Winter 2008

Ageism In Healthcare: Time for a Change
By Richard Currey, PA-C
Aging Well
Vol. 1 No. 1 P. 16

Ageism exists everywhere. Healthcare is not exempt. But progressive researchers are proving the power of self-perception to improve health outcomes and change ageist attitudes.

As a practicing physician assistant, I work in a busy urban emergency department (ED). More than half of our patients are aged 60 or older. Many arrive because of mishaps or illnesses that may bring anybody of any age to an ED, and we provide the same quality care for them as we do for younger patients.

At the same time, I’m aware of an age-based discrimination directed toward older patients. At 58, perhaps I’m more sensitive about this than my younger colleagues are, but I can be guilty of ageism, too, if only by complicity. EDs are hectic, and those who work in them are quick to mentally pigeonhole those we treat there. Older patients are typically medically complex absorbers of time and resources that can lead ED practitioners to refer to their cases as “train wrecks.”

There are other similar phrases routinely used for older patients—”Disaster waiting to happen.” “Nightmare on a stretcher.” “Dotty old guy in bed three.” “Gramps down the hall.” “Sweet old lady.”

Understand, these expressions are rarely voiced with overt hostility. Some are spoken gently or intended to be humorous. There are those who argue they’re excusable in the frenetic world of an ED. But these discriminatory labels, no matter how they’re ultimately intended or directed, all tend to demean or devalue. They’re all emblematic of ageism, a complex phenomenon carrying a continuing burden of social and political prejudice that has real costs to the health, well-being, and longevity of thousands of older adults.

Involuntary, Perhaps, but Practiced
The term ageism was coined in 1968 by Robert N. Butler, MD, a pioneer in geriatric medicine and author of the book Why Survive? Being Old in America. A founding director of the National Institute on Aging (NIA) and the country’s first department of geriatrics at Mount Sinai School of Medicine, as well as current president of the International Longevity Center (ILC), Butler was among the first to identify and describe the phenomenon of age prejudice, initially defining it as “a systematic stereotyping of and discrimination against people because they are old.” His work established that ageism was an authentic concern with disturbing implications, and it’s an “ism” that remains with us.

Aging inevitably involves an increased demand for healthcare services at some level and at some point for nearly every older American. Yet any overview of the current state of elder healthcare resounds with disturbing data. For example, based on the ILC’s 2006 report on ageism in America, 90% of older Americans never receive routine screening tests for bone density, colon or prostate cancer, or glaucoma—all conditions that increase with age. Sixty percent of older adults don’t receive routine preventive health services, including screening for high blood pressure or cholesterol. And 35% of doctors continue to believe, despite ample evidence to the contrary, that elevated blood pressure is a “normal” part of aging.

Medical research mirrors this discrimination. Breast cancer is a disease affecting women over the age of 65 in more than one half of occurrences. But in clinical trials evaluating new drugs for treating breast cancer, less than 10% of participants are 65 or older. Indeed, clinical trials in general exclude or under-recruit older people as study participants.

A number of other surveys and studies further confirm widespread ageism throughout healthcare. A 2006 study published in BMJ found that carotid artery blockage, overwhelmingly a problem of older adults, was routinely underinvestigated in older patients. A survey conducted at Johns Hopkins University School of Medicine revealed that 80% of medical students would aggressively treat pneumonia in a girl aged 10, while only 56% would do the same for a woman aged 85.

In a 2003 presentation at the American Thoracic Society, E. Wesley Ely, MD, MPH, of Vanderbilt University School of Medicine, noted that people 65 or older account for more than half of all intensive care unit (ICU) days nationwide, and people 75 or older account for seven times more ICU days than those under 65. Despite this, further research done by Ely uncovered clear evidence of age bias in ICUs. While older ICU patients generally require more interventions and resources, “Older patients actually receive less aggressive care than do younger patients,” he reported, noting that the use of mechanical ventilation in the ICU sharply decreases in patients 70 or older.

And since ICU care may presage nursing home care for many, it’s troubling that more than one half of the country’s nursing homes cannot meet minimum standards, and, according to the ILC report, only roughly 10% are adequately staffed.

Meanwhile, lengthy data and compelling evidence confirms that preventive care addresses many elder healthcare deficiencies. Aside from mitigating the impact of uncontrolled disease, lengthening life, and improving quality of life along the way, prevention saves money in personal and government budgets. But, plainly put, prevention doesn’t generate revenue. In New York City alone, many diabetes prevention and treatment centers have closed due to a lack of revenue, even though a few hundred dollars invested in diabetes prevention can save more than $11,000 per patient in the form of acute or emergency care driven by the absence of earlier disease prevention.

