- Level of Acculturation
- Placing older patients on the continuum of acculturation can help providers avoid mistaken assumptions about expected differences or similarities from mainstream elders.
- Informal indicators of acculturation that can be used quickly
- Length of time older patients or their ancestors have been in the U.S.
- Language used at home, fluency in spoken and written English
- Degree of ethnic affiliation, as reflected in ethnic community participation and use of ethnic media
- Patterns of Decision-Making (e.g., individual vs. collective)
- Preferred Interaction Patterns
- Direct/indirect communication
- Formal vs. informal
- Other (see communication section)
Clinical Assessment Domains
Domains may vary by practice profession, and not all will be used by every provider.
Health and Social History
(See comments on communication and written measures above)
- Review historical cohort experiences of elder’s population prior to assessment and refer to those experiences in taking the social history (see discussion of cohort analysis in the Fund of Knowledge module).
- Issues of elder abuse may be particularly difficult to assess in elders from cultural backgrounds in which there are varying definitions of elder abuse or in which family image may be more important that individual health (Tartara, 1999). Indications may emerge anywhere throughout the assessment. Particularly consider when there are:
- physical signs (bruises, burns, etc.) and/or
- behavioral symptoms (e.g. depression)
- Physical examinations by someone of the opposite sex are unacceptable in many cultures.
- Ask for preference of presence of other family members during physical exam.
- Throughout the assessment, inform elder of procedures and ask for permission to examine different areas of the body.
- Preferred amount and type of information communicated to the elders and their family during and after the physical exam varies cross-culturally (Adler, et al, 2004; Adler & Kamel, 2002) (e.g., some Chinese elders prefer that information be given to their son or other family member, and that they be the decision makers about the elders’ care, especially in relation to serious illness.) The elders should be asked how much information they would like and whom they prefer to have the information.
- Symptom recognition, meaning, and report is expressed differently by elders of different cultures [e.g. “air heavy” or “air not right” may mean dyspnea for some American Indian elders; “heavy heart” may indicate depression among Chinese]
Cognitive and Affective Status
Dementia and depression are considered to be mental illness in some cultures and are often highly stigmatized. In other cultures, dementia is seen as a normal part of aging and is defined as a minimal problem. (See comments on assessment instruments above.)
The concepts of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) will likely be foreign to many elders from other cultures. In some cases, independence of elders is not a high value, so that dependency is expected and assumed. Questions can be translated, if needed, and administered orally or in writing if literacy and reading levels are adequate. Drawings, illustrations, and other culturally appropriate symbols may also be used. Also see comments on translations.
- Living patterns: Who lives in the home, relationship to elder, and length of time in the home
- Support from those people who live with the elder
- Safety, comfort, and convenience of the home to elders health status
- Economic stability and adequacy
- Composition and structure
- Kinship patterns and social support: expectations of and for family members (e.g. for elder care) Stereotypes that ethnic families “take care of their own” can be very misleading since some elders from ethnic backgrounds are not part of strong family networks and are vulnerable to loneliness and isolation.
- Decision-making: In many cultures, there is not the assumption of patient autonomy in decision-making as there is the U.S. ethical paradigm, and the family is assumed to be the decision-maker about health care.
- Spokesperson, if any, for the family
- Gender sex-role allocation
- Family connectedness. Culture influences whether the elder and family are more individualistic or collectivistic (allocentric).
- Community and Neighborhood Assessment
- Overall features of the community and neighborhood: e.g. involvement of ethnic elders in the community
- Population characteristics: e.g. ethnic community, length of time in community, proportion of elders, children, and adults in population, intergenerational relations, status of elders.
- Environmental and safety conditions: (e.g. topography, sidewalks, pavement, air and water quality, crime rate.)
- Services available and used by elder and their family: e.g. allopathic, folk and alternative health practitioners, social services, religious, shopping (such as food, clothing, banking), educational, transportation, recreational and elder services (such as senior center).
- Support from neighborhood and community members
End-of-Life Preferences (when appropriate)
Since talking about death is considered inappropriate in some cultures (e.g., Chinese, Navajo) the issue should be approached carefully and sensitively, and only in the context of an established trusting relationship. A possible introduction after several visits might be, “In case something happens to you and you are not able to make decisions about your care, we need to know what your preferences are.”
- Availability of advance directives
- Preference for hospital or home end of life care
- Death rituals for care of the body and mourning behaviors during and after death
- Attitudes about organ donation and autopsy
Problem Specific Data: Elicit Explanatory Models of Illness from Patient and Relevant Family Members
- The use of explanatory models has been demonstrated to be effective in improving patient-provider communication and showing respect for the patient’s point of view. Ultimately, it is argued, its use will increase patients’ trust of providers, appropriate clinical management, and likelihood of elder’s agreement with and adhering to provider’s recommendations.
- The objective is to elicit the older patient’s view of his illness experience, its causes, potential consequences, and possible treatments.
- To elicit the patient’s explanatory model of illness, questions such as the following can be used (Kleinman, Eisenberg, Good, 1978; Harwood, 1981):
- What do you think caused your problem?
- Why do you think it started when it did?
- What do you think your sickness does to your body? How does it work?
- How severe is your sickness?
- How long do you think it will last?
- What are the main problems your sickness has caused you?
- Do you know others who have had this problem? What did they do to treat it?
- Do you think there is any way to prevent this problem in the future? How?
Intervention-Specific Data (Tripp-Reimer, Brink, and Saunders, 1984)
- What are you and/or your family doing for this problem? What kinds of medicines, home remedies, or other treatments have you tried for this sickness? Have they helped?
- What type of treatment do you think you should receive from me?
- Elicit cultural specific content as needed for specific interventions. For example, if dietary recommendations are being made, elicit data about food preferences and practices; if discharge planning is needed, elicit information regarding family care patterns, resources, and residential preferences
- Is there any other information that might help us design a treatment plan?
- How should family be involved: family structure, roles, and dynamics, and life style and living arrangement need to be identified. How should family members treat one who has this condition/problem?
- Does anyone else need to be consulted?
Outcomes-Specific Data: Negotiating Therapeutic Outcome Criteria with Older Adults/Family Members
- What are individual/family expectations for quality care?
- What are the most important results you hope to receive from this treatment?
- What is best outcome from family/individual perspective?
- What is worst outcome from family/individual perspective?