How Will the U.S. Healthcare System Meet the Challenge of the Ethnogeriatric Imperative?

Much of the geriatric imperative that is facing providers in the United States is an ethnogeriatric imperative, because one-third of older Americans are projected to be from one of the minority populations by mid-century, and that vastly underrepresents the actual diversity providers will see. Because of the vast heterogeneity of culture, language, health beliefs, risk for disease, and other factors, it is important for policy makers and health providers to be familiar with the diverse characteristics and needs of the various groups that will need geriatric care if they are to receive effective services. Challenges to high-quality ethnogeriatric care include disparities in health status and health care, differences of acculturation level and other characteristics within the populations, language and limited English proficiency, health literacy, culturally defined health beliefs and syndromes, and specific beliefs and preferences about long-term and end-of-life care. Some models of successful ethnogeriatric care have been identified and have in common the involvement of members of the target population in the development and design of the services and the use of cultural liaisons from the ethnic community being served, such as community health workers, or promatores . Thirteen recommendations are suggested for policy and practice changes in multiethnic and ethnic-specific health programs to provide competent ethnogeriatric care in the U.S. healthcare system.     

Curricular framework: core competencies in multicultural geriatric care

Strategies to reduce the documented disparities in health and health care for the rapidly growing numbers of older patients from diverse ethnic populations include increased cultural competence of providers. To assist geriatric faculty in medical and other health professional schools develop cultural competence training for their ethnogeriatric programs, the University of California Academic Geriatric Resource Program partnered with the Ethnogeriatric Committee of the American Geriatrics Society to develop a curricular framework. The framework includes core competencies based on the format of the Core Competencies for the Care of Older Patients developed by the Education Committee of the American Geriatrics Society. Competencies in attitudes, knowledge, and skills for medical providers caring for elders from diverse populations are specified. Also included are recommended teaching strategies and resources for faculty to pursue the development of full curricula.     

Ethnogeriatric education: Need and content

The population of elders from ethnic minority populations in the U.S. is growing much more rapidly than the exploding older population as a whole, yet few geriatric providers are being educated concerning ethnic elders' diverse health care needs. Examples are given of the diversity of ethnic elders' health risks, health beliefs and expectations of treatment, and utilization patterns of health care services being incorporated into ethnogeriatric curriculum being developed by the Stanford Geriatric Education Center.Supported by a grant from the Bureau of Health Professions for Geriatric Education Centers.     

Attitudes and preferences of Korean-American older adults and caregivers on end-of-life care

A growing body of literature suggests that diverse attitudes toward the end of life exist across and within ethnic minority groups. This focus-group pilot study examined social and cultural factors influencing views of Korean-American older adults and caregivers on advance care planning and hospice care. A total of 20 older adults and 16 caregivers in west central Florida participated in one of four focus groups. This study found diverse attitudes among Korean Americans toward end-of-life care and cultural and structural barriers to advance care planning and hospice use. Older adults and caregivers both expressed a lack of knowledge about advance care planning and hospice and agreed that the family would make the final decision about the end-of-life care, while acknowledging the challenge of initiating communications about treatment preferences. They interpreted the Korean value of filial piety to support both curative and palliative treatment. The traditional norm of home death and importance of physician communication influenced preferences for hospice and advance care planning, respectively. Future outreach and education efforts should include development of culturally sensitive educational and communication tools and collaboration with ethnic community organizations and healthcare providers in the dissemination and education of these instruments.     

The ETHNIC(S) mnemonic: a clinical tool for ethnogeriatric education

Geriatrics healthcare providers need to be aware of the effect that culture has on establishing treatment priorities, influencing adherence, and addressing end-of-life care issues for older patients and their caregivers. The mnemonic ETHNIC(S) (Explanation, Treatment, Healers, Negotiate, Intervention, Collaborate, Spirituality/Seniors) presented in this article provides a framework that practitioners can use in providing culturally appropriate geriatric care. ETHNIC(S) can serve as a clinically applicable tool for eliciting and negotiating cultural issues during healthcare encounters and as a new instructional strategy to be incorporated into ethnogeriatric curricula for all healthcare disciplines.     

