# Presentation: 167824

## Predictors of Functional Limitations Among American Indian and Alaska Native Elders

- Leander R. McDonald, PhD
- Richard L. Ludtke, PhD
- Kyle J. Muus, PhD
- Patricia Moulton, PhD
- National Resource Center on Native American Aging
- Center for Rural Health
- University of North Dakota School of Medicine & Health Sciences

**Notes:**
The presentation is entitled “Predictors of Functional Limitations Among American Indian and Alaska Native Elders”.  
Apologize to the elders and tell them who you are!!!!  

## Purpose of the Project

- The purpose of this project was to assist tribes in collecting data they could use to build long-term care infrastructure in their communities.
- Multiple methods are used throughout the study, but the main method of data collection is the survey instrument (administered face-to-face with the elders).

**Notes:**
The purpose of this study...

## Population 

- Native American elders residing primarily on reservations
- Individuals age 55 and over living on or around Indian areas.
- Age 55 is considered comparable to 65 and over in the general population

**Notes:**
The population we are concentrating on are Native Americans age 55 and over living on or around Indian areas or reservations.  
Age 55 is considered comparable to those 65 and over in the general population due to the lower life expectancy of Native Americans.

## Sampling Design

- Get everyone in small populations
- Sample in large populations
- Systematic or simple random sampling

**Notes:**
We suggest getting everyone in smaller populations.
Smaller populations are those having less than 200.
For larger populations we suggest using a sample.  
Since many tribal senior services already have a list of the elders in their community, we recommend systematic or simple random sampling.

## Data is collected on 

- General health status
- Activities of Daily Living (ADL’s)
- Instrumental Activities of Daily Living (IADL’s)
- Indicators of chronic disease
- Indicators of vision and hearing
- Tobacco and alcohol use
- Diet and exercise
- Weight and weight control
- Social supports

## National Resource Center Provides:

- Survey instruments – a standardized tool
- Assistance with sampling
- Training on data collection
- Technical support
- Data entry
- Data analysis
- Statistical profiles of your elders
- Comparisons with national norms

**Notes:**
The survey instrument is a standardized tool on scannable paper.
We provide assistance with sampling.  
Training is provided at the regional or national level through regional offices, or through forums such as the AoA Listening Sessions or the National Indian Council on Aging Conference.    
Technical support is available via telephone or email.
Data entry is provided through a scanner.  
The process varies, but we try hard to not go over two weeks in returning the data to the tribes.
Data analysis
Frequencies are run on the data
The statistics are entered on a comparison template and returned to the tribe. 
The end result is the tribe is able to compare their statistics not only to the nation, but to the other tribes participating in the study.
The data belongs to the tribe, but they allow us to use it as part of the larger aggregate file.

## National Tribal Data (N=9,403) & National Data Source Comparisons

| 
Question | 
Response (s) | Tribal Data
(55 and over) | National Tribal Data
(55 and over) | 94’ NLTCS 
(65 and over)  |
| --- | --- | --- | --- | --- |
| 4.  Because of a health or physical problem, do you have difficulty -- | a.  Bathing or showering? |  | 13.7% | 36.8% |
|  | b.  Dressing? |  | 9.5% | 15.8% |
|  | c.  Eating? |  | 6.5% | 8.1% |
|  | d.  Getting in or out of bed? |  | 11.3% | 22.1% |
|  | e.  Walking? |  | 25.9% | 33.7% |
|  | f.  Using the toilet, including getting to the toilet? |  | 6.6% | 22.8% |
| 5.  Because of a health or physical problem, do you have difficulty-- | a.  Preparing your own meals? |  | 15.4% | 19.7% |
|  | b.  Shopping for personal items (such as toilet items or medicines)? |  | 13.0% | 34.8% |
|  | c.  Managing your money (such as keeping track of expenses or paying your bills)? |  | 7.4% | 17.9% |
|  | d.  Using the telephone? |  | 6.2% | 9.6% |
|  | e.  Doing heavy housework (like scrubbing floors, or washing windows)? |  | 33.1% | 51.6% |
|  | f.  Doing light housework, (like doing dishes, straightening up, or light cleaning)? |  | 14.2% | 17.0% |
|  | g.  Getting outside? |  | 13.2% | 44.2% |

**National Tribal Data (N=9,403) & National Data Source Comparisons**

## Local Communities Provide:

- Obtaining a resolution from their tribal councils
- Locating a list and selecting names for the sample
- Data collection
- Receiving the findings and getting them to the right people
- Local implementation and coordination

