HEALTH AND HEALTH CARE OF
ASIAN INDIAN AMERICAN ELDERS

Kannayiram Alagiakrishnan, M.D.
Division of Geriatric Medicine,
University of Alberta, Edmonton, Canada

Anita Chopra M.D., FACP
New Jersey Geriatric Education Center and Center for Aging
University of Medicine and Dentistry of New Jersey, Stratford, New Jersey

DESCRIPTION

This module reviews issues in health care for elders living in the U.S from Asian Indian backgrounds. In addition to suggestions for understanding and caring for Asian Indian elders, information on demographics, historical periods of migration, and special health risks are included. This module is designed to be used in conjunction with the Core Curriculum in Ethnogeriatrics.

LEARNING OBJECTIVES

After completing this module, learners should be able to:

1. Recommend strategies for caring for Asian Indian elders that honor their religious and cultural traditions.

2. Describe the influence of Ayurvedic medicine and Hinduism on the beliefs about health and illness of Asian Indian elders in the U.S.

3. List three conditions that are more prevalent among Asian Indians than the average for older adults in the U.S.

4. Discuss the traditional role in the family for elders in Indian culture.

5. List and explain at least three ways culturally appropriate end of life care may differ for Asian Indian elders compared to older Americans from European backgrounds.

CONTENT*

I. Introduction and Overview

A. Demographics

According to the 2000 census, there are over 1.6 million people of Asian Indian origin in the United States. Asian Indians began immigrating to the U.S. as early as the turn of the 20th century. Between 1980 and 1990, the population of Asian Indians in the U.S. increased by 125%. Due to family reunification laws, the number of Asian Indian elders who followed their offspring to this country has also risen.
There are now two major groups of Asian Indian elders, those who came to U.S. in the late 1960’s and early 70’s, and the group who came much later. According to the 1990 Census data, there were approximately 23,000 Asian Indian elders over the age of 65; 83% are foreign born and 51% do not speak English very well. Only 12%, however are classified as linguistically isolated (without an adult who speaks English in the household) – the smallest of any Asian ethnic group. For additional information on characteristics of Asian Indian elders, see the chart in the Introduction to the Asian Pacific Islander modules.

B. Place in the Family

Older Asian Indian immigrants are often financially dependent on their children. They face the challenges of a culturally different society, such as a language barrier, culture mismatch, new lifestyle factors, and role reversal. In traditional Indian society, extended family members usually live together as a single-family unit. Often, the husband's parents will join the family after they have retired or when help is needed. The grandparents' role in raising the children is highly respected, and they form the linkage to the Indian culture, religion, and heritage.

C. Religion and Language

The majority of Asian Indians practice the Hindu religion. Others practice Sikhism, Buddhism, Jainism, Christianity, or Islam. While there are more than three hundred languages and dialects spoken in India, Hindi, the national language is spoken by over 40% of the population. Other languages spoken are Gujarati, Punjabi, Bengali, Urdu, Marathi, Oriya, Kannada, Tamil and Malayalam. However, English is becoming a popular second language. Older Indian immigrants may not speak English and may need a translator for health care transactions.

*Citations for specific information are not included in the text. References for the much of the content are sources in the reference list.

II. Pattern of Health Risks

Health problems prevalent among Asian Indians include:

Immigrant Asian Indian men in the U.S. have a high prevalence of coronary heart disease, non insulin-dependent diabetes, lower high-density-lipoprotein (HDL) cholesterol levels and hypertriglyceridemia. All these have “insulin resistance’’ as a common pathogenetic mechanism, which seems to be the most important risk factor. The prevalence of coronary artery disease (CAD) is three times higher in Asian Indian women than in women in the U.S. as a whole.

In India only one in 40 women gets breast cancer, but in United States one out of every eight Asian Indian women will get the disease, the highest incidence in the world. According to the American Cancer Society, South Asian women have the second highest incidence of cancer among Asian Pacific Islanders.

Asian women, including Asian Indian women, are at a high risk for osteoporosis. According to the National Osteoporosis Foundation, because of the differences in bone mass and density between these groups, Asian and Caucasian women are at higher risk than African Americans and Hispanics.

