Careers in Elder Care
Elders play a vital role in American Indian and Alaska
Native communities. They have long been respected and
treasured. Both on reservations and in urban areas, elders
are working with the younger generations to restore and
maintain their tribes’ languages, stories, knowledge, and
traditions.
One way to honor elders and give back to communities is to
become a physician, nurse, dentist, social worker or other
health professional who contributes to making sure that
elders have the highest quality health care possible. This
means addressing the poor health status of many elders and
providing care that helps them prevent illness and
maximizes their quality of life.
Currently, Western health care for Native elders is
seriously suboptimal. Becoming a health professional,
particularly a health professional in a leadership role,
provides opportunities to help redesign the system of
health care for Native elders so that it is comprehensive,
well-coordinated, accessible, culturally-sensitive and
complements traditional medicine.
The need for health professionals who can competently care
for aging people is particularly pressing because the aging
population is growing rapidly, not only in Native
populations but throughout the United States. Currently
health professionals with expertise in elder care are in
short supply in the U.S., including Indian Country. This
means that there are excellent career opportunities in
elder care throughout the United States.
Health
and Health-Related Disparities
Margaret P. Moss,
PhD, JD, RN,
is an enrollee of the Three Affiliated Tribes of North
Dakota. She is an example of an American Indian nurse
who is making a difference. As a young nurse at Santa Fe
Indian Hospital, she was concerned that elders didn’t
come for care until they were extremely ill, and even
though some elders needed full-time care when they were
discharged from the hospital, they typically refused to
go to a nursing home or other eldercare facility in the
city. Moss’ many concerns about elder health led her on
a journey that included studying the health care of Zuni
elders, as part of earning her doctoral degree. Next she
earned a law degree so she could address the many legal
barriers to good health care. More recently, as part of
a Robert Wood Johnson fellowship, she worked on health
care legislation in Washington D.C..
Moss, like many others, has been appalled by the abuse and
broken treaties that have led to the poor health status and
premature death of elders. She says, “At age 40 American
Indian elders have problems that the dominant culture has
at age 60. At 40 they already have heart problems, asthma,
diabetes, arthritis, and probably deteriorating
kidneys.
The
average lifespan for elders in the Aberdeen area of the
Indian Health Service (IHS) is age 64, so these people
don’t reach the age where they get benefits like Medicare.
At Pine Ridge, the average age for the life span of a man
is 42. This is the lowest life span for any race in
America.”
Yet, despite the fact that the IHS is caring for the
sickest group of people and that the federal government has
treaty-based trust responsibilities for providing health
care to Indian people, Moss points out that federal funding
for Indian people is dismal.
In the general U.S. population, an average of $6,000/yr is
spent per person on health care in federal programs, such
as Medicaid and Medicare.
In the Veterans Administration, which is federally funded,
an average of $4,300/yr is spent per veteran.
In federally-funded prisons, an average of $3,500/yr is
spent on each prisoner.
In sharp contrast, the Indian Health Service receives
$2,500/yr per person.
Underfunding means that there are far too few health
professionals, health care facilities, resources and
services for elders as well as members of the other
generations.
(Hopefully, funding will be improved with the
reauthorization of the Indian Health Care Improvement Act,
which was included in the new health care legislation.)
Need for Elder-Oriented Facilities and Services
Most elders
want to live independently in their homes. In her work and
research, Moss discovered that many elders don’t seek
timely care for such reasons as lack of accessible clinics
and services, lack of transportation, and uneasiness about,
even distrust of, Western medicine. Also, many Native
elders do not want to go off the reservation to get care,
particularly in a nursing home. Moss says, “They’d rather
die on the reservation than come out for care.” Besides
missing their families and communities, Elders, have
trouble in non-Native facilities where it’s difficult for
them to communicate, where they are not served familiar
food, and where they can’t perform their ceremonies.
Priscilla A.
Day, Anishinaabe,
MSW, EdD, is an enrolled member of the Minnesota
Chippewa Tribe from the Leech Lake Reservation. She is a
professor in the Department of Social Work in the
University of Minnesota Duluth. Day notes that a large
number of elders were sent off to boarding schools as
children. Being in the institutionalized setting of a
nursing home can trigger traumatic memories of being in
a boarding school.
Current and future health professionals need to be creative
in finding more ways for providing elders with services in
their homes and communities. And they need to find ways to
provide accessible higher-level, culturally-competent,
full-time care for elders who live both on and off
reservations. Moss says, “There are only 12 or so nursing
homes on the 300 or so reservations. Yet American Indian
people have functional disability and chronic disease
earlier and with more severity than the general
population.”
Frances
Stout, Tohono
O’odham, RN, and her colleagues have been lauded for the
ways they are responding to the need for nursing and
hospice care on the Tohono O’odham Nation. Click on
“Frances
Stout” and see
the article about how the Tohono O’odham Nation is
bringing its people home and providing them with
exemplary care.