**Notes:**
It’s the community’s responsibility to obtain a tribal resolution from the tribal council granting permission to participate in the project
They are responsible for providing a list and selecting names for the sample.
Data collection is best handled by local people who are familiar with the elders, their culture, and language.
Once the data is returned to the tribes, we suggest using the tribal or local newspaper, radio stations, or television to return the information to the community.  
Many times we see studies conducted on our reservations and nothing is ever returned.
Since the people never see the results, the importance of research is lost within that community.
Additionally, having hard numbers to back up what we already know increases our chances of making the needed changes within our areas.  
Therefore, we stress the importance of getting the information to tribal leaders, health officials, and others who can help disseminate and use the findings from the needs assessment.   
We also suggest that tribal leaders mandate a copy of the data and any reports generated from research to be returned to their tribe.  
They in turn should take the data and reports, and archive them in a tribal data warehouse like tribal planning.      
So, if someone is writing a grant for the elderly, they can go and pull the numbers needed to support their proposal. 

## Current Status of Cycles I & II

**Cycle I**
- 171 tribes from 89 different sites are represented in national file
- 9,403 Native elder participants have filled out the survey
- At least one tribe from 11 of the 12 I.H.S. Regional Areas is represented in the national file

**Cycle II**
- 149 tribes from 58 sites are now collecting data
- Additional tribes are now getting resolutions passed through their tribal councils
- For both Cycles I & II, we have assisted a total of 309 tribes from 130 sites.

**Notes:**
For Cycle I, 171 tribes from 89 different sites are represented in the larger aggregate national data file
With 9,403 Native elders have filled out the survey
For Cycle II, 149 tribes from 58 sites have resolutions on file and are now collecting data
Additional tribes are getting their resolutions passed through their tribal councils to participate in the needs assessment.
For both Cycles I & II, we have assisted a total of 309 tribes from 130 sites across the nation.
We anticipate a rush of additional tribes as we get closer to the Title VI elder nutrition grant renewal date as they require a needs assessment for renewal of these grants.  
At least one tribe from 11 of the 12 I.H.S. Regional Areas are represented.

## The Health of American Indian and Alaskan Native Elders

**Notes:**
The following slides give descriptive statistics from the study along with comparisons with the U.S. general population.  

## Chronic Diseases – Arthritis (N=9,403)

- Native elders were 18% more likely to experience arthritis than the U.S. general population.

## Chronic Diseases – Congestive Heart Failure (N=9,403)

- Native elders were 46% more likely to experience congestive heart failure than the general U.S. population.

## Chronic Diseases – Stroke (N=9,403)

- Native elders were 15% more likely to experience a stroke than the general population.

## Chronic Diseases – Asthma (N=9,403)

- Native elders were 43% more likely to experience asthma than the U.S. general population.

## Chronic Diseases – Cataracts (N=9,403)

- Native elders were 27% less likely to experience cataracts than the general population.

## Chronic Diseases – Breast Cancer (N=5,525)

- Native elder women were 30% more likely to experience breast cancer than the U.S. general population.

## Chronic Diseases – Prostate Cancer (N=3,595)

- Native elder men were 245% more likely to experience prostate cancer than the U.S. general population.

## Chronic Diseases – Colon/Rectal Cancer (N=9,403)

- Native elders were 50% less likely to experience colon/rectal cancer than the U.S. general population.

## Chronic Diseases – High Blood Pressure (N=9,403)

- Native elders were 17% more likely to experience high blood pressure than the U.S. general population.

## Chronic Diseases – Diabetes (N=9,403)

- Native elders were 169% more likely to experience diabetes than the U.S. general population.

## Vision (N=9,403)

**Notes:**
Native elders had close to 4 times the rate of blindness than their national counterparts at 11% compared to 3%.
For eyeglasses or contact use, the Native elders were less likely to wear glasses or contacts at 86%.   
For those having trouble seeing even with eyeglasses the rate is 33% compared to 19% for the nation, which could be a possible indicator of the need for a new prescription or new glasses.

## Hearing (N=9,403)

**Notes:**
Native elders were over 4 times more likely to be deaf in one or both ears at 18% compared to 4% for the nation.  
If you have higher rates of deafness, than you probably going to have higher rates of hearing aid use.  
This is reflected in hearing aid use column with the Native elders double the national percentage at 13%.   
Native elders have less trouble hearing even w/hearing aid at 18% compared to 23% for the nation.
Maybe, these elders just hear what they want to hear too.

