ContentServer PDF

GE NER ATIO NS Journal of the American Society on Aging
By Karin M. Ouchida and Mark S. Lachs
Not for Doctors Only:

Ageism in Healthcare
Ageism in the healthcare sphere is not just demeaning,
but can be dangerous, as it is often the cause for both
over- and under-treatment of older adults.
r. 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.
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
Ageism Among Healthcare Providers
throughout the surgical procedure. Another
Adults ages 65 and older see doctors on average example of explicit ageism involves a respected
twelve times per year, and nearly 80 percent see internal medicine resident flippantly telling her
a primary clinician at least once per year (Davis team that she is worried because her patient on
et al., 2011). These visits represent critical opmorning rounds looked like this. The resident
portunities for providers to promote physical
closes her eyes and opens her mouth with her
and psychosocial health, and patients expect
tongue protruding off to one side. She then says,
counseling that is individualized for their func- But then I remembered . . . Im on the geriatrics
tional status, life expectancy, and care prefservice. The resident had made her face into the
erences. Providers knowledge and attitudes
Q signa disparaging term, originated in Samuel
about aging can affect how accurately and
Shems novel The House of God, that describes
sensitively they distinguish normal changes
extremely moribund patients (Shem, 1978).
associated with aging from acute illness and
Sadly, despite the growing need for more prochronic disease. Ageism can take the form of
viders with geriatrics expertise, many physiciansa provider dismissing treatable pathology as a
in-training come to view the care of older adults
46 | Fall 2015 Vol. 39. No. 3
Copyright 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
distributed in any form without written permission from the publisher: American Society on Aging, 575 Market
St., Suite 2100, San Francisco, CA 94105-2869; e-mail: info@asaging.org. For information about ASAs publications
visit www.asaging.org/publications. For information about ASA membership visit www.asaging.org/join.
Pages 4657
Ageism in America: Reframing the Issues and Impacts
as frustrating, uninteresting, and less rewarding

