by Malak Abou Raya

Let’s start with a scenario: an 80-year-old woman walks into your office complaining of fatigue. What is the first thing that comes to your mind?

There is an important rule about our brains that we should all be aware of and that is they like to take shortcuts. This includes relying on stereotypes and biases to form conclusions within a fast-paced environment which helps the brain conserve energy and redirect it to what is perceived to be more important tasks. Our brain’s inclination to jump to conclusions isn’t always harmful, however, it poses a real risk to patients in the context of healthcare especially when that involves not listening to a patient or not prioritizing their comfort.

There are, of course, a multitude of biases and stereotypes that we rely on to make decisions, but one of the least mentioned and most socially acceptable of those is age discrimination.

Introduction to Age Discrimination

According to the World Health Organization (WHO), age discrimination is defined as the “stereotypes (how we think), prejudice (how we feel), and discrimination (how we act) towards others or oneself based on age.”

There are lots of terms that can be used to describe age discrimination, but perhaps the most common of those is ageism, which is actually commonly used in reference to age discrimination against older persons. Ageism has been understood to be more of a general term for all kinds of age discrimination acts, but because of its close ties to discrimination against older adults, new terms have been coined for age discrimination against younger people. The most accurate of those terms is adultism which represents an accurate depiction of the oppression faced by children and young people because of an adult-oriented world.

For the sake of clarity, “ageism” and “age discrimination” will be used in reference to age discrimination in general, and “adultism” will be used in reference to age discrimination against younger people.

Despite being an issue faced by all age groups at some point in their lives, ageism is more socially acceptable than other forms of discrimination like sexism, racism, or ableism. In our present, fast-paced world, the ability to reach a conclusion or make a decision quickly has become more important than ever. That is why, unconscious stereotypes and biases that society enforces upon us are appealing shortcuts for our brains. For example, in our earlier scenario, if an 80-year-old woman walked into your office complaining of fatigue, you would unconsciously conclude that this was a normal part of aging. Likewise, if a 10-year-old child walks in with a parent complaining of memory loss, you might not consider the possibility of a condition like childhood dementia because it is so unlikely for a 10-year-old child to have a disease meant for a 70-year-old.

Age discrimination has three types:

Institutionalized age discrimination
Interpersonal age discrimination
Self-directed age discrimination

Institutionalized age discrimination refers to the laws, rules, polices, and even societal norms that place unfair constraints on a particular age group. Interpersonal age discrimination happens in interactions among people, or to make it relevant to our topic, between healthcare professionals and patients. Finally, self-directed age discrimination occurs when an individual starts to internalize age-discriminatory attitudes and stereotypes, which may lead an individual to restrain themselves from pursuing new opportunities, speaking their mind, etc.

“The first step in solving a problem is recognizing there is one.”

—Will McAvoy

Manifestations of Ageism and Adultism in Healthcare

The groups of people most affected by ageism are women and people of different ethnicities, lower education, and lower socioeconomic status.

There are a multitude of scenarios in which we could unconsciously make our patients feel patronized and dismissed. Some of these are well-intentioned (like elderspeak) and others that are normalized in our societies like telling jokes at the expense of an older person or not taking a younger person seriously. We cannot address every manifestation of ageism in one article for that will require extensive research that is beyond our scope. However, what we can do is talk about the most common of these scenarios and their dangers so that future healthcare professionals are aware of them.

Common manifestations include:

Attributing symptoms to “getting old”
Elderspeak
Assuming all older people are the same
Excluding a disease without evidence
Assuming a patient can’t make their own health-related decisions

1. Attributing Symptoms to “Getting Old”

The aging process is complicated and, as we will discuss, different from person to person, but that doesn’t negate the fact that the likelihood of diseases significantly increases in older persons. These diseases are by no means a part of the normal process of aging and they should be treated and taken as seriously as they would be in younger patients.

Going back to our example at the start of this post, if an 80-year-old woman complained of lower energy levels than usual, she wouldn’t be taken as seriously as a 30-year-old complaining of the same issue. Similarly, the concern of an older person around the same age complaining of blurred vision might be dismissed and a treatable condition like presbyopia could be missed.

2. Elderspeak

Elderspeak is defined as a form of communication in which the rhythm, sound, sentence structure, and meaning of speech are inappropriately simplified so that it sounds like baby talk. It is also characterized by a high-pitched and overnurturing voice, use of terms of endearment like “sweetie”, and a collective pronoun substitution for example, using “we” instead of “you”.

Many health professionals believe that using this form of speech helps with the expression of care, facilitating comprehension, and overall, nurturing for older patients, but that isn’t true. Studies have shown that this form of communication can be detrimental to patients’ self-perception and negatively impacts treatment in patients suffering from dementia which in turn advances the behavioral and psychological symptoms of the disease. It is very common for patients with dementia to resist care and treatment and that is why, communication techniques are a very important factor in facilitating care (more on that later).

