (e.g., impending death, terminal diagnosis).
Gender Issues
- Same-gender clinicians may be preferred to discuss sensitive health issues or for physical exams
- Elicit information confidentially from older adults if they feel uncomfortable expressing themselves in the presence of family members
End-of-Life Care
- Advance directive utilization limited by awareness and language barriers
- Discussing death may be a taboo topic and should be discussed with respect and caution
- Clarify who all should be involved in EOL decision-making
- Discuss religious and spiritual considerations proactively to define specific preferences:
- Rituals
- Spiritual care providers: priest, chaplain, imam, swami, purohit
- Place of death: majority prefer home
- Level of mental alertness vs. sedation at EOL