We can do better: Addressing ageism against older adults in healthcare

Sources and consequences of ageism in healthcare

Older adults are a heterogenous group, and many of us who practice in Geriatric Medicine or Care of the Elderly advocate that chronological age is an inaccurate measure of health or prognosis. ⁴ Alternative measures, like the Clinical Frailty Scale, take into account multiple factors and are often better predictors of clinical outcomes.^4,10 However, stereotypes against older adults based on age alone develop early, with an onslaught of exposures to the negative aspects of ageing from movies, television, music, and social media. ¹ We also pick up on implicit bias by observing the language and behaviour of those around us. ¹ The positive or negative experiences we have had with older people throughout our lifetimes are also robust predictors of ageism directed at others. ¹¹ The quality of contact with older adults, both personally and professionally, even goes so far as to impact the likelihood that medical and nursing students would consider a career in geriatrics.^12-15 Personal anxiety about one’s own ageing, or fear about death and dying, also predict negative attitudes towards older people.^16,17

In healthcare, negative attitudes towards older adults translate to age discrimination with lapses in ethics-based care in myriad forms, which can be seen from the ‘micro’ individual level to the ‘macro’ structural and systemic level. Ageism at the provider and patient level can manifest through paternalistic or infantilizing approaches, limited involvement in consent discussions, cognitive bias (e.g. attributing patient concerns/symptoms to ‘old age’), exclusion from recommended screening, investigation and/or treatment guidelines, and therapeutic nihilism.^12,18 We have all seen examples of these kind of breaches of medical ethics – confidential information or consent being discussed with families instead of a capable older patient; older adults suffering from untreated depression because ‘it’s normal to be sad when you’re old’; or delayed diagnosis of breast cancer in an older person who was not screened according to recommended guidelines.

Institutional or structural ageism includes exclusion from clinical research that generates evidence for practice, geographic and transportation barriers, medication and resource costs (including disparate access to supportive care in the community), and technological barriers.^12,18-20 Websites, phone apps, online registration, and other digital platforms lead to a heavier burden of exclusion, evidenced by the challenges many older adults faced trying to register online for COVID-19 vaccinations in Canada and trying to navigate virtual healthcare visits when outpatient clinics were shut down.^3,21

Unequal access to rehabilitative or restorative care facilities also limits the opportunity for older adults to reach their health and functional potential after acute illness, and further feeds into negative stereotypes about ‘bed blockers’ or ‘bounce backs’. ²² For more severely frail older patients (whose health can be thought of as a complex system in tenuous balance), single system management in acute care without the capacity to manage the whole person can predictably lead to further healthcare crises and readmissions. ²³ Use of the pejorative ‘failure to cope’ readmission diagnosis puts the onus on the patient instead of recognizing a failure of the system to care for and support people during recovery. ²⁴

Our trainees thus learn biased language and ageist practices from us as clinical teachers, often unconsciously and inadvertently. We teach them medical ethics and strive to provide equitable care, but ageist cultural practices are so deeply imbedded in our language and behaviour that we accidentally pass them on through the hidden curriculum (the transmission of behaviours, beliefs, and attitudes unintentionally shared to students through role-modelling) – an important and often unrecognized source of teaching in medicine. ²⁵ Studies have demonstrated that medical and nursing students frequently witness age discrimination in their learning environment, often by physicians or nurses and most often when working in a hospital inpatient unit.^12,26 Learners in medicine also have limited exposure to outpatient geriatrics during training and are instead exposed to a biased sample in acute care, seeing only the sickest old rather than the robust well – further cementing misconceptions about ageing. ²⁴

A shortage of Geriatric-trained health professionals further impacts the provision of adequate care to older adults – widening the care gap and emphasizing challenges to distributive justice for this population.^2,18 Despite the fact that people are living longer and older adults have outnumbered children in Canada since 2016, there are still tenfold less geriatricians than pediatricians practicing in Canada.^27,28 Inadequate numbers of training positions and job opportunities lead to unbalanced allocation of resources and further health disparities, with long waitlists and geographic clustering of specialists resulting in many older Canadians being unable to access specialized Geriatrics care.^28,29

A growing body of evidence demonstrates that age discrimination has negative outcomes for older adults who experience it. They may face new or slower recovery from disability, decreased longevity, poorer physical and mental health including suicidal ideation, increased social isolation, and higher healthcare costs.^1,30 Self-directed ageism (through unconscious internalization of negative attitudes and stereotypes) can result in self-limiting behaviour and is also significantly associated with reduced physical and mental health in older people. ³¹ Additionally, some older adults experience multiple overlapping burdens of vulnerability including racism, ableism (prejudice against people with disabilities), mentalism (discrimination against people with mental conditions or cognitive impairment), sexism, and poverty.^5,7,17,32 The consequences of unethical care and age discrimination thus fuel the fire of ageism itself, leading to a cycle of increased admissions, longer lengths of stay, more readmissions, further alienation from society, and deterioration in mental health, cognition, and function for older adults in the healthcare system.^5,30,32

