Dr. Robert N. Butler coined the term ageism in 1968 and spent his career trying to eradicate it. Unfortunately, despite his many accomplishments, “systematic stereotyping and discrimination against people because they are old” still occurs today (Achenbaum, 2013).
The healthcare community is not immune to the deleterious effects of ageism. It permeates the attitudes of medical providers, the mindset of older patients, and the structure of the healthcare system, having a potentially profound influence on the type and amount of care offered, requested, and received.
Ageism Among Healthcare Providers
Adults ages 65 and older see doctors on average twelve times per year, and nearly 80 percent see a primary clinician at least once per year (Davis et al., 2011). These visits represent critical opportunities for providers to promote physical and psychosocial health, and patients expect counseling that is individualized for their functional status, life expectancy, and care preferences. Providers’ knowledge and attitudes about aging can affect how accurately and sensitively they distinguish normal changes associated with aging from acute illness and chronic disease. Ageism can take the form of a provider dismissing treatable pathology as a feature of old age, or treating expected changes of aging as though they were diseases (Kane, Ouslander, and Abrass, 2004).
Ageism among healthcare providers can be explicit or implicit. The geriatrician and writer Dr. Louise Aronson (2015) describes a disturbing example of explicit ageism in which a surgeon asks the medical student observing his case what specialty she is thinking of pursuing. When she answers, “Geriatrics,” the surgeon immediately begins mimicking an older adult complaining about constipation in a high-pitched whine. The attending surgeon had a reputation for being an outstanding teacher, yet repeats this parody throughout the surgical procedure. Another example of explicit ageism involves a respected internal medicine resident flippantly telling her team that she is worried because her patient on morning rounds “looked like this.” The resident closes her eyes and opens her mouth with her tongue protruding off to one side. She then says, “But then I remembered . . . I’m on the geriatrics service.” The resident had made her face into “the Q sign”—a disparaging term, originated in Samuel Shem’s novel The House of God, that describes extremely moribund patients (Shem, 1978).
Sadly, despite the growing need for more providers with geriatrics expertise, many physicians-in-training come to view the care of older adults as frustrating, uninteresting, and less rewarding overall. These negative views likely are influenced by the predominant exposure of medical trainees to hospitalized geriatric patients versus community-dwelling older adults, and by the inherent challenges in caring for medically complex older adults who need extensive care coordination within an increasingly fragmented system (Adelman, Greene, and Ory, 2000).
Trainees’ attitudes are further shaped by the persistent misconceptions that older patients are demented, frail, and somehow unsalvageable. In Higashi and colleagues’ study based on observations of inpatient teams and interviews with students and residents about their experiences caring for elderly patients, a resident said, “It’s always a bigger save when you help a 35-year-old woman with kids than it is to bring an altered 89-year-old with a urinary tract infection back to her semi-altered state” (Higashi et al., 2012).
Dr. Becca Levy (2001) points out that ageism can also operate as implicit thoughts, feelings, and behaviors toward older people that occur without conscious awareness or control. Whether provider ageism is explicit or implicit, it puts older patients at risk for under-treatment and over-treatment. Healthcare providers must also be attentive to unique features of medical encounters with older patients. Older adults may have sensory or cognitive impairments and may be accompanied to the medical encounter by a third person. Clinicians can learn to recognize implicit ageist attitudes and actions, and adopt communication techniques to effectively elicit the patient’s concerns and preferences to provide individualized care.
Potential for under-treatment
Experts in aging often underscore the profound heterogeneity of the elderly population by saying, “If you’ve seen one 85-year-old, you’ve seen one 85-year-old.” Unfortunately, the reported experiences of older adults suggest that healthcare providers remain prone to stereotyping older adults or “applying age-based, group characteristics to an individual, regardless of that individual’s actual personal characteristics” (Macnicol, 2006). In Dr. Erdman Palmore’s Ageism Survey (2001) of community-dwelling older adults ages 60 to 93, 43 percent of respondents reported that “a doctor or nurse assumed my ailments were caused by my age,” and 9 percent said they were “denied medical treatment because of age.”
In a cross-sectional survey design, Davis et al. (2011) used the Expectations Regarding Aging Scale to assess primary care clinicians’ perceptions of aging in the domains of physical health, mental health, and cognitive function. The majority of providers surveyed were physicians, but the sample also included nurse practitioners and physician assistants who serve as primary care providers (PCP). Most PCPs agreed with the statements “Having more aches and pains is an accepted part of aging” (64 percent), and, “The human body is like a car: when it gets old, it gets worn out” (61 percent ). More than half of PCPs (52 percent) agreed that one should expect to become more forgetful with age, and 17 percent agreed “mental slowness” is “impossible to escape.” Few PCPs believed getting older was associated with social isolation (4.8 percent) and loneliness (5.9 percent), but 14.7 percent of respondents agreed with the statement “It’s normal to be depressed with you are old.” One-third of the physicians agreed that increasing age was associated with worrying more and having lower energy levels. These results demonstrate how pain, fatigue, cognitive impairment, depression, and anxiety could easily go undiagnosed and untreated if healthcare providers erroneously attribute these symptoms and conditions solely to advancing age.
