Feb.7, 2005

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Ellen Rothman Photo by Graham Ramsay

Failing Elders Weigh Heavily on Reservation Families

Last winter, in the middle of a cold, snowy night, Mary Begay dislocated her shoulder again. The high desert of the Navajo reservation, where I work as a physician, can be frigid with temperatures near zero in the dead of winter. This was her sixth visit to our emergency department for the same issue: She had dislocated her shoulder after lifting a heavy piece of wood to put in her fire.

“I keep telling her not to lift such heavy woods,” her son Peter told me. “But she won’t listen.” His mother’s home was in their family compound, so there was plenty of help during the day. But she slept alone, and there was no one else to tend to her fire at night.

Over the past seven years, I have watched as my own mother and aunts have struggled with my grandmother’s care, transferring her first from my aunt’s home to an assisted-living facility and, finally, to a nursing home this past month. As my mother and she walked into the nursing home, my grandmother asked, “Why are you throwing me away?”

Families often have difficulty acknowledging an elder’s diminishing capabilities. My grandmother had always been the matriarch, holding together our Holocaust-scarred family. Her dementia, insidious and difficult to recognize at first, ultimately made it impossible to keep her at home.

Rural reservation living introduces additional challenges to coping with failing elders. When daily life is so difficult, taking on the additional chores of an aging parent or grandparent can be overwhelming.

Poverty and Poor Health

One afternoon, I decided to pay Mary a visit at home. I pulled in to the rutted driveway of her cinderblock house. There was a small hogan where her son slept, but the next nearest home was more than a mile away. I had passed the last power line when I turned off the highway more than 8 miles previously. A windmill with a water tank that I had passed a few miles up the road suggested that there were no water lines to the homes in this area, either.

“I’ve been looking to fix up the house. We’ve got no running water, no electric,” Peter said. “But… no money.” He shrugged his shoulders. He had the familiar faint, sticky sheen of someone unable to wash regularly.

The stifling heat provided by a wood stove was palpable as I left the cold afternoon outside. Mary was preparing fry bread. The kitchen was haphazard, with mismatched linoleum floor tiles and various containers stacked tidily on every possible surface. A completed puzzle of the Swiss Alps provided the only decoration, glued low on a wall like a picture.

During my short stay, the tiny home swung madly from cloying heat to biting chill as the fire burned down and was stoked again. “I wish we had a pellet stove,” Peter commented. Pellet stoves are the new rage on the rez. Relying on processed wood pellets rather than logs, they relieve hours of chopping and “hauling woods,” as local Navajo refer to the process. “Even though there is plenty of wood out there,” Peter said, gesturing towards the hills and mesas behind his home. “My mom can’t chop anymore. At least I wouldn’t have to do that.”

Down, But Not Yet Out

Tom Cowboy, another elder, arrived in our emergency department one cold afternoon after wandering away from his home. Tom had recently returned to the reservation from the nursing home more than 140 miles away. He wanted mutton and blue corn mush. He wanted his family.

“I just don’t know what to do anymore. I sleep on the floor by his bed so I can tell if he tries to walk away, but he must have stepped over me,” his daughter said.

Institutionalized elder care does not fit the Navajo’s tradition of large extended families. At the same time, Navajo are living longer than they ever have before. With high rates of diabetes, many have complicated care regimens that families struggle to accommodate. When superimposed on the substandard living arrangements, the situation can quickly become untenable.

Our social worker negotiated to readmit Tom to the nursing home he had just quit, over the grumbling of the institution’s staff, when they anticipated a vacancy within a few days.

The day before his bed would become available, I saw Tom and his daughter again in the emergency department. He had wandered from his home again. This time, he was not as lucky. By the time his family found him, he had fallen while climbing a fence, and X-rays revealed he had a broken hip.

— Ellen Rothman, HMS '98, practicing in northern Arizona on the Navajo Reservation

The opinions expressed in this column are not necessarily those of Harvard Medical School, its affiliated institutions, or Harvard University.

Copyright 2005 by the President and Fellows of Harvard College