Oun Oy, 90, right, lives with her son and his family. A home health aide helps them care for her. Jessica Kourkounis for The New York Times

As Parents Age, Asian-Americans Struggle to Obey a Cultural Code

International New York Times | 14 Jan. 2014

SOUDERTON, Pa. — Two thick blankets wrapped in a cloth tie lay near a pillow on the red leather sofa in Phuong Lu’s living room. Doanh Nguyen, Ms. Lu’s 81-year-old mother, had prepared the blankets for a trip she wanted to take. “She’s ready to go to Vietnam,” Ms. Lu said.

But Ms. Nguyen would not be leaving. The doors were locked from the inside to prevent her from going anywhere — not into the snow that had coated the ground that day outside Ms. Lu’s suburban Philadelphia home, and certainly not to her home country, Vietnam.

Ms. Nguyen has Alzheimer’s disease, and Ms. Lu, 61, a manicurist who stopped working two years ago when her mother’s condition worsened, is her full-time caretaker. In Vietnam, children must stay home and care for their aging parents, Ms. Lu said. Elders “don’t want nursing home,” she said: Being in a nursing home creates “trouble in the head.” The family now relies financially on Ms. Lu’s husband, a construction worker.

In a country that is growing older and more diverse, elder care issues are playing out with particular resonance for many Asian-Americans. The suicide rate for Asian-American and Pacific Islander women over 75 is almost twice that of other women the same age. In 2012, 12.3 percent of Asian-Americans over 65 lived in poverty, compared with 9.1 percent of all Americans over 65. Nearly three-quarters of the 17.3 million Asians in the United States were born abroad, and they face the most vexing issues.

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Penn Asian Senior Services, led by Im Ja Choi, helps Asian-Americans who face language and other barriers to elder care. Jessica Kourkounis for The New York Times

Language barriers and cultural traditions that put a premium on living with and caring for the elderly further complicate the issue at a time when the population of older Asian-Americans is surging. According to the Administration on Aging, an agency of the Health and Human Services Department, the number of Asian, Hawaiian and Pacific Islanders over age 65 is expected to grow to 2.5 million by 2020 and 7.6 million by 2050, from fewer than one million in 2000.

Asian-Americans are hardly alone in their desire to care for aging relatives themselves. Many Hispanic families share a similar commitment. But despite those expectations, more Latinos are entering nursing homes, and facilities that specifically serve Latinos are increasingly in demand. Also, finding a home health aide or nursing home supervisor who speaks Spanish is usually easier than finding one who speaks, say, Khmer.

Zhanlian Feng, a senior research analyst at RTI International who has studied demographic shifts, said that filial piety, or respect for one’s elders — a concept based on Confucian philosophy — was a large part of Asian-Americans’ cultural expectations.

“This idea that the younger generation is culturally mandated to take care of their parents is deeply ingrained in the Chinese culture,” Mr. Feng said. “Children are supposed to take care of older parents in need.” But that tradition is being eroded, he said, by the increasing number of families that are geographically dispersed or in which both spouses have to work.

That is changing somewhat, both here and in Asia. The aging population has forced some communities in China to create nursing homes and assisted-living facilities, which barely existed there years ago, Mr. Feng said. And retirement communities for Asian-Americans are increasingly popular.

Health care providers in the United States confront culturally sensitive questions like whether to address patients by their first name or whether to ask someone who may have been a refugee about war trauma. Language barriers are another hurdle, said Kun Chang, Northeast regional coordinator at the National Asian Pacific Center on Aging.

Mr. Chang said limited English proficiency among older Asian-Americans was “the No. 1 issue.” “Are we able to address that culturally and with linguistic services?” he said.

For Ms. Lu, putting her mother in a nursing home where she would be unable to communicate with the staff is not currently an option. Instead, through a program offered by Penn Asian Senior Services, known as Passi, she is learning to care for her mother at home. But despite Ms. Lu’s sunny demeanor, the strain is evident.

“I don’t work, but I’m so tired,” she said. “Sometimes it makes me crazy, too.”

She began to lock the doors after Ms. Nguyen left one night and walked a few miles before the police found her. Ms. Nguyen has also been known to remove framed family portraits from the living room wall to take on her imaginary trips to Vietnam.

“If I can’t take care,” Ms. Lu said, she will have to consider a nursing home. “But not now,” she said. “In the nursing home, she’s scared.”

The challenges Ms. Lu and so many others are facing underscore the need for culturally competent elder care services for Asian-Americans, said Im Ja Choi, founder and executive director of Passi, which trains home health aides who speak languages including Korean, Mandarin and Vietnamese.

Ms. Choi founded the organization after her own mother developed stomach cancer. “When she was sick, I could not just abandon her at a nursing home,” she said. “That’s not in my culture, either.” She added: “That’s the agony of Asian-Americans. They have to work, and their children go to school and their parents remain at home by themselves. They put them in a senior housing complex, and there they are alone.”

The need for services that would let Asian-Americans keep their loved ones at home, where they can speak their own language and eat familiar foods, has influenced Ms. Choi’s organization. It is expanding to a new two-building, 29,300-square-foot facility in Philadelphia, where it will provide ethnic meals, a community center, counseling, caregiver training and other activities for clients of a variety of Asian nationalities. Ms. Choi said the center would also serve non-Asian clients.

“I am a proponent for home care because my mother, who everybody predicted wouldn’t live more than two months, lived eight years under my care,” she said. “That’s living proof.”

Pheng Kho, 68, came to the United States from Cambodia in 1981 with his wife, his two children and his mother, Oun Oy. In 2012, Ms. Oy, 90, had a stroke that left her unable to perform many daily tasks. “After she left from the hospital, at that time she cannot stay home alone,” Mr. Kho said. 

He and his wife tried to care for Ms. Oy alone but soon realized that while they did not want to send her to a nursing home, they needed help. In the summer of 2012, they contacted Passi, and a Cambodian home health aide now visits twice a week.

Mr. Chang of the National Asian Pacific Center on Aging said that as the Asian-American population aged, he expected to see more community groups and nonprofits trying to provide tailored services. Mainstream elder care providers are just beginning to realize the challenges in serving this demographic, he said.

“They haven’t figured this out because they have to think in a very different way,” Mr. Chang said. “They have to hire more bilingual staff to design these services. It’s a cultural change.”

AARP is also setting its sights on Asian-Americans, said Daphne Kwok, the organization’s vice president for multicultural markets and engagement for Asian-Americans and Pacific Islanders. It has been meeting with groups like Mr. Chang’s to learn more about the needs of the population and to recruit members.

Ms. Kwok described the term “caregiving” as “mainstream terminology.” For Asian-Americans, “it is what is expected of us,” she said. “We don’t see it as caregiving in the American definition of caregiving.”