The use of elderspeak is unconsciously triggered depending on the level of the patient’s dependency on a nurse assistant, age, cognitive impairment, wheelchair bound, etc. There are two dimensions of elderspeak: warmth and superiority. The perceived degrees of these two influences whether the patient’s experience with elderspeak is positive or negative. It is however generally recommended to replace elderspeak with better and more reliable communication methods.

3. Assuming all Older People are the Same

One of the misconceptions we have about aging is that all older people go through the same mental and physical decline, which is inaccurate. Some also assume that in our contemporary world, 70 is the new 60, which is also incorrect.

There are many factors that affect the progression of aging from genetics to environmental factors to exercise. Based on these factors, some can lose their physical and mental capabilities faster or slower than others so that a 70-year-old can have the same mental abilities as a typical 30-year-old, while others may go through the mental decline earlier than their peers. There are many varieties among older people and a part of our jobs is respecting and taking that into account when treating them.

Older age is characterized by a higher risk of developing diseases such as cardiovascular disease, cancers, neurological disorders, and so on. That is why it is not accurate to assume that 70-year-olds’ bodies today are ten years younger than they were before. Even though contemporary medicine has significantly increased the likelihood of living past our fifties, organ systems still deteriorate faster as we age. Some might go through that deterioration at a different pace, but that still doesn’t make 70 the new 60.

4. Excluding a Disease Without Evidence

It is generally advised to suspect common health problems first, but once those are eliminated, a healthcare professional has to be open to other diagnoses, especially if those options are more dangerous.

In our earlier example about the 10-year-old patient with the memory issues, what would a healthcare professional’s first thought be? Would among those options be childhood amnesia? What if the doctor ends up prescribing supplements and the patient keeps coming back with more complaints? Would the doctor consider a different diagnosis then or would they remain stuck in their tunnel-vision view of the patient’s condition and remain convinced that the issue is benign?

5. Assuming a Patient Can’t Make Their Own Health-Related Decisions

Some healthcare professionals, while attending to patients who are either younger or older, might wrongly assume that these patients are incapable of making their own health-related decisions. In the case of an older person, a healthcare professional might conclude that due to their mental and physical decline, the older adult might feel burdened with the decision or that they are completely incapable of choosing a treatment for themselves.

For a child (16 or younger) however, it is natural to assume they can’t make a decision and the majority of children naturally wouldn’t have the necessary decision-making capacity, unless they are believed to have enough intelligence, competence, and understanding to decide on their own in the absence of a guardian. People aged 16 or over, no matter how young or naive they look, a healthcare professional should assume they are capable of refusing or accepting treatment and therefore must address them directly.

In summary, unless the patient is a child or their mind is impaired, addressing a family member would be an unnecessary and demeaning measure.

Consequences of Age Discrimination in Healthcare

A holistic approach to medicine is an ideal all medical professionals are trying to achieve with the end goal of treating the patient as a whole, mind, body, and spirit included. On the other hand, ageism threatens to reduce everyone to stereotypes based on their age which completely contradicts the goal of the holistic approach to medicine.

Despite being widely debated, there are couple of consequences most studies agree on:

Impact on patients’ mental health
Compromised care and misdiagnosis
Inaccuracy in clinical results
Economical impacts

1. Impact on Patients’ Mental Health

The most common effect age discrimination has on psychological well-being is depression, but it has also been associated with unhealthy diet, excessive drinking or smoking, stress, anxiety, lowered life satisfaction, and even a shorter lifespan. Curiously, it has been found that the mental health impacts are minimal if an individual didn’t already have internalized self-directed ageist beliefs. However, many older adults are inclined to internalize ageist beliefs and stereotypes that society forces on them, thus falling into the unhealthy patterns we mentioned earlier.

Ageism alone wasn’t directly linked to mental disorders in younger populations, however, when it was combined with other types of discrimination like skin color, race, and class, it became associated with common mental disorders. Additionally, in individuals with lower education, ageist beliefs regarding memory capacity affected their memory performance.

For patients with dementia, elderspeak (that is the use of baby talk with older patients) can lead to not just depression, but also increased emotional outbursts, verbal and physical aggression, and communication block or withdrawal. It might also trigger negative vocalizations like loud speaking, screaming, yelling, and crying and all of that will hinder care in a nursing home.

2. Compromised Care and Misdiagnosis

As we age, the overall incidence of disease increases, but that doesn’t make diseases a symptom of aging. Dismissing a patient’s complaint as a normal part of aging without conducting the proper tests to exclude the most dangerous conditions wouldn’t just feed the patient’s self-directed age-based stereotypes, but it would also greatly impact their care. This delay in diagnosis and treatment can make a previously manageable disease much worse than it could have been.