## Dental Services Needed (N=9,403)

**Notes:**
A few quick slides on the dental...
The highest need for our nation’s Native elders was denture work at 24%.
18% needed teeth filled or replaced at lower rates than their national counterparts.
15% needed teeth pulled compared to 11% for the nation.  
We see the three highest need categories are related to one another, because you need your teeth pulled or replaced before you can get dentures.
The work needed to improve appearance category is at 10% compared to 3% for the U.S. general population.  
Good dental care affects all aspects of one’s personal life, whether they’re out trying to get a job or maybe if you are trying to find a SNAG.
My teeth are yellow from being prescribed tetracyline as a child, so there’s nothing I can do about that.
I don’t know how I got my wife, I think she was just happy I had all my teeth.
The point I’m trying to make is that our self-concept is affected by our appearance, and if we have good self-concept, we have a better quality of life.
For no dental services needed, our Native Elders were at 31% compared to 59% for the nation.  

## Behavioral Risk Factors

## Tobacco Usage (N=9,403)

**Notes:**
Native elders had lower rates of smoking than the nation at 26% vs 34%.  
Native elders chewed more at 5% compared to 4% for the U.S. general population.

## Cigarettes Smoked a Day (N=9,403)

**Notes:**
All smoking is considered bad, but if you’re going to smoke, I guess it’s better to smoke less and that’s what these numbers show.  The Native elders who smoked, smoked less.  

## Chewing Tobacco (N=9,403)

**Notes:**
Again, any tobacco use can be hazardous to your health.  The Native elders who were chewing, tended to chew less.

## How long since last drink of alcoholic beverage? (N=9,403)

**Notes:**
Contrary to stereotypes to American Indians, Indian elders are much less likely to drink alcoholic beverages.
There’s a lot of heavy drinking going on in Indian Country, but those who drink heavily, don’t survive to become elders.
45% of the Native elders hadn’t taken in a drink in the last 3 years
And, 22%, reported never taking a drink in their life.

## Binge Drinking (N=9,403) (5 or more drinks on one occasion)

**Notes:**
SAMHSA has defined binge drinking as 5 or more drinks on one occasion.   
Native elders reported 86% for none compared to 93% for the nation.  
For 1 or 2 days, the Native elders were twice as likely to have 5 or more drinks on one occasion at 8% compared to 4% for the general population.
For 3 to 5 days, the Native elders were at 3% compared to 2% for the U.S. general population.  
And for 6 or more days, the elders were double at 4% compared to 2% for the nation.
This means that the Native elders who do drink are more likely to binge drink when compared with their general population counterparts.
Those who do drink, drink more.

## Breakfast (N=9,403)

**Notes:**
Breakfast is used as an indicator of good eating habits.  
Here, we see the Native elders are less likely to eat breakfast at 61% compared to 77% for the nation.  
If one skips breakfast, they are more likely to overeat and become obese.
So, we need to bring up our percentages for eating breakfast everyday. 

## Exercise (N=9,403)

**Notes:**
Exercise activities included walking, running, biking, swimming, aerobics, pow-wow/other dancing, calisthenics, gardening, and weight lifting.
The Healthy People 2010 goals for exercise range from 25% of the adult population for vigorous exercise such as walking or running to 40% for flexibility and strength maintenance such as calisthenics and weight lifting.  Part of the argument for promotion fitness is that this directly relates to ADL limitations.  
The more physically fit you are, the more likely you are going to be independent into your old age.
Our data show that Indian elders are more likely to engage in exercise activities than the general population with more also engaging in multiple exercise activities.
So, the Native elders are exercising more than the general population. 
And, that’s a good thing.  Especially with those experiencing the difficulties of diabetes and arthritis.

## Body Mass Index (N=9,403)

**Notes:**
Although the Native elders are exercising more, they’re not seeing the benefits that the general public is seeing in their weight maintenance.  
This is reflected in the Body Mass Index.
Body Mass Index is a term used to show the relationship between height and weight. Your weight should be proportionate to your height. 
The points defined by the BMI scale are indicators of increased risk of diseases like diabetes, hypertension, etc.
Falling in the overweight/obese category is the single most important predictor of non-insulin dependent diabetes or Type II diabetes.
Native elders were less likely to be in the low/normal category and more likely to be overweight or obese category. 
Although the Native elder group is close by 1% in the overweight category, they are over double the nation’s percentage of obesity at 40%.
The Healthy People 2010 goals for weight suggest a target of less than 15% for the obese category and a target of 60% in the healthy weight category.
So, we need to move about 25% of the people in the obese group and about 11% from the overweight group over to the low/normal group to be on target with the 2010 document.  
The data from our study show a significant problem exists at the obese category.  This relates to numerous health problems including of course, Type II diabetes, coronary heart disease, stroke, and some types of cancer.