Even though Asian Indian physicians comprise the highest proportion of foreign medical graduates practicing in the U.S, most Asian Indians do not possess adequate knowledge with regard to health issues. The majority of Asian Indians, especially the vegetarians, believe that they are eating a healthy diet, but many Asian Indian dieticians think otherwise. Many Asian Indians are not aware of basic nutritional factors. The typical Asian Indian diet averages 56% of energy intake from carbohydrates, 32% from total fat and 8% from saturated fat. The high fat intake is associated with obesity and low leisure time activity. Exercise is also something many Indians, especially women, do not do on a regular basis. Many Asian Indian women have been conditioned to play passive games rather than be involved in action sports.

III. Culturally Appropriate Geriatric Care: Fund of Knowledge

To care for elders from Asian Indian backgrounds effectively, it is important for providers to be familiar with their traditional health beliefs and historical experiences that may have influenced their attitudes toward health care.

A. Health Beliefs

Many elders believe in the traditional Indian system of medicine called Ayurvedic Medicine as the means of preventing and curing illness. Ayurveda is an intricate system of healing that originated in India, thousands of years ago. Ayurveda is made up of two Sanskrit words, ‘Ayu’ meaning life and ‘veda’ meaning the knowledge of. Ayurveda is not merely a medical system dealing with physical disorders. It is a science that relates to the complete human being (body, mind, senses and soul). It explains how balance can be attained physically, mentally and spiritually. According to it, each individual is made up of three doshas (vata, pitta or kapha). Each Dosha represents certain bodily activity. The ratio of the doshas varies in each individual. When any of the doshas becomes accumulated, Ayurveda will suggest specific lifestyle and nutritional guidelines to assist the individual in reducing the dosha that has become excessive. They may also suggest herbal supplements to hasten the healing process.

There are aspects of the Hindu religion that commonly affect health care decisions. Hinduism is a social system as well as a religion; therefore customs and practices are closely interwoven. "Karma" is a law of behavior and consequences in which actions of past life affects the circumstances in which one is born and lives in this life. Despite complete understanding of biological causes of illness, it is often believed that the illness is caused by "Karma".

Health is usually related to the connectedness of the body, mind and spirit. Most elderly focus spiritually in preparing the soul for life after death. Some believe that mental illness is due to possession of the evil eye.

B. Historical Experiences

The Alienation of Land Act in India under British rule prohibited certain non-farming castes from owning agricultural land; it prompted 3000 people to move to West Coast of the U.S. in 1908, many of whom were Sikh farmers. In 1946, legislation gave Asian Indians the right to become American citizens and bring relatives to the U.S., but the annual quota was small. More Indians immigrate when the door was opened by the 1965 Immigration Act that granted visas to people in certain professions and with more education. Elders continue to come to the U.S. as “followers of children”. Between 1989 and 1992, for example, almost 14,000 individuals aged 60 and over immigrated to the U.S. from India.

IV. Culturally Appropriate Geriatric Care: Assessment

Older Asian Indian immigrants may not speak English and may need a health care interpreter or translator.

Modesty is highly valued among Asian Indians, and patients usually feel more comfortable with same sex-care providers. Direct eye contact from women to men may be limited. Sensitivity and care should be taken in situations that may cause the patient embarrassment, such as wearing an examination gown, which the patient may consider too short.

Hindu women wear a thread around their necks (mangalsutra) and it should not be removed during the exam.

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

Mental illness is considered as a stigma, so it is frequently concealed and presented to the physician as somatic complaints, such as headaches or stomach pain, instead of anxiety or depression.

Elderly patients may be stoic in expression of pain. It is important to observe non- verbal behavior.

An active and commanding doctor who takes charge and gives prescriptions for medications may be preferred. Physicians may be perceived as incompetent if they say something such as, “ I do not know what is wrong, we need to do more tests,” or “It is just a cold. There is no need for medicine.”

Because of the close- knit family structure, healthcare decisions are frequently discussed within the immediate family before seeking outside help. Women are more passive in the Indian Culture and men play a major role in health care decisions. These roles are slowly changing among immigrants now.

