One factor explaining the expansion of this segment of the AI/AN population is the increasing life expectancy (see Figure 1). The life expectancy for AI/ANs born between 1972 and 1974 was 63.5 years, compared to 71.1 years for those born between 1992 and 1994 (IHS, 1997). There has been a corresponding increase in the number of chronic diseases and rates of disability for AI/AN elders. According to 1997 IHS data, the top five leading causes of death among AI/ANs between the ages of 55 to 64 are diseases of the heart, malignant neoplasms, cerebrovascular diseases, diabetes mellitus, and pneumonia and influenza (see Figure 2).

It is critical to recognize the heterogeneity between and within the 500 to 600 tribal groups, which is manifested in the epidemiology of disease and the cultural values and beliefs of each group. For example, while the overall leading causes of death among AI/ANs are diseases of the heart, in the Alaska, Navajo and Albuquerque areas they are accidents and adverse effects (IHS, 1998-1999). One must avoid the tendency to generalize the following findings, discussion and recommendations to all tribal groups and villages.

According to results from the Strong Heart Study, a prospective epidemiologic study of AIs in Arizona, Oklahoma, North Dakota and South Dakota between 1989 and 1995, the coronary vascular disease (CVD) incidence rates for AIs aged 45 to 74 was approximately two times higher than in a similar study of whites and African-Americans, and the CVD rates for AIs appeared to be increasing (Howard et al., 1999). In this same study, stroke rates for AI women were similar to other U.S. populations, but rates for AI men were lower. Diabetes, which continues to increase in AI/AN populations, had a significant independent effect on CVD rates in this population. In the Strong Heart Study, diabetes prevalence rates ranged from 32.4% to 70.9%, with higher prevalence rates and higher rates of central adiposity and unfavorable lipoprotein changes in women compared to men (Howard et al., 1998).

An interesting diabetes aside is a study that found a greater difference in the prevalence rate of diabetes among the AI geriatric population (age 55 to 74) -- but not among those 45 to 54-using the newer American Diabetes Association diagnostic criteria compared to the World Health Organization criteria (Lee et al., 2000).

Among AI/AN men, lung, prostate, colon, stomach and liver cancers are the top five leading causes of cancer deaths, while among AI/AN women, lung, breast, colon, ovarian and pancreatic cancers head the list (IHS, 1997). Palliative care for these and other cancers is an area of cancer therapy that is relatively underdeveloped in AI/AN communities. Vaccination rates as low as 49% for influenza and 22% for pneumococcus were found in an urban AI population (Buchwald et al., 2001).

Chronic liver disease and cirrhosis compose the ninth leading cause of death among AI/AN elders (IHS, 1997). The medical complications of cirrhosis and liver failure from alcoholism are well-known. In addition, alcoholism accounts for a portion of the high mortality rates from accidents and injuries, the seventh leading cause of death among AI/AN elders. In one study that looked specifically at an urban Indian elder population, the proportion of AI/AN heavy drinkers was no different from that of the general population, but the age-specific (age 65 to 74) alcohol death rate was higher than in a similar white population (Barker and Kramer, 1996). There are, however, regional variations. In a substudy of the Strong Heart Study on the Cheyenne population (age 45 to 76), more elder men (71%) than women (28%) used alcohol heavily (Lowe et al., 1997). Participants in this study were asked if they ever drank heavily, but there was no quantified amount to define heavy drinking. Men were more likely to be current drinkers, binge drinkers and to have a positive screen for alcoholism using the Short Michigan Alcoholism Screening Test (SMAST). Women who were heavy drinkers were more likely to show signs of depression.

There is much to learn about and to determine for AI/AN communities, whose cultural values and beliefs may not be congruent with those of Western society and medicine. Organ transplantation and advanced directives are ethical areas not clearly defined for this population.

In 1991, the federal Patient Self-Determination Act requiring health care facilities to inform patients of their right to accept or reject any medical therapy was enacted. Since that time, it has become evident that discussion methods may need to be revised when dealing with AI/AN elders. For example, in a sample of Navajo patients (mean age=60), it was found that discussing matters concerning death and dying may bring them to reality (Carrese and Rhodes, 1995). Their recommended approach for such discussions included: a) making an assessment of the patient's willingness to discuss this information; b) preparing for such discussions by establishing a trusting relationship, involving family, making it clear that no ill will is intended and involving traditional healers if desired; c) the discussion must be positive, not hurried, and third-person reference is preferred; and d) discussion follow-up must reveal actions by the providers that relay hope (Carrese and Rhodes, 2000).

A similar approach may be used for other AI/AN tribes and villages, but it must be individually tailored. The timing of the discussion of advanced directives also may vary within AI/AN communities compared to the white population. Western medicine recommends that advanced directives discussions be conducted in an elective situation such as a clinic, as opposed to an acute emergency situation. Within some AI communities, however, the discussion seemed most successful when conducted in the acute situation (Hepburn and Reed, 1995).

Another obvious factor is the educational level of the patient, particularly if the information is delivered in writing. Providers must determine the patient's first language. If the AI/AN language is primarily spoken-and this is likely with the elder population-then effective medical translators must be employed who understand the medical terms that are used, are aware of the limits of the communication process (i.e., the translator must not interpose their own words/beliefs into the communication) and understand the ethics of translation. Knowledge of the race and cultural beliefs of the translator are also critical. For example, there may be a taboo against using a Navajo translator to enhance communication around death and dying issues, as the translator may be accused by the patient of wishing death upon them. Several studies have supported the concept that effective communication between health care provider and patient is enhanced by the use of medically trained interpreters and by the provider's knowledge of the patient's culture (D'Avanzo, 1992; Haffner, 1992; Wardin, 1996).

Very little is known about palliative care approaches and treatment among AI/ANs. This should prompt health care providers to pay particular attention to this area of medicine, as AI/AN communities do find this an important issue. Providers must also realize that the current Western paradigm of palliative care may need to be tailored to the unique needs of AI/AN communities.

In all interventions, the most important criterion is respect for the patient. With respect comes the acknowledgement and acceptance of the patient and their culture, enhanced communication -- the building stone for the development of trust -- and equality in the patient/physician relationship.

Dr. McCabe is associate professor in the department of family and community medicine at University of New Mexico School of Medicine. A Navajo physician, she chairs the geriatric section of her department.

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Treating American Indians/Alaskan Native Elders