## Functional Limitations

**Notes:**
These next slides give us an indication of the functionality of the Native elder.
If the elder has higher rates of chronic disease, then we would logically assume they would have higher rates of activity limitations.
Before we explore this further, we must first come to a general definition of functionality.

## Functional Limitations

- The majority of definitions concerning functional limitations or disability refer to activities of daily living (ADL’s) and instrumental activities of daily living (IADL’s) as indicators of functionality.

**Notes:**
Functional limitations reflect the level of disability in the population and relate to criteria normally used for admission to nursing homes, assisted living and to community based long term care programs.  
Definitions of functional disability vary considerably, but nearly all use information about “activities of daily living” (ADLs) or “instrumental activities of daily living” (IADLs).  

## Activities of Daily Living (ADL’s)

- Eating
- Walking
- Using the toilet
- Dressing
- Bathing
- Getting in/out of bed

**Notes:**
ADLs include difficulties with eating, walking, using the toilet, dressing, bathing and getting in and out of bed.  These are considered fundamental to survival.  

## Instrumental Activities of Daily Living (IADL’s)

- Cooking
- Shopping
- Managing money
- Using a telephone
- Light housework
- Heavy housework
- Getting outside

**Notes:**
IADLs reflect activities required for independent living, but that are less severe than ADLs.  
These are cooking, shopping, managing money, using a phone, doing light or heavy housework and getting outside the home.  
These would tend to be used as indicators of home and community based services.

## Functional Limitation Categories

| 
Categories | 
Limitations
 | 
Recommended Services |
| --- | --- | --- |
| 
Little or none | 
No ADL limitations, up to one IADL
limitation  | 
No Services Required |
| Moderate | One ADL limitation with fewer than 2 
IADLs  | Home and Community
Based Services |
| Moderately
Severe | 2 ADL limitations  | Assisted Living |
| Severe | 3 or more ADL limitations  | Skilled Nursing Facility |

**Notes:**
In this section, we combine ADLs and IADLs into a classification that places people into one of four levels of need, and corresponds to different levels of care.  
This was modeled after a report prepared by Kunkel and Applebaum for the U. S. Department of Human Services.
The lowest level requires no long term care services and is the level of functional limitation to which all would aspire.  
The Moderate category reflects a beginning level of long term care need and would most appropriately be met with home and community based services.  
Moderately severe functional limitations serve as the threshold for assisted living.  
The severe functional limitation category serves as the basis for admission into skilled nursing care or nursing home facility. 
Using these categories, we are able to estimate the numbers of people at these different levels of need, and to who would be appropriate candidates for different levels of long term care services. 

## Rates of Functional Limitation

## Rates of Functional Limitation: Native Elderly and U.S. by Age

| 

Functional Limitation | 
65-74 |  | 
75-84 |  | 
85 and over |  |
| --- | --- | --- | --- | --- | --- | --- |
|  | Native American | U.S. | Native American | U.S. | Native American | U.S. |
| Little or none | 61.4%
 | 61.4% | 49.2% | 46.7% | 31.2% | 20.8% |
| Moderate | 21.2% | 16.6% | 26.4% | 23.2% | 27.8% | 23.5% |
| Moderately Severe | 5.9% | 6.6% | 8.5% | 8.5% | 12.0% | 13.8% |
| Severe | 11.5% | 15.4% | 15.9% | 21.6% | 29.0% | 41.9% |

- U.S. Data Source:  1994 National Long Term Care Study

**Notes:**
The pattern observed when comparing the levels of functional limitation between the United States non-institutional population for all races with the Native American elders in this data indicates a general trend of greater severity among the total population, particularly among the oldest cohorts.  
While the trend is not uniform and some comparisons find Native American’s with greater limitations, the oldest old clearly have the highest need in both populations and the acknowledged need is greater in the total population than is the case for the Native American elders. 
Note the majority of the Native elders who show a need for services fall in the moderate category or the category defined as those needing home and community based services rather than those requiring assisted living or skilled nursing.   