Research has shown that pain is consistently under-treated among older adults. Qualitative studies demonstrate that while patients may harbor ageist expectations about the inevitability of pain in older age, their medical providers reinforce these beliefs by dismissing or minimizing back pain. In one study of an ethnically diverse sample of adults ages 65 years and older who had experienced restricting back pain in the last three months, a New York City focus group participant described the following exchange with his doctor: “Look I can’t walk. What am I supposed to do?” He [the doctor] says, “How old are you?” I said, “I’m close to 90.” [The doctor replies] “What do you expect? You’re an old man” (Makris et al., 2015).
Another common ageist misconception among healthcare providers that can affect diagnosis and treatment of patients is that older adults are no longer sexually active. While the prevalence of sexual activity declines with age, 53 percent of 65- to 74-year-olds and 26 percent of 75- to 85-year-olds report having sex with at least one partner in the previous year. Among the 75- to 85-year-olds who are sexually active, more than 50 percent had sex two to three times per month. Among sexually active men and women, more than half suffer from a bothersome problem related to sex, but only 38 percent of men and 22 percent of women have talked to any physician about it (Lindau, 2007). Physicians who are unaware of their older patients’ sexual health and behaviors will fail to address problems like decreased libido and erectile dysfunction, and miss diagnoses of sexually transmitted diseases, including HIV.
Potential for over-treatment
In healthcare settings, age discrimination (Macnicol, 2006) also can result in harmful over-treatment if medical providers offer misguided health recommendations based on chronological age without assessing an individual’s functional status, other comorbid conditions, and preferences.
Given the unsustainable rate of growth in healthcare spending in the United States, health economists and policy experts have focused on over-treatment as a category of waste. According to some estimates, waste accounts for approximately a third of all U.S. health spending, and over-treatment represents $158 to $226 billion of that waste. Examples of over-treatment specific to older patients include universal prostate-specific antigen screening for prostate cancer, which can result in over-diagnosis of benign or slow-growing tumors, excessive treatment with surgery, and unnecessary harms like urinary incontinence following surgery; intensive care at the end of life that is inconsistent with patient preference; and, overuse of tests and procedures lacking evidence of benefit (Berwick and Hackbarth, 2012; Health Affairs, 2012).
In 2012, the American Board of Internal Medicine launched the Choosing Wisely campaign, asking medical specialties to identify commonly used tests and procedures that lack solid proof of benefit and may cause harm. The campaign aims to foster conversations between patients and providers about the necessity of medical tests and treatments. Examples of medications, tests, and procedures that geriatric patients and providers should question include the placement of percutaneous feeding tubes in patients with advanced dementia, the excessive use of diabetes medications that can result in hypoglycemia, the use of harmful sedatives (like benzodiazepines) for insomnia or agitation, and the use of antibiotics for bacterial colonization of the urine, without clinical symptoms or signs of infection (Choosing Wisely, 2015a).
Surgeons also are trying to individualize care to avoid under- and over-treatment. They are incorporating novel assessment tools to help forecast surgical risk and paying attention to both morbidity and mortality. Each year, more than 4 million major operations are performed on geriatric patients ages 65 and older in the United States. To effectively counsel patients and caregivers about the benefits and risks of surgery, physicians must estimate both the perioperative mortality risk of the procedure and the patient’s life expectancy. Both the surgeon and the primary care physician should also understand the older patient’s overall treatment goals and expectations. Known risk factors for surgical mortality include cognitive impairment, functional dependence, malnutrition, frailty, and preoperative institutionalization, but these vary according to how the risk factor is defined, the procedure type, and the clinical setting. For example, cognitively impaired patients (defined as a diagnosis of dementia) undergoing total knee replacement had a 1.8-fold higher risk of 90-day mortality, but a six-fold-increase in one-year mortality following a hip fracture (Oresanya, Lyons, and Finlayson, 2014).
