EDITORIAL
Ethnicity and Aging he concept that an older person who comes from gerontological services to be introduced to native a cultural background significantly different from Americans in their mid-fifties. Virtually no data exist on the health status and that of the majority is at increased risk for poor quality of life and early mortality, ie, the double jeop- problems of other economically disadvantaged, ethniardy hypothesis, is often stated but poorly researched. cally unique older populations, such as the Amish and In a previous editorial' we pointed out that African- those living in Appalachia. In addition, while America Americans have a lower life expectancy than Cauca- has acted as a classic melting pot for many persons of sians, but much of this difference is explained by European ancestry, new immigrants from Europe conincreased infant mortality and death before old age.' tinue to form ethnic minorities with their own unique A clear disadvantage of ethnicity in old age is speaking cultures. Each of these ethnically diverse groups of a language that differs from that of the majority of the older persons present their own set of challenges to the population. This can lead to increasing isolation and culturally sensitive geriatrician. Recently, the Journal has carried a number of articles the development of depression. Older Hispanics living in Los Angeles have a high prevalence of dysphoria, comparing older African-Americans to older Caucaand this is particularly prevalent among those who do sians. Murden et a19 found that the Mini-Mental State not speak English.' However, in many cases it is diffi- Examination performed equally well for Caucasians cult to discriminate between the effects of ethnicity on and African-Americans when adjusted for educational level of the persons being examined. Strogatz et all0 aging and the more devastating effects of poverty. Miles and B a n ~ a r d ,in ~ the October issue of the found that postural hypotension is almost twice as Journal, discuss in detail some of the geriatric charac- prevalent among Caucasians than African-Americans. teristics of older African-Americans. Like African- This difference may be due to the more pronounced Americans, older Hispanics are more likely than Cau- alpha-adrenergic vasoconstriction in African-Ameri-, casians to assess their health status as fair or poor cans." Aronow and Kronzon'* examined the preva(36.5% vs 28.3%), have more restricted activity days lence of coronary risk factors in a large population (42.2% vs 36.5%) and bed disability days (19.2% vs residing in a long-term health facility in New York. 14.%), and are less likely to have some form of health Older African-Americans had more hypertension, diinsurance (95.7% vs 98.4%).4Diabetes mellitus occurs abetes mellitus, and obesity and less hypertriglycerimore commonly in Hispanics, and older Hispanics demia than older Caucasians. Older African-Americans have a greater mortality rate from diabetes than do with hypertension were more likely to have echocarCau~asians.~ Influenza and pneumonia mortality is diographic left ventricular hypertrophy than older much higher in older Hispanics than in Cau~asians.~Caucasians with hypertension. The culturally sensitive geriatrician needs to recogStudies on Hispanic elders in America have generally been flawed by failing to recognize that there are three nize that cultural background may shape the answers major hispanic groups, ie, Mexican origin, Cuban ori- to medically important questions among older persons. For example, Japanese fatalism (shi-ka-ta-ga-nai) may gin, and Puerto Rican origin. Native Americans represent the smallest well de- lead to a person not seeking appropriate early screening fined minority group.6 They come from 460 distinct for disease because "it can't be helped as stronger forces tribal groups. These groups have different disease pat- shape events." The enryo (self-effacement) tradition terns; eg, Oklahoma Indians have a high prevalence of may lead an older Japanese to refuse home services lung cancer, and gallbladder cancer is common among even when wanted. The knowledge of the typical herbal remedies utisouthwestern Indians and esophageal cancer among Eskimo-Aluet. Diabetes mellitus is particularly preva- lized in the population can lead to solutions of diaglent among native Americans with the frequency being nostic problem^.'^ For example, among African-Amergreater than 30% in the Pima, Papago, Seminole, Up- icans, asafetida, which is used for gas, can lead to land Yuman, and S e n e ~ aProtein-energy .~ malnutrition diarrhea; catnip, which is taken for colds, to central has been documented to be extremely prevalent among nervous system stimulation; and chamomile, which is elderly Navajo patients.8 There has been little planning used for loss of appetite, to ragweed pollen allergy. for the long-term-care needs of older native Americans, The ubiquitous ginseng tea is often a cause of hyperparticularly among the majority who still live in tribal tension.14 The widespread belief that ethnic minorities will take areas. There is a special need to provide in-home rehabilitation services for older native Americans. In better care of their elders than Caucasians do has led addition, because many native Americans are physio- to the failure to provide adequate, ethnically sensitive logically aged at an earlier chronological age than other nursing home facilities. In addition, it often creates ethnic groups, there is a desperate need for preventive pressure on the family to provide home care in eco-
