Taking Care of Our Folks: A Manual for Family Members Caring for the Black Elderly

By Deborah Liggan

With the growing concern over healthcare in America, studies show that elderly African- Americans often come out on the losing end of the system due to lack of health insurance. Because of this growing population, taking care of elderly patients in the African-American community has become the responsibility of their family. If youre facing such a situation, your questions may be many and your answers few.

Taking Care of Our Folks is a definitive guide to caring for your elderly relatives. Drawing on comprehensive and detailed research, this essential resource aims to ensure that elderly African-Americans receive culturally competent healthcare and live more productive, independent, and pain-free lives. Deborah Y. Liggan, MD, discusses the major health issues and offers case studies of how each illness affects this ethnic group. She offers up-to-date information on nutrition, pharmacology, technological advances, and self-help for each disease. Topics focus specifically on elderly African-Americans and include: Neurology of aging Cardiovascular problems Mental health and aging Approach to gastrointestinal problems Prominent cancers With clear and concise language, Taking Care of Our Folks will serve as an invaluable tool for caregivers and aging patients alike. Take the first step to competent and compassionate caregiving today!

• Language: English
• Publisher: iUniverse
• Release date: May 29, 2009
• ISBN: 9780595623044

Deborah Liggan

Deborah Y. Liggan, MD, is a physician whose research and writing focuses on exploring the importance of cultural variables in medicine. She has lived on three different continents, achieved a varied educational background, and succeeded in both civilian employment and military service.

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Contents

Preface

Introduction

SECTION ONE

Assessments in Daily Living

Chapter 1

Aging in the African-American Elderly

Chapter 2

Nutritional Concerns in the Black Elderly

Chapter 3

Physical Fitness: How to Help Our Loved Ones Live Stronger and Longer

Chapter 4

Mobility and Falls in the Black Elderly

Chapter 5

Sleep Disorders in the Black Elderly

SECTION TWO

The Neurology of Aging in Black Americans

Chapter 6

How to Control Pain in Our Loved Ones

Chapter 7

Detecting Hearing Loss in Our Loved Ones

Chapter 8

Urinary Incontinence in the Black Elderly

Chapter 9

Taking Care of the Black Elderly with Diabetes

Chapter 10

Caregiving for the Elderly with Arthritis

SECTION THREE

Cardiovascular Problems in African-American Elders

Chapter 11

Management of Hypertension in the Black Elderly

Chapter 12

Heart Failure in the Black Elderly

Chapter 13

Taking Care of the Elderly after a Stroke

Chapter 14

Ischemic Heart Disease in the African-American Elderly

Chapter 15

Poor Circulation in the Legs of the

African American Elderly

SECTION FOUR

Mental Health and Aging in African Americans

Chapter 16

Dementia and Race:

Are There Differences between African Americans and Caucasians?

Chapter 17

Alzheimer’s Disease in African Americans

Chapter 18

Caregiving for Depression in Late Life

Chapter 19

Suicidal Ideation in the Black Elderly

SECTION FIVE

Approach to Gastrointestinal Problems in the Elderly

Chapter 20

Disorders of Swallowing and Food Intake in the Elderly

Chapter 21

Inflammatory Bowel Disease: Crohn’s Disease and Ulcerative Colitis

Chapter 22

Malabsorptive Disorders in the Elderly

Chapter 23

Abdominal Obesity, Ethnicity, and Gastroesophageal Reflux Disease (GERD)

Chapter 24

Racial Differences in the Impact of

Irritable Bowel Syndrome

SECTION SIX

Cancers Prominent in the African American Elderly

Chapter 25

Lung Cancer in African Americans

Chapter 26

Breast Cancer in African-American Women

Chapter 27

Comprehensive Care of the Prostate Cancer Patient

Chapter 28

Colorectal Cancer in African Americans

Chapter 29

Gastric Cancers in the African-American Elderly

Preface

Taking Care of Our Folks

Racial, ethnic, and cultural disparities exist in all aspects of society, but nowhere are they more clearly documented than in health care. When white and African-American persons are asked how they view their health and medical care, it is clear that they have different experiences and different expectations. Many studies of clinical populations have reported significant differences between whites and blacks in the prevalence of rates of physical and mental disorders. Disparity in health-care parameters starts at the beginning of life; the rate of low-birthweight infants (<2500 grams) among blacks is 110 percent higher than that of whites. The statistical significance becomes evident as these low-birthweight children develop into adults impaired with physical and mental handicaps.