Consensus‐Based Recommendations for an Adequate Workforce to Care for People with Serious Illness

The lack of an adequately prepared workforce is a critical barrier to delivering high‐quality community‐based care for individuals living with serious illness. This article presents 16 consensus‐based recommendations to improve the capacity of the workforce in this area within the next 5 years, focusing on older adults. The recommendations were developed at a summit of 40 national leaders from practice, payment, labor, advocacy, and research arenas. The consensus‐based recommendations include specific steps for geriatrics leaders including curriculum reforms to increase skills in the care of older and seriously ill populations, expanding experiential learning opportunities for students to increase interest in careers in geriatric and palliative care, developing and improving curriculum in interprofessional and cultural competency skills, preparing clinicians to support incorporation of home care aides and family caregivers as healthcare team members, development of skills to support shared decision making with patients, and requiring specific skills related to serious illness care in licensing, accreditation, and continuing education regulations. Together, these recommendations put forward a charge to healthcare leaders to act to ensure a workforce that will optimize support for those with serious illness living in the community. J Am Geriatr Soc 67:S392–S399, 2019.     

Harnessing technology and collaboration for an online ethnogeriatric educational resource

The paper describes the development and testing of a Web-based educational resource for usability and acceptability by health care providers who care for ethnic older adults. The work was undertaken as a dissertation project. The purpose of the Website is to provide on-demand ethnogeriatric information to enhance provider-patient interaction. Focus groups of clinicians and ethnic older adults were used in order to identify content relevant to the care of frail ethnic older adults. Collaboration with the Stanford Geriatric Education Center, On Lok SeniorHealth Services, Inc., Pepperdine University Graduate School of Education, and a network of virtual consultants provided support to the project. The site contains information on 15 cultures, 12 religions, and 6 ethnic minority cohort groups. Testing by snowball sampling generated survey data from 96 respondents, consisting of general practitioners (24%), pediatric specialists (20%), and geriatric specialists (18%). The Website was considered useful for provider-patient communication (77%) and would be recommended to others (99%). The Web-based information resource, called "Diversity, Healing, and Healthcare," currently exists as a resource rather than as a defined learning module and can be accessed at http://www.gasi. org/diversity.htm.     

The Experience of Family Caregivers of Older Korean Americans With Dementia Symptoms

Despite the rapid growth of the older ethnic minority population, knowledge about dementia care for this population is limited. This study examined the experience of dementia caregiving among Korean Americans. We conducted four focus groups with 23 family caregivers of older Korean Americans with dementia symptoms and identified eight themes: (a) struggling and overwhelmed; (b) keeping the cultural roles and responsibility; (c) doing it by themselves; (d) family as a source of stress; (e) limited knowledge and misconceptions; (f) learning as they go; (g) undiagnosed dementia and misunderstandings about medical care; and (h) barriers to use of services and need for culturally responsive services. The findings underscore that Korean Americans need dementia caregiver programs that are linguistically and culturally responsive.     

African Americans,Mental Health,and Aging

A critical examination of the literature suggests that older African Americans are more likely to be diagnosed with depression, anxiety, and dementia. Assessment is complicated by potential differences in symptom presentation or reporting and a lack of assessment instruments validated for use with ethnically diverse older populations. Disparities in treatment are exacerbated for several reasons, including failure to access formal treatment, differences in symptomatology response to treatment, lack of available mental health resources, and stigma. Results indicate an enhanced awareness and training of the cultural context of mental health should be considered in clinical practice and research.     

Ethnic diversity in aging and aging services in the U.S.: Introduction

This collection on ethnic diversity in aging in the U.S. grew out of two symposia presented at the 1990 annual meetings of the Southwestern Anthropological Association. The papers in this volume focus on smaller and relatively little-known ethnic populations which are currently under-represented in the literature on minority aging. This collection begins to form the basis for cross-cultural comparisons which take into account population size, location and history. Topics include ethnography of aging, applied research, best practice models and policy analysis. Using varied methods and approaches, this collection (1) reports on the implications of a culturally diverse older population; and (2) recommends flexible programs and resource allocation to serve the needs of ethnic minority elderly.     

