Understanding and combatting ageism in healthcare

Dane Wanniarachige
Dublin, Ireland

 

Their last hand to hold” by Emily Nguyen.
February 22, 2019.

As I waited for the tram on a windy day in Dublin, I noticed an older man wearing a flat cap shuffling unhurriedly towards the busy platform with a noticeable parkinsonian gait. The tram slowed to a halt and as soon as the doors opened, a gust of wind blew the gentleman’s hat upward and behind him into a parking lot enclosed by a tall iron fence.

“My hat, my hat!” he cried out. I noticed that several passengers looked over their shoulders as they boarded, but most did not give it a second thought as the doors closed, leaving the man in a new crowd of bustling people eager to reach their next destination.

Ageism is predominantly defined as negative attitudes toward older adults.1 In Robert Butler’s (1969) paper where he first coined the term ageism, he says that the attitude “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.”2 This predisposition manifests like other forms of discrimination, where a group is considered to be different or “other.” As a result, older persons are “categorized as senile, rigid, and old-fashioned in morality and skills… we subtly cease to identify them as human beings, which enables us to feel more comfortable about our neglect and dislike of them.”2

In an opinion article about ageism in healthcare, Dr. Kenneth Rockwood, a Canadian geriatrician, recalls this discussion with a trainee doctor: healthcare is overstretched, she argued. “We can’t do everything for everyone, so why spend money on old people, who have little chance of benefit?” For her, ageism is not all that bad — in fact, it is a practical response to limited resources.3

The student doctor’s attitude is embedded in the philosophy of utilitarianism – patients who can contribute more to society should be given priority. In a study by Wiseman (2007), utilitarian attitudes were exhibited by university students who were asked to triage healthcare situations – as opposed to a more egalitarian approach that supposes all people are of equal worth. In a response to a survey asking introductory psychology students to rank the priority for treatment of a hypothetical patient with kidney disease, participants favored patients who were young, had children, and were mentally healthy.4

The irony of this attitude, of course, is that ageism is one form of prejudice against our own selves, specifically our “feared future self.”5 This attitude persists despite the understood inevitability of aging and our exposure to the scale at which it is occurring. The World Health Organisation estimates that the population of people over age sixty will reach two billion by 2050 – composing 22% of the global population.6 One explanation for the cultural willingness to maintain such an attitude is the Terror Management Theory. This theory suggests that a fundamental function of societal ageism is to protect ourselves from the anxiety of our own mortality. Because of the association between age and death, ageism allows “the younger person to deny the reality that they too will eventually become part of that outgroup.”5

As the world transitions to accommodate the realities of normal aging, there are stark consequences of this pervasive prejudice toward older adults. Compared to other forms of discrimination such as sexism and racism, not only is ageism socially acceptable, it is strongly institutionalized, undetected, and unchallenged.7 These attitudes are so deep-seated that older people internalize them and hold negative self-views that affect their well-being.8 It is therefore critical not only to account for these stereotypical concepts of an older person, but also determine how they are detrimental in healthcare – stereotypes by definition fail to recognize the complexity and variation within a population. In Jan Baars’ (2012) Aging and the Art of Living the author was shocked by the treatment of the elderly as “almost another species who were mainly of interest as objects of care.”9 Conceptualizing older adults in single-dimensional views such as “demented” or even “wise,” undermines care that should be “embedded in the life of persons with dignity in their own right, not simply problematic beings needing care.” He says that carers for this population should regard patients as “socially located, vulnerable, and unique individuals ready to live possible futures filled with perils and promise.”9

Ageist societal conceptions have negative impacts on health – those who hold negative views of self have poorer recovery from disability. Furthermore, these values are embedded in the institution of healthcare, resulting in poorer health outcomes.7

 

How Can We Combat Ageism?

While volunteering in a long-term care center a few years ago, I spent some time with a pleasant gentleman named Walter. The octogenarian, now confined to a wheelchair, told me his story: his wife had died a few years ago, he had buried one of his children, and many of his closest friends were now gone. But despite his hardships and his loneliness, Walter was friendly and gentle and exuded warmth. Every day, I would take Walter out to the courtyard where he enjoyed the sunshine and we would chat. He told me about his passion for music, and how he played piano in bars and clubs when he was a younger man, “We called it pop music, it’s different from what the pop music is now,” he said.

I asked him if he knew there was a piano in the gymnasium, which he was surprised to hear. I will never forget the first time I excitedly wheeled Walter down to the piano. I removed the bench and rolled his wheelchair into the proper position. Without missing a beat, his fingers danced on the keys and a crowd slowly gathered around the piano of other patients and residents smiling and clapping their hands. Walter was beaming. For the rest of my time in that center, the favorite part of my day was taking Walter down to the piano whenever he asked, to be treated to a display of the beauty and compassion of a man through his music.

To see an older adult as less than what they are – an amazing human being – is not only detrimental to them, but to ourselves. When my grandmother was dying in Sri Lanka, the last time my family visited, I watched my dad transfer her emaciated body from the wheelchair to the bed and clear her airway with a suction catheter. This was not just a frail old woman, who could barely speak and was dependent on caregivers. It was a woman who gave birth to and raised nine children from a small mountain village in Sri Lanka. A woman who saw me grow up and took care of me. A woman who, despite the language barrier, I loved to make laugh with my goofy behavior. She was my grandmother.

According to Butler, “Ageism allows the younger generations to see older people as different from themselves; thus, they subtly cease to identify with their elders as human beings.”10

Evidence suggests that overcoming future-self discrimination is quite intuitive. The more time people spend caring for older adults, the more these ageist attitudes recede. In Lytle and Levy’s (2017) study that tested The Positive Education about Aging and Contact Experiences (PEACE) model, they determined two key factors for reducing ageism: education about aging, and extended contact.11 In Jonson’s (2012) article published in The Gerontologist he suggests that society is struggling to update the stereotypes of old age, “a misunderstanding that can be corrected with factual information… The health, mental abilities, financial security, social activity, and life satisfaction of older people has increased, but most people have not heard the good news.”12 