Not long ago, administrators at the MetroHealth Skilled Nursing Center realized something was changing at the 144-bed Cleveland facility.
“Almost every month I’ve been getting more and more calls from Hispanic elders and their families,” says Tina Szatala, the nursing home’s long-term care senior administrator.
So last year, MetroHealth started offering seniors the option to room with another Hispanic resident and signed up for Spanish-language cable. Hispanic volunteers translate the newspaper and the center hosts potlucks with Latin American foods.
“My job is to create an environment where these residents can function at their highest level and we can engage them in activities they have enjoyed all their life,” says Szatala.
Maria Serra, whose father has been at MetroHealth for two years, says she’s thrilled with the changes. Roberto Serra Ortiz, 85, has dementia, diabetes and heart disease.
“The Spanish people get to be together and they bring in the food we like — it’s nice,” she says.
MetroHealth is right to plan for a future where the face of a graying America is not the color we might expect it to be. In the coming decades the elderly population is going to be far more diverse than before. In 2006, 81 percent of senior citizens were white; in 2050 whites will make up only 61 percent of those over 65.
“This is a significant change,” says Peggye Dilworth-Anderson, a researcher who has been studying aging and ethnicity for 30 years.
The population of Hispanic seniors will grow the fastest, from just over 2 million in 2005 to 15 million in 2050. From 2006 to 2050, the percentage of African-American seniors will jump from 9 percent to 12 percent. And while Asian senior citizens currently make up about three percent of the elderly population, their numbers will more than double as early as 2040.
Johnny Prater, 91, right, leads a group singing gospel music while activities coordinator Mary Evans, 58, background left, claps and sings along, at Concordia Care in Cleveland Heights, Ohio.
Experts say this diversity will have a deep impact on society — from the number of seniors with certain chronic conditions to the languages that health care workers speak; to the foods served at a day center to the ways and convince seniors to stay healthy.
A more diverse senior population is a plus for everyone, says Dilworth-Anderson, who is also the director of the Center for Aging and Diversity at the University of North Carolina.
For example, many black and Hispanic elders are cared for by a wide network of friends and family. Recognizing that tradition, doctors can make similar suggestions to ethnic groups that have not historically embraced that practice, Dilworth-Anderson says. “The richness of diversity can help us in problem solving.”
A report issued in March by the Federal Interagency Forum on Aging Related Statistics, which compiled data from 15 government agencies, found that, as a whole, today’s elderly are healthier and wealthier. But significant disparities remain, especially for blacks and Hispanics. The report found that almost 20 percent more black seniors than white seniors suffer from hypertension. About 16 percent of white seniors are diabetic, while 29 percent of blacks and 25 percent of Hispanics have the disease.
“You’re going to have a larger percentage of minorities and still have an increase, in general, in the numbers of senior citizens,” says Dilworth-Anderson. Indeed, the total senior population is expected to jump from about 12 percent now to 20 percent by 2030.
Some minority groups fare better than others when it comes to health. A 2006 Harvard University study that examined race and county of residence, found that Asian women living in Bergen County, New Jersey, can expect to reach age 91. That’s the highest life expectancy of any other group living in any other area in the country. American Indians in South Dakota fared the worst, living only 58 years.
The study looked at government data from 1980 to 2000, examining every county in the U.S Researcher Christopher J. L. Murray says one of the biggest surprises was that income level did not have as big of an impact on longevity as expected. For example, whites in Appalachia and whites in rural Minnesota were both below the national average on income, but those living in Minnesota lived longer. “Income,” Murray says, “is not the entire story. We do know it’s a reasonable hypothesis that diet and other cultural patterns and behaviors are playing a role.”
Higher percentages of Asians live longer, Murray says, because Asians are generally less likely to be obese, to suffer from high cholesterol, or to smoke or drink excessively.
“The risk factors that account for chronic disease are very strongly influenced by culture and what you see people doing around you,” says Murray.
Some of that story plays out every afternoon at the Long Life Adult Day Care Center in Bergen County, New Jersey, where about two dozen Korean senior citizens gather daily. When told that Asian women have the longest lives, Bang Ki Hwa, 72, laughed.
“I like that,” she says in Korean. A staff member acts as a translator. Hwa says her health is good and her arthritis and high blood pressure improved after she started coming to the center.
Asked why she thinks Asians live longer, Hwa cites a belief in God, the fact that Korean food is full of vegetables and the hard work of raising a family and maintaining a household. Plus, she says, “I’m a very positive lady!”
Paul Choe, 87, agrees with that sentiment, saying it’s “because we live happily.” Choe and a friend, Ji Chan Kim, 81, spent part of the afternoon shooting pool.
The Long Life Center caters to two specific clienteles: Korean clients congregate in the afternoon, while the mornings draw Russian seniors. Signs in the center are written in both languages and staff members play different music and serve different food for each group. One recent day the Russians lunched on borscht and buckwheat kasha while the Koreans had a snack of noodle soup and kimchi.
May Ludman, a social worker at the center, says they didn’t specifically seek to serve these two groups — they just naturally congregated because they are on Medicaid and the center accepts the program designed for poor seniors. Ludman says she has noticed differences between the groups; one being that the Korean seniors are less likely to seek treatment for psychological problems.
“We will see symptoms of depression and anxiety but they won’t talk about it to their doctors,” she says.
The Russian clients are more likely to talk about how they feel. Asked about her health, Hwa talked only briefly about her problems, while Russian senior Klara Shekhtman, 85, gave a long list of aches, pains, and medical conditions.
“But when I come here, I forget I have so many illnesses,” says Shekhtman, with Ludman translating. The fact that the center provides so much Russian culture is key.