As black adults age, they find themselves locked out of the health delivery system that offers a portion of its citizens some of the best health care in the world. By every economic indicator, more Americans have jobs, fatter paychecks, and more investments than ever before. But instead of increasing the access of blacks to the health system, U.S. Census Bureau figures indicate that a record number of minority citizens have no health insurance. Attempts to incorporate black Americans into mainstream health delivery systems have not been promising. The causes are many, including increasing health-care costs, the cost of health insurance, and welfare reform moving many out of Medicaid and into low-paying jobs without insurance.

Especially in the case of older African Americans, distrust in health institutions often bars early detection of disease. To further compound the problem, when blacks do receive medical assistance, there are clear disparities in the care that they are given. The fact that racial differences exist in the presentation of symptoms and resulting diagnoses is only part of the problem. For example, there is a 240 percent higher rate of amputations among minority populations than among whites. That means that six non-whites get a limb cut off for every one white person—and this happens independent of insurance status.

Of the leading causes of death, black mortality is often preventable with known, basic, cost-effective medical treatments. Consequently, black deaths from stroke are 80 percent higher than among whites. Heart disease claims the lives of people of color at an alarmingly young age. Cancers of the breast, prostate, and cervix are responsible for multitudes of lost lives while these same diseases have high cure rates in the majority population. Cumulatively, life expectancy is five to seven years shorter for blacks than for whites in America.

This text is not intended to replace treatment-seeking. It is written to ensure that elderly people of color receive culturally competent health care and therefore live more productive, independent, and pain-free lives. In each chapter, a racial/ethnic model of the disease is presented. Case vignettes relating to the illness provide up-to-date and authoritative information on nutrition, pharmacology, technological advances, and self- help. Explanations of the major health concerns and issues for aging people of color are clear and concise. With this book as a guide, African Americans will be well versed in the most current and proven practices, treatments, and interventions for major health problems afflicting elderly people of color. This book is ideal for people with chronic illness who want to know more about controlling and managing disease.

The twentieth century has witnessed an exponential growth in the number and proportion of Americans older than sixty-five years—from three million (4 percent) in 1900 to thirty-four million (13 percent) in 1997. Even more remarkable will be the population rise that will begin in the year 2011 as the first of the postwar baby boom generation (those born between 1946 and 1964) reach the traditionally defined old age of sixty-five years. Epidemiologists expect an unprecedented explosion in the number of people older than sixty-five years with potentially disabling chronic illnesses. Currently only 20 percent of the elderly reside in nursing homes. Caregiving by family members in the home is projected to remain the dominant source of elderly care.

The aging society is a viable marketplace for literature that will improve the quality of life for persons over age sixty-five years as well as their caretakers. Taking Care of Our Folks is projected to receive attention from the medical community as well as the public at large because it is the only publication of its kind. It is a text that answers the needs of busy health professionals by serving as a tool to instruct aging patients on many issues in medicine and public health. It serves as a guide for caregivers of chronically ill elders to increase their competence in outpatient disease management.

This is a critical time to assess the individual needs of older persons and develop community resources. During this millennium we will witness an increasing market for caregiver education and support programs. The market response to date varies from regularly scheduled meetings to one-time workshops. The literature supporting these programs is usually specific to the illness (e.g., text for relatives caring for someone with Alzheimer’s disease). Although this market analysis is multidimensional and multidisciplinary, several major issues emerge as critical needs: guidelines for caregivers, ethnic considerations when choosing a family physician, activities of daily living, and end-of-life decisions. Caregivers of specific ethnicity are addressed, as well as common chronic medical illnesses such as hypertension, stroke, and diabetes, which are disproportionately more prevalent among blacks than white Americans.