Joseph et al. (2014) studied geriatric trauma patients and found that a measure of frailty was superior to chronological age in predicting in-hospital complications, discharge to a skilled nursing facility, and death. Frailty has been defined as a geriatric syndrome marked by decreased physiologic reserve resulting in increased vulnerability to poor health outcomes in the face of stressors like acute illness, surgery, and hospitalization. The 50-item Frailty Index used by Joseph and colleagues assessed social activity, mood, activities of daily living, and nutrition, in addition to age, comorbidities, and medications. Academic general surgeon Emily Finlayson has focused on characterizing the long-term functional impact of colon cancer and vascular surgery because her clinical experience conflicted with existing data showing older adult patients have only transient and reversible declines in function after surgery. In her study that looked at a national sample of frail nursing home residents ages 65 and older who underwent resection of colon cancer, more than half of the study population had died and 24 percent had sustained functional decline one year after their surgeries (Finlayson, 2012).
Finlayson hypothesizes that the previous research looked at healthier community-dwelling older adults, used self-reported measures of function, and followed participants for six months, as opposed to a year. In a different study, led by Finlayson, of elderly nursing home residents who had surgery to re-establish blood flow to their lower extremities, 51 percent of patients had died at one year and 32 percent sustained functional decline. The functional decline is especially significant given that 75 percent of the participants were not ambulatory prior to the procedure (Oresanya et al., 2015). Finlayson is quick to point out that she does not want her findings to be used to automatically bar geriatric patients or, specifically, nursing home residents from being offered surgery for cancer or for peripheral vascular disease. Her research, and that of Joseph et al., underscores the heterogeneity of the older adult population, the need to incorporate functional measures preoperatively to assess surgical risk, and the importance of studying long-term functional outcomes.
Communication during medical encounters with older patients
Effective communication between the older adult patients and their healthcare providers to elicit individual goals and preferences is one of the keys to avoiding under- or over-treatment. Unfortunately, studies show that providers communicate differently in medical encounters involving older versus younger adults. When Greene et al. (1986) analyzed the content of eighty audiotaped medical visits, physicians provided better questioning, information, and support to younger patients. Doctors were rated as less patient, less engaged, and less egalitarian with their older patients. Also, physicians responded less to the issues raised by older patients, devoting more time to provider-raised topics. Greene and colleagues hypothesized that their findings reflect different power dynamics, where the generation of older adults in their sample were more likely to respect authority. The results might change if the study were repeated today with a cohort from the Baby Boom Generation (Greene et al., 1986).
Communication between healthcare providers and older adults also is more likely to be complicated by sensory deficits, cognitive impairment, functional limitations, and the presence of an accompanying relative or caregiver in the medical visit (Adelman, Greene, and Ory, 2000). With increasing age, there are expected changes in vision, hearing, and memory. Approximately a third of adults ages 65 and older report some hearing loss (Kane, Ouslander, and Abrass, 2004) and a quarter of individuals ages 75 and older have vision impairment (Cassel and Leipzig, 2003). Alzheimer’s dementia affects 8 percent to 15 percent of people ages 65 and older, but the prevalence of dementia doubles every five years until age 85.
Healthcare providers should remember that the presence of sensory and cognitive changes does not necessarily signify functional impairment. Even in patients diagnosed with dementia, the degree and type of cognitive deficits ranges widely. Unfortunately, older patients may encounter healthcare providers who automatically shout or raise their voices when communicating, or worse, ignore them altogether and speak only to a younger person who accompanied them to the visit. Palmore (2001) reported that a third of respondents in his Ageism Survey described encountering providers who assumed they could not hear well or could not understand, and 39 percent felt they were “patronized or talked down to.”
One way healthcare providers unknowingly patronize older adults is to use “elderspeak”—speaking slowly, with exaggerated intonation, elevated pitch and volume, greater repetitions, and simpler vocabulary and grammatical structure. Older adults perceive elderspeak as demeaning and studies show it can result in lower self-esteem, withdrawal from social interactions, and depression, which only reinforce dependency and increase social isolation (Williams, Kemper, and Hummert, 2005). In patients with dementia living in long-term-care settings, elderspeak has been shown to increase resistance to care (Herman and Williams, 2009). Providers can routinely screen older patients for hearing and vision loss and memory impairment, and employ verbal and written communication strategies to ensure patients understand and retain medical information.
In Higashi and colleagues’ (2012) ethnographic study of negative attitudes toward older adults among medical trainees, a medical student and an intern each describe witnessing poor communication occurring because providers assumed an older patient was cognitively impaired. “Sometimes staff talk about their condition in front of them without addressing them,” one student said, and, “People just don’t explain as much to them, they . . . more just reassure and tell them they’re going to be [okay] and don’t explain the details of their illness,” said an intern. Failing to speak directly to the patient can have huge implications for the quality of patient care; clinicians might obtain incomplete or erroneous histories, and provide inadequate patient education.