So, if prevention is a proven remedy for at least some of the health burdens of elders—i.e., one that eases consumption of already limited resources and makes a demonstrable difference in health and well-being—the focus is nevertheless elsewhere. The goal of doctors and organized medicine is to cure people, notes Dennis O’Mara, former associate director for adult immunization at the Centers for Disease Control and Prevention. After that, doctors focus on management of diseases that, in the absence of prevention, have become chronic. “Prevention comes in a poor third,” O’Mara says.

Preconceptions Breed Misconceptions
As with any form of discrimination, the engine of ageism is fueled by preconceptions rooted in fear. Played out in social situations and interactions, these fears become biases that, even if subtle, tend to undermine and exclude. Butler attributed age-based discrimination, at least in part, to complex unspoken and unrecognized emotional reactions to innate fears of physical decline, mortality, and isolation. And as with all discriminatory behavior, we can temporarily ease those fears by stereotyping and exclusion.

If negative stereotyping of elders is among the root causes of ageism, the research of Becca Levy, PhD, of the Yale University School of Public Health sheds light on this self-perpetuating social malady. Over the last decade, Levy has explored how negative self-perceptions and self-images related to aging are directly related to poor health outcomes.

Levy’s interest in the relationship of aging and self-perception goes back to her graduate school days when she visited Japan. “I noticed that older people in Japan seemed to enjoy a more respected place in society than we afford our elders here in the United States,” she recalls, adding that the Japanese elders seemed to be healthier and happier than those in the states. “I found myself wondering if self-image or societal respect played an actual role in other, more concrete factors, like incidence of disease, cognitive capacities, or overall health.”

Among a number of assessment techniques, Levy has employed subliminal imagery—pictures that flash quickly past on a computer screen depicting either positive or negative images of aging—as well as reactions to television programming or self-reported assumptions about aging. Her work has led to striking correlations between negative self-perceptions of age and increased risk of elevated blood pressure (and therefore increased risk of vascular disease), hearing decline, poor memory performance, and shorter lives.

One of Levy’s studies examined people between the ages of 62 and 82 who were asked to recall their most stressful event in the last five years and then were shown positive or negative age-associated words or phrases on a computer screen. The negative group demonstrated elevated blood pressure and other measures of increased cardiovascular burden. The positive group, however, experienced a decrease in blood pressure.

In other studies, Levy and her colleagues have consistently demonstrated that positive self-perceptions of aging can improve memory, thinking and cognition, mood, self-confidence, overall functionality, and longevity (adding 7.5 years). If many older people attribute their decline to the inevitable and unyielding processes of aging, Levy’s research clearly says the opposite. In other words, the power of positive thinking is powerful indeed. Yet our culture is an ageist one, where age-positive images can be hard to come by.

“The preconception has long been that functions such as memory or hearing simply deteriorate with age, and there was nothing to be done about it,” Levy says. “Our work demonstrates that how a person feels about getting older plays a vital role in how their body functions. Aging brings inevitable change, of course, but much of the decline we’ve taken for granted isn’t necessarily an absolute.”

“What we want to do is build on our findings,” she says. “We’ve established the links between attitude and self-perception and well-being and improved health outcomes. Now we will work toward evidence-based tools for health promotion among older individuals,” says Levy, the recipient of the 2007 Donoghue Medical Research Foundation’s $600,000 Investigator Award.

Improvements and Change
Levy’s research has helped form the basis of an initiative called Vital Visionaries (VV). Managed by the NIA on behalf of the Society for the Arts in Healthcare, VV is fueled in part by Levy’s insights into the health effects of internalized negative stereotypes. Other research has observed that medical students who interact with older adults earlier in their education maintain better attitudes about aging and are less likely to be the purveyors of the negative stereotypes.

With these insights as a point of departure, VV collaborates with several major medical schools and museums, pairing medical students and elders in a variety of arts activities. Aside from the fact that arts activities have been demonstrated to enhance wellness, VV offers students the opportunity to interact with older adults outside the hospital. Since medical students’ exposure to elders is mainly in settings of extreme illness and frailty, NIA Deputy Director Judith Salerno, MD, MS, has noted that this tends to create skewed perspectives. “A first step toward improving care for elders is to improve how students see them,” she says.

Mounting a concerted, coordinated attack on health and medical ageism has been and will continue to be no easy task. With the first Senate hearing on age-based discrimination in healthcare just four years ago, the issue has only just begun to register on the national agenda.

