Abstract
Older adults are major consumers of health care. Within the context of an ageing society, their presence in the health care system will continue to grow. Ageist stereotypes and discrimination against older adults have an impact on the health and well-being of older citizens and are potential barriers to health equality. This chapter addresses ageism at different levels of the health care setting with a review of empirical research and health care policy. At the micro [personal] level, manifestations of ageism include attitudes toward older adults among physicians, nurses, and other health care professionals. Ageist communication styles used with older patients, age-biased clinical decision-making regarding diagnostics and treatments, and self-directed ageism in older patients are also discussed. Macro-level [institutional or structural] aspects of ageism are then examined, as reflected in health care reimbursement structures, participation of older adults in clinical trials, institutional policies governing care, and the lack of emphasis on geriatric-specific training for health care professionals. The chapter closes with an integration of the findings and a discussion of the challenges in identifying and reducing ageism in this setting. Conclusions are drawn and recommendations for future research and practice are made.
Keywords
- Ageism
- Geriatrics
- Attitudes toward ageing
- Health care policy
- Patient-centered care
13.1 Introduction
According to the World Health Organization, 23.1% of the global burden of disease [measured in disability-adjusted life years, or DALYs] can be attributed to illness in persons aged 60 years and older [World Health Organization 2008]. Throughout much of the world, the ongoing demographic shifts in the population has resulted in the steady growth of the older adult patient group in the health care system [Thiem et al. 2011]. Further, despite general agreement that older adults do not access medical care as frequently as needed [European Commission 2008], per-person health care spending is much higher for older adults than for younger adults. In the USA, for example, those over 65 years make up less than 15% of the population but account for over 36% of total health care costs [Jecker 2013]. In Germany, older citizens with multiple medical conditions comprise the 5% of health care users responsible for over 30% of prescription drug costs [Kuhlmey et al. 2003]. Within the National Health Service in the United Kingdom, older persons make up two-thirds of all care consumers [United Kingdom Department of Health 2001]. The growing group of “old-old” patients [those aged 85+] with complex medical needs accounts for an over-proportionate amount of health care spending in Europe [Konig et al. 2013; Kuhlmey et al. 2003; Lehnert et al. 2011].
Thus, older adults represent a highly significant group of users of the health care system, and their care has a major impact on health care costs. Additionally, being a regular consumer of medical services is a significant part of daily life for many older adults around the globe. As the “third age” has been extended through longer average lifespans, so too are older persons living with more chronic and acute health problems and relying on care through the health system to maintain functioning and prolong life.
Despite their importance as health care consumers, a recent report issued by the Institute of Medicine [Institute of Medicine 2008] argues that negative attitudes towards older adults persist in the health care community, across professional disciplines, and across care settings. Ageist stereotypes, prejudice, and discrimination are potential barriers for health equality, in terms of the quantity and quality of care provided to older patients and their health-related outcomes [Courtney et al. 2000; Robb et al. 2002]. Ageism is similar to other known forms of discrimination such as gender-based discrimination [sexism] and ethnicity-based discrimination [racism]. Whereas sexism and racism rely on biological attributes which are life-long and usually cannot be changed, however, the bias against older persons will affect all of us who live long enough [Levy and Banaji 2002; Palmore 2001]. In the words of Robert Butler [1975], who coined the term, ageism results in older persons being “categorized as senile, rigid, and old-fashioned in morality and skills. Ageism allows those of us who are younger to see old people as ‘different.’ We subtly cease to identify with them as human beings, which enables us to feel more comfortable about our neglect and dislike of them” [p. 894]. More recently, Iversen and colleagues proposed a comprehensive description of ageism with the goal of further refining the operationalization and conceptualization of the construct in research [Iversen et al. 2009]. This definition encompasses dimensional concepts already well-established in social psychology: [1] cognitive dimension [stereotypes]; [2] emotional dimension [prejudice]; and [3] behavioral dimension [discrimination]. This dimensional approach reflects the fact that, on the basis of age-based categorizations or stereotyping, people can have biased thoughts or feelings about older people and/or engage in discriminating behavior toward older people. These authors go on to state that ageism can be conscious [explicit] or unconscious [implicit], and can be expressed at three levels: interpersonally, among individuals [the micro level]; intra-group, that is, within social networks [the meso level]; and through institutional policies or cultural traditions [the macro level].
