CALD Older People Assessment Tool

CALD Older People Assessment Tool

• Record ethnicity, languages spoken and religion.
• Assess level of acculturation.
• Assess family patterns of decision-making (e.g., individual vs. collective) and who is the key decision-maker.

Acculturation

Placing older clients on the continuum of acculturation can help providers avoid mistaken assumptions about expected differences or similarities from mainstream elders.

Informal indicators of acculturation that can be used quickly:

• Length of time older clients or their ancestors have been in New Zealand
• Language used at home, fluency in spoken and written English
• Degree of ethnic affiliation, as reflected in ethnic community participation and use of ethnic media.

Patterns of decision making

Explore preferred interaction patterns, that is:

• What is the client’s preferred language
• Is a direct or indirect form of communication most appropriate for this client
• What is the client’s preferred form of address (formal or informal)
• Are there other considerations in interactions with the client, such as the gender and status of the health practitioner.

Health and social history

Ask about the older person’s migrant or refugee journey to New Zealand and refer to these experiences in taking a social history.

Ask questions to try and determine if there is abuse.

Elder abuse

Issues of elder abuse may be particularly difficult to assess in elders from cultural backgrounds in which there are varying definitions of elder abuse or in which family image may be more important than individual health (Tartara, 1999). Particularly consider when there are:

• physical signs (bruises, burns, etc.) and/or
• behavioral symptoms (e.g. depression).

Physical examination

Physical examinations by someone of the opposite sex are unacceptable in many cultures.

Ask if the older person would like other family members to be present during physical examination.

Throughout the assessment, inform the client of procedures and ask for permission to examine different areas of the body.

The preferred amount and type of information communicated to the client and their family during and after the physical exam varies cross-culturally (Adler, et al, 2004; Adler & Kamel, 2002) (e.g., some Chinese older people prefer that information be given to their son or other family member, and that they be the decision makers about the older person’s care, especially in relation to serious illness).

Symptom recognition, meaning, and report are expressed differently by older people of different cultures (e.g., “heavy heart" may indicate depression among Chinese older people).

Functional status

The concepts of Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs) may be unknown to many older people from CALD backgrounds. ADLs such as banking can be difficult to assess where these skills have not been needed in home countries.

In some cases, the independence of older people is not a high value, so that dependency is expected and assumed. However, it is important to understand the client’s baseline functioning and previous occupation/interests/hobbies.

Questions can be interpreted or translated, if needed, and administered orally or in writing if literacy and reading levels are adequate.

Drawings, illustrations, and other culturally appropriate symbols may also be used.

• Living patterns: Who lives in the home, relationship to older person, and length of time in the home.
• Support from those people who live with the older person.
• Safety, comfort, and convenience of the home to older person’s health status.
• Economic stability and adequacy

Family assessment

• Composition and structure.
• Kinship patterns and social support.
• Decision-making.
• Spokesperson, if any, for the family.
• Gender sex-role allocation.
• Family connectedness (culture influences whether the older person and family are more individualistic or collectivistic).

Kinship patterns and social support: expectations of and for family members (e.g. for elder care). Stereotypes that ethnic families "take care of their own" can be very misleading since some older people from ethnic backgrounds are not part of strong family networks and are vulnerable to loneliness and isolation.

Decision making: In many cultures, there is not the assumption of client autonomy in decision making as there is in a western medical ethical paradigm, and the family is assumed to be the decision maker about health care.

• Overall features of the community and neighbourhood: E.g., involvement of CALD older people in the community and religious community.
• Population characteristics: e.g., ethnic community, length of time in community, proportion of older people, children, and adults in population, intergenerational relations, status of elders.
• Environmental and safety conditions: e.g., topography, pavements, road crossings, crime rate.
• Services available and used by older person and their family: e.g., traditional and alternative health practitioners, social services, religious community, shopping (such as food, clothing, banking), educational, transportation, recreational and elder services (such as senior citizens centres; age concern; ethnic older persons support services).
• Support from neighbourhood and community members.

End-of-Life preferences (when appropriate)

• Availability of advance directives and ACP
• Preference for hospital or home end of life care
• Death rituals for care of the body and mourning behaviour during and after death
• Attitudes about organ donation and autopsy

Since talking about death is considered inappropriate in some cultures (e.g., Chinese groups) the issue should be approached carefully and sensitively, and only in the context of an established trusting relationship.

A possible introduction after several visits might be, "In case something happens to you and you are not able to make decisions about your care, we need to know what your preferences are".

Problem specific data: Elicit explanatory models of illness from client and relevant family members

To elicit the client's explanatory model of illness, questions such as the following can be used (Kleinman, Eisenberg, Good, 1978; Harwood, 1981):

• What do you think caused your problem?
• Why do you think it started when it did?
• What do you think your sickness does to your body? How does it work?
• How severe is your sickness?
• How long do you think it will last?
• What are the main problems your sickness has caused you?
• Do you know others who have had this problem? What did they do to treat it?
• Do you think there is any way to prevent this problem in the future? How?

The use of explanatory models has been demonstrated to be effective in improving client─provider communication and showing respect for the client's point of view.

Ultimately, it is argued, its use will increase clients' trust of providers, appropriate clinical management, and likelihood of older people’s agreement with and adherence to provider’s recommendations.

The objective is to elicit the older client's view of his/her illness experience, its causes, potential consequences, and possible treatments.

Intervention-specific data (Tripp-Reimer, Brink, and Saunders, 1984)

• What are you and/or your family doing for this problem? What kinds of medicines, home remedies, or other treatments have you tried for this sickness? Have they helped?
• What type of treatment do you think you should receive from me?
• Is there any other information that might help us design a treatment plan?
• How should family be involved: family structure, roles, and dynamics, and life style and living arrangement need to be identified.
• How should family members treat one who has this condition/problem?
• Does anyone else need to be consulted?

Elicit cultural specific content as needed for specific interventions. For example, if dietary recommendations are being made, elicit data about food preferences and practices; if discharge planning is needed, elicit information regarding family care patterns, resources, and residential preferences.

What are individual/family expectations for quality care?

What are the most important results you hope to receive from this treatment?

What is the best outcome from family/individual perspective?

What is the worst outcome from family/individual perspective?