Ageism in Clinical Encounters
August 2020 Issue
We're getting older. Obviously, each of us is aging by the hour, but the US population is also aging. According to 2019 population data from the Census Bureau, "The 65-and-older population grew by over a third (34.2 percent or 13,787,044) during the past decade, and by 3.2 percent (1,688,924) from 2018 to 2019. The growth of this population contributed to an increase in the national median age from 37.2 years in 2010 to 38.4 in 2019…."1 A decrease in birth rate and an increase in life expectancy both contribute to this phenomenon, but the most significant contribution comes from the aging of the baby boomer generation.2 Babies born in 1946 (at the beginning of the baby boom following World War II) turned 65 in 2011, those born in 1964 (the end of the boom) will turn 65 in 2030, and by 2034 there will be more older adults than children in the United States.2 Interestingly, despite this change in national demographics, a comparison of the American Board for Certification in Orthotics, Prosthetics and Pedorthics' 2006 and 2015 Practice Analysis surveys shows a decline in the percentage of patients over the age of 65 seen by the respondents.3 Whatever the exact numbers are, O&P clinicians report that between 30 and 40 percent of the patients they see are over the age of 65, and it is reasonable to predict that this percentage will increase over the next decade.
Different demographic groups present different clinical challenges. For example, providing care effectively to infants and young children involves working closely with adult caretakers and requires a set of skills to accommodate various developmental stages, reduced cognitive capacity, and limited verbal abilities. In addition to the challenges inherent within each group, clinicians may encounter challenges caused by their own attitudes regarding patients with those particular characteristics. These attitudes may be overt and clearly understood, or deeply ingrained and not explicit. This article examines biases based on age.
Ageism, or "prejudice by one age group towards other age groups" was first described in a 1969 article by Robert Butler, a physician, gerontologist, and founding director of the National Institute on Aging.4 Butler compared discrimination based on age to discrimination based on race or social class, and while it can be seen in any age group toward any other, he put particular emphasis on negative attitudes directed by younger individuals toward those who are older. He suggested that ageism could be expected to be "especially evident in America" because of the emphasis in American society on "pragmatism, action, power, and the vigor of youth over contemplation, reflection, experience, and the wisdom of age…."4 In explaining the source of this bias against the elderly, Butler described all forms of prejudice as an "effort to justify one's own weaknesses by finding them in others…. Personal insecurity, once generalized, becomes the basis of prejudice and hostility…. Age-ism reflects a deep seated uneasiness on the part of the young and middle-aged—a personal revulsion to and distaste for growing old, disease, disability; and fear of powerlessness, ‘uselessness,' and death."4
The author of a recent article on ageism supported Butler's description of the roots of bias against the elderly: "Worries about the outcomes of the aging process reflect personal fears about aging and are probably related to an inner desire to satisfy social ideals of youth, typical of western societies, which promote an anti-aging culture…. Young adults, anxious about their future, attribute to older people the negative stereotypes that they fear will describe their own futures."5 Cecilia Flores-Sandovala and Elizabeth Anne Kinsella, PhD, researchers at Western University in London, Ontario, write: "In a society that worships youthfulness, ageism arises from rejection of the reality of human mortality and the denial of older age," and suggest that to younger individuals, older adults "represent a reminder of potential decline and eventual death."6
Providing care to patients who have experienced extreme physical trauma has often caused me to think about and fear my own vulnerability and the risks of experiencing similar trauma, and I suspect that other practitioners have similar thoughts and feelings. When caring for elderly patients we may be reminded of our own aging and physical decline, and the associated feelings of vulnerability and fear may induce negative attitudes toward and responses to those patients. These negative perspectives can be strengthened when the health conditions are caused, at least in part, by unhealthy behaviors such as physical inactivity, obesity, and smoking. We may find ourselves resenting the inevitability of our own decline, as well as the increased demands placed on us by patients who we believe have not cared for themselves appropriately or have unreasonable expectations given their age. If not properly addressed, these negative attitudes can creep into our interactions with patients, and result in lower quality care.
Manifestations of Ageism
When a particular bias is pervasive within a culture it can be difficult to detect because the ways in which it is expressed are easily interpreted as normal and even appropriate. Closer consideration of words, behaviors, and attitudes common in everyday life often reveal underlying stereotypes and patterns of prejudice. Pejorative or patronizing terms, like "old fogey," "old fart," "little old lady," "old bag," "sweetie," and "honey" can marginalize or demean elderly people, and associate them with negative generalizations related to their age.4,7 Praising older people by comparing them to younger people, talking to their younger companions rather than directly to them, assuming that they lack familiarity with technology, and thinking it's "adorable" when they do things normally associated with youth can indicate assumptions about the general inferiority and irrelevance of older individuals.7
Researchers Debra Roter, DrPH, and Judith Hall, PhD, report in their 2006 book Doctors Talking With Patients / Patients Talking With Doctors that "evidence of negative physician attitudes towards elderly adults in outpatient medical practice is sparse and somewhat contradictory" and even describe some ways in which physician communication with older patients was superior to communication with younger patients. Physicians can be more courteous and warm, and provide more appropriate explanation to older patients.8 However, Hazel Macrae, PhD, reports that "older persons are stereotyped as lonely, depressed, incompetent, asexual, intellectually rigid, sickly and senile," and a 2002 review of ageism research spanning 30 years concluded that "research has consistently shown that the attitudes of health care professionals regarding older adults tend to be the same as or even worse than society in general."9 Negative attitudes common in society become even more serious if they inappropriately influence medical decisions and decrease the quality of care. While evidence of blatant ageism may be lacking, there is research evidence that physicians treat older patients worse than they treat younger patients.8 Some of the findings described by Roter, Hall, and Macrae are shown in Figure 1 (pg. 30).
