AT&R services for South Asian older people

Assessment

Formality of address

The concept of respect is an important one for traditional South Asian older people. Providers should address clients with warmth and respect and use a formal mode of address until given permission to use first names, if ever. Old age is often synonymous with wisdom, and the concepts of filial piety are central, consequently older adults expect deferential treatment as their due. Older South Asian people often treat the doctor with the same level of respect and deference.

Role of the doctor

Older South Asian people may be more accustomed to a paternalistic medical system in which the doctor determines the care plan and makes the decisions.

Gender issues

Older women may prefer to be examined by same-gender health practitioners. Having a female relative available when examining an older woman is highly recommended as it facilitates a frank interaction (e.g., questions concerning incontinence).

Married Hindu/Buddhist women may wear a sacred thread/gold chain with pendants and beads around their necks. These should not be removed during examination or surgery without the client’s approval. Sensitivity should be taken to protect the client’s modesty (e.g., avoid short examination gowns). In addition, direct eye contact from women to men may be limited.

Traditional beliefs

Although the biological causes of illness are understood, there is often believed that illness and disability is caused by karma.

Treatment

Approaches to decision making

Many South Asian families have a hierarchy of decision makers, usually beginning with the oldest son as the primary contact and disseminator of information.

Families may consult the GP often to get as much information as possible but may be reluctant to discuss personal, emotional and financial issues with health providers.

Effective care plans

Most South Asian clients prefer a family-centred approach. Older adults and their children often prefer not to disclose negative information to clients because they may worry that the truth may take away hope and increase suffering.

Disclosure and consent

Older adults who are ill may practice “closed awareness”, i.e., although they may be fully aware of the gravity of their illness, they may be unwilling to discuss the illness and prognosis openly with their family. Family members may request that the physician withhold information from their loved one.

The client may expect doctors to have all the answers and to make all the decisions for the client. As a result, the client takes a passive role, answering but not asking questions, and waiting for the doctor to give their diagnosis and recommendations. Most of the time medical advice is accepted without question.

Value of assertiveness

A doctor who takes charge and gives prescriptions for medications may be preferred. Doctors may be perceived as incompetent if they sound unsure.

For example, a less optimal way of communicating information to the client is:

Dr Murray: “Mrs Sharma, I am not sure if what you have is late onset lupus or Sjogren’s Syndrome. Your test results are inconclusive. I am going to start you on a medicine called hydroxychloroquin and see how you respond. What do you think?”

Mrs Sharma’s interpretation of the statement: “This doctor does not know what disease I have. He wants to start me on a new medication and he is asking me what I think? I am not a doctor? What can I say?”

Using Assertive Communication (adapted from Periyakoil & Dara, 2010) is a more optimal way of stating the same information:

Dr Murray: “Mrs Sharma, there are two diseases that can mimic each other and cause the symptoms you have. One is called lupus and the other is called Sjogren’s. Your test results are not helping us identify the exact disease you have. Your situation is not uncommon. I am going to start you on a medication which will help your symptoms. I am also going to monitor your symptoms and blood work very carefully to see how you respond to the medication. I need you to take the medicines regularly and keep a log of your symptoms. I want you to come back to the clinic in four weeks.”

Inpatient care

Hospital food

Many South Asian older adults observe religious dietary restrictions, e.g., many Hindus are vegetarians or vegans. Older Hindus will consume milk and butter but not cheese and eggs. Other considerations:

• Beef is forbidden for Hindus who eat meat.
• Muslim people require a halal diet.
• Foods containing pork and pork products (gelatine, etc.) are prohibited for Muslims and Hindus.

Hospital dress code

Some clients decline to wear hospital gowns and pyjamas as these have been used by others, even when reassured that these have been washed and sterilised.

When a client in hospital has a sacred thread across their chest (in men, this is a upanayanam) and around the neck in women (a mangalsutra), it should not be removed or cut without the permission of the client or family.

Surgery and procedures

Some South Asian older adults may prefer to have surgery only on some auspicious days and times of the day. This is less important during emergency procedures, but is a challenge during elective procedures. It is important to explore this with the client and their family when scheduling procedures and surgery, to negotiate a solution.

Medications

Many older South Asian clients may not adhere to the prescribed out-patient medication regime. Many Hindu older people may be using Ayurvedic (pronounced: Are-yer–ved–ic) medications (this is a form of traditional medicine and an alternative treatment). It is important to elicit and document this in client notes.

Body care

Modesty is a strong South Asian value, especially for women. Older adults are averse to being touched and examined, by a practitioner who is of the opposite gender, including such procedures as ECGs enemas and catheterisation. Women are wary about breast and cervical screening.

Clients strongly prefer care from a practitioner of the same gender if feasible. Family members may want to help in providing intimate body care to avoid care being provided from a care-giver of the opposite gender.

Communication

Communication with people with limited English is challenging. Family members may insist on serving as interpreters. Using professional interpreters is strongly recommended.

Visiting hours

Family and friends will often want to stay with a hospitalised person and be included in performing personal care. This can result in a high volume of visitors. Visitors are expected to spend a significant time with the client at the bedside.
Home health care

For many South Asian older adults, the activities of social workers and home-based support services are unfamiliar and are often not welcomed. Family may seek help from family and friends and are unlikely to place an older adult in residential aged care.

Rehabilitation

Some South Asian cultures may believe that resting is an important part of recovery especially after a major surgery. If client’s are not willing to participate in exercise or help in daily activities, it may be due to the client’s expectation of dependence on family members for activities of daily living during recovery and rehabilitation. Increasing health professional efforts to explain the process and consequences of rehabilitation will assist.