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POSITIONS

RESEARCH

1. The American Geriatrics Society (AGS) supports increased funding in bio-medical, epidemiological, and clinical research related to the care of ethno-culturally and racially diverse older adults. Research is needed to explore differences in issues of chronic disease, the "illness" experience, functional status, normal aging, appropriate clinical assessment and management, long-term care, palliative and hospice care, and quality of life across the entire spectrum of ethnic, cultural, and racial groups.
   
   
EDUCATION

2. The AGS supports education in ethno-culturally appropriate care for healthcare providers as well as the curriculum development necessary to provide such training in professional education.
   
   
CLINICAL CARE

3. The AGS supports access to quality care for all elders, regardless of race, religion, or national origin.
4. The AGS supports ethno-culturally appropriate health care.
5. The AGS supports the development of a database that addresses the health care issues of ethno-culturally diverse elders such as a database for basic disease processes with information on prevalence, presentation and management issues.
   
   
ORGANIZATIONAL

6. The AGS encourages and supports the participation of providers from various ethnic and racial backgrounds, especially those underrepresented in health care, at all levels of the organization's activities. These activities include committee membership, chair and board membership with inclusion and participation in all topics of geriatrics and not just those specific to ethnic or racial issues
7. The AGS seeks ways to increase the number of health care providers interested in ethnogeriatric research, education, and clinical care.

BACKGROUND

Ethnogeriatrics is the component of geriatrics that integrates the influence of race, ethnicity, and culture on the health and well-being of older adults. The increasing diversity of the older adult population in each of these facets necessitates this attention. The American Geriatrics Society (AGS) is especially concerned about research issues, health care provider education, and clinical care in ethnogeriatrics as well as increasing the role and participation of providers from diverse backgrounds in the AGS.

The United States Census projection reflects an increasing diversity in the population of adults over the age of 65. In 2003, 82% of this older population identified themselves as non-Hispanic white and 18% in one of the "minority" categories -- black/African American, American Indian/Alaska Native, Asian, Native Hawaiian or Other Pacific Islander, two or more races, and Hispanic/Latino. Due to the changing demographics, these percentages are projected to be 75% and 25% by 2030, and 64% and 36% by 2050, respectively. This increase in "minority" populations is expected to have a significant impact on the American health care system raising issues of culturally appropriate care to the level of an imperative.

In considering "minority" groups in the United States, it is important to appreciate the heterogeneity within any one of these groups both from a cultural and intergenerational standpoint. For example, differences in values and beliefs may exist between those older persons who were born elsewhere, and those born in the United States. Cultural variations may also exist as African-Americans may include those with origins from various regions of the United States, the Caribbean, Central or South America, or Africa. Similarly, Hispanic or Latino populations may include Mexican-Americans, Puerto Ricans, Cubans, as well as those from the Dominican Republic, and South or Central America. Asians may also include those with origins in China, the Philippines, Japan, Vietnam, Cambodia, India, or other areas. The category of American Indian/Alaska Native includes over 500 federally recognized tribes. Each of these sub-populations is comprised of peoples of diverse customs, cultures and/or dialects as well.

The burgeoning diversity of older adults in the United States necessitates that healthcare professionals and healthcare systems provide ethno-culturally appropriate care while avoiding over-generalizations and stereotyping.

POSITIONS

RESEARCH

Position #1. The American Geriatrics Society (AGS) supports increased funding in bio-medical, epidemiological, and clinical research related to the care of ethno-culturally and racially diverse older adults. Research is needed to explore differences in issues of chronic disease, the "illness" experience, functional status, normal aging, long-term care, palliative and hospice care, and quality of life across the entire spectrum of ethnic, cultural, and racial groups.

Rationale:

Most of the diseases affecting the geriatric population have been studied in primarily white populations. Despite the projected growth in the diverse elder populations, there is little information on clinical issues that specifically affect these groups. Research is scant on many minority groups and, traditionally, these groups have been excluded from major research studies in this country. The available literature tends to ignore the significant degree of variability and diversity within each ethnic and racial group. There has been little emphasis on how racial, ethnic or socioeconomic factors influence health as people age. Additionally, more information is needed on health beliefs and health seeking behaviors and their impact on health care utilization and access.

Future research projects must be inclusive in terms of ethnicity and gender, including participation in clinical trials. Large-scale epidemiological studies have been started in some ethnic elderly groups but must be expanded and made more inclusive. The question of valid and reliable assessment tools must be examined and incorporated into research designs, with more thorough evaluation than simple translation of instruments. Research designs need to be developed that are sensitive to the complexity of age, ethnicity, and the interrelationship of race-ethnicity and socioeconomic status with explicit care being taken to avoid using one as a 'proxy' for the other.

Areas of particular concern regarding ethnic elders include: mental health, particularly depression and dementing illnesses; cancer, particularly of the breast, prostate, and lung; diabetes and obesity; hypertension, coronary artery disease, cerebrovascular disease, and other common diseases in which significant disparities in treatment and outcomes exist. The impact on longevity of cultural diversity with respect to lifestyle and nutritional patterns should also be explored. Additionally, research elucidating the characteristics of resiliency in ethnic elders will provide greater knowledge and understanding of factors influencing quality of life, the impact of illnesses and life expectancy. Effective strategies for caring for diverse elders facing chronic or life threatening illness and working with their families is also an important area of research.

Diverse elders must be included in investigations about normal aging and development in, so that issues of biological and physiological functioning can be examined, with specific correlation on how this influences health care delivery. For example, we know that the aging process can affect, on average, the pharmacokinetics and metabolism of many drugs. What, if any, difference does race, ethnicity or either of these combined with age make in drug metabolism? Are there genetic determinants of health and disease?