Building a Culturally Competent Workforce to Care for Diverse Older Adults: Scope of the Problem and Potential Solutions

The population of minority older adults is going to explode over the next four decades. Older adults from racial and ethnic minorities face persistent and pervasive health disparities. Health disparities exert a huge fiscal burden on the nation. The national financial cost of health disparities for the years 2002 to 2006 was an estimated 1.23 trillion dollars. As the aging population becomes more diverse, these disparity‐related costs are expected to increase. Older adults from racial and ethnic minorities face multiple barriers to accessing health and support services that will help them to age and die in place in the community. Patient‐related barriers include limited English proficiency, low health literacy, varying levels of acculturation, biases about Western healthcare and medications, mistrust of clinicians, inability to navigate the complex healthcare system, and cultural beliefs and taboos. Clinician‐related barriers include ageism (ie, discrimination against older people due to negative and inaccurate stereotypes), conscious and unconscious bias, being deeply entrenched in the culture of biomedicine, and the lack of training in the principles and practice of providing culturally respectful care. Health system–related barriers include lack of culturally tailored services, including access to medical interpreters. We conclude by identifying three specific strategies to facilitate culturally humble and respectful care for diverse patients. J Am Geriatr Soc 67:S423–S432, 2019.     

American Geriatrics Society/Association of Directors of Geriatric Academic Programs Curricular Milestones for Graduating Geriatric Fellows

This article describes the curricular milestones for geriatric fellows and the process used to develop them. The curricular milestones were developed to determine what every graduating geriatric fellow should be able to demonstrate to ensure that they will be able to practice effectively and safely in all care settings and with different older adult populations. Three major domains were identified: Caring for the Elderly Patient, Systems‐Based Care for Elder Patients, and Geriatric Syndromes. Six hundred thirty‐five geriatricians each reviewed and commented on one domain. These geriatricians represented important stakeholder groups: geriatric fellowship program directors; Association of Directors of Geriatric Academic Programs (ADGAP) members, who are primarily geriatric program and fellowship directors; the American Geriatrics Society (AGS) and ADGAP Education Committee; the AGS Teacher's Section; Geriatric Academic Career Award awardees; and through the American Board of Internal Medicine and the American Board of Family Medicine, board‐certified geriatricians who spend more than 50% of their time in clinical practice. The AGS and ADGAP boards approved the final set of 76 Geriatric Curricular Milestones, which were posted on the Portal of Geriatric Online Education in December 2012. These curricular milestones are intended to assist geriatric fellowship directors as they develop curricula and assessments to inform program director reporting to the Accreditation Council for Graduate Medical Education in the Next Accreditation System, which begins in July 2014.     

Treating hepatitis C in African Americans

Background: The epidemiology, natural history and response to therapy of chronic hepatitis C differs significantly between African Americans and other ethnic populations. The reasons for these differences are not entirely clear but include mode of transmission, viral kinetics, immune responsiveness, and demographics. Objective: Review of the peer‐reviewed literature and expert opinion from 1990 to 2005 regarding features of hepatitis C virus (HCV) infection in African Americans, differences in presentation and response to therapy, and treatment recommendations. Results: The epidemiology of HCV infection in African Americans appears to be predominantly associated with socio‐economic status and high‐risk behaviors. However, disease course, response to treatment, and virologic outcome may be a function of race. African Americans may clear HCV less efficiently than other ethnic groups, although impaired immune responsivity may also lead to decreased necro‐inflammatory activity and progression to cirrhosis. Therapy‐naive African Americans have lower sustained virologic response rates to this treatment than other populations. Conclusions: Strategies to improve outcomes in African Americans include higher doses of current medications, medications with fewer adverse events, and new experimental molecular therapies.     

Addressing the Community‐Based Geriatric Healthcare Workforce Shortage by Leveraging the Potential of Interprofessional Teams

As Americans live longer lives, we will see an increased demand for quality healthcare for older adults. Despite the growth in the number of older adults, there will be a decrease in the supply of a primary care physician workforce to provide adequately for their care and health needs. This article reviews the literature that explores ways to address the primary care workforce shortage in a community‐based geriatric healthcare setting, with special attention to elevating the role of nurses and caregivers and shifting the way we think about delivery of care and end‐of‐life conversations and planning. The shift is toward a more integrated and collaborative approach to care where medical and nonmedical, social services, and community providers all play a role. Several models have demonstrated promising positive benefits and outcomes to patients, families, and providers alike. The goal is to provide high quality care that addresses the unique attributes of older adults, especially those with complex conditions, and to focus more on care goals and priorities. The many barriers to scaling and spreading models of care across varied settings include payment structures, lack of education and training among all stakeholders, and, at the top of the list, leadership resistance. We address these barriers and make recommendations for a path forward where healthcare providers, policymakers, patients, families, and everyone else involved can play a role in shaping the workforce caring for older adults. J Am Geriatr Soc 67:S400–S408, 2019.     