Most of the major advocacy organizations, including the NIA, the ILC, the American Association of Retired Persons, and the American Society on Aging, offer solid recommendations to address healthcare ageism. The ILC report is perhaps the most formidable overview available and issues calls to action on many different aspects of ageism. Virtually every organization and expert agree that key elements of any campaign to address ageism must include sweeping reforms in health policy; fresh, commanding legislation that can address inequities and empower services; and widespread innovations in medical education.

Nearly every type of professional practitioner who cares for elders, including physicians, nurses, physician assistants, nurse practitioners, psychologists, and social workers, as well as paramedics, firefighters, and other first responders, must receive more thorough education in geriatric issues, needs, and care. Specialized training in geriatric medicine should be intensified, helping to create specialized geriatric teams, similar to stroke teams, that Ely believes should exist in every hospital and major medical facility.

But, as with other “isms,” reforming ageism demands fundamental change in attitudes, preconceptions, assumptions, and expectations. Fighting the problem at this fundamental level is where Levy believes key victories will be scored. She contends that future treatments aimed at reducing stress in older adults should include specific strategies that reduce the tide of negative aging self-stereotypes and actively promote positive ones. We are all exposed to a river of subliminal imagery and language on a daily basis, whether through television, newspapers, or magazines, much of which overtly discriminates against age and aging, and cues all of us to hold the old in disdain. But Levy’s discovery that negative stereotyping actually drives negative health outcomes opens the door to fundamental changes in the way medical care is delivered to older Americans in the future.

Age-based discrimination runs deep, but changes are at hand. Politicians are now paying attention, and with the widely-heralded arrival of the boomer generation into their elder years, grassroots action and local political clout should take on new energy. Researchers like Levy and Ely are providing measurable data that will help reinvent geriatric medicine and create better, faster, and smarter medical care. Programs such as VV seek to make a difference in the attitudes of our future physicians.

But the road ahead is still a long one. Ageism in healthcare—and other aspects of our collective lives—depends on our own capacity to recognize internalized prejudices and uproot them at their source in ourselves. Until then, we’ll continue to see the illness, early death, isolation, and abandonment that has characterized elder healthcare for far too many years.

— Richard Currey, PA-C, is a freelance writer based in the Washington, DC, area where he works with several agencies within the National Institutes of Health as a writer and consultant.

Vital Visionaries: Breaking The Barriers

In March 2003, a study conducted by Marie Bernard, MD, and other investigators at the University of Oklahoma’s Reynolds Department of Geriatric Medicine ran in the Journal of the American Geriatrics Society. The text noted that “healthcare professionals tend to believe that most older individuals are frail and dependent, and that those who are not are atypical.” That statement, coupled with the fact that there are approximately 9,000 geriatricians in the country but an estimated 36,000 will be needed by 2030, and the research of Becca Levy, PhD, outlined in the article, ultimately inspired the basis for Vital Visionaries (VV).

VV has three objectives that haven’t changed since its inception: to encourage interaction between healthcare professionals and older adults, to generate improved understanding and appreciation of elders by medical students, and to make elders more aware of their creative abilities.

Initially, VV was a collaboration developed by the National Institute of Aging (NIA), in tandem with Baltimore’s American Visionary Art Museum and Johns Hopkins School of Medicine. The pilot program, which took place in March and April 2003, brought together 14 older adults (aged 65 and up) and 15 first-year medical students, all of whom were volunteers. They worked on creative projects for four two-hour sessions. At the program’s end, the students’ feelings about elders and aging were measured. The results: 75% wanted “a larger number of older patients in future practice,” 93% disagreed with the statement “I have little in common with older people,” and 100% disagreed with the statement “Older people are difficult to talk to.” A number expressed interest in receiving specific geriatric training.

The next VV, in 2006, involved four medical schools in the East and Midwest with essentially the same number of older adults/students at each. All took place in museums. This time, sessions included viewing art, ice-breaking activities, informal conversation, and hands-on activities such as visual arts, poetry writing, and movement. Things ended on an equally optimistic note as the students rated older people as “interesting, progressive, optimistic, and pleasant.” The elder participants agreed with positive statements about their lives and their level of satisfaction with them. Medical student comments ranged from, simply “awesome” to “My attitudes toward older people changed much more than I expected.”

For 2007 to 2008, VV has partnered with OASIS, a national nonprofit educational organization aimed at improving the quality of life for older adults. Participation has doubled—eight student-elder locations are finalized, and two more are in the works. Clearly, the concept is working—and well. “Vital Visionaries provides a window into the simple measures we can take to bridge generations and confront ageism,” says Judith Salerno, MD, MS, deputy director of the NIA. “I hope that such efforts can improve the notion of aging among physicians faced with the challenges—and rewards—of caring for older people.”

— Arn Bernstein is a Philadelphia-based freelance writer and editor.