The quasi-medical literature available on healing in African-American culture takes a two-pronged approach. There is healing that occurs in direct response to persons having had spells put on them by conjurers. The process of healing involves removing the spell and restoring the person to physical and mental health. In the second manifestation of healing, the process occurs in response to some natural illness, or to a physical counterpart of a psychological problem. Perhaps one of the prevailing self- imposed stereotypes African-American writers have been guilty of adhering to is making their characters almost too healthy, almost too little in need of physical nurturing. In Taking Care of Our Folks, realistic clinical vignettes portray African-American elders with chronic illnesses that must be managed with lifestyle modifications and medications. Whenever possible, misconceptions from folklore are corrected.

Healers throughout African-American history have held a certain status within their communities. In this context, authorship by a physician of color gives Taking Care of Our Folks an outstanding market advantage.

Deborah Y. Liggan, MD

Introduction

Throughout these chapters, we will use the terms black and African American interchangeably. Both refer to Americans who share a common ancestral descent from people historically indigenous to sub-Saharan Africa. Compared to Americans of European descent, at every point of their life span, African Americans have greater morbidity and mortality.

The primary audience for Taking Care of Our Folks is the inquirer who needs a brief, authoritative introduction to the key topics and issues in aging within this ethnic group.

SECTION ONE

Assessments in Daily Living

We have tolerated the national crisis in geriatric health care for too long. Especially in aging blacks, later life is synonymous with limited health-care resources, poor communication with health professionals, and isolation from social supports. How do we begin to repair the deficiencies in the delivery of health care to older African Americans? First, it must be acknowledged that older blacks have a higher prevalence than whites of many major physical disorders, yet minorities have a lower likelihood of using health services. Second, this disparity demands investigation of the impact of multiple adverse influences on health care in later life. Third, current information needs to be widely disseminated. This requires translation of medical data into a journalistic style that captures the attention of a public audience. The ultimate goal in conducting focused research and publicly addressing the issues surrounding the health needs of black elderly is not only to better connect this subpopulation with resources. The long-range potential is to advance the medical community’s ability to better diagnose, treat, and prevent health problems among African Americans as they age.

Despite increases in expenditures and expansions of many U.S. health and social welfare programs, racial disparities persist in many aspects of American society. Particularly troubling is the reality that the health of our nation’s population differs so greatly by race. A number of studies in recent years have documented substantial differences between whites and African Americans in health status, morbidity and mortality, access to health services, and perceptions of quality in health-care services received.

In the early part of this century, it was often assumed that the United States would witness a melting pot phenomenon by which all ethnic groups would lose their individual identities and become simply Americans. This change did not take place. Among the factors that have helped to maintain the distinctness and allegiance of individuals to their ethnic background have been: (1) residence in a distinct ethnic neighborhood, (2) utilization of the mother tongue, (3) common socioeconomic status, and (4) adherence to traditional religious values and customs.

Social research on the black aged is undergoing a period of transition. Earlier phases focused on comparisons of the black and white aged populations, documenting the relatively disadvantaged social and economic position of blacks. Recent studies have renewed emphasis on the importance of race and culture as mediators of social behavior in the elderly. While the status of the elderly in general has shown considerable improvement over the years, the black aged have continued to lag behind whites in terms of social and economic status. Indicators of income, education, and health status continue to document the deprived position of blacks relative to whites. It should be indicated, however, that compared to past cohorts of elderly blacks, today’s black aged are better fed, better housed, and in better health.

Chapter 1

Aging in the African-American Elderly

Elderly African Americans are more likely than other aging adults to suffer poor health status, delay seeking medical care, and forgo necessary care for potentially serious symptoms. Minority elderly people receive fewer screening services for cancer and cardiovascular risk factors, present with later-stage diagnoses of cancer, and experience more avoidable hospitalizations than white elderly people. They also face an increased risk of death, particularly when hospitalized. Although the status of the elderly in general has shown considerable improvement over the years, the black aged continue to lag behind whites in terms of social, economic, and health status. Incidence rates of hypertension, heart disease, stroke, end-stage renal disease, dementia, and prostate cancer are higher among African Americans than among the white population. As a result, people of color bear greater levels of financial strain and caregiver burden.