care providers remain prone to stereotyping
overall. These negative views likely are influolder adults or applying age-based, group
enced by the predominant exposure of medical
characteristics to an individual, regardless of
trainees to hospitalized geriatric patients versus
that individuals actual personal characteristics
community-dwelling older adults, and by the
(Macnicol, 2006). In Dr. Erdman Palmores
inherent challenges in caring for medically
Ageism Survey (2001) of community-dwelling
complex older adults who need extensive care
older adults ages 60 to 93, 43 percent of responcoordination within an increasingly fragmented
dents reported that a doctor or nurse assumed
system (Adelman, Greene, and Ory, 2000).
my ailments were caused by my age, and 9 perTrainees attitudes are further shaped by the cent said they were denied medical treatment
persistent misconceptions that older patients
because of age.
are demented, frail, and somehow unsalvageable. In Higashi and colleagues
study based on observations of inpatient Negative views of elders are influenced by
teams and interviews with students and the predominant exposure of medical
residents about their experiences caring
trainees to hospitalized geriatric patients
for elderly patients, a resident said, Its
versus community-dwelling older adults.
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
In a cross-sectional survey design, Davis et al.
tract infection back to her semi-altered state
(2011) used the Expectations Regarding Aging
(Higashi et al., 2012).
Scale to assess primary care clinicians percepDr. Becca Levy (2001) points out that ageism tions of aging in the domains of physical health,
can also operate as implicit thoughts, feelings,
mental health, and cognitive function. The majand behaviors toward older people that occur
ority of providers surveyed were physicians, but
without conscious awareness or control. Wheth- the sample also included nurse practitioners and
er provider ageism is explicit or implicit, it puts
physician assistants who serve as primary care
older patients at risk for under-treatment and
providers (PCP). Most PCPs agreed with the
over-treatment. Healthcare providers must also
statements Having more aches and pains is an
be attentive to unique features of medical enaccepted part of aging (64 percent), and, The
counters with older patients. Older adults may
human body is like a car: when it gets old, it gets
have sensory or cognitive impairments and may
worn out (61 percent ). More than half of PCPs
be accompanied to the medical encounter by a
(52 percent) agreed that one should expect to
third person. Clinicians can learn to recognize
become more forgetful with age, and 17 percent
implicit ageist attitudes and actions, and adopt
agreed mental slowness is impossible to
communication techniques to effectively elicit
escape. Few PCPs believed getting older was
the patients concerns and preferences to proassociated with social isolation (4.8 percent)
vide individualized care.
and loneliness (5.9 percent), but 14.7 percent of
respondents agreed with the statement Its
Potential for under-treatment
normal to be depressed with you are old. OneExperts in aging often underscore the profound third of the physicians agreed that increasing
heterogeneity of the elderly population by sayage was associated with worrying more and
ing, If youve seen one 85-year-old, youve seen having lower energy levels. These results demonone 85-year-old. Unfortunately, the reported
strate how pain, fatigue, cognitive impairment,
experiences of older adults suggest that healthdepression, and anxiety could easily go undiagCopyright 2015 American Society on Aging; all rights reserved. This article may not be duplicated, reprinted or
Fall 2015 Vol. 39. No. 3 | 47
nosed 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 cant walk. What am I
supposed to do? He [the doctor] says, How old
are you? I said, Im close to 90. [The doctor
replies] What do you expect? Youre 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
48 | Fall 2015 Vol. 39. No. 2
Pages 4657
chronological age without assessing an individuals 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
Pages 4657
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 patients life expectancy. Both the surgeon
and the primary care physician should also
understand the older patients 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
Fall 2015 Vol. 39. No. 3 | 49
Pages 4657
tia 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
Communication during medical
the
presence of sensory and cognitive changes
encounters with older patients
does
not necessarily signify functional impairEffective communication between the older
ment.
Even in patients diagnosed with dementia,
adult patients and their healthcare providers to
the degree and type of cognitive deficits ranges
elicit individual goals and preferences is one of
widely. Unfortunately, older patients may enthe keys to avoiding under- or over-treatment.
counter healthcare providers who automatically
Unfortunately, studies show that providers
shout or raise their voices when communicating,
communicate differently in medical encounters
or worse, ignore them altogether and speak only
involving older versus younger adults. When
to a younger person who accompanied them to
Greene et al. (1986) analyzed the content of
the visit. Palmore (2001) reported that a third
eighty audiotaped medical visits, physicians
of respondents in his Ageism Survey described
provided better questioning, information, and
support to younger patients. Doctors were rated encountering providers who assumed they could
as less patient, less engaged, and less egalitarian not hear well or could not understand, and 39
percent felt they were patronized or talked
with their older patients. Also, physicians
down to.
responded less to the issues raised by older
One way healthcare providers unknowingly
patients, devoting more time to provider-raised
patronize
older adults is to use elderspeak
topics. Greene and colleagues hypothesized that
speaking slowly, with exaggerated intonation,
elevated pitch and volume, greater
Research has shown that pain is consistently repetitions, and simpler vocabulary and
grammatical structure. Older adults
under-treated among older adults.
perceive elderspeak as demeaning and
studies
show
it can result in lower self-esteem,
their findings reflect different power dynamics,
withdrawal from social interactions, and dewhere the generation of older adults in their
pression, which only reinforce dependency
sample were more likely to respect authority.
and increase social isolation (Williams, Kemper,
The results might change if the study were
and Hummert, 2005). In patients with demenrepeated today with a cohort from the Baby
tia living in long-term-care settings, elderspeak
Boom Generation (Greene et al., 1986).
Communication between healthcare provid- has been shown to increase resistance to care
(Herman and Williams, 2009). Providers can
ers and older adults also is more likely to be
routinely screen older patients for hearing and
complicated by sensory deficits, cognitive
vision loss and memory impairment, and emimpairment, functional limitations, and the
ploy verbal and written communication stratepresence of an accompanying relative or caregies to ensure patients understand and retain
giver in the medical visit (Adelman, Greene,
medical information.
and Ory, 2000). With increasing age, there are
In Higashi and colleagues (2012) ethnoexpected changes in vision, hearing, and memographic
study of negative attitudes toward older
ry. Approximately a third of adults ages 65 and
adults
among
medical trainees, a medical stuolder report some hearing loss (Kane, Ouslander,
dent
and
an
intern
each describe witnessing
and Abrass, 2004) and a quarter of individuals
poor communication occurring because providages 75 and older have vision impairment
(Cassel and Leipzig, 2003). Alzheimers demen- ers assumed an older patient was cognitively
to assess surgical risk, and the importance of
studying long-term functional outcomes.
50 | Fall 2015 Vol. 39. No. 2
Pages 4657
impaired. Sometimes staff talk about their