3. Inaccuracy in Clinical Results

Getting old increases the likelihood of diseases like heart disease, dementia, arthritis, cancer, etc. but older people are often excluded from clinical trials (especially pharmacology studies) of these very diseases. And even when they are included, older people are often lumped together into one age group like “60 and older” and that neglects the variety within the “older adults” age group.

Researchers prefer younger volunteers because of the comorbidities and polypharmacy common in old age which might skew the results. Older people are also perceived to be frail and if they suddenly suffer complications, it could be attributed to many factors and not necessarily the variable being studied. All these factors make the health of older people more unpredictable which means that a larger sample size (thus increased funding) has to be used to gain statistically accurate insights. This defect in the representation of older age groups makes it harder to gauge the benefits of the drugs because the benefits observed in younger people might not reliably translate into benefits in older patients.

It has been found that older people have been excluded from 49% of Parkinson’s disease clinical trials despite this disease being more prevalent as we age. Older people are also excluded from trials in cardiology, internalized medicine, nephrology, neurology, preventive medicine, psychiatry, rheumatology, oncology, and urology.

4. Economic Impacts

Almost all the points we discussed so far will lead to more expenses. For example, impacts on patients’ mental health will make it harder for them to seek professional help when they notice a benign issue. The delay of diagnosis and treatment might aggravate the previously benign condition which will inevitably cause increased expenses for the treatment. Delaying the diagnosis and treatment or misdiagnosis by the healthcare professionals themselves will also lead to the same effect.

Last but not least, with the inaccurate results of research efforts and the under-representation of older age groups, prescribing a drug or treatment plan for older adults will be difficult. Thus, further research on other drug options that are safer to use with specific combinations of drugs and conditions will be unavoidable.

Even once the treatment regimen starts, because of the psychological effects of ageism, the patient themselves might refuse to take the medicine. This issue is especially apparent in dementia patients in nursing homes with the usage of elderspeak.

It has even been estimated that because of ageism the United States spent an approximate number of 63 billion dollars on the eight most expensive conditions.

Taking Action: Making the World a Better Place for all Ages

Aging is often a very challenging process in which the body goes through many changes which might lead to older people losing their self-esteem. As future or current healthcare providers, we have to ensure that our older populations understand they aren’t a burden on society and help them see the positive aspects of their aging process. It is also important to ensure the younger populations aren’t feeling left out of society because of their young age and its associated stereotypes.

Here is what we can do based on the type of age discrimination discussed earlier:

Increased Research Initiatives (Institutionalized)
Policies and Laws (Institutionalized)
Increasing intergenerational contact (Interpersonal)
Development of good communication techniques (Interpersonal)
Identifying the biases that affect our judgments (Interpersonal)
Interventions for self-directed age discrimination
More anti-ageism tactics

“The problem is not that we have a problem. It’s a problem if we don’t deal with the problem.”

—Mary Kay Utech

Interventions Against Institutional Age Discrimination

1. Increased Research Initiatives

As with any other problem facing us in the healthcare community, we have to first conduct evidence-based research to understand all its different facets. Despite being a prevalent issue, there are many gaps in our knowledge and an especially problematic lack of research on ageism in younger populations.

It seems like the entire field of adultism resulted as a consequence of studies of ageism on older persons. Most of our knowledge of the topic actually came from studies that focus on older age groups as their primary focus with younger persons as a comparison group.

Additionally, a systematic review reported that only 8.6% of the studies examined were conducted in underdeveloped countries despite 92.7% of health associations related to age discrimination being significant there. This also shows that more research is needed in underdeveloped countries.

Moreover, additional research is needed on the psychological effects of ageism and how it interacts with other forms of discrimination as well as the various manifestations of ageism in everyday life. Studies should also look into the relationship between the three types of ageism, and find a way to measure ageism as it is a very subjective matter.

Studies have found that young people were rated more favorably than older adults but despite that, adolescents are seen as more impulsive, rebellious, and undisciplined. Younger people also felt looked down on during interpersonal interactions with older adults.

2. Policies and Laws

This is a very essential and unavoidable step to combat institutionalized ageism. First of all, the education of younger populations about aging in a non-biased fashion and increasing the discussion of ageism should be an immediate first step after research. However, the steps of education and research can work in a positive feedback loop where more education can generate more research and more research will encourage more education, and so on.

Furthermore, there should be a stronger legal framework to prevent direct age-based discrimination, like the unfair denial of treatment based on age. And, for proper representation of older adults in clinical trials, there has to be a national or supranational legislation that demands proof of a treatment’s effectiveness in the population most likely to need it before a license is provided. There should also be more funding available for larger samples, transportation, and nurses and geriatricians to ensure maximum care of volunteers.