## Life Expectancy at Birth, ages 55, 65 and 75 by IHS Area

**Notes:**
When the data is broken down into regional areas, the rates vary.
In Alaska, arthritis rates are high at 58%, which we believe is attributable to climatic reasons.  
North Dakota Native elders have lower rates of chronic disease in all of the categories except arthritis, asthma, and diabetes.
We believe these rates to be attributable to the lower life expectancy of American Indians in the Aberdeen Area.  
Although it appears that the American Indian population in ND have less chronic disease, and are thus healthier.
They are actually dying as a result of chronic disease, trauma, and late or lack of diagnosis before they become elders.
Of the twelve areas, the four with the lowest life expectancy tend to be located in rural or frontier rural areas.

## Native Elder Population Projections 1990-2020

**Notes:**
We put together some population projections for the nation show the increase in the elder population from 1990 to 2020.
You can see the increase in the elder population in all age levels throughout the slide.
The largest group will be the young elder from age 55-64, but there’s also increases in the 65 and above categories.  
Those in the older age groups would have the most difficulty with physical limitations, and would require more services.   

## Functional Limitation Levels Applied to Services and Personnel

| Level Functional Limitation | Service Goals | Services with best fit | Personnel required |
| --- | --- | --- | --- |
| Little or none (59%) | Health promotion, preventive care, maintaining vitality | No caregiver services required Health Promotion/Prevention | Health educators, physical trainers, therapists  |
| Moderate (21%)
This category represents entry level functional limitations and requires assistance usually consistent with remaining in one’s home.   | Supportive services to aid persons in remaining in own domicile.  Train and support informal providers and buffer them with respite and contact services for a range of possible tasks. | Informal care – w/supports
Chronic Disease Management
Home & community based
Day/night care*
Durable medical* equipment
Home health care*
Homemaker services*
Physical therapy
Occupational therapy
Medication assistance*
Speech therapy
Mental health services
Transportation services*
Nutritional services*
Personal care*
Respite care*
* Require local providers | Family and friends
Trainer for skills
Facility staff – LPN/CNA
Rental source
RN, LPN, CNA, PT, OT...
Cleaning and chore assts.
PT, PT aides, tele-health
OT, OT aids, tele-health
Medication aide
Speech therapist
Psychologist, Psychiatrist, Psych. Social Worker,
Van driver
Dietician, aide
Trained attendants
Trained respite providers or institutional site |

## Functional Limitation Levels Applied to Services and Personnel Cont...

| Level Functional Limitation | Service Goals | Services with best fit | Personnel required |
| --- | --- | --- | --- |
| Moderately Severe (7%) | The goal for this level of care is to provide housekeeping and meals along with a modest level of oversight.  People may contact for services from the home and community based services in addition to the basic services found in these settings.  Assisted living establishes the goal for this cluster in that it seeks to maintain resident control over services. | Congregate care
Basic care facilities
Assisted Living
 | Institutional staff as required by state regulations |
| Severe (13%)
With 3 or more ADLs, this level
tends to become prime candidates
for skilled nursing care.  They 
represent care needs with 
relatively high levels of acuity.
 | Skilled nursing care is the most fully institutional and is reserved for those with medical needs necessitating this level of care.  | Skilled Nursing Care
 | Institutional staff as required by state regulations |
| Terminal as special category  | End of life care occurs at all points on the above continuum, but is concentrated at the higher levels of limitation.  The goal is physical and emotional comfort.  | Hospice Care
 | *Hospice volunteers and coordinator |

## Acceptance of Nursing Homes & Assisted Living (N=9,403)

**Notes:**
Question:  If at some point in your life you became unable to meet your own needs, would you use...?
66% would accept assisted living care.
18% of tribal elders would accept nursing home care.
States have been quick to regulate nursing homes and the construction of new facilities.
Therefore, assisted living has become the option of choice.
Assisted living can meet almost all of the needs with considerable less red tape and less expense then you would experience if you try to build a nursing home.  

## Type of Services Utilized (N=9,403)

**Notes:**
The top 5 services provided to elders are Meals on Wheels, dietary, transportation, physician services, and social services.  
Meals on Wheels and dietary services are mainly due to efforts of Title VI programs.
With a huge amount of the transportation being provided by the CHR programs.