T
JAGS 40:1183-1184, 1992 0 1992 by the American Geriatrics Society
0002-8614/92/$3.50
1184
MORLEY
JAGS-NOVEMBER 1992-VOL. 40,NO. 11
nomically disadvantaged situations. This may be com- between minority groups would be attenuated if unipounded by the lack of adequate home care support versal basic health care were available to all peoples. within certain areas of the inner cities. It has been my JOHN E. MORLEY, MB, BCH experience that medical residents (predominantly CauGeriatric Research Education and Clinical Center casian) often wish to discharge older African-AmeriSt. Louis VA Medical Center cans home to the inner city earlier than they would and Division of Geriatric Medicine discharge older Caucasians, because they believe that St. Louis University Medical School the African-American will receive greater family supSt. Louis, MO port! The geriatrician needs to learn not to over-generalize the ethnic differences. Just as with aging, where there REFERENCES tends to be an increase in the variation around the 1. Morley JE. lntemational aging: Why does the United States do so poorly. J Am Geriatr SOC1991;39:836-838. mean, the same is true for many typical ethnic findings. Kemp BJ, Staples F, Lopez-Aqueres W. Epidemiology of depression and For example, while the majority of African-American 2. dysphoria in our elderly Hispanic population: Prevalence and correlates. J women do not develop osteoporosis, we have noted Am Geriatr Soc 1987;35:920-926. that a substantial minority of older African-American 3. Miles TP, Bamard MA. Morbidity, disability and health status of black American elderly: A new look at the oldest-old. J Am Geriatr Soc 1992; women (usually those who are thin and of a lighter 40:1047-1054. complexion) appear to develop osteoporosis with a 4. Marikides KS, Mindel CH. Aging and Ethnicity. Newbury Park, C A Sage Publications, 1987, p 89. frequency similar to that of older Caucasian women. Morley JE, Perry HM 111. The management of diabetes mellitus in older It is clear that a number of differences, both in impact 5. individuals. Drugs 1991;41:548-565. of different diseases and in culturally acceptable ways 6. Cuellar JB. Aging in the American Indian and Alaskan Native. In: Morley ed. Geriatrics. St. Louis: Manning Co., 1992, in press. of dealing with diseases, exist between different ethnic 7. JE, Ghodes DM. Diabetes in American Indians: A growing problem. Diabetes groups. In many cases it remains uncertain whether Care 1986;9:609-613. the differences in disease impact are truly ethnically 8. Williams R, Boyce WT. Protein malnutrition in elderly Navajo patients. J Am Geriatr Soc 1989;37397-406. related or more generally due to economic status of 9. Murden RA, McRae TD,Kaner S, Bucknam ME. Mini-Mental State Exam some disadvantaged minority groups. Protein-energy scores vary with education in blacks and whites. J Am Geriatr Soc 1991; 39:149-155. malnutrition remains a major factor in morbidity 10. Strogatz DS, Neenan NL, Bamett EM, Wagner EH. Correlates of postural among older persons and needs to be taken into achypotension in a community sample of elderly blacks and whites. J Am Geriatr SOC1991;39:562-566. count when assessing the impact of ethni~ity.'~ Light KC, Obrist PA, Sherwood A et al. Effects of race and marginally Finally, it needs to be recognized that many disad- 11. elevated blood pressure on response to stress. Hypertension 1987;lO: vantaged older persons from ethnically disadvantaged 555-563. groups are in desperate need of basic health care. It is 12. Aronow WS, Kronzon I. Prevalence of coronary risk factors in elderly and whites. J Am Geriatr Soc 1991;39:567-570. essential that all segments of the United States popu- 13. blacks Hikoyeda N, Grudzen M. Traditional and non-traditional medication use lation have adequate access to health care. In addition, among ethnic elders. Working Paper No. 10. Stanford Geriatric Education Center, Stanford, CA 94305, pp 1-60, 1992. stressing preventive practices will, in the end, be more 14. Morley JE. The aging endocrine system. Postgrad Med 1983;73:107-120. cost-effective than our present focus on tertiary care. 15. Morley JE.Why do physicians fail to recognize and treat malnutrition in older persons. J Am Geriatr Soc 1991;39:1139-1140. Much of the difference in morbidity and mortality
