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.
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