By some estimates, more than 50 percent of the time a partner, friend, or caregiver accompanies the older adult to medical encounters (Adelman, Greene, and Ory, 2000). While the third person can be helpful for providing history, recording medical information, and advocating for the patient, the presence of another individual also changes the visit dynamic. Greene et al. (1994) compared triadic and dyadic initial visits of adults ages 60 and older to a primary care practice affiliated with a large urban teaching hospital. Patients who were accompanied to their medical visit had poorer functional status and were more likely to require assistance with ambulation.
In the triadic encounters, the patients raised fewer topics across all content areas and raters reviewing transcripts of the encounters rated the patients as less assertive and expressive. The third person present often talked with physicians about the patient instead of with the patient. Doctors and the third parties frequently referred to the older adult as “he” or “she.” Almost 75 percent of the time, the third party answered questions for the patient even when the patient was capable of responding. A third person may believe he or she is being helpful, but if they answer questions for the patient, this could prevent providers from obtaining an accurate history and from recognizing cognitive impairment, depression, and elder abuse. And, a third person can hinder the older adult’s ability to form a close relationship with the physician—a relationship that has been shown to affect adherence, patient satisfaction, and even health status.
Ageism Among Older Adults
Health providers are not the only ones who may harbor or exhibit ageist attitudes. Older adults often possess very negative views of aging, not realizing the potential impact on their health. Older adults who believe pain, fatigue, depressed mood, dependency upon others, and decreased libido are a normal part of aging are less likely to seek healthcare (Sarkisian, Hays, and Mangione, 2002) and therefore are at risk for being under-treated. In one study focusing on depression, older participants who attributed feeling depressed to aging were four times less likely to believe they should discuss the symptom with a doctor (Sarkisian, Lee-Henderson, and Mangione, 2003). Those with low expectations for aging are less likely to engage in physical activity (Sarkisian et al., 2005) and other preventive behaviors like having regular physical examinations, eating a balanced diet, using a seatbelt, exercising, and limiting alcohol and tobacco use (Levy and Myers, 2004). Providers can routinely ask about pain, mood, energy level, functional status, and sexual health, and then educate patients about options for evaluation and treatment.
Not all older adults believe normal changes with aging signal inevitable decline. On a commonly used “Attitudes Toward Own Aging” scale, those with positive attitudes feel they have as much energy now as they did the previous year, are generally as happy now as they were when they were younger, and feel things are better than they expected them to be. Levy and Meyers (2004) found that individuals with these positive self-perceptions are more likely to engage in preventive health behaviors over twenty years. In other long-term studies, positive self-perceptions were associated with better functional health and were more predictive of changes in functional health over time than socioeconomic status, race, self-rated health, and gender (Levy, Slade, and Kasl, 2002.). Levy et al. (2012) found that older persons with positive age stereotypes were 44 percent more likely to fully recover from severe disability than those with negative age stereotypes. Finally, older individuals who held more optimistic views of aging lived 7.5 years longer than those with less positive perceptions of aging (Levy et al., 2002).
While much research focuses on how negative self-perceptions of aging could result in under-reporting and under-treatment, negative views of aging might also lead to over-treatment. The Baby Boom Generation began turning 65 in 2011, and has a reputation for wanting to appear youthful, fearing the aging process, and believing medical technology will allow them to live longer than their parents (AARP, 2011). A baby boomer wanting to prevent or postpone the aging process might be extra vigilant about symptoms and seek out more medical care.
Compared to the cohort of older adults studied by Greene and colleagues (1986), the baby boomers are probably more likely to get their agendas addressed during medical visits because they are perceived as driven, technologically savvy, and not afraid to question authority. To try to limit unnecessary treatments and tests, the American Academy of Family Physicians’ Choosing Wisely List advised doctors to avoid performing the following procedures: imaging tests for low-back pain in the absence of red flags like fever, weight loss, and neurological deficits; annual electrocardiograms for low-risk patients without any cardiac symptoms; and, PAP smears for screening of cervical cancer in women older than age 65 who have had normal PAPs in the past, and do not have any new sexual partners (Choosing Wisely, 2015b).
The Society for General Internal Medicine recommends against annual “health maintenance” visits because they have not been shown to reduce morbidity, mortality, or hospitalization, but instead create potential harm from unnecessary testing (Choosing Wisely, 2015c). Recognizing the need to shift the emphasis from tests and procedures to more functional assessment and counseling, The Centers for Medicare & Medicaid Services (CMS) created an annual wellness visit that reimburses providers for time spent screening for depression and anxiety, assessing functional status and social support, reconciling medications, reviewing vaccines, and discussing other preventive health measures (CMS, 2015).