The truth is that many of the normal changes of aging produce subjective discomfort. For instance, loss of the elasticity of connective tissue leads to stiffer joints and minor aches and pains. Impairment in visual acuity makes it harder to do basic tasks such as reading or driving a car. Another concern of the elderly results from changes in sleep patterns. Older persons take longer to fall asleep, are awakened more frequently during the night, and have decreased amounts of stage 4 (deep) sleep and rapid eye movement. These alterations commonly lead to a sense that sleep is less restful or satisfying. Due to sensory failure and chronic illness, older persons increasingly depend on others. One of the major goals of geriatric care is to maintain the elder’s independence and sense of control.

There is scant literature that addresses the unmet needs of elderly adults with specific chronic conditions, such as diabetes or hypertension. Two myths dominate the social literature on the black family. The first is a view of older blacks cared for by loving and extended family members. The second is a view of the impoverished, lonely, older black abandoned by a disorganized and incompetent family system. The reality lies somewhere in between. Research on the black family and social support networks has been based predominantly on these anecdotal data.

Early studies indicated that African-American families tend to provide the bulk of care for their older family members. More recent research indicates that, over the past decade, this level of personal caregiving has begun to erode. The multiple demands on African-American families caring for both children and aging parents can lead to higher levels of stress. Especially when elders are chronically ill, there is a greater possibility that family caregivers will develop problems in response to stresses inherent in the caregiving role. Social scientists have clearly documented that the burden of care correlates with the extent of the elder’s actual impairment in mental capacity, everyday behavior, and activities of daily living.

Age stratification studies have focused on four major topics. First, age structure refers to how the population is divided roughly into age strata, with differentiated individual contributions according to their age, and how customs, rules, beliefs, and norms prescribe which roles are open, closed, or appropriately performed at different ages in school, marriage, the economy, and other institutions. A major emphasis is on how this age structure of people and roles changes and on the sources of such change.

Second, age relationships (age differences, age inequalities, age segregation or integration, age conflicts) can influence interactions within and across age strata boundaries. At any time, people in various age strata, different as they are in age and cohort experience, are continually interacting in the same society, and their relationships are strongly affected by the strata to which they belong. It is important to note that a change in any one stratum has consequences for other strata by contributing to potential changes both in the social structure and in the aging patterns of individuals.

Third, aging operates in tandem with cohort flow to sort people into age strata and channel them through the age-graded roles. Lifelong aging is an integral element of age stratification systems, as individuals age and change biologically, psychologically, and socially, moving up through the age strata and across historical time. In each stratum they are allocated to new roles and socialized to perform them. While individuals are growing older, the environing society with its age-stratified roles and the people in those strata are simultaneously changing and influencing the character of the life course.

Fourth, cohort flow forms the link between age and social change. If aging constitutes mobility through the age strata, influencing a person’s capacities and performances at every age, the continuing flow of cohorts yields the numbers and kinds of people who populate the societal age strata. As society changes, successive cohorts differ in size and composition and in the aging patterns of their individual members. Moreover, when many individuals in the same cohort are affected by social change in similar ways, their collective response can initiate further social change; that is, new patterns of aging are not only caused by social change, they also contribute to it.

Case Illustration

Mrs. D., a sixty-four-year-old African-American woman, was brought to her family physician by her husband, who reported that his wife, whose health had been quite good, had been functioning rather poorly for the last six weeks. During this time, the patient gradually changed from a rather outgoing and vivacious person to someone who kept to herself and had lost interest in her activities, such as playing golf and participating in her weekly reading club. Over the last six weeks Mrs. D. had lost eleven pounds and had become increasingly irritable. Her daughters noted that she sometimes was slow in understanding concepts and seemed to be mildly confused. Physical examination and laboratory workup were appropriate for her age. Her family physician noted that Mrs. D.’s responses to his questions seemed to be quite slow, and that she looked sad and somewhat agitated. She showed no signs of hallucinations or delusional thinking but acknowledged that the future held nothing for her. Mrs. D. demonstrated mild impairment in her ability to think problems through and seemed to have difficulty in concentrating.