condition in front of them without addressing
them, one student said, and, People just dont
explain as much to them, they . . . more just reassure and tell them theyre going to be [okay]
and dont 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 adults ability to form a close relationship
with the physiciana 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 undertreated. 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
Fall 2015 Vol. 39. No. 3 | 51
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
52 | Fall 2015 Vol. 39. No. 2
Pages 4657
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 Butlers 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 youngold (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
Pages 4657
schools had nine or more full-time faculty

engaged in education, research, and clinical
carethe 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 nonfederally 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.
verse 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 diseasedisease 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).
Surgeons also are trying to individualize
This follows previous research demoncare to avoid under- and over-treatment.
strating older patients with unstable
angina, acute congestive heart failure,
The final example of ageism in the healthand acute myocardial infarction were less
care system concerns the inadequacy of single
likely to receive standard life-saving therapies
disease clinical practice guidelines (CPG) and
(Giugliano et al., 1998).
the exclusion of older adults with multiple
Older adults with multiple comorbidities and
chronic illnesses from the trials that are used
cognitive or functional impairment are generally
to generate these guidelines. Twenty percent
excluded from the randomized controlled trials
of Medicare beneficiaries have five or more
that eventually form the basis of clinical pracchronic illnesses (Tinetti, Bogardus, and
tice guidelines. The trials often use restrictive
Agostini, 2004). In one year, these individuals
admission criteria to maximize the accuracy of
have an average of fifty prescriptions filled, see
the results for the target population, but at the
fourteen different physicians, and make thirtyexpense of being able to generalize the results to
seven office visits, putting them at risk for adother patients. If the health needs of older adults
Fall 2015 Vol. 39. No. 3 | 53
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 Alzheimers Disease, but
16 percent did have exclusion criteria for other
psychiatric conditions.
Conclusion
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.
54 | Fall 2015 Vol. 39. No. 2
Pages 4657
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 Medicines 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
Pages 4657
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 YorkPresbyterian
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.
References
AARP. 2011. Poll: Perceptions of
Boomers; What Are the Beliefs Held
About the Baby Boom Generation?
www.aarp.org/health/fitness/info01-2011/bulletin_poll_perceptions_
of_boomers.html. Retrieved
July 27, 2015.
Achenbaum, W. A. 2013. Robert
N. Butler, M.D. (January 21, 1927
July 4, 2010): Visionary Leader.
The Gerontologist 54: 612.
Adelman, R. D., Greene, M. G., and

Ory, M. G. 2000. Communication
Between Older Patients and Their
Physicians. Clinical Geriatric
Medicine 16: 124.
Alexander, K. P., et al. 2007. Acute

Coronary Care in the Elderly, Part
1: Non-ST Segment Elevation
Acute Coronary Syndromes.
Circulation 115: 254969.
ADGAP. 2015. 2015 Match Data

Presentation. http://adgap.
americangeriatrics.org/fellowshipresources/match-information/
adgap-survey-results/. Retrieved
July 28, 2015.
Aronson, L. 2015. The Human

Lifecycles Neglected Stepchild.
The Lancet 385(9967): 5001.
Beck, M. 2013. More Doctors Steer

Clear of Medicare. The Wall Street
Journal, July 29. www.wsj.com/
articles/SB10001424127887323971
204578626151017241898. Retrieved
July 28, 2015.
Fall 2015 Vol. 39. No. 3 | 55
Benjamin, R. M. 2010. Surgeon