Ageism in the Healthcare System
Using Butler’s original definition of ageism as “systematic stereotyping and discrimination against people because they are old,” one could argue that the healthcare system discriminates against older adults in several ways. First, the number of doctors with advanced geriatrics training is declining. Second, more physicians are opting out of Medicare. Third, using data from clinical trials and the recommendations from clinical practice guidelines is problematic when caring for older adults with multiple chronic illnesses because they are often excluded from the study populations.
By 2030, one in five Americans will be age 65 or older. There will be 61 million “young-old” (ages 65 to 84) and 9 million “old-old” (ages 85 and older). Unfortunately, as the demand for providers with geriatrics expertise increases, the physician supply remains inadequate. Currently, there are approximately 7,300 certified geriatricians but only 50 percent of fellowship-trained geriatricians are recertifying (Bragg et al., 2012). While the number of geriatrics fellowship positions has increased slightly from 430 to 455 over the last three years, the number of slots filled has remained around 300 or less (ADGAP, 2015).
More geriatricians are needed for direct patient care but they also are needed in academic environments to teach medical trainees and inspire them to choose careers in geriatrics, to conduct aging research, and to pioneer new models of care. From 2005 to 2010, the number of full-time geriatric medicine physician faculty and research faculty increased from 1,690 to 2,008. Yet in 2010, only half of all medical schools had nine or more full-time faculty engaged in education, research, and clinical care—the estimated minimum number needed to develop and maintain an effective medical school geriatrics curricula (Bragg et al., 2012).
Compounding the shortage of geriatricians, more doctors may be closing their practices to patients with Medicare because of frustration with declining reimbursement rates and increasing requirements like the use of electronic health records. Bishop, Federman, and Keyhani (2011) analyzed data from a national survey of physicians working in non–federally funded, non–hospital-based office practices, and found that physician acceptance of new Medicare patients only declined from 95.5 percent in 2005 to 92.9 percent in 2008. Data released by the CMS confirm that the percentage of physicians opting out remains small, but the absolute number increased 250 percent, from 3,700 doctors in 2009 to 9,539 in 2012 (Beck, 2013). Doctors may be limiting the number of Medicare patients in their practices even if they do not opt out completely. Patients who live in wealthier urban and suburban areas may have difficulty finding a Medicare provider, or face long wait times for appointments because other patients in the area are willing and able to pay out of pocket.
The final example of ageism in the healthcare system concerns the inadequacy of single disease clinical practice guidelines (CPG) and the exclusion of older adults with multiple chronic illnesses from the trials that are used to generate these guidelines. Twenty percent of Medicare beneficiaries have five or more chronic illnesses (Tinetti, Bogardus, and Agostini, 2004). In one year, these individuals have an average of fifty prescriptions filled, see fourteen different physicians, and make thirty-seven office visits, putting them at risk for adverse drug events, conflicting medical advice, and duplicate tests (Benjamin, 2010). The majority of CPGs have no specific recommendations for patients with more than one chronic illness, so clinicians try to combine several disease-specific CPGs, increasing the risk of adverse drug events and disease−disease interactions. Boyd et al. (2005) analyzed fifteen CPGs representing the most common chronic diseases managed by primary care providers such as heart failure, atrial fibrillation, diabetes mellitus, osteoarthritis, and chronic obstructive pulmonary disease (COPD). Most of the CPGs reviewed did not modify suggestions for older adults with multi-morbidity, discuss the quality of the evidence underlying recommendations, or advise incorporation of patient preferences and life expectancy into treatment plans. When Boyd and colleagues applied the relevant CPGs to a hypothetical 79-year-old woman with COPD, diabetes, osteoporosis, hypertension, and osteoarthritis, they found she would be advised to take twelve medications requiring nineteen doses per day, and to do fourteen non-pharmacologic activities, such as weight-bearing exercise and diabetes self-management. Of note, in 2007, the American Heart Association published a two-part series with age-specific practice guidelines for “Acute Coronary Care in the Elderly” (Alexander et al., 2007). This follows previous research demonstrating older patients with unstable angina, acute congestive heart failure, and acute myocardial infarction were less likely to receive standard life-saving therapies (Giugliano et al., 1998).
Older adults with multiple comorbidities and cognitive or functional impairment are generally excluded from the randomized controlled trials that eventually form the basis of clinical practice guidelines. The trials often use restrictive admission criteria to maximize the accuracy of the results for the target population, but at the expense of being able to generalize the results to other patients. If the health needs of older adults are not being addressed in the CPGs and are not part of the evidence used to generate these guidelines, then physicians may not be able to extrapolate CPG recommendations. Cox and colleagues (2011) conducted a descriptive analysis of fourteen CPGs. Twelve provide specific recommendations for individuals ages 65 and older, but only five guidelines gave recommendations for frail elderly ages 80 and older. Approximately 2,200 of the 2,500 studies used to create the clinical practice guidelines had information about the mean participant age. Only thirty-one of the 2,200 studies had an average participant age of 80 and older, representing 1.4 percent of the total number of studies (Cox et al., 2011).