Clinical Presentation

The gap in attitudes between the races is associated with differing life experiences. Specifically, current research examines ageism as a process of systematic stereotyping and discrimination against people because they are old, just as racism and sexism accomplish this for skin color and gender. Older people are categorized as senile, rigid in thought and manner, and old-fashioned in morality and skills. Perceptions of ability to access appropriate medical care and of health status are just a sample of the areas in which disparities exist.

The results of recent studies suggest that the day-to-day lives of African Americans do differ in many respects from the lives of whites. In the past, the only two options were to care for the elder at home or institutionalize the elder in a nursing home. Today the concept of continuum of care is based on the recognition that the elderly need different services at different stages in the aging process, as health conditions and degree of illness vary. Unfortunately, many elderly people and their caregivers are not aware of the spectrum of service alternatives to institutional care.

Intervention programs that focus on ways to decrease caregiver burden include the following:

1. Educational experiences: courses and workshops for caregivers that aim to increase adaptive coping skills by providing information and the opportunity to discuss common problems and workable solutions

2. Support groups that reduce caregiver isolation and enhance social support networks

3. Day care, which provides time off for caregivers to care more adequately for themselves

4. Brief planned nursing home admission or respite care

5. In-home assistance: visiting nurse or home health aide

Many aged persons refuse to recognize signs of deteriorating health and wait too long to turn to preventive or remedial community services; then, due to the severity of their condition, nursing home care may be the only option. How long should a family member keep an elder at home, providing support services there? If the elder’s health declines at home, should the caregiver increase services or move the elder to a nursing home?

How do we measure up to the continuum of care for our elderly folks? The different health levels range from well elderly persons, regardless of their chronological age, who need services such as recreation and legal aid; to the semi-ambulatory or frail elderly who do not need twenty-four-hour nursing care but do need personal services; to the severely ill who need twenty-four-hour medically oriented services. In response to these needs, the continuum ranges from living in one’s own home, to shared housing, to specially designed apartments, to congregate housing, to board-and-care homes and foster homes, to intermediate-care facilities, to skilled nursing facilities.

Knowing the dramatic stressful impact of moving the person, how long can we keep a person in their own home, providing support services there? When is it best to move a person to congregate housing, and if their health declines, should we increase services or move them to a nursing facility?

The social advantages in age-congregated housing include making more friends, expanded opportunities for mutual support, available leisure activities, participation in organizations, and ease in behaving appropriately in a group of individuals of similar age. In each stratum, the elderly are allocated to new roles and socialized to perform them. While individuals are growing older, the environing society with its age-stratified roles and the people in those strata are simultaneously changing and influencing the character of the life course.

The goal of palliative care is to achieve the best quality of life for elders and their families while maximizing comfort and maintaining dignity. This includes four dimensions of quality of life:

Physical well-being. Pain is only one element that affects physical well-being. Other symptoms and disorders common among elderly persons include decreased nutrition and dehydration, shortness of breath, nausea and vomiting, fatigue, incontinence, and bowel problems.

Psychological well-being. Anxiety and depression are common symptoms in life-threatening illness; their intensity often escalates in the elderly. Other common psychological symptoms include delirium, restlessness, and terminal agitation.

Social well-being. Care of the elderly is not limited to the needs of the individual, but refers to care of the entire family. It is important to reinforce family-centered care and to close the gaps in communication among patients, family caregivers, and health-care providers.

Spiritual well-being. Although this includes religious faith, it also encompasses other dimensions of spirituality, such as living with uncertainty and suffering, maintaining hope, and seeking meaning in the remaining life. For elders and their loved ones, spiritual needs escalate and become paramount as death draws nearer.