V. Culturally Appropriate Geriatric Care: Treatment

Fasting frequently is a common practice among elderly women. It is done because of religious belief that it improves the welfare of the family. Health providers should respect these practices if the patient's medical condition can tolerate it.

Nutrition should be taught based on the cultural diet of the patient.

Many elderly do not prefer counseling as an option for problem resolution.

A. Inpatient Care

Hospital food can present a problem for Asian Indians, particularly those who strictly observe religious dietary restrictions. Hospital meals may also be too bland for most Asian Indians. Many will prefer to know whether the food served to them contains beef as beef is forbidden for Asian Hindus. Foods containing pork are prohibited for Muslims who follow religiously prescribed diet.

Some patients hesitate to wear clothing that others have worn before them, even though it has been washed and sterilized.

When a patient is in the hospital the sacred thread across the chest in men and around the neck in women should not be removed or cut without the permission of the patient or family. Sikh men do not cut their hair and wear a bracelet and kirpan. If the hair must be cut, it is important to explain the need to the patient and family.

Some elders prefer to have the surgery only on some auspicious days. If procedures such as an enema or bladder catheterization must be done, elders would prefer that someone of the same sex do it.

Family and friends will likely want to stay with a hospitalized person and be included in performing personal care. The patient will be more likely to feel happy rather than tired after a visit by their family members and friends, and may be disappointed if certain people do not appear. It is not only enough to drop in briefly, but instead the visitors are expected to sit and spend time with the patient. For many Indians, hospital visits are a very important way to provide support for the sick person and the family.

B. End of Life Issues

The cultural and religious background of Asian Indian elders often influence end of life care decisions. Older patients are more likely to subscribe to family centered decision making rather than being autonomous. Sometimes family members may ask the physician not to tell patients their diagnosis or other important information. Open-ended questions as to why the family does not want the patient to know may be helpful.

Many patients prefer to die at home, and there are specific rituals and practices in each religious community. Many believe suffering is due to karma, which is inevitable. When close to death, family members are likely to be present in large numbers. A dying person may wish to be moved to the floor, with an idea of being close to the mother earth. Family members will prefer to wash the body after death. The preference is also for cremation. The mourning Hindu family may prefer to have a Hindu priest perform a prayer and blessing. It is very important to provide privacy to the family after the death of a family member to allow for the religious rites to be performed. It is an accepted practice for family members and others to have an open expression of grief. After cremation there is a mourning period of from 10 to 40 days.

Most Indians do not readily agree to a post mortem examination or organ donation.

VI. Access and Utilization of Health Care Services

Older Asian Indian women often recommend home treatment. Home remedies, such as massage, bathing and herbal medicines may be used first, while a physician is sought out only for serious illness.

Some behaviors that many elders prefer include: ritual chanting by a priest; tying a thread around the sick person’s wrist; and writing a protective verse to be worn in a metal cylinder on a chain around the neck or wrist. Sick persons may also promise gifts to the temple god if they recover.

For many Asian Indian elders, the activities of social workers and home care nurses are unfamiliar and often not welcomed. Home visits by these providers are not always acceptable. They seek help from family and friends and are unlikely to place an elder in a nursing home except as a last resort.

INSTRUCTIONAL STRATEGIES

In addition to lecture and readings, the following cases can be used for discussion or written assignments.

Case 1: An 85-year-old Asian Indian female is admitted to the hospital with lower gastrointestinal bleeding. She is diagnosed with colon cancer. Her children are very caring and supportive of their mother. They request the physician not to tell their mother the diagnosis.

How should the physician respond to the family’s request?

Discussion:

While it is the legal obligation of the physician to obtain informed consent from the patient, it is also important to maintain an alliance with the family. It is not uncommon for the older parent to depend on the family to make medical decisions. Older Asian Indians are much more likely to subscribe to family centered decision rather than being autonomous. This presents a difficult situation and may require significant negotiation with the family. Open-ended questions to find out why the family does not want the patient to know may be helpful. Sometimes offering to go with the family and informing the patient may work.

Case 2: A 70-year-old woman lived in India for most of her life and moved to the United States two years ago. She came in to the doctor’s office with a complaint of generalized tiredness. On questioning she also revealed problems with sleeping. No active medical problems were found, and she was not on any medications. When she was asked, whether she feels depressed she said “No”. On further questioning she expressed some dissatisfaction with her life and pointed out the life here is lonely. Her weekdays are confined to the four walls of the house.
What should the physician do?