Lewis et al. (2003) looked specifically at cancer clinical trials and found that although 61 percent of new cancer diagnoses (and 70 percent of cancer deaths) occur in older adults, they continue to make up a minority of trial participants. Using National Cancer Institute data with characteristics for 59,300 patients across 495 trials, they found that older adults were included in more in trials for late-stage cancers (41 percent of participants) versus early-stage cancers (25 percent). While less than 1 percent of all trials had age cut-offs, older adults were commonly excluded from participation based on lab abnormalities (hematologic, hepatic, renal), cardiac conditions, and functional status. More than 80 percent of the cancer trials required participants be ambulatory, capable of working, or independent in activities of daily living. Interestingly, only 3 percent of trials specifically excluded patients with Alzheimer’s Disease, but 16 percent did have exclusion criteria for other psychiatric conditions.
While ageism unfortunately still exists among the attitudes of health providers, older adults and the healthcare system itself, there are numerous interventions underway that should begin to mitigate it.
Encouraging non-ageist attitudes among healthcare providers requires that they learn to recognize and appreciate the heterogeneity of older adults. This will happen when medical trainees gain exposure to older adults outside the hospital, so ageism does not become “an occupational hazard of the health profession” (Greene, 1986). Geriatrics education also needs to be a required part of the medical school curriculum because the majority of students will go on to care for older adults whether they end up in surgical or medical specialties. The Institute of Medicine’s report, Retooling for an Aging America, called for more universal geriatric education among health professionals in 2008 (Leipzig, 2009). However, while 85 percent of medical schools offer a geriatrics elective experience, only 27 percent of medical schools require geriatrics rotations during the clerkship years (Bragg et al., 2012). Meanwhile, medical students complete required clinical rotations in pediatrics and obstetrics even though most will never care for children or pregnant woman after they graduate. Minimum geriatrics competencies already exist and recommend that every medical student upon graduation possess the ability to safely prescribe medications, assess functional status, and make clinical decisions based on elderly patients’ prognosis and personal preferences (Leipzig, 2009). More medical schools have begun to incorporate longitudinal curricula where trainees are paired with patients over years in order to witness patient experience first-hand, and begin to understand the challenges in navigating the healthcare system.
Older adults can change their self-perceptions of aging, but ageist stereotypes are both pervasive in American culture and harmful to the physical and psychological well-being of older adults. The demographic changes that will result in one in five Americans being age 65 or older in 2030 likely will not be sufficient. Strategies for reducing ageism will require targeted educational and media campaigns like the successful AARP campaign to increase physical activity among older adults, which included an intensive consumer market research plan based on data combined from three national surveys, focus groups, and in-depth one-on-one interviews to identify opportunities and barriers to change behaviors at the individual and community levels (Ory et al., 2003).
Geriatrics as a field and profession has already started to rebrand itself and will need to use some of the same strategies as AARP. To foster positive attitudes toward aging, older adults need something akin to the “What to Expect” series for pregnant mothers, or the standard anticipatory guidance counseling that is embedded in each well child visit. However, given the power and persistence of negative attitudes, it might be best to have a “What Not to Expect” guide to aging to dispel harmful assumptions that depression, social isolation, dementia, pain, and fatigue are part and parcel of getting older. Such a guide, if created by multi-disciplinary experts in aging and embedded into routine office visits, could also offer practical advice on distinguishing normal from abnormal aging, promoting and maintaining physical and cognitive function, and navigating the healthcare system.
Eradicating ageism within the healthcare system will require more substantial changes. Creating funding for geriatrics fellows to pursue a second year of training for educational or clinical research, and improving reimbursement for practicing geriatricians will help support academic departments and divisions, perhaps fueling a better pipeline of highly qualified trainees who have an genuine interest in caring for older adults. To address the shortage of qualified geriatrics providers, more nurse practitioners and physician assistants should be encouraged to obtain geriatrics training and certification. Geriatrics educators can also look to form partnerships within their medical departments with colleagues in cardiology, oncology, and nephrology, and should collaborate with the general and specialist surgeons as well so that the trainees in these fields and the patients benefit from the dual expertise. Finally, it is imperative to begin including older adults in clinical trials that go on to form the basis of clinical practice guidelines.