“If people don’t feel like they can talk to someone, if they don’t feel understood it affects their health and they become very upset and depressed,” she says.
Despite the findings of the Harvard study on income level, Dr. Murray says, “income is good for your health.” And according to the Interagency Forum report, those in all minority groups are more likely than whites to be poor. Seven percent of white seniors live in poverty, but those numbers jump to almost 23 percent for blacks, 19 percent for Hispanics and 12 percent for Asians.
“This is not about their present situation, but a past life of having to deal with being poor and uninsured,” says Dilworth-Anderson, the UNC professor. “It’s about lacking access to health care, having a limited education and having family members who are often no better off than the elderly they are caring for.”
When considering the impact of poverty on old age, one factor is the expense of nursing home care, as the national average nursing home cost is about $70,000 a year. Research from the Interagency Forum shows that blacks are entering nursing homes in greater numbers. In 1985 there were 82,000 blacks over 65 in nursing home care; by 2004 those numbers had almost doubled.
Dilworth-Anderson says the increase can be attributed in part to a higher divorce rate and smaller family size, which means fewer relatives to care for an elderly person.
“More black families are changing culturally,” she says. “They are seeing nursing home placement as a viable option — it’s not all about problems.”
Additionally, more black seniors might be going to nursing homes now because blacks are living longer, notes Professor Steven Wallace, a University of CLA professor who has examined race and aging for 20 years. Indeed, the average lifespan for a black American increased from 68 years in 1980 to 73 years in 2004.
“In the early 80’s if an African American had a stroke it was his or her only one and they died,” he says.
Like many in the black community, Lillie and Dewayne Holmes, Sr. put off nursing home care for his 94-year-old mother, Eleanor, as long as they could. Twelve years ago the couple moved Eleanor into their Omaha home from the family’s native Louisiana when she started losing her sight. They chose a nursing home in February after her dementia worsened and she could no longer bathe or make it to the bathroom, even with help.
Dewayne Holmes says nursing homes do carry a stigma in the black community, which expects family and church to care for elders. “I always knew I’d bring her up here. It’s the way that blacks have experienced things, put certain value on things.”
The couple, both 59, say they are happy with the nursing home they’ve chosen. As for their own old age, they are comforted by the pensions and 401k plans they have through their jobs with the public school system. Dewayne Holmes survived a bout of leukemia 20 years ago, as well as a more recent stroke. He also has a pacemaker.
“I’m the healthy one,” Lillie Holmes says, laughing. “I take care of everyone.”
But the experience with her mother-in-law makes her wonder about their own future.
“Will our children do the same thing for us as we did for his mother?” she says. “I know the expense of assisted living facilities.”
For many blacks, once they do go to a nursing home, they are more likely to end up in the country’s worst facilities, according to a study published in the journal Health Affairs in 2007. Among the findings: black residents were 1.4 times as likely as whites to be in a nursing home that had been cited with a deficiency that caused actual harm or immediate jeopardy to residents. They were also 2.6 times more likely to be at a facility with predominantly Medicaid residents.
The facilities supported mostly by Medicaid have fewer resources, says Vincent Mor, the study’s author.
“People go to the nursing home that is close by,” says Mor, community health professor at Brown University in Rhode Island. “It’s just like elementary schools in the inner city — they are much worse than those in the suburbs. It’s not just the dollars but it’s also who wants to work there. It is all of those classic social problems that are a consequence of racial segregation.”
Mary LeFever also sees the problems facing minority seniors as a sociological one, although she looks at it from a personal perspective, not as a researcher.
“If we had not had the problems of the past — the segregation and the lack of opportunity… . I don’t think stress levels would be where they are today,” she says.
LeFever, a 60-year-old teacher from Long Beach, California, was the oldest of nine children. Her mother was Mexican and Native American and her father was Italian. Seven of her siblings have or have had diabetes. LeFever says she grew up in Texas in a “traditional Latino family,” where her elders were revered.
“My grandmother lived across the street and I’d walk by her house every day and my mother always made me go inside and my grandmother would bless me,” LeFever says. “It was something only she could impart because she was older and wiser.”
“I was brought up that you owed it to your grandparents to do well, to do better than they did,” she says. As she grows older, LeFever says, things are different with her four grown daughters and three grandsons. “They don’t always have the respect for me I wish they had, the respect I had for my mother and grandmother.”
Providing so-called “culturally sensitive,” care for the elderly is nothing new, but experts say it will be more important as the numbers of elderly minorities climb.
Wallace, associate director of UCLA School of Public Health, says many food programs for the elderly rely on government assistance, providing meals that are often far from ethnic. Even something as simple as getting rice at every meal — a feature that would make many Asian seniors more comfortable — can be a challenge.
“It’s simple things like, how you prepare chicken. Do you prepare it in a way that a Mexican senior would recognize? Or do you make chicken cacciatore from Italy.”
The questions are not trivial. Seniors who don’t eat well, don’t fare well, he says.
It’s a shame, Wallace says, that many in the health care community sees ‘the elderly,’ as one homogonous group. Especially because even within an ethnic group, there can be huge variations.
“In the Asian community you have your computer programmers but there are plenty of dishwashers in Chinatown,” he says. “An older Cuban who came here to seek refugee status is completely different from an older Mexican who walked across the desert and worked in the construction field for 30 years.”
Wallace says caring for the country’s elderly might be easier if our culture were more uniform, as in Japan, which also has the highest percentage of elders worldwide. But Wallace believes America’s strength comes from its diversity.
“We have always been a nation of immigrants,” he says. “That actually helps keep our country young and as a young country, we have the resources to take care of our older people. The trick will be to match our resources with the need.”