Current research findings on end-of-life decision making among racially or ethnically diverse groups

PURPOSE: We reviewed the research literature on racial or ethnic diversity and end-of-life decision making in order to identify key findings and provide recommendations for future research. DESIGN AND METHODS: We identified 33 empirical studies in which race or ethnicity was investigated as either a variable predicting treatment preferences or choices, where racial or ethnic groups were compared in their end-of-life decisions, or where the end-of-life decision making of a single minority group was studied in depth. We conducted a narrative review and identified four topical domains of study: advance directives; life support; disclosure and communication of diagnosis, prognosis, and preferences; and designation of primary decision makers. RESULTS: Non-White racial or ethnic groups generally lacked knowledge of advance directives and were less likely than Whites to support advance directives. African Americans were consistently found to prefer the use of life support; Asians and Hispanics were more likely to prefer family-centered decision making than other racial or ethnic groups. Variations within groups existed and were related to cultural values, demographic characteristics, level of acculturation, and knowledge of end-of-life treatment options. Common methodological limitations of these studies were lack of theoretical framework, use of cross-sectional designs, convenience samples, and self-developed measurement scales. IMPLICATIONS: Although the studies are limited by methodological concerns, identified differences in end-of-life decision-making preference and practice suggest that clinical care and policy should recognize the variety of values and preferences found among diverse racial or ethnic groups. Future research priorities are described to better inform clinicians and policy makers about ways to allow for more culturally sensitive approaches to end-of-life care.     

Similarities and differences in attitudes toward long-term care between Japanese Americans and Caucasian Americans

The purpose of this study was to compare attitudes toward the use of long-term care between older Japanese Americans (n = 1,244) and older Caucasian Americans (n = 1,354). When presented with a hypothetical situation in which they have dementia, 39% of older Japanese Americans and 42% of older Caucasians intended to be cared for at home, whereas 53% versus 38%, respectively, intended to use nursing home care (P <.001). If the hypothetical situation was hip fracture, 81% of older Japanese Americans and 72% of older Caucasians intended to be cared for at home, with 13% of both groups intending to use nursing home care (P = NS). The subjects' perceptions of what their families, friends, ministers, and communities would want them to choose differed, with more uncertainty among Caucasians (P <.001). For provision of home care, Japanese Americans were more likely to rely on loved ones than Caucasians, who were more likely to rely on paid providers. Multivariate logistic regression showed ethnicity to be independently related to intention to use nursing home care in the dementia scenario, controlling for demographic variables. Being married lowered the odds of intending to use nursing homes in any situation. We conclude that Caucasian Americans intend to use paid home health care at higher rates than Japanese Americans if they become disabled by dementia. Japanese Americans demonstrated more certainty about the influences of others on their opinions, suggesting a more stable cultural norm in this population, and intended to use more nursing home care in the event of permanent debility (dementia).     

Physician‐Assisted Suicide Attitudes of Older Mexican‐American and Non‐Hispanic White Adults: Does Ethnicity Make a Difference?

Little is known about attitudes toward physician‐assisted suicide (PAS) in various ethnic groups. This study compares attitudes held by older Mexican Americans and non‐Hispanic whites and examines subject characteristics that may influence their responses. A convenience sample of 100 older Mexican Americans and 108 non‐Hispanic whites (n=208) aged 60 to 89 were recruited from four primary care community‐based practice sites in San Antonio, Texas. Interview items measured attitudes toward PAS, cognitive status, functional status, and religiosity. Older Mexican Americans (52.7%) reported stronger agreement than non‐Hispanic whites (33.7%) with PAS. Male sex (odds ratio (OR)=2.62, 95% confidence interval (CI)=1.09–6.35) predicted agreement with legalization in Mexican Americans, whereas lower religiosity scores (OR=0.84, 95% CI=0.75–0.94) were predictive of agreement in older non‐Hispanic whites. This study is the first to find positive attitudes among community‐dwelling older Mexican Americans toward PAS that are higher than those of older non‐Hispanic white adults. Sex and religious views were important determinants of positive attitudes toward PAS. Larger, more‐generalizable studies should be conducted to confirm the attitudinal patterns that have been identified in this study.