Ethnicity and Aging he concept that an older person who comes from gerontological services to be introduced to native a cultural background significantly different from Americans in their mid-fifties. Virtually no data exist on the health status and that of the majority is at increased risk for poor quality of life and early mortality, ie, the double jeop- problems of other economically disadvantaged, ethniardy hypothesis, is often stated but poorly researched. cally unique older populations, such as the Amish and In a previous editorial' we pointed out that African- those living in Appalachia. In addition, while America Americans have a lower life expectancy than Cauca- has acted as a classic melting pot for many persons of sians, but much of this difference is explained by European ancestry, new immigrants from Europe conincreased infant mortality and death before old age.' tinue to form ethnic minorities with their own unique A clear disadvantage of ethnicity in old age is speaking cultures. Each of these ethnically diverse groups of a language that differs from that of the majority of the older persons present their own set of challenges to the population. This can lead to increasing isolation and culturally sensitive geriatrician. Recently, the Journal has carried a number of articles the development of depression. Older Hispanics living in Los Angeles have a high prevalence of dysphoria, comparing older African-Americans to older Caucaand this is particularly prevalent among those who do sians. Murden et a19 found that the Mini-Mental State not speak English.' However, in many cases it is diffi- Examination performed equally well for Caucasians cult to discriminate between the effects of ethnicity on and African-Americans when adjusted for educational level of the persons being examined. Strogatz et all0 aging and the more devastating effects of poverty. Miles and B a n ~ a r d ,in ~ the October issue of the found that postural hypotension is almost twice as Journal, discuss in detail some of the geriatric charac- prevalent among Caucasians than African-Americans. teristics of older African-Americans. Like African- This difference may be due to the more pronounced Americans, older Hispanics are more likely than Cau- alpha-adrenergic vasoconstriction in African-Ameri-, casians to assess their health status as fair or poor cans." Aronow and Kronzon'* examined the preva(36.5% vs 28.3%), have more restricted activity days lence of coronary risk factors in a large population (42.2% vs 36.5%) and bed disability days (19.2% vs residing in a long-term health facility in New York. 14.%), and are less likely to have some form of health Older African-Americans had more hypertension, diinsurance (95.7% vs 98.4%).4Diabetes mellitus occurs abetes mellitus, and obesity and less hypertriglycerimore commonly in Hispanics, and older Hispanics demia than older Caucasians. Older African-Americans have a greater mortality rate from diabetes than do with hypertension were more likely to have echocarCau~asians.~ Influenza and pneumonia mortality is diographic left ventricular hypertrophy than older much higher in older Hispanics than in Cau~asians.~Caucasians with hypertension. The culturally sensitive geriatrician needs to recogStudies on Hispanic elders in America have generally been flawed by failing to recognize that there are three nize that cultural background may shape the answers major hispanic groups, ie, Mexican origin, Cuban ori- to medically important questions among older persons. For example, Japanese fatalism (shi-ka-ta-ga-nai) may gin, and Puerto Rican origin. Native Americans represent the smallest well de- lead to a person not seeking appropriate early screening fined minority group.6 They come from 460 distinct for disease because "it can't be helped as stronger forces tribal groups. These groups have different disease pat- shape events." The enryo (self-effacement) tradition terns; eg, Oklahoma Indians have a high prevalence of may lead an older Japanese to refuse home services lung cancer, and gallbladder cancer is common among even when wanted. The knowledge of the typical herbal remedies utisouthwestern Indians and esophageal cancer among Eskimo-Aluet. Diabetes mellitus is particularly preva- lized in the population can lead to solutions of diaglent among native Americans with the frequency being nostic problem^.'^ For example, among African-Amergreater than 30% in the Pima, Papago, Seminole, Up- icans, asafetida, which is used for gas, can lead to land Yuman, and S e n e ~ aProtein-energy .~ malnutrition diarrhea; catnip, which is taken for colds, to central has been documented to be extremely prevalent among nervous system stimulation; and chamomile, which is elderly Navajo patients.8 There has been little planning used for loss of appetite, to ragweed pollen allergy. for the long-term-care needs of older native Americans, The ubiquitous ginseng tea is often a cause of hyperparticularly among the majority who still live in tribal tension.14 The widespread belief that ethnic minorities will take areas. There is a special need to provide in-home rehabilitation services for older native Americans. In better care of their elders than Caucasians do has led addition, because many native Americans are physio- to the failure to provide adequate, ethnically sensitive logically aged at an earlier chronological age than other nursing home facilities. In addition, it often creates ethnic groups, there is a desperate need for preventive pressure on the family to provide home care in eco-