Strategies to address ageism in healthcare

Although the above paints a dire picture, changing societal understanding and behaviour towards older adults is possible. It requires sustained and coordinated action by a wide variety of leaders in healthcare, including public and private stakeholders at all levels ranging from individual to system-wide. ¹ The Revera Report on Ageism in Canada (2016) surveyed older Canadians and identified that the top changes they hope to see are (1) investment in technologies that help older people live independently for longer, (2) raised awareness about ageism to make it socially unacceptable, and (3) provision of more government funding for healthcare solutions that address the needs of an ageing population. ³³ International organizations, such as the WHO, have also identified ageism as an important priority for human rights and ethical care and have developed a global campaign to combat ageism. ¹ They suggest that ageism is best tackled through three main strategies, including intergenerational activities to reduce prejudice; education to increase knowledge and empathy and reduce misconceptions; and policy and law reform to address and protect against ageism and enforce ethics-based healthcare for all. ⁸

Evidence supports the efficacy of relatively low-cost and logistically feasible strategies involving intergenerational contact and educational activities.^1,34 Programs that aim to increase positive experiences with older adults combined with education on ageing and ageism appear to be successful in changing negative attitudes and decreasing prejudice – particularly when directed towards adolescents and younger adults. ³⁴ This evidence-based practice provides healthcare leaders with tangible examples of practical ways to enact change in their organizations. Examples include intergenerational creative arts programs, cooking classes, gardening programs, and even integrating some high school classes into a retirement community environment.^35,36 Within Canadian healthcare, leaders in medical education are advocating for change, and students are increasingly benefiting from new intergenerational opportunities within the curriculum to gain understanding, skills, and knowledge to better care for older people. ³⁷

From an educational perspective, the Canadian Geriatrics Society identified a set of core competencies for the care of older persons in 2008, which are still inconsistently taught across Canada. ³⁸ A major challenge of increasing geriatrics teaching in undergraduate medicine is the sheer volume of information across specialties that needs to be taught. Creative solutions are thus necessary. In an effort to increase early student exposure to geriatric medicine using extracurricular time, Queen’s University introduced a structured pre-clerkship observership program that resulted in high student participation, good care of the elderly role-modelling, and stimulated student interest in a career in geriatric medicine. ³⁹ The application of innovative and system-wide programs like the above demonstrate that effective leadership can translate to more inclusive teaching and promote a non-ageist culture.

Increasing age-related curriculum in other health fields is equally important. There is no consistent curriculum on caring for older adults in nursing schools or other healthcare related programs like clinical pharmacy, physiotherapy, occupational therapy, or social work.^40,41 Better foundational education reduces the prevalence of ageism and allows for better whole-person care. ⁴¹

Hospital managers also hold an important role in reshaping workplace practices and ageism culture in healthcare. Education and workplace campaigns that celebrate effective empathetic care for older adults can be effective leadership tools in changing practice. Dispelling misinformation and misconceptions about ageing, redefining the accepted workplace language and culture, and providing robust institutional support for those working with older populations can improve quality of care and better align with medical ethics principles. ²⁰ Development and enforcement of policies that address discrimination and protect the rights of all patients can likewise be effective. ¹

Better funding of training programs and job opportunities for healthcare workers with a specialty in caring for older adults will translate into increased resources, services, and timely access to equitable care. ²² Health professionals trained in comprehensive geriatric assessments and holistic care of older adults are necessary to properly address the care needs of an ageing population and uphold distributive justice. Adequate education and training also improve the quality of role-modelling and work to transform ageist culture in medicine. ³⁴

From a research perspective, older adults are often unethically excluded from trials based on unexplained age cut-offs – which means that evidence-based treatment data cannot often be applied to care decisions. Advocacy focused on broadening inclusion criteria has led to some improvements over time, but there is still a significant under-representation of older adults in research. ¹⁹ Increase care to study design to reduce arbitrary upper age cut-offs in randomized control trials with no valid contraindications is thus an important part of addressing systemic medical ageism. ¹⁹ At minimum, clinical trials should be transparent about why age cut-offs are included in their exclusion criteria.

Further research into healthcare-associated ageism and evidence for effectiveness of interventions will help better inform policy development and practice reform.^3,20,42 Additionally, national campaigns like the National Seniors Strategy in Canada and global campaigns like the UN Decade of Health Ageing (2021–2030) showcase the hope and promise that we are ready and willing to change.^43,44