Discussion:

Since there is stigma to mental illness, most Asian Indian elders will present their psychological problems with physical complaints. This cultural reason should be understood by the treating physician and information should be obtained sensitively and addressed carefully. To get better compliance, it is better to treat as a psychosomatic medical illness, rather than a mood disorder.

Case 3: A 70-year-old Indian Muslim was admitted to the hospital for pneumonia. Speech therapy evaluation revealed swallowing dysfunction. A modified diet containing gelatin was recommended. However, the patient refused to eat gelatin.

Discussion:

Muslims who follow the kosher diet may reject this food. This person has come from an ethnocultural tradition that prohibits eating of pork. Gelatin is made from pig bones. So the dietitian should understand this cultural reason for avoiding such food items and offer alternatives.

STUDENT EVALUATION

1. Most Asian Indians are willing to agree to autopsy and organ donation.
__ (A) True __ (B) False

Answer: B
Discussion: Most Indians do not agree to autopsy and organ donation. In some religions if autopsy is performed, organs should be returned to body afterward.

2. In traditional Indian society, extended family members usually live as a single-family unit.
__ (A) True __ (B) False

Answer: A
Discussion: The family unit is greatly valued in the traditional society. Often the parents will join their son’s family household after they retire or if help is needed. The grand parent’s role in raising the children is highly regarded.

3. The prevalence of coronary artery disease is higher in Asian Indian women than in women in U.S. as a whole.
__ (A) True __ (B) False
Answer: A

Discussion: The prevalence of coronary artery disease is three times higher in Asian Indian women than in women in U.S. as a whole.

4. The most common religion practiced by Asian Indians is
__ (A) Buddhism
__ (B) Hinduism
__ (C) Sikhism
__ (D) Christianity
Answer: B

Discussion: Asian Indians are a multi religious society. Hinduism is the most common religion practiced in India. Other religions practiced include Islam, Sikhs, Christianity and Buddhism.

5. For majority of Indians, eating beef is forbidden.
__ (A) True __ (B) False
Answer: A

Discussion: More than eighty percent of the people in India practice Hinduism. Beef is forbidden in Hinduism. Many Asian Indians are vegetarians.

6. Asian Indian women generally prefer same sex health care providers.
__ (A) True __ (B) False

Answer: A
Discussion: Modesty is highly valued among Asian Indians elders, and patients generally feel more comfortable with same sex health care providers.

7. Asian Indian elders who are linguistically isolated comprise the largest group of any Asian ethnic group in the U.S.
__ (A) True__ (B) False

Answer: B
Discussion: Only 12% of Asian Indians elders are linguistically isolated. They comprise the smallest group of any Asian ethnic group; 83% of Asian Indians are foreign born and 51% do not speak English well.

REFERENCES AND RESOURCES

Ananth, J. (1984, October). Treatment of immigrant Indian patients. Canadian Journal of Psychiatry. 29, 490-493.

Bhopal, R., Unwin, N., White, M., et al. (1999). Heterogeneity of coronary heart disease risk factors in Indian,Bangladeshi, and European origin population: Cross sectional study British Medical Journal, 319, 215-220.

Enas, E. A., Garg, A., Davidson, M. A., et al. (1996). Coronary heart disease and its risk factors in first- generation immigrant Asian Indians to the United States of America. Indian Heart Journal, 48(4), 343-353.

Humes, K.,& McKinnon, J. (2000) The Asian and Pacific Islander population in United States: March 1999. U.S. Census Bureau, Current population reports (Series P20-529). Washington, DC: U. S. Government Printing Office.

Kalavar, J. M.” (1999, July 10-16). Intergenerational relations and service utilizations: The experience of Asian Indian elderly in the United States [Research abstract]. Bethesda, MD: National Institute on Aging, Summer Institute on Aging Research.

Panganamala, N. R., & Plummer, D. L. (1998). Attitudes toward counseling among Asian Indians in the United States. Cultural Diversity and Mental Health, 4(1), 55-63.