## Analyses

## Office of Rural Health Policy Project

- A grant from ORHP funded the linkage of the Native Elder data to the Area Resource File (ARF, 2003).
- The ARF File is a database of county level medical resources such as the number of doctors, physician assistants, nurses, and facilities.
- Using frontier codes (Frontier Education Center, 1998), a rurality variable was created that designated the county as frontier, rural, or urban.
- Frontier was defined as a county with less than 6 people per square mile.
**	****	****	****	****	**
**	****	**

**Notes:**
Rurality 
Urban=UIC 1,2 
Rural=UIC 3-9
Frontier=UIC 3-9 and frontier county status

## Purpose of the analysis

- The purpose of this analysis was to determine if demographics, geography, health status & behaviors, and health care access & utilization were predictors of functional limitation status within American Indian and Alaskan Native elder populations.

**Notes:**
The purpose of this analysis was to determine....

## ANALYTIC MODEL

**Demographics**
**(gender, age, income, education, **
**household size) **

- Demographics

## Slide 50

## Advanced age
Lower education & income
Albuquerque Region
NOT being in these Regions: Aberdeen, Bemidji, Billings, Portland, AK, CA
Frontier location
Having arthritis, CHF, stroke, asthma, cataracts, breast cancer, other cancer, hypertension, diabetes
Less walking, gardening & aerobic/dancing
1+ hospitalizations in the past year
Vision screening within past year
Dental checkup more than a year ago
Greater numbers of SNFs per 1,000 population

- Lower education & income
- Albuquerque Region
- NOT being in these Regions: Aberdeen, Bemidji, Billings, Portland, AK, CA
- Frontier location
- Having arthritis, CHF, stroke, asthma, cataracts, breast cancer, other cancer, hypertension, diabetes
- Less walking, gardening & aerobic/dancing
- 1+ hospitalizations in the past year
- Vision screening within past year
- Dental checkup more than a year ago
- Greater numbers of SNFs per 1,000 population

***Functional Limitations*** in Native Elders was Associated with:

**Notes:**
Advanced age – the older you are, the harder it is to get around.
Lower education & income – these two are always related, because the less the money you have, the less likely you are to have access to healthcare.  
Albuquerque Region – This is primarily related to higher life expectancy.  The elders in this area are living longer, hence they are experiencing more functional limitation. 
Again, life expectancy is related to the following bullet.  These regions have lower life expectancy, so they are not living long enough to have functional limitation.
Those residing in frontier areas are more likely to have functional limitations, which is an indicator of the need for long-term care services in these areas.  
Those elders who were told by a doctor they had arthritis, chf, stroke, asthma, cataracts, breast cancer, other cancer, hypertension, and diabetes were all more likely to have functional limitation.
 Those elders who did less walking, gardening, and aerobic dancing were more likely to have functional limitation.
These last 3 bullets relate to access to healthcare.
Those who had more than 1 hospitalization in the past year were more likely to have functional limitation.  This makes sense as those who are sicker are more likely to have problems getting around.
Those elders who had a vision screening less than a year ago were less likely to have functional limitation.  
If you’re going to the eye doctor on a regular basis, then you are probably watching your health a little better.
On the other hand, those who had NOT been to the dentist for more than a year were more likely to have functional limitation.  
Again, this is an indicator of health access.  If you are not taking care of your teeth, than maybe, you not getting other checkups.  
This can be related to the person, or this can be related to the lack of services among American Indian populations.
This last bullet, elders with more functional limitation were more likely to live in those areas where skilled nursing facilities were located.     

## Conclusions

- Due to lower levels of functional limitation, Native elders would benefit from wellness and chronic disease management programs to improve quality of life.
- The prevalence of arthritis, heart disease, stroke and cancer may lead to increased functional limitation with age.
- Many chronic diseases are co-morbid.  Screening and early treatment is essential for maintaining vigor in Native elders.
- Elders also indicated a need for creating a healthy home environment with home modifications, equipment, access to services and resources.