Erik Erikson views this final stage of psychosocial development as a struggle between achieving ego integrity versus lapsing into despair. Successful life review leads to ego integrity, allowing the elder to live more fully in the present. Despair occurs when an individual cannot accept certain events in the past or come to terms with the outcome of his or her life. Given society’s emphasis on work, it may appear surprising that retirement does not lead to adverse health consequences. Before retirement, work often provides a sense of identity and meaning. Retirees who develop new meaning and formulate new goals report the greatest level of subjective well-being. Similarly, studies show that older persons who believe they are performing useful roles have greater longevity.

SELECTED READING

Blendon, R.J., A.C. Scheck, and K. Donelan. How White and African Americans View Their Health and Social Problems, JAMA, vol. 273, no. 4 (1995): 341–346.

Jackson, J.J. Minorities and Aging (Belmont, California: Wadsworth, 1980).

Jackson, J.J. Race, National Origin, Ethnicity, and Aging, in Handbook of Aging and the Social Sciences, 2nd edition, ed. R.H. Binstock and E. Shanas (New York: Van Nostrand Reinhold, 1985): 264–303.

Levin, J. and W.C. Levin. Ageism: Prejudice and Discrimination Against the Elderly (Belmont, California: Wadsworth, 1980).

Osgood, N.J. Patterns of Aging in Retirement Communities, Journal of Applied Gerontology, vol. 2 (1983): 28–43.

Rosow, I. Social Integration of the Aged (New York: Free Press, 1967).

Storandt, M. Psychology’s Response to the Graying of America, American Psychologist, vol. 3, no. 38 (1983): 323–326.

Chapter 2

Nutritional Concerns in the Black Elderly

Many of us have relatives who seem to eat virtually nothing. Indeed, some of our loved ones do not eat a balanced diet, even though it is provided by the nursing home or family meal. Consequently, many older persons are poorly nourished. If the problem is ignored, they will not be aware of inadequacies in their diet until there are some dramatic consequences. Semi-starved individuals experience generalized weakness and are unable to carry out even minimal physical activities. They complain of coldness, especially in the arms and legs. The development of night blindness and dryness of the eyes occurs in loved ones with a poor intake of yellow and green vegetables such as carrots, spinach, and sweet potatoes. What are the reasons for inadequate nutritional intake in the elderly? Many of our loved ones forget to eat due to dementia. Besides forgetfulness, some have emotional problems such as depression. Still others suffer from tremors that interfere with the ability to feed oneself. Maintaining good nutrition is a challenge at all stages of dementia. In early disease, poor visuospatial skills and diminished judgment can cause problems. For example, faced with a tray full of foods, elders may choose none; however, given foods one by one or in smaller portions, elders are more likely to eat.

The families of persons with nutritional deficiency can often detect malnutrition because they become aware of changes in their loved ones’ eating patterns. The following simple screening tool for nutrition in the elderly can be administered by a family member and may help to prevent nutritional problems.

• Do you have an illness that has made you change the kind and amount of food you eat?

• Do you eat fewer than two meals a day?

• Do you rarely eat fruits, vegetables, or milk products?

• Do you have tooth or mouth problems that make it difficult to eat?

• Without wanting to, have you lost ten pounds or more in the past six months?

If your loved one has zero to one yes answers, his or her nutrition is good. Three yes answers indicate moderate nutritional risk. Talk to your dietician to see what you can do to improve your loved one’s eating habits. Four yes answers indicate high nutritional risk. Bring this checklist the next time your elder sees the doctor, and ask for help to improve your loved one’s nutritional status.