Karin M. Ouchida, M.D., is Joachim Silbermann Family Clinical Scholar in Geriatrics at Weill Cornell Medical College in New York City, assistant professor of Medicine at the College, and the program director for the Cornell Geriatrics Fellowship at New York–Presbyterian Hospital. Mark S. Lachs, M.D., is the Irene F. and I. Roy Psaty Distinguished Professor of Clinical Medicine and professor of medicine at Weill Cornell.
Editor’s Note: This article is taken from the Fall 2015 issue of ASA’s quarterly journal, Generations, an issue devoted to the topic “Ageism in America: Reframing the Issues and Impact.” ASA members receive Generations as a membership benefit; non-members may purchase subscriptions or single copies of issues at our online store. Full digital access to current and back issues of Generations is also available to ASA members and Generations subscribers at Ingenta Connect. For details, click here.
AARP. 2011. “Poll: Perceptions of Boomers; What Are the Beliefs Held About the Baby Boom Generation?” Retrieved July 27, 2015.
Achenbaum, W. A. 2013. “Robert N. Butler, M.D. (January 21, 1927–July 4, 2010): Visionary Leader.” The Gerontologist 54: 6–12.
Adelman, R. D., Greene, M. G., and Ory, M. G. 2000. “Communication Between Older Patients and Their Physicians.” Clinical Geriatric Medicine 16: 1–24.
ADGAP. 2015. “2015 Match Data Presentation.”Retrieved July 28, 2015.
Alexander, K. P., et al. 2007. “Acute Coronary Care in the Elderly, Part 1: Non-ST Segment Elevation Acute Coronary Syndromes.” Circulation 115: 2549–69.
Aronson, L. 2015. “The Human Lifecycle’s Neglected Stepchild.” The Lancet 385(9967): 500–1.
Beck, M. 2013. “More Doctors Steer Clear of Medicare.” The Wall Street Journal, July 29. Retrieved July 28, 2015.
Benjamin, R. M. 2010. “Surgeon General’s Perspectives. Multiple Chronic Conditions: A Public Health Challenge.” Public Health Reports (125) September−October.
Berwick, D. M., and Hackbarth, A. D. 2012. “Eliminating Waste in U.S. Health Care.” Journal of the American Medical Association (JAMA) 307(14): 1513–6.
Bishop, T. F., Federman, A. D., and Keyhani, S. 2011. “Declines in Physician Acceptance of Medicare and Private Coverage.” Archives of Internal Medicine 171(12): 1117–19.
Boyd, C. M., et al. 2005. “Clinical Practice Guidelines and Quality of Care for Older Patients with Multiple Comorbid Diseases: Implications for Pay for Performance.” JAMA 294(6): 716–24.
Bragg, E. J., et al. 2012. “The Development of Academic Geriatric Medicine in the United States from 2005 to 2010: An Essential Resource for Improving the Medical Care of Older Adults.” Journal of the American Geriatrics Society 60: 15405.
Cassel, C. K., and Leipzig, R. M., eds. 2003. Geriatric Medicine: An Evidence-Based Approach (4th ed.). New York: Springer.
Choosing Wisely. 2015b. “American Academic of Family Physicians: Fifteen Things Physicians and Patients Should Question.” Retrieved July 27, 2015.
Choosing Wisely. 2015c. “Society for General Internal Medicine: Five Things Physicians and Patients Should Question.” Retrieved July 27, 2015.
Cox, L., et al. 2011. “Underrepresentation of Individuals 80 years of Age and Older in Chronic Disease Clinical Practice Guidelines.” Canadian Family Physician 57: 263–9.
Davis, M., et al. 2011. “Primary Care Clinician Expectations Regarding Aging.” The Gerontologist 51(6): 856–66.
Finlayson, E., et al. 2012. “Functional Status After Colon Cancer Surgery in Elderly Nursing Home Residents.” Journal of the American Geriatrics Society 60: 967−73.
Greene, M. G., et al. 1986. “Ageism in the Medical Encounter: An Exploratory Study of the Doctor−Elderly Patient Relationship.” Language & Communication 6(1/2): 113–24.
Greene, M. G., et al. 1994. “The Effects of the Presence of a Third Person on the Physician−Older Patient Medical Interview.” Journal of the American Geriatrics Society 42(4): 413–9.
Giugliano, R. P., et al. 1998. “Elderly Patients Receive Less Aggressive Medical and Invasive Management of Unstable Angina: Potential Impact of Practice Guidelines.” Archives of Internal Medicine 158(10): 1113–20.
Centers for Medicare & Medicaid Services (CMS). 2015. “The ABCs of the Annual Wellness Visit.” Retrieved July 27, 2015.
Choosing Wisely. 2015a. “American Geriatrics Society: Ten Things Physicians and Patients Should Question.” Retrieved July 14, 2015.