**Notes:**
GENERAL CONCLUSIONS FROM THIS RESEARCH AND THE CONTEXT:
 The demographic context for Native American elders is taken from population projections and these show that Native American elders are relatively young.  They are more likely to be clustered in the beginning elder age groups than the general population.  According to our analysis, the odds of being disabled decrease among the younger cohorts.  A consequence of this is that the elders present functional limitations more frequently as none or at a low level of severity.  With these levels of limitation, Native American elders are more likely to be the healthy disabled and are prime candidates for wellness and chronic disease management in order to preserve their vitality and their quality of life.
Chronic disease prevalence rates suggest that Native American elders may be at risk for future increases in functional limitations and we are concerned that elders in medically underserved areas may under report present levels ADLs and IADLs.  Those with chronic diseases are on a pathway leading toward disability, especially those with arthritis, heart disease, stroke and cancers.
Access to care is critical not only for treatment, but also for early diagnosis and creating an awareness of one’s health status.  A lack of access to care produces artificially low rates for diseases, especially silent diseases such as hypertension and lead to high levels of severity when diagnosis is delayed.
Co-morbidity for disabling diseases is high.  For example, the odds of hypertension is higher among diabetics, stroke victims, victims of congestive heart disease and arthritics and this leads to an increased likelihood of future disabilities.  Screening for potentially disabling diseases such as arthritis, stroke and heart disease along with early treatment is essential for maintaining vigor for Native American elders.
Elders indicate the need for creating an environment that is supportive of healthy lifestyles.  They seek home modifications, equipment, access to services and resources.

## Preliminary Policy Implications

- AHRQ should fund research to evaluate wellness interventions such as Minnesota’s Wisdom Steps, among Native elders.
- Federal agencies should develop a collaborative model for health promotion reaching American Indians through rural health clinics, tribal health and tribal colleges.
- IHS and CMS (Medicare and Medicaid) should provide health screening for early detection of chronic disease especially arthritis, diabetes, heart disease and cancer.
- A joint CMS and IHS disease management demonstration program should target the most prevalent chronic diseases in Native elders including arthritis, diabetes and high blood pressure.

**Notes:**
Policy recommendations:
Prevention is critical.  Wellness programs such as Minnesota’s Wisdom Steps represent interventions that could potentially serve as models for the nation’s tribes.  The Agency for Health Research and Quality (AHRQ) should develop a  program to evaluate wellness interventions among Native American elders in order to identify best practice models and to discern whether these practices would be cost effective.  
Health promotion should become a major goal infused into programs of health care, community education, and human services.  To accomplish this task, an interagency team including the Indian Health Service, the Department Education and the Department of Human Services should be created with the charge of developing a collaborative model for health promotion that reaches people through educational institutions, clinic visits and in their homes.  While the target population of elders is imperative, prevention must also address younger age groups such as those in pre-retirement cohorts.  
Health Screening designed for early detection and treatment of chronic diseases most likely to lead to functional limitations is also essential.  According to our data, these would include arthritis, heart disease, stroke and cancers.  Health screenings for elders (55 yrs of age or older) should become a responsibility of the Indian Health Service and attached to health promotion programs. These should be funded with earmarked funds and should not compete with existing lines of funding.

## Home safety audits should be provided by Housing and Urban Development in order to ensure that the home environment fits the needs of the Native elder and include necessary equipment. 
HHS community and faith based programs along with ORHP and AHRQ  should support initiatives that seek innovative designs for providing home and community based long term care services and support for Native elders living in rural and frontier areas (e.g., PACE structured to meet rural circumstances).  
Programs to decrease prevalence of chronic illness in future elders should support student retention and seek to build American Indian career opportunities since education and income are predictors of health and disability.  

- HHS community and faith based programs along with ORHP and AHRQ  should support initiatives that seek innovative designs for providing home and community based long term care services and support for Native elders living in rural and frontier areas (e.g., PACE structured to meet rural circumstances).
- Programs to decrease prevalence of chronic illness in future elders should support student retention and seek to build American Indian career opportunities since education and income are predictors of health and disability.