Human beings require thirty-five essential nutrients and a source of water and calories to maintain health. For a variety of reasons, a precise definition of dietary requirements for elderly people is difficult. Physiological changes with aging include diminished taste and smell sensations, dental problems, dementia, and difficulty swallowing. These problems may contribute to a diminished intake of nutritious meals. The most common diet deficiency is inadequate intake or excessive utilization of protein and calories. There are two problem areas where the relation between aging and nutrition is concerned. The first is the effect of age on the nutritional state, and the second is the effect of nutrition on aging. The mechanisms responsible for most cases of protein-calorie starvation include decreased intake, increased nutrient losses (e.g., short bowel syndrome), and hypermetabolism (e.g., major trauma). A variety of psychosocial factors (e.g., isolation, alcoholism, depression, low income) and physiological changes (e.g., diminished taste and smell sensations, dental problems, dementia, dysphagia, acid peptic disease) may contribute to a diminished intake of nutritious meals.

Case Illustration

Several African-American women of three generations (daughters, mothers, and grandmother) lived in the same community and were from low-income, metropolitan areas in New York state. The three generations lived within thirty miles of each other, except for one daughter who was away during college class sessions. Their educational backgrounds ranged from eighth grade to some postgraduate education. The women expressed a social connections theme: they valued bringing family members together through food. The women in these families described an exchange system for managing food and nutrition. This system stressed the themes of equal opportunity and social relationships. Each family member made a contribution to food and meals or exchanged meal duties for other household work.

The grandmother in this family, Mablean, was a seventy-eight-year-old black woman who suffered from a number of health problems that needed special attention and care. She reported diet-related chronic diseases such as diabetes, hypertension, and heart disease. She described herself as the head of the shared household with granddaughters and great-grandchildren. Her main contribution was to make sure that the household bills got paid, and she was very proud of her role in preparing the Sunday dinner, the biggest meal of the week. She was proud that she had been able to help out when her family needed her. By helping out, she was continuing a long family tradition. Her own grandmother had helped out when she was growing up, by cooking and bringing in food until her mother got home, and by teaching Mablean how to cook. She viewed the food and care that she received as her rightful compensation for prior years of family service.

Mablean’s daughter, a sixty-two-year-old mother figure, held the primary responsibility for taking care of the rest of the family’s food and nutrition needs. She was respected as a caretaker, the family member who watched over the nutrition and health of elder family members. Her thirty-year-old daughter, Sharon, lived in a boarding house. She held two jobs, one as a clerical worker and the other in retail sales, and was eating in her car between jobs. When Sharon was growing up, her mother had been very busy working split shifts and going to school at night. Sharon described how much her family had relied on her grandmother when her mother was not able to prepare meals for the family.

In another family using the exchange system, a twenty-seven-year-old daughter, Keisha, held household responsibilities that included helping care for her niece and nephew. She had no food shopping or preparation responsibilities. Keisha worked and exchanged her household labor for her sister’s cooking. Her sister, who was pregnant, shouldered most of the food shopping and cooking responsibility in the household in exchange for financial and child-care help.

Clinical Presentation

Little is known regarding how to achieve healthful eating patterns among minorities. In particular, understanding the food management strategies of African-American women is critical because they experience a disproportionately high incidence of diet-related chronic diseases, including cardiovascular disease, hypertension, diabetes mellitus, obesity, and some cancers, when compared to white women. Normal nutrition needs include a basal caloric expenditure rate of 1,800 to 2,000 calories per day. The protein contribution of this caloric expenditure is about 10 grams of nitrogen, in approximately 60 or 70 grams of protein.

The major effect of age on nutritional state is apparently due to a decreased food intake that may result from age-associated cellular loss or decreased physical activity. These effects may be amplified by health, economic, and social factors. The semi-starved individual experiences generalized weakness and is unable to sustain even minimal physical activity. In advanced starvation, edema is common. It appears first in the face, followed by swelling of the feet and legs. The skin develops a parchment-like look, thinning and wrinkling, so that the patient appears prematurely aged. Hair becomes brittle and easily pluckable. Complaints of coldness, especially in the extremities, are frequent. The patient often appears anxious and complains of aches in the ribs, sternum, pelvis, and lower extremities. If the principal cause of weight loss is deficient caloric intake, the elder’s diet history will reveal a substandard intake of energy and protein. Two major decisions must be made. The first is to decide