Many older people from a refugee background have had poor or no prior access to healthcare before arriving in Australia, and undiagnosed and undertreated chronic illnesses are common (eg diabetes, hypertension, osteoarthritis, chronic obstructive pulmonary disease [COPD]).
High rates of post-traumatic stress disorder (PTSD) are seen in those who have experienced war, imprisonment, torture and dislocation (refer to Part A. Mental health and Part B. Care of older veterans).
The gender of the treating professional and interpreter may be very important for CALD patients; it is important to check and not to make any assumptions.
The age stated in a medical file is often based on ‘assigned date of birth’ on the patient’s arrival visa documents, which can be wildly inaccurate. This has implications for health (eg age-based screening and Pharmaceutical Benefits Scheme [PBS] requirements) and wider determinants of health (eg aged pension entitlement).
It is impossible to overestimate the sense of dislocation experienced by someone migrating in the last couple of decades of their life. Providing comfort and reassurance and building a lasting therapeutic relationship is vital for this patient population group.
Health literacy and language factors have a large effect in the area of medication management. To avoid differing degrees of mayhem, the ‘golden rules’ of geriatric prescribing serve well:6
- Keep regime as simple as possible.
- Commence one medication at a time, and use the ‘start low, go slow’ approach.
- Review promptly for efficacy and adverse effects.
- Use one pharmacy that must keep all scripts.
- Encourage same brand and consider Webster packs.
- Explain ‘novel’ concepts (eg no ‘sharing’ of medications, long-term use of many medications).
- Check use of traditional medicines and informal importing of medicines.
Metabolic profiles (pharmacogenomics) may affect patients differently (eg Asian skin reaction to carbamazepine).5
Refer to Part A. Medication management for more information.
Dementia may be viewed more as a normal part of ageing than a medical condition among CALD communities. There are instances where if cognitive impairment predates migration, the older patient may never know they are in Australia.
The standard ‘Western-centric’ Mini-Mental State Examination (MMSE) can be unproductive in people who have no recorded date of birth or formal education. The use of the Rowland Universal Dementia Assessment Scale (RUDAS) has been validated for use in CALD populations.7
Managing advancing dementia and its sequelae, particularly in an RACF setting, may require a flexible solution, and families and carers can advise staff on specific approaches. For example, underwear is not worn in many cultures, which would make continence pants in continence management unacceptable.
Refer to Part A. Dementia for more information.
Screening and immunisation
New entrants to Australia will need comprehensive screening for infectious and chronic diseases, and also a full catch-up on immunisation:
Recrudescence of previously treated infections (eg tuberculosis,8 schistosomiasis) can prove diagnostically elusive and require specialist referral.
Nutritional and bone health
Dietary preferences are often well catered for within the home of older CALD people; however, this can often be unmet in hospital and RACFs.
Edentulism is prevalent where access to healthcare has been scant.
Vitamin D, iron and B12 deficiencies are common in CALD people, and screening is advised.9
The use of unsafe footwear (eg sandal, thongs) is often common and, combined with sensory and balance loss, increases falls risk (refer to Part A. Falls).
Ongoing tobacco use is common in this population group, and alcohol use may be hidden. Betel (areca palm) nuts, which are popular in South Asia, East Africa and the Pacific, combined with tobacco in a ‘quid’ placed in the user’s cheek for hours (producing a mild stimulant effect) can lead to oral cancers.10 When taking a smoking history, it is important to specifically ask about chewing tobacco.
More information on the smoking cessation is available in the RACGP’s Supporting smoking cessation: A guide for health professionals.
Kava is popular among CALD communities from the Pacific, and has been implicated in acute hepatitis.
The incidence of PTSD in survivors of torture and trauma exceeds 50%, but will not present in a way congruent with the Diagnostic and statistical manual of mental disorders, fifth edition, (DSM-5).11 Stigma surrounding mental illness in many communities may strongly affect the older person’s engagement with assessment and treatment.7
Along with the effect of social isolation, onset of dementia and associated communication deficits, depression can emerge and may respond to both drug and non-drug interventions. Finding out what was important to the person in their country of origin can be informative for the patient and their family. Each state and territory has its own organisation to which GPs can refer people affected by trauma (refer to ‘Resources’ below).
The use of the Translated Geriatric Depression Score can assist GPs in the management of older CALD patients with mental health issues.
Abuse of older people
The abuse of older people is often a complex issue that is under-reported, and carries more stigma in CALD communities. Particularly be aware of financial abuse, psychological abuse and extension of spouse violence into old age.
Clinical and medical histories are difficult to obtain in older CALD people, and constipation is a very common cause of elusive abdominal pain; an abdominal plain X-ray is often illuminating.
Helicobacter pylori should be treated and cure tested. A common reason for representation with reflux symptoms is patient discontinuation of proton pump inhibitors (PPIs). Festivals often involve spicy foods and ‘mini epidemics’ of gastro-oesophageal reflux disease (GORD).
Preventive health screening (eg cervical or bowel cancer screening) may not have been conducted for older CALD people.
More information on preventive health is available in the RACGP’s Guidelines for preventive activities in general practice.