Ageism Among the Old
Donizetti points out that "ageism is quite different from other forms of prejudice because it represents bias and discrimination by members of one group against members of a second group which the first group will one day join…. Furthermore, all individuals are destined to become old, unless death arrives before they can experience old age."5 Younger people who harbor negative attitudes toward older people strengthen individual and societal stereotypes and biases that are bound to negatively impact them later in life. While there is some evidence that ageist attitudes decrease with age, there is a "tendency of elderly people to have a more prejudiced attitude toward their own age group."5 As surprising as this may be, it is consistent with the way other forms of prejudice impact other groups. Macrae notes that "victims of prejudice and discrimination often adopt the dominant groups' negative image of the subordinate group," and quotes another researcher in reporting that older individuals "tend to accept many of the negative stereotypes about old age that younger people accept."9 To distance themselves from negative stereotypes about old age, elderly individuals may "avoid identification with their own group" by looking and acting younger, and avoiding behaviors and associated with old age.9 Elderly patients may reference stereotypes about older persons' excessive healthcare utilization or frequent complaining by pointing out that their behavior does not fit this pattern.9 Contrasting their behavior with the stereotype can serve to reinforce it: "Most old people are a certain way, but I'm not." The negative attitudes that go along with the stereotype are likely to impact every older patient, even those who consider themselves the exception.
Positive Stereotypes With Negative Impact
Well-meaning attempts to encourage positive experiences during aging can also reinforce negative stereotypes and biases. Flores-Sandovala and Kinsella describe how our attempts to convey caring and improve communication can degrade into elderspeak, "a patronizing form of speech…that involves high and exaggerated pitch, slow rate of speech, simple vocabulary and sentence structure, the use of collective pronouns, as well as personal terms of affection."6 The terms "active aging" and "successful aging" can strengthen the idea that people who exhibit the productivity and independence commonly associated with youth are more valuable than characteristics associated with old age.6 "Perceptions of aging, including the dichotomies between ‘successful'/‘unsuccessful' aging and ‘active'/‘inactive' aging, are heavily influenced by the systemic structures within which health practitioners work, as well as biomedical perspectives, which may unintentionally promote the idea of decline and a negative view of the aging process."6 People may be viewed as more valuable if they can delay the consequences of aging, or at least act as if they are not old. This perspective "gives little attention to poverty, trauma, suffering and marginalization," which are daily realities for many of our patients.6 Examining these attitudes can reveal to what extent our assessment of an individual's worth and value is attached to his or her youth and physical health. Most of us value economic productivity, comfort, and health, and prefer to retain them as we age. However, this can cause us to devalue individuals who have none of those things. We must remember that older adults are more than "a collection of deficits and incapacities."6
Most clinicians know that it would be unwise to rely on age-based assumptions about a patient's function when designing an orthotic or prosthetic intervention. As professionals devoted to improving functional capabilities, we must be aware of other ways in which we may unintentionally marginalize elderly patients. It is our professional duty to support and encourage increased activity and function, and it is appropriate to celebrate our patients' achievements in that regard. However, the inherent worth and value of every patient is unrelated to his or her functional ability. Working with high-functioning patients may be more rewarding in many ways, but finding ways to celebrate the dignity of every patient can help us avoid treating those who are more limited with less respect and care.
The way we talk about and treat elderly patients in every aspect of our interactions can reinforce negative stereotypes or contribute to a more accurate and positive understanding of their worth. Taking the time to think about and discuss our attitudes toward the elderly can reveal opportunities for growth. According to Donizetti, "the acquisition of new knowledge concerning a given object or population has been considered one of the most effective methods of changing attitudes."5 Discussing cases and sharing stories about elderly patients in a way that celebrates their inherent worth rather than their functional accomplishments can contribute to a more holistic understanding of their value. O&P EDGE
John T. Brinkmann, MA, CPO/L, FAAOP(D), is an assistant professor at Northwestern University Prosthetics-Orthotics Center. He has over 25 years of experience in patient care and education.
1. US Census Bureau. "Older Population and Aging," "65 and Older Population Grows Rapidly as Baby Boomers Age." https://www.census.gov/topics/population/older-aging.html; https://www.census.gov/newsroom/press-releases/2020/65-older-population-grows.html
2. US Census Bureau. "The Graying of America: More Older Adults Thank Kids by 2035." https://www.census.gov/library/stories/2018/03/graying-america.html#:~:text=Fewer%20babies%2C%20coupled%20with%20longer,substantial%20imprint%20on%20the%20population.
3. The American Board for Certification in Orthotics, Prosthetics and Pedorthics. "Practice Analysis of Certified Practitioners in the Disciplines of Orthotics and Prosthetics." https://www.abcop.org/individual-certification/Documents/Practitioner%20Practice%20Analysis.pdf
4. Butler, R. N. 1969. Age-ism: Another form of bigotry. The Gerontologist 1;9(4_Part_1):243-6.
5. Donizzetti, A. R. 2019. Ageism in an aging society: The role of knowledge, anxiety about aging, and stereotypes in young people and adults. International Journal of Environmental Research and Public Health 16(8):1329.
6. Flores-Sandoval, C., and E. A. Kinsella. 2020. Overcoming ageism: critical reflexivity for gerontology practice. Educational Gerontology 46(4):223-34.
7. Star Tribune. "12 examples of everyday ageism." October 17, 2017. https://www.startribune.com/12-examples-of-everyday-ageism/451306773/
8. Roter, D., and J. A. Hall. 2006. Doctors talking with patients/patients talking with doctors: improving communication in medical visits. Greenwood Publishing Group.
9. Macrae, H. 2018. ‘My opinion is that doctors prefer younger people': older women, physicians and ageism. Ageing & Society 38(2):240-66.