Geriatrically-Competent
Health Professionals are Needed
On reservations
and throughout the United States, most physicians, nurses,
social workers and other health professionals spend a large
percentage of their professional lives working with older
adults. Few, however, have the specialized skills and
knowledge required when addressing the complex needs of
older adults.
Melvina
McCabe, Navajo,
MD, is addressing this issue. She directs the
New Mexico Geriatric Education
Center whose
mission is to improve the health care of American Indian
elders by provide geriatric education to a wide range of
health professionals who work together and with families
and communities in caring for elders. Drs. McCabe and
Moss and other educators across the nation are also
working to include more geriatric education in the
schools in the health professions so that the next
generation of health professionals will be better able
to take care of aging adults.
Some
Members of the Health Team
Families
provide most of the care needed by their elders. As the
demands of family members grow, however, this is becoming
more difficult. Traditional healers also play an important
role in some Native elders’ lives. Moss says, “Elders are
often speakers of their language, and they continue to use
traditional prayer and medicine.”
Good elder care requires the coordinated efforts of many
people, including the following health professionals.
Family physicians are educated to
take care of all generations in a family, including older
adults. They know that when a grandmother or grandfather is
sick, this can have an impact on the whole family. Family
physicians can help families think through how they can
help their elders. Younger members of the family, for
example, can help by cooking the food their elders need,
assisting the elders with bathing, eating, and walking, and
listening to their elders’ stories.
Geriatricians,
such as Dr. McCabe, are family physicians and internists
with special training in the health needs and care of older
patients. As people get older, their bodies change. Bones
become more brittle. Muscles lose their tone. The immune
system doesn’t work as well. As a result, older people are
more likely to suffer from health problems, including both
acute (sudden, severe) and chronic (ongoing) conditions.
Geriatricians are educated in the changes that occur in
aging people and the implications of these changes for
diagnosing and treating elders.
The U.S., including Indian Country, greatly needs more
geriatricians. Currently there is only one geriatric
specialist for every 2,500 Americans over age 75. With the
rapid growth in the elderly population, unless many more
geriatricians are educated, by 2030 there could be just one
geriatrician for every 20,000 older patients.
Geriatric
nurses are in great
demand because half of all patients who admitted to the
hospital are over age 65, but only one percent of nurses
are certified in geriatrics. Nurses who care for the aging
need to be aware of the special concern and needs of
elders. This includes being sure that the elder’s needs are
met, not only in the hospital and clinic but also at home.
When Winona Begay,
Navajo,
discharges patients, she often has to counsel them about
their medications and other treatments. If elders can’t
care for themselves on their own, she tries to link them
with resources in the community. Some elders don’t need
to be hospitalized but might need to be linked with
community resources.
Physical therapists can help elders
improve their strength and balance, which diminishes with
age, through exercises and treatments. Physical therapists
can also help elders deal with some of the incapacitating
conditions commonly associated with aging, such as
arthritis, osteoporosis, stroke, and hip and joint
replacements.
Occupational
therapists can help elders
successfully engage in the activities of daily living, such
as eating, bathing, dressing, grooming, and doing laundry.
Like physical therapists, they might teach the elders
exercises and, when appropriate, suggest assistive devices,
such as eating aids, dressing aids, canes, walkers, and
special beds.
Pharmacists are aware that
elders are likely to have prescriptions for many drugs and
so make sure that this kind of polypharmacy won’t result in
adverse drug reactions. Also, when recommending medications
and doses, they keep in mind that the aging body handles
drugs differently than younger bodies.
Dietitians,
who
are trained to care for older people are aware of how the
physiologic changes that accompany aging can affect
people’s nutritional status. For example, decreases in the
senses, particularly in the taste buds, may affect the
elder’s appetite. Denture wearers may chew less efficiently
than they did with their natural teeth.
Yvonne
Jackson, Cherokee,
PhD, RD, is Director of the Office of American Indian,
Alaskan Native and Native Hawaiian Programs in the U.S.
Office of Administration on Aging. The services funded
by Jackson’s office include, congregate meals,
transportation services, home-delivered meals, home
supportive services, support for caregivers, and
nutrition screening and education. If elders have
complex nutritional problems, they are referred to
registered dietitians, such as Valora Tom, Navajo,
and Wynona Woolf, Yakama,
who keep in mind
the elders’ traditional diets and what foods are
affordable and accessible.
Dentists
can
help older people keep and maintain their teeth. In the
past, loss of teeth in the elderly was seen as inevitable,
but this does not need to be the case.
Optometrists can help elders
keep their eyesight. Dr. George
Foster,
Muskogee/Creek, Dean Emeritus of Northeastern
State University Oklahoma College of Optometry, helped
create an outreach program with Cherokee Nation that is
enabling many elders to have greatly improved eyesight.
