Cultural competency critical in elder care

The need to address disparities in treatment and diagnosis of Alzheimer's and other age-related diseases increases as the percentage of minorities in the elderly population increases.

By Victoria Stagg Elliott, amednews staff. Aug. 6, 2001.

When Maureen T. Sturman, MD, assesses the patients who come to her clinic for signs of Alzheimer's or other forms of dementia, she is able to test them not just in Spanish but in the specific dialect they speak -- something she considers crucial for an accurate evaluation.

Translators are available not just for the most common languages spoken in her area, such as Polish and Chinese, but for many other Asian, European and African languages.

Recognizing differences
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There are important reasons for such accommodations.

"If it's a family member translating for the neuropsych test, they may unintentionally assist on the patient's behalf," she said.

It's all part of an emerging awareness of the role cultural difference can play in recognizing Alzheimer's. While administering the tests, for instance, Dr. Sturman uses a computer program that adjusts the scores for the patient's educational level. She has also had to learn the different ways ethnic groups will interpret and present their symptoms.

As the director of the one-year-old memory assessment clinic run by Cook County Hospital in Chicago, these are the kinds of steps she has had to take for her predominantly African-American and Latino patients. She is part of a growing movement of health care workers who are starting to deal with the aging of America, the expected increase in age-related illnesses, and also the increasingly multi-ethnic nature of this elderly patient population.

Life expectancies of minority populations now mirror that of Caucasians.

Minorities now make up 16% of those over the age of 65. By 2050, a quarter of all elderly will be members of minority groups, according to Ramón Valle, PhD, professor emeritus at San Diego State University's School of Social Work. The life expectancies of minorities will also catch up with Caucasians, with the average Latino living to 87 and Asian- American to 86. In addition, research suggests Latinos and African-Americans may be more susceptible to Alzheimer's, although actual prevalence among minorities is unknown.

"The care community can no longer afford to ignore U.S. population trends if it is to provide quality care to the growing numbers of people with Alzheimer's disease," said Dr. Valle, during the annual Alzheimer's Assn. conference last month in Chicago. "Providing dementia-capable care is no longer enough. It's time to mobilize and provide culturally competent care."

That care can include physicians and health care providers who can speak the patient's first language, important particularly in the latter stages of the disease when a person retains only the earliest learned skills. Many ethnic elderly are more likely to be taken care of by extended families that are less likely to participate in caregiver support groups, in part because of inconvenient meeting places and times.

Early diagnosis now crucial

But while many experts warn of the coming flood of Alzheimer's cases among minority elderly, they are also highly critical of the quality of services available.

Experts complain that the neuropsychological screening and diagnostic tests are frequently biased -- resulting in a higher rate of false-positives among minorities. Even so, fewer minority patients are referred for services; therefore, they tend to be diagnosed later than Caucasians.

In the past, the point of diagnosis was less important because good treatments were not available. Now, however, early diagnosis is crucial because drugs can slow or halt a patient's symptoms and are most effective in the early stages.

"It doesn't matter that they're being overdiagnosed, because they're not getting referred for evaluation anyway," said Vicki Lampley, MD, MPH, assistant professor in the department of geriatric medicine at the University of Oklahoma in Oklahoma City. "It's unclear why. We're hoping it's not straight racism."

There is also much less known about the natural history of the disease among African-Americans, Latinos, Asian-Americans and Native Americans. Minorities are less likely to be involved in research, a legacy of the Tuskegee syphilis study. In addition, much of the investigation done has been designed to exclude sufferers with comorbid conditions such as diabetes or hypertension, which are much more common in the minority population.

"A lot of the work on Aricept [donepezil hydrochloride], for example, our best studied Alzheimer's drug, has been on a largely white population and people who don't have a lot of concomitant medical illnesses," said Dr. Sturman. "A lot of our patients do. While we offer treatment and presume that they're going to work in patients who may have hypertension, heart disease and diabetes -- which are very common among African-Americans and Latinos -- we don't know."

Experts say increasing ethnic minority participation in research is important not just to understand how the disease progresses and treatments work in various populations, but also to further understand the genetic factors that affect the history of the condition among everyone.

"We need to understand what is similar and different -- the different responses to drugs, different styles of family caregiving and the different levels of access and benefits from services -- to more fully understand the disease," said Marcia Neundorfer, PhD, senior research associate with the Alzheimer Center at the University Hospitals of Cleveland.