There are a number of theories which attempt to explain the origin of ageism. Two theories in particular are highly relevant to healthcare providers and have received considerable attention [Nelson 2005]. The functional approach theory [Snyder and Miene 1994] views stereotyping as serving an important function in the cognitive realm [e.g., using rapid categorization to enhance efficiency] and social realm [e.g., identifying oneself with the social in-group]. Categorization may serve an important function for clinical decision making. This theory, along with the Terror Management Theory [Greenberg et al. 2002], also emphasizes that a negative bias against older persons acts as an ego-protective mechanism, used to deny and distance ourselves from the negative aspects of old age. According to the Terror Management Theory, ageism is closely associated with a human desire to dissociate one’s self from reminders of one’s own inevitable death, leading to attitudes and behaviors that reinforce separation from individuals or groups that arouse fear of death, such as older persons [Greenberg et al. 2002]. As old age is also closely associated with deteriorating health, diminishing functional abilities, and lower social status, which leads to low self-esteem [Martens et al. 2005], the adoption of ageist attitudes and behavior serves to enhance our identification with our social in-group, and to help us dissociate ourselves from reminders of our own future decline.
One can understand intuitively that anxiety regarding severe illness or death may be highly relevant within the health care setting. Health care professionals often have prolonged exposure to the most infirm, ill, and senile older adults, which may bias their perspective and intensify their willingness to disassociate from the older population through ageist practices [Kearney et al. 2000; Lookinland and Anson 1995; Palmore 1990]. There is some empirical support for the association of more negative attitudes with higher anxiety about ageing among health care workers [Liu et al. 2015].
This chapter presents a focused look at age bias as it is manifested in the health care setting. Of note, in this chapter we concentrate on the medical care setting, whereas the chapter by Bodner and colleagues [2018; Chap. 15] in this volume explores ageism within the mental health care system, and the chapter by Fialova and colleagues [2018; Chap. 14] is focused on pharmacological treatments and ageism. We leave a detailed critique of research methodology in this area to Buttigieg and colleagues [2018; Chap. 29] in this volume. Within the micro level [provider to patient], we review research examining attitudes toward, beliefs about, and clinical practices with older patients. On the macro [policy and cultural] level, we examine geriatric care and reimbursement policy across countries, and look at the very limited presence of older patients in the development of new therapies and within health care training curricula. We briefly consider the challenge of distinguishing between discrimination based on age and reasoned, conservative care provided by clinicians to their older patients. Finally, we offer conclusions and recommendations for the future.
13.2 Providers and Patients: Ageism at the Micro Level
13.2.1 Ageist Attitudes and Practices Among Health Care Professionals
There is an ample body of literature documenting negative attitudes towards older patients among health care providers, though conclusions are limited due to the use of a wide range of measurement approaches [for example, a number of different instruments have been used to assess “ageist” attitudes]. Lookinland and Anson [1995] reported that registered nurses, as well as high school students interested in becoming nurses, exhibited negative attitudes and stereotypical beliefs related to ageing and older adults, with the latter exhibiting the least favorable attitudes and views. One study found that nurses tend to assign a lower status to geriatric nursing compared to other practice areas [Wells et al. 2004] and in another study, nursing trainees indicated a general lack of interest in working with older adults [Hayes et al. 2006]. However, a recent survey study [Boswell 2012] among health care students in an undergraduate course on ageing found no clear tendency toward more negative or positive attitudes.
Several review articles have focused on attitudes toward older adults among health care providers. Attitudes among physicians are complex and mixed [Meisner 2012], with some studies of this population demonstrating clearly negative evaluations of older adults and others more neutral or positive evaluations. This also appears to be true of studies of attitudes toward ageing among nurses [Liu et al. 2013]. There may be shifts in attitudes among health care professionals over time: results of a recent systematic review suggested an improvement in medical students and physician attitudes since 2000, but a decrease from positive to more neutral attitudes towards older people among nurses and nurse trainees [Liu et al. 2012]. A review of studies examining nurses working in the acute health care setting revealed primarily positive attitudes toward ageing, though some studies reported negative attitudes, mainly reflecting a negative emotional evaluation of patients [Courtney et al. 2000]. Most concerning, these authors found evidence in their review for an association between negative attitudes and clinical practice decisions.