Generals Perspectives. Multiple
Chronic Conditions: A Public
Health Challenge. Public Health
Reports (125) SeptemberOctober.
Berwick, D. M., and Hackbarth,
A. D. 2012. Eliminating Waste in
U.S. Health Care. Journal of the
American Medical Association
(JAMA) 307(14): 15136.
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): 111719.
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): 71624.
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.
Centers for Medicare & Medicaid
Services (CMS). 2015. The ABCs
of the Annual Wellness Visit.
www.cms.gov/Outreach-and-Ed
ucation/Medicare-Learning-Net
work-MLN/MLNProducts/down
loads/AWV_chart_ICN905706.pdf.
Retrieved July 27, 2015.
Choosing Wisely. 2015a. American
Geriatrics Society: Ten Things
Physicians and Patients Should
Question. www.choosingwisely.
org/societies/american-geriatricssociety/. Retrieved July 14, 2015.
56 | Fall 2015 Vol. 39. No. 2
Choosing Wisely. 2015b. American

Academic of Family Physicians:
Fifteen Things Physicians and
Patients Should Question. www.
choosingwisely.org/societies/
american-academy-of-family-phy
sicians/. Retrieved July 27, 2015.
Choosing Wisely. 2015c. Society
for General Internal Medicine: Five
Things Physicians and Patients
Should Question. www.choosing
wisely.org/wp-content/uploads/
2015/02/SGIM-Choosing-WiselyList.pdf. 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: 2639.
Davis, M., et al. 2011. Primary Care
Clinician Expectations Regarding
Aging. The Gerontologist 51(6):
85666.
Finlayson, E., et al. 2012. Functional Status After Colon Cancer
Surgery in Elderly Nursing Home
Residents. Journal of the American
Geriatrics Society 60: 96773.
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):
11324.
Greene, M. G., et al. 1994. The
Effects of the Presence of a Third
Person on the PhysicianOlder
Patient Medical Interview. Journal
of the American Geriatrics Society
42(4): 4139.
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): 111320.
Pages 4657
Health Affairs. 2012. Health Policy

Brief: Reducing Waste in Health
Care. December 13. www.
healthaffairs.org/healthpolicy
briefs/brief.php?brief_id=82.
Retrieved August 12, 2015.
Herman, R. E., and Williams, K. N.
2009. Elderspeaks Influence on
Resistiveness to Care: Focus on
Behavioral Events. American
Journal of Alzheimers Disease and
Other Dementias 24(5): 41723.
Higashi, R., et al. 2012. Elder Care
as Frustrating and Boring:
Understanding the Persistence
of Negative Attitudes Towards
Older Patients Among Physiciansin-Training. Journal of Aging
Studies 26(4): 47683.
Joseph, B., et al. 2014. Superiority
of Frailty Over Age in Predicting Outcomes Among Geriatric
Trauma Patients: A Prospective
Analysis. JAMA Surgery 149(8):
76672.
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 Dont Know. The New
York Times, July 1. www.nytimes.
com/2009/07/02/opinion/02
leipzig.html?_r=0. Retrieved
August 12, 2015.
Levy, B. R. 2001. Eradication of
Ageism Requires Addressing the
Enemy Within. The Gerontologist
41(5): 5789.
Levy, B. R., and Myers, L. M. 2004.
Preventive Health Behaviors
Influenced by Self-perceptions
of Aging. Preventive Medicine
39(3): 6259.
Pages 4657
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: 40917.
Levy, B. R., et al. 2002. Longevity Increased by Positive Selfperceptions of Aging. Journal of
Personality and Social Psychology
83(2): 26170.
Makris, U. E., et al. 2015. Ageism,

Negative Attitudes, and Competing
ComorbiditiesWhy Older Adults
May Not Seek Care for Restricting
Back Pain: A Qualitative Study.
BMC Geriatrics 15(39): 19.
Oresanya, L. B., Lyons W. L., and
Finlayson, E. 2014. Preoperative
Assessment of the Older Patient: A
Narrative Review. JAMA 311(20):
211020.
Levy, B. R., et al. 2012. Association

Between Positive Age Stereotypes
and Recovery from Disability in
Older Persons. JAMA 308(19):
19723.
Oresanya, L. , et al. 2015. Functional Outcomes After Lower

Extremity Revascularization in
Nursing Home Residents: A
National Cohort Study. JAMA
Internal Medicine 176(6): 9517.
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):
13839.
Ory, M., et al. 2003. Challenging