[See “Educating Optometrists and
Caring for Indian People”.]
Social
workers and other mental
health professionals can help older adults stay in charge
of their lives and deal with such issues as grief over the
loss of family members and friends and stress over
financial and health issues. They can also help elders and
their families manage certain mental disorders, such as
Alzheimer’s disease and other dementias that typically
occur later in life.
Social workers can provide direct counseling, run support
groups for family caregivers, and help elders navigate the
health care system and identify and access community
resources. Social workers can also contribute to policy
making and advocate for their clients.
Podiatrists
can
help elders deal with the foot-related complications of
diabetes as well as various other conditions that can
affect the aging feet.
Researchers
can
help determine the health care needs of the aging
population. Organizations, such as the Centers for American
Indian and Alaska Native Health at Colorado School of
Public Health, ensure that when Native elders are the focus
or research, the research is done in collaborative,
respectful ways.
Particular
Need for Native Health Professionals
Many non-Native
health professionals are providing high-quality, sensitive
care to Native elders. However, says Moss, “People are more
comfortable with other people who look like them and
already understand some of their fundamental beliefs and
truths. Especially when elders are sick, it takes energy
for them to explain what they need. If the provider doesn’t
understand their culture, elders not only have to muster
the energy to ask for what they need, but they often need
to explain why they need it.
“If elders need to have an ear of corn in their bed as
they’re rolled out to surgery, it’s much easier for them to
make that request of a Native person who doesn’t need an
explanation. Native people know that elders have to do some
things.”
Because Native people tend to share some common values,
even if they aren’t working with their own tribe, they can
help create strategies and services that are congruent with
the elderly people for whom they care.
Characteristics
of Effective Health Professionals
Health
professionals who provide high-quality care to elders know
about the changes in aging bodies, and they know they know
the difference between the characteristics of normal aging
and pathology/problems. They are comfortable with the fact
that they might not be able to cure some problems but they
can help elders be as vital and functional as possible.
Effective health professionals are patient. They know that
some elders take longer to communicate as they age and that
their bodies can take longer to heal. These health
professionals are also comfortable with frailty and death.
Day says that relationships are important to elders. “My
grandmother’s doctor took time to look at the family photos
and letters that my grandmother brought with her to her
appointments. She would tell him about her life, and he
would take time to listen. When people work with elders,
they should understand the importance of relationships.”
Day also says, “People who work with elders should be
gentle, compassionate, caring, and respectful. They should
have some understanding of the elder’s history and culture.
They should understand if someone wants to smudge or bring
in a traditional person or eat traditional food. They
should understand the importance of the extended family.
And they should respect that the life ways of elders can
vary. For example, some elders practice traditional ways,
some are practicing Christians and some believe in both
ways.”
Health professionals need to be able to relate to the whole
person, including their spiritual dimension. Moss says, “In
Western nursing, we learn about the four areas of health:
physical, mental, emotional and spiritual. We learn the
most about the physical domain. We pay some attention to
mental and a little to emotional, but we may never get to
the spiritual, even though the spiritual is often the
priority of Native elders.”
Joys
and Rewards
Family
physician, Adrienne
Laverdure,
Turtle Mountain
Band of Chippewa Indians, says, “Throughout
the years I’ve learned a lot from the elders. I will
always remember the ones that have passed. They have not
only taught me about living but about end-of-life care.
Sometimes the best care for elder patients is to spend
time with them and make the extra effort to learn about
them. They can teach us a lot about respect for
patients.”
Moss is fascinated by the lives that elders have lived and
also enjoys learning from them. “It’s been enriching to
take care of elders from other tribes because even if the
younger generation had lost some of its traditionality, the
elders are likely to know about the traditional, even if
they don’t practice.” Speaking of an elder with whom she
became close, Moss says, “It was almost like having another
grandmother.”
Day says that one of her joys is to hear about elder’s
experiences. As part of some research that she and her
colleagues are doing, they’ve been asking elders from many
reservations, “What does it take to raise a healthy Indian
child?” In response to this question, elders have provided
good advice and told many fascinating stories about what it
was like when they were growing up.
Advice
If you want to
find out if you enjoy working with elders, Moss and Day
recommend volunteering in settings where you can work with
elders. Moss says that her own daughters are volunteering
at a nearby nursing home and senior center. Moss also
recommends taking college classes related to aging and
introductory courses in the health professions that may
offer field visits at elder care facilities.
According to
the Institute of Medicine, only one-third of baccalaureate
nursing programs require a course in geriatrics and only 29
percent of baccalaureate programs have a faculty member who
is certified in geriatrics. Eighty percent of social work
students in undergraduate programs have no coursework in
aging. This means that when you explore health professions
schools, it’s important to find one that includes
geriatrics in the curriculum