EDUCATION

Position #2. The AGS supports education in ethno-culturally appropriate care for healthcare providers as well as the curriculum development necessary to provide such training in professional education.

Rationale:

Geriatrics is now a part of the curriculum of many American medical and nursing schools; however, few have addressed the issue of ethnicity and aging and many lack content on these health care concerns. Resources within the AGS should be used to develop and disseminate curricula for healthcare professionals, for example, through the AGS annual meeting, and the Journal of the American Geriatric Society, which will continue to address topics on ethno-cultural health and aging. Such topics might include the basic approach to culturally appropriate care, the evaluation and the assessment of diverse elders, clinical implications of biculturalism, diversity in long-term care issues, end-of-life care issues, patient education issues, and the use of an interpreter in clinical care. The Geriatric Review Syllabus and Doorway Thoughts: Cross Cultural Health Care for Older Adults are other resources.

CLINICAL CARE

Position #3. The AGS supports access to quality care for all elders, regardless of race, religion, or national origin.

Rationale:

Access to health care is a cornerstone to the development of culturally appropriate health services for ethnic elders. Many ethnic elders are frail and living with multiple chronic conditions, but then are receiving episodic or crisis oriented health care. Access to health care must be examined, with particular attention focused on the barriers that prevent access to quality health care. Issues such as poverty, inadequate health literacy, and communication barriers are known to influence both access to care and the quality of care received.

Perhaps because of these factors, these elders may seek health services less frequently, and later in the course of an illness than white elders. One of the important components of access is the degree to which ethnicity influences an individual's perception of a given illness, and the decision to seek health care. Not to be overlooked are the roles that racism and discrimination play in both access and quality of care that is received. Current information seems to indicate that more ethnic elders in the largest populations are poorer, less well educated and have more chronic health conditions than the average older Americans. They seem to have the same health conditions as their white counterparts, but often develop them at an earlier age and live with chronic disease for a greater proportion of their lives. This greater degree of chronicity and disability significantly impacts their functional status and quality of life.

While some older adults adapt easily to the U.S. society and its norms, many others do not. Such cultural isolation may lead to unrealistic expectations and miscommunication during health care encounters. It is important for health care professionals and systems to help educate less acculturated older adults about the U.S. health care system and how to navigate it most effectively.

Position #4. The AGS supports ethno-culturally appropriate health care.

Rationale:

It is imperative that health care systems and health care providers systematically incorporate an ethno-culturally-relevant perspective into all aspects of care for older adults in order to ensure quality care and the best healthcare outcomes possible.

Positions #5. The AGS supports the development of a database that addresses the health care issues of ethno-culturally diverse elders, such as a database for basic disease processes with information on prevalence, presentation and management issues.

Rationale:

The provision of health care for ethno-culturally diverse elders continues despite the dearth of knowledge that currently exits with respect to health issues specific to these elders. A data system using the information and experiences of clinicians who are currently providing care to the various populations in this country should be developed. Emphasis should be placed on frail elders living in rural as well as urban areas, with the goal of supporting functional independence and improving quality of life. This data base, for example, could be accessed by clinician educators and health care providers caring for ethnic elders such as a physician new to caring for a Hispanic elder with diabetes.

ORGANIZATIONAL

Position #6. The AGS encourages and supports the participation of providers from various ethnic and racial backgrounds, especially those underrepresented in health care, at all levels of the organization's activities. These activities include committee membership, chair and board membership with inclusion and participation in all topics of geriatrics and not just those specific to ethnic or racial issues.

Rationale:

In view of the demographics projected for ethnic elders into the next century, there will be a significant need for health care providers of diverse ethnic backgrounds to actively participate in the organization. Such participation is essential to the success of the organization's promotion of quality health care for older Americans.

Position #7. The AGS seeks ways to increase the number of health care providers interested in ethnogeriatric research, education, and clinical care.

Rationale:

In view of the demographics projected for ethnic elders into the next century, there will be a significant need for all health care providers, not just members of these same ethnic populations, to have an interest in the needs of, and to provide care for the elders of these groups. Traditionally, many of the providers serving ethnic populations have been members of these same ethnic/racial groups themselves.

Credits
Prepared by the members of the Ethnogeriatrics Advisory group: Sharon A. Brangman MD, Co-Chair, David V. Espino MD, Co-Chair, Mary Kane Goldstein MD, Melvina McCabe MD, Richard Reed MD, and Carleen Tylenda MD and approved by the AGS Board of Directors in 1994. Revised by the AGS Ethnogeriatrics Committee, with special thanks to Kimberly A. Hickey MSN, ARNP and approved in May 2003 by the AGS Board of Directors Representative to Ethnogeriatrics Committee. Revised June 2006 by the Ethnogeriatrics Committee, with special thanks to Jacqueline Lloyd MD, Sandra Moody-Ayers MD, Gwen Yeo PhD, and Marianne Tanabe, MD.

References

1. Administration on Aging. Achieving Cultural Competence: A Guidebook for Providers of Services to Older Americans and Their Families. www.aoa.gov.
2. Collaborative on Ethnogeriatric Education. Curriculum in Ethnogeriatrics: Core Curriculum and Ethnic Specific Modules, 2002. www.stanford.edu/group/ethnoger. Accessed 8-1-2006.
3. Federal Interagency Forum on Aging Related Statistics. Older Americans 2000: Key Indicators of Well-Being. Washington, DC.
4. National Consensus for Quality Palliative Care http://www.nationalconsensusproject.org. Accessed 9-23-2006.
5. Smedley BD, Stith AY, Nelson AR (Eds.) Unequal Treatment: Confronting Racial and Ethnic Disparities in Health Care. Washington, DC: Institute of Medicine, 2003.
6. U.S. Census. www.census.gov.