Health Affairs. 2012. “Health Policy Brief: Reducing Waste in Health Care.” December 13. Retrieved August 12, 2015.
Herman, R. E., and Williams, K. N. 2009. “Elderspeak’s Influence on Resistiveness to Care: Focus on Behavioral Events.” American Journal of Alzheimer’s Disease and Other Dementias 24(5): 417−23.
Higashi, R., et al. 2012. “Elder Care as ‘Frustrating’ and ‘Boring’: Understanding the Persistence of Negative Attitudes Towards Older Patients Among Physicians-in-Training.” Journal of Aging Studies 26(4): 476–83.
Joseph, B., et al. 2014. “Superiority of Frailty Over Age in Predicting Outcomes Among Geriatric Trauma Patients: A Prospective Analysis.” JAMA Surgery 149(8): 766–72.
Kane, R. L., Ouslander, J. G., and Abrass, I. B., eds. 2004. Essentials of Clinical Geriatrics (5th ed.) New York: The McGraw-Hill Companies, Inc.
Leipzig, R. 2009. “The Patients Doctors Don’t Know.” The New York Times, July 1. Retrieved August 12, 2015.
Levy, B. R. 2001. “Eradication of Ageism Requires Addressing the Enemy Within.” The Gerontologist 41(5): 578–9.
Levy, B. R., and Myers, L. M. 2004. “Preventive Health Behaviors Influenced by Self-perceptions of Aging.” Preventive Medicine 39(3): 625–9.
Levy, B. R., Slade, M. D., and Kasl, S. V. 2002. “Longitudinal Benefit of Positive Self-perceptions of Aging on Functional Health.” Journals of Gerontology, Series B: Psychological Sciences and Social Sciences 57: 409–17.
Levy, B. R., et al. 2002. “Longevity Increased by Positive Self-perceptions of Aging.” Journal of Personality and Social Psychology 83(2): 261–70.
Levy, B. R., et al. 2012. “Association Between Positive Age Stereotypes and Recovery from Disability in Older Persons.” JAMA 308(19): 1972–3.
Lewis, J. H., et al. 2003. “Participation of Patients 65 Years of Age or Older in Cancer Clinical Trials.” Journal of Clinical Oncology 21(7): 1383–9.
Lindau, S. T., et al. 2007. “A Study of Sexuality and Health Among Older Adults in the United States.” New England Journal of Medicine 357(8): 762−74.
Macnicol, J. 2006. Age Discrimination: A Historical and Contemporary Analysis. New York: Cambridge University Press.
Makris, U. E., et al. 2015. “Ageism, Negative Attitudes, and Competing Comorbidities—Why Older Adults May Not Seek Care for Restricting Back Pain: A Qualitative Study.” BMC Geriatrics 15(39): 1−9.
Oresanya, L. B., Lyons W. L., and Finlayson, E. 2014. “Preoperative Assessment of the Older Patient: A Narrative Review.” JAMA 311(20): 2110–20.
Oresanya, L. , et al. 2015. “Functional Outcomes After Lower Extremity Revascularization in Nursing Home Residents: A National Cohort Study.” JAMA Internal Medicine 176(6): 951−7.
Ory, M., et al. 2003. “Challenging Aging Stereotypes: Strategies for Creating a More Active Society.” American Journal of Preventive Medicine 25(3Siii): 164−71.
Palmore, E. 2001. “The Ageism Survey: First Findings.” The Gerontologist 41(5): 572–5.
Sarkisian, C. A., Hays, R. D., and Mangione, C. M. 2002. “Do Older Adults Expect to Age Successfully? The Association Between Expectations Regarding Aging and Beliefs Regarding Healthcare-seeking Among Older Adults.” Journal of the American Geriatrics Society 50(11): 1837–43.
Sarkisian, C. A., Lee-Henderson, M. H., and Mangione, C. M. 2003. “Do Depressed Older Adults Who Attribute Depression to ‘Old Age’ Believe It Is Important to Seek Care?” Journal of General Internal Medicine 18(12): 1001–5.
Sarkisian, C. A., et al., 2005. “The Relationship Between Expectations for Aging and Physical Activity Among Older Adults.” Journal of General Internal Medicine 20(10): 911–15.
Shem, S. 1978. The House of God. New York: Dell Publishing.
Tinetti, M. E., Bogardus S. T., and Agostini, J. V. 2004. “Potential Pitfalls of Disease-specific Guidelines for Patients with Multiple Conditions.” New England Journal of Medicine 351(27): 2870–4.
Williams, K., Kemper, S., and Hummert, M. L. 2005. “Enhancing Communication with Older Adults: Overcoming Elderspeak.” Journal of Psychosocial Nursing Mental Health Services 43(5): 12–6.
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