Discrimination based on age may be reflected in clinical practice and decision-making among health care providers. Studies using both hypothetical decision-making scenarios and patient record review have demonstrated age-based disparities in diagnostic procedures as well as in the types of treatment offered to patients. These reports emerge from various fields of medicine including cardiology [Bowling 1999], oncology [Kagan 2008], and stroke treatment [Hadbavna and O’Neill 2013]. For example, a study conducted in England revealed that though the prevalence of breast cancer is considerably higher among older women compared to younger women [40% of cases are over age 70], only 11% of these older women had received breast cancer screening examinations by their physician. Moreover, only 7% of the physicians participating in that study conducted breast examinations on older female patients on a routine basis [Haigney et al. 1997]. A study conducted among physicians and second-year medical students indicated an age bias in beliefs regarding follow-up treatment for patients undergoing surgery for breast cancer [Madan et al. 2001, 2006]. Younger patients described in vignettes were significantly more likely to be recommended for breast-conservation therapy, whereas a higher percentage of older patients were recommended for modified radical mastectomy. This study also found that younger patients were more likely to be recommended for breast reconstruction procedures following mastectomy. Among lung cancer patients in the U.K., the likelihood of being referred for surgery was lower for older people, despite clinical evidence that post-operative recovery outcomes are not dependent on age [Peake et al. 2003]. The same trend has been found in cardiology: coronary heart disease in older patients, specifically older women, is more likely to be treated pharmacologically rather than surgically [Wenger 1997]. A U.S. study found evidence of age-related under-treatment of heart attacks relative to national treatment guidelines, with older patients less likely to receive standard diagnostic procedures and recommended treatments [McLaughlin et al. 1996].
13.2.2 Ageist Communication by Health Care Professionals
Another aspect of age discrimination relates to the way health care providers communicate with older adults. A number of studies provide evidence that patronizing and ineffective communication can characterize discourse between providers and older patients [Ambady 2002]. Overall, physicians involve older patients in medical decisions less frequently than they involve younger patients. Further, physicians tend to be less patient, less respectful, less involved, and less optimistic with older patients compared to younger patients [Greene et al. 1996]. While there is certainly individual variability in patient preferences for the type of communication with a health care provider, there is no evidence that these attributes of interpersonal communication are preferred by older persons. Above and beyond the potentially negative emotional experience for older patients and family members in the face of a provider’s “poor bedside manner,” provider communication styles may have substantive negative health consequences for the patient [Nussbaum et al. 2005]. For example, one research study analyzing videotaped encounters between a physical therapist and an older patient found that distancing and indifferent behaviors [e.g., not smiling; looking away from the client] were related to more negative short- and long-term cognitive and physical health outcomes for the patient [Ambady 2002].
In a study of nurses, the quality of communication with and care provided to older patients was found to be associated with attitudes toward ageing [Caris-Verhallen et al. 1999]. More negative nurse attitudes were related to shorter, more superficial, and more task-oriented conversations with older patients. The nurses tended to speak to the older patients in a patronizing tone and did not involve them in consultations or decisions. In a similar vein, McLafferty and Morrison [2004] found that nurses’ negative attitudes towards older patients were reflected in low expectations for rehabilitation as well as in more detached treatment of the patients. In this study, nurses were less likely to use humor with their older patients, and were less likely to remember the names of older patients compared to younger patients. A recent qualitative study which compared physicians, nurses, and social workers in Israel found that exclusion of older patients from conversations about their own medical care characterized the interactional styles across disciplines. These health care professionals tended to either “bypass” the older patient by approaching younger family members, or to make clinical decisions without any meaningful patient input. In follow-up interviews, health care providers listed several primary reasons for this type of communication style: [1] lack of self-awareness of this pattern; [2] “choosing the way that is easiest” [i.e., it is simpler to have health care discussions with a younger family member rather than the older patient]; and [3] the provider “not relating to the patient [as a person]” [Ben-Harush et al. 2016].
An operant-observational study conducted in a nursing home revealed yet another detrimental pattern of communication between staff and residents, termed the “dependency-support script” [Baltes et al. 1980]. Findings showed that nursing assistants were more positively responsive to dependent behaviors than to expressions of independence, and reacted with a dependence-supporting response [i.e., praising residents for their acceptance of help]. The authors asserted that this type of communication reinforces dependency and discourages independent behavior in older adults. This association was identified in the Ben-Harush et al. [2016] study as well, as described clearly in a quote by a social worker:
When an older person enters the hospital, there is a certain approach towards them that makes them more dependent. The patient can be a very independent person… and somehow the attitude of the personnel towards them makes them change…they immediately put a diaper on people who did not need a diaper before… Something about entering a hospital promotes a regression for every person, and for older adults the regression is even harsher. They put a diaper on so fast because they don’t want to deal with it. Someone has to help these patients stand and walk them to the bathroom… there is no time… [Ben-Harush et al. 2016].
13.2.3 Factors Associated with Ageism in the Medical Setting
Factors Associated with Health Care Personnel
A handful of studies have examined predictors of ageist attitudes among health care providers. Among nursing students and registered nurses in Sweden, younger age [