Aging Stereotypes: Strategies for
Creating a More Active Society.
American Journal of Preventive
Medicine 25(3Siii): 16471.
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): 76274.
Palmore, E. 2001. The Ageism

Survey: First Findings. The
Gerontologist 41(5): 5725.
Macnicol, J. 2006. Age Discrimination: A Historical and Contemporary Analysis. New York: Cambridge University Press.
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): 183743.
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): 10015.
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): 91115.
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): 28704.
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): 126.
Fall 2015 Vol. 39. No. 3 | 57
Copyright of Generations is the property of American Society on Aging and its content may
not be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.

ContentServer PDF

Caricato da

Informazioni sul documento

Titolo originale

Copyright

Formati disponibili

Condividi questo documento

Condividi o incorpora il documento

Opzioni di condivisione

Hai trovato utile questo documento?

Questo contenuto è inappropriato?

Copyright:

Formati disponibili

ContentServer PDF

Caricato da

Copyright:

Formati disponibili

GE NER ATIO NS Journal of the American Society on Aging

By Karin M. Ouchida and Mark S. Lachs

Not for Doctors Only:

feature of old age, or treating expected changes

46 | Fall 2015 Vol. 39. No. 3

Ageism in America: Reframing the Issues and Impacts

as frustrating, uninteresting, and less rewarding

Fall 2015 Vol. 39. No. 3 | 47

GE NER ATIO NS Journal of the American Society on Aging

nosed and untreated if healthcare providers

48 | Fall 2015 Vol. 39. No. 2

chronological age without assessing an individuals functional status, other comorbid

than 4 million major operations are performed

Ageism in America: Reframing the Issues and Impacts

superior to chronological age in predicting

Fall 2015 Vol. 39. No. 3 | 49

GE NER ATIO NS Journal of the American Society on Aging

tia affects 8 percent to 15 percent of people ages

50 | Fall 2015 Vol. 39. No. 2

impaired. Sometimes staff talk about their

Ageism in America: Reframing the Issues and Impacts

shown to affect adherence, patient satisfaction,

Ageism Among Older Adults

Fall 2015 Vol. 39. No. 3 | 51

GE NER ATIO NS Journal of the American Society on Aging

persons with positive age stereotypes were 44

52 | Fall 2015 Vol. 39. No. 2

counseling, The Centers for Medicare & Medicaid

Ageism in the Healthcare System

Ageism in America: Reframing the Issues and Impacts

schools had nine or more full-time faculty

verse drug events, conflicting medical advice,

Fall 2015 Vol. 39. No. 3 | 53

GE NER ATIO NS Journal of the American Society on Aging

are not being addressed in the CPGs and are

54 | Fall 2015 Vol. 39. No. 2

Encouraging non-ageist attitudes among

Ageism in America: Reframing the Issues and Impacts

successful AARP campaign to increase physical

Adelman, R. D., Greene, M. G., and

Alexander, K. P., et al. 2007. Acute

ADGAP. 2015. 2015 Match Data

Aronson, L. 2015. The Human

Beck, M. 2013. More Doctors Steer

Fall 2015 Vol. 39. No. 3 | 55

GE NER ATIO NS Journal of the American Society on Aging

Benjamin, R. M. 2010. Surgeon

56 | Fall 2015 Vol. 39. No. 2

Choosing Wisely. 2015b. American

Health Affairs. 2012. Health Policy

Levy, B. R., Slade, M. D., and Kasl,

Ageism in America: Reframing the Issues and Impacts

Makris, U. E., et al. 2015. Ageism,

Levy, B. R., et al. 2012. Association

Oresanya, L. , et al. 2015. Functional Outcomes After Lower

Lewis, J. H., et al. 2003. Participation of Patients 65 Years of Age or

Ory, M., et al. 2003. Challenging

Lindau, S. T., et al. 2007. A Study

Palmore, E. 2001. The Ageism

Sarkisian, C. A., Hays, R. D., and

Sarkisian, C. A., Lee-Henderson,

Fall 2015 Vol. 39. No. 3 | 57

Potrebbero piacerti anche