T
JAGS 40:1183-1184, 1992 0 1992 by the American Geriatrics Society
0002-8614/92/$3.50
1184
MORLEY
JAGS-NOVEMBER 1992-VOL. 40,NO. 11
nomically disadvantaged situations. This may be com- between minority groups would be attenuated if unipounded by the lack of adequate home care support versal basic health care were available to all peoples. within certain areas of the inner cities. It has been my JOHN E. MORLEY, MB, BCH experience that medical residents (predominantly CauGeriatric Research Education and Clinical Center casian) often wish to discharge older African-AmeriSt. Louis VA Medical Center cans home to the inner city earlier than they would and Division of Geriatric Medicine discharge older Caucasians, because they believe that St. Louis University Medical School the African-American will receive greater family supSt. Louis, MO port! The geriatrician needs to learn not to over-generalize the ethnic differences. Just as with aging, where there REFERENCES tends to be an increase in the variation around the 1. Morley JE. lntemational aging: Why does the United States do so poorly. J Am Geriatr SOC1991;39:836-838. mean, the same is true for many typical ethnic findings. Kemp BJ, Staples F, Lopez-Aqueres W. Epidemiology of depression and For example, while the majority of African-American 2. dysphoria in our elderly Hispanic population: Prevalence and correlates. J women do not develop osteoporosis, we have noted Am Geriatr Soc 1987;35:920-926. that a substantial minority of older African-American 3. Miles TP, Bamard MA. Morbidity, disability and health status of black American elderly: A new look at the oldest-old. J Am Geriatr Soc 1992; women (usually those who are thin and of a lighter 40:1047-1054. complexion) appear to develop osteoporosis with a 4. Marikides KS, Mindel CH. Aging and Ethnicity. Newbury Park, C A Sage Publications, 1987, p 89. frequency similar to that of older Caucasian women. Morley JE, Perry HM 111. The management of diabetes mellitus in older It is clear that a number of differences, both in impact 5. individuals. Drugs 1991;41:548-565. of different diseases and in culturally acceptable ways 6. Cuellar JB. Aging in the American Indian and Alaskan Native. In: Morley ed. Geriatrics. St. Louis: Manning Co., 1992, in press. of dealing with diseases, exist between different ethnic 7. JE, Ghodes DM. Diabetes in American Indians: A growing problem. Diabetes groups. In many cases it remains uncertain whether Care 1986;9:609-613. the differences in disease impact are truly ethnically 8. Williams R, Boyce WT. Protein malnutrition in elderly Navajo patients. J Am Geriatr Soc 1989;37397-406. related or more generally due to economic status of 9. Murden RA, McRae TD,Kaner S, Bucknam ME. Mini-Mental State Exam some disadvantaged minority groups. Protein-energy scores vary with education in blacks and whites. J Am Geriatr Soc 1991; 39:149-155. malnutrition remains a major factor in morbidity 10. Strogatz DS, Neenan NL, Bamett EM, Wagner EH. Correlates of postural among older persons and needs to be taken into achypotension in a community sample of elderly blacks and whites. J Am Geriatr SOC1991;39:562-566. count when assessing the impact of ethni~ity.'~ Light KC, Obrist PA, Sherwood A et al. Effects of race and marginally Finally, it needs to be recognized that many disad- 11. elevated blood pressure on response to stress. Hypertension 1987;lO: vantaged older persons from ethnically disadvantaged 555-563. groups are in desperate need of basic health care. It is 12. Aronow WS, Kronzon I. Prevalence of coronary risk factors in elderly and whites. J Am Geriatr Soc 1991;39:567-570. essential that all segments of the United States popu- 13. blacks Hikoyeda N, Grudzen M. Traditional and non-traditional medication use lation have adequate access to health care. In addition, among ethnic elders. Working Paper No. 10. Stanford Geriatric Education Center, Stanford, CA 94305, pp 1-60, 1992. stressing preventive practices will, in the end, be more 14. Morley JE. The aging endocrine system. Postgrad Med 1983;73:107-120. cost-effective than our present focus on tertiary care. 15. Morley JE.Why do physicians fail to recognize and treat malnutrition in older persons. J Am Geriatr Soc 1991;39:1139-1140. Much of the difference in morbidity and mortality