Interventions Against Interpersonal Age Discrimination

3. Increasing Intergenerational Contact

During the care of older patients, nursing professionals are especially important because their attitudes, behaviors, and knowledge represent the quality of care. However, nurses’ ageist beliefs can influence their interactions with older patients.

In a systematic review, the opinions of nursing students on older people were assessed and it was found that nursing graduates had more positive attitudes towards older patients than undergraduates. This has been attributed to the fact that with increased practice and interaction with older patients, ageist beliefs and attitudes typically decrease. Other studies showed that both younger and older age groups interact with each other based on stereotypes and increased intergenerational contact decreases the reliance on negative biases and stereotypes. Instead, it fosters communication, respect, and understanding between generations.

4. Development of Good Communication Techniques

For older patients, especially those suffering from dementia, resistance to care and treatment is very common. The feelings of frustration and inability to communicate with these patients are understandable, and the health caregiver might decide to convert to elderspeak (or baby talk), thinking that it will lead to a better outcome. This well-intentioned approach from many healthcare providers can decrease the responsiveness to treatment and that will consequently exacerbate the symptoms of dementia.

For this reason, scientists developed “Communication Enhancement” models to understand individual patients’ needs and enhance communication skills. It is important to note that an improvement in communication may not directly decrease the neuropsychiatric symptoms in dementia patients, but it has much better results than elderspeak and has the potential to improve the quality of care.

An effective communication strategy for patients with Alzheimer’s disease includes the usage of short and syntactically simple sentences, removal of environmental distractions, usage of closed-ended questions, addition of more information, paying personal attention to the patient’s needs, and usage of supportive speaking.

5. Identifying the Biases That Affect Our Judgments

In Thinking Fast and Slow, the late author Daniel Kahneman explains the two systems our minds use to think: the impulsive, intuitive, spontaneous System 1, and the analytical, cautious, evidence-based System 2. Kahneman explains that System 1 has evolved to save us from predators and other dangers before our conscious brain becomes aware of it. This intuitive system of thinking isn’t inherently bad or inaccurate. Rather, it detects patterns it had previously seen and makes a quick decision based on that rather than relying on the much slower system 2 which wouldn’t be useful in high-stress situations where reflexive decisions are necessary.

On the other hand, because some patterns might be inaccurate, System 2 is also necessary. In the context of healthcare, when there is uncertainty (this means we are faced with a new situation, System 1 can’t recognize the pattern, and thus can’t predict the likelihood of a future event), our logical, evidence-based system kicks in. That is why, uncertainty is what determines when our evidence-based system works. Problems then start to arise when the patterns System 1 relies on are based on inaccurate biases like “exercise is harmful for older people” or “younger people are reckless and can’t make their own decisions” without triggering uncertainty.

It is important for the vitality of our patients that we recognize that, despite what we might think, each and every one of us has a bias of some sort. This isn’t an admission of defeat or failure. It is simply an admission of being a human who is prone to human error. What we can’t do as health professionals, however, is ignore these biases under the assumption that we are less biased than others. It is important to face, understand, and learn to recognize these errors in our thoughts before making a decision that could inadvertently affect someone’s life.

6. Interventions Against Self-Directed Age Discrimination

While we need to act on institutionalized and interpersonal age discrimination, it is also essential that we don’t forget about the significance of self-directed ageism. It is impossible to ensure that patients will never face ageism, so helping them cope with the unfortunate but very likely event will protect them from most of the negative impacts of ageism in the future.

These are a couple of interventions that have been proven to decrease the detrimental effects of ageism in patients with internalized ageist beliefs:

Age group identification: Increasing individuals’ pride in their respective age group.
Emotional reactions: Decreasing or managing overall negative emotional reactions like sadness, anger, shame, etc.
Self-perception of aging and purpose of life: Fostering positive views of the aging process and the future.
Body esteem: Fostering a positive view of individuals’ bodies and appearance.
Flexible goal adjustment (FGA): Increasing flexibility in setting goals when faced with obstacles or challenges.

7. More Anti-Ageism Tactics

Direct debiasing by explicitly warning against ageism
Don’t assume an older adult’s life is devoid of meaningful activities
Don’t assume older adults wouldn’t understand their disease or treatment plans
Avoid labels like “elderly”, “Gen Z-ers”, or “boomers”
Ensure technological availability to all ages

Conclusion

Ageism has numerous manifestations and as a result, there are a multitude of different tactics to combat it, but perhaps the most potent of those is changing our thinking models. This way, we wouldn’t just be challenging ageism, but all forms of discrimination. If there should be a single takeaway from this article, I argue it should be to challenge our thought processes and biases and to never get tired of doing so for as long as we are humans, there is little possibility for our minds to rely only on logical thinking for everyday decisions.

To ask the right question is already half the solution of a problem.”

—Unknown

For More on This Topic/References

Understanding Age Discrimination in Healthcare: Definition, Types, Effects, and What We Can Do About It