**Notes:**
The Indian Health Service should develop and disseminate chronic disease management programs designed to empower patients and caregivers. While chronic disease management programs may serve diverse chronic diseases, it is important to focus on the most debilitating diseases which are arthritis, heart disease, stroke and cancers according to our data. These programs should be monitored as experimental programs with a goal of producing model delivery systems for isolated rural and reservation populations.
As an implied goal of independent living is embedded in the preceding recommendations, it becomes imperative that individual homes measure up to the needs of their residents.  Home safety audits should become standard practice for the elder population to ensure optimal conditions for independent living.  A special initiative under Housing and Urban Development should provide an assessment of person/environment fit on a regular basis.  These environmental assessments should be broadly defined as to include medical equipment such as safety bars in bathrooms, toilet risers and such items that enable  people to function at optimal levels in their home environments.
A  special  initiative under AHRQ should be established that seeks innovative designs for providing home and community based long term care services and  supports for demographically challenged reservations.  This initiative should seek to encourage new provider delivery models designed specifically for isolated and sparse populations and should allow for experimentation with reimbursement strategies and should include funds for evaluation.  A 3 to 5 year program on 4 reservation sites selected to represent the diversity in these demographically challenged places is recommended.  Community/University partnerships should be encouraged in this initiative to ensure the adaptation of current materials and state of the art knowledge in the design of new model programs.  
Education and income are twin predictors of health and disability.  It is essential for the long run that measures to support student retention and to enhance Native American students’ perceptions of career opportunities be increased.  A special initiative under the Department of Education with a 3 to 5 year timeframe should solicit model interventions along with evaluation in order to locate cost effect mechanisms for enhancing perceptions of opportunities and improving student retention.  While this recommendation deviates from immediate attention to elders, it is considered critical for the long term.  Future generations must realize more of the untapped potential of Native American youth.  They are the elders of tomorrow.

## Factors contributing to the longevity of the oldest, old Native American elders’ need further exploration.  Identifying common elements that have contribute to living  long, healthy lives may help guide Native American tribal leaders in targeting programs that will enhance Native Americans’ quality of life.
 Socioeconomic factors significantly contribute to one’s health status over the course of a lifetime.  Those elders with the lowest incomes and educational levels are the most likely to suffer from high blood pressure, a precursor to many other health problems.  Therefore, it is imperative that efforts be focused to improve socioeconomic conditions in addition to improving access to health care.  All Native Americans, including current and future elders, will benefit from improved socioeconomic status. 

-  Socioeconomic factors significantly contribute to one’s health status over the course of a lifetime.  Those elders with the lowest incomes and educational levels are the most likely to suffer from high blood pressure, a precursor to many other health problems.  Therefore, it is imperative that efforts be focused to improve socioeconomic conditions in addition to improving access to health care.  All Native Americans, including current and future elders, will benefit from improved socioeconomic status.

## There is a direct relationship between income and population density for Native American elders.  Thus, frontier Native American elders are at the greatest risk for not having enough income to support their medical and daily needs.  The Social Security Administration and Tribal entities should consider what types of resources are needed in these frontier communities, and develop a strategy for meeting these unmet needs. IHS and CMS should consider the availability of Medicare for Native American elders irregardless if they have contributed to Social Security.  Access to Medicare would provide frontier Native American elders with a broader network of health care providers than are currently available through I.H.S. in frontier communities.

## IHS should develop a special initiative for colon/rectal screening because of the high correlation between colon/rectal cancer and lung cancer.  This finding indicates that the colon/rectal cancer has metastasized to the lung; therefore, improved screening would help diagnose colon/rectal cancer before it spreads to other organs, ultimately, improving survivability.
Because many Native American elders indicated they had limited access to dental, hearing, and vision screenings, IHS    should implement community screening programs for Native American elders’ designed to remedy these problems before they contributing to other negative health outcomes, such as fall injuries or poor nutrition.  

- Because many Native American elders indicated they had limited access to dental, hearing, and vision screenings, IHS    should implement community screening programs for Native American elders’ designed to remedy these problems before they contributing to other negative health outcomes, such as fall injuries or poor nutrition.

## The high average BMI among Native American elders indicates an opportunity to develop wellness programs that focus on healthy eating choices and physical activity.  As obesity has become a national epidemic, addressing these issues through a community environment perspective, which includes a multi-generational approach, may have the most positive impact on the health of all Native Americans.
Urban Native American elderly are the most likely to indicate they have asthma.  The Environmental Protection Agency’s work in air quality and asthma management should be extended to cover tribal communities.  The primary goal of this initiative would be to identify successful asthma management programs and locate the factors that contribute to their success.  

- Urban Native American elderly are the most likely to indicate they have asthma.  The Environmental Protection Agency’s work in air quality and asthma management should be extended to cover tribal communities.  The primary goal of this initiative would be to identify successful asthma management programs and locate the factors that contribute to their success.

## Richard L. Ludtke richard_ludtke@medicine.nodak.eduLeander R. McDonald rmcdonal@medicine.nodak.eduNational Resource Center on Native American AgingTel: 701-777-6780/800-896-7628Fax: 701-777-6779Website:  http://medicine.nodak.edu/crh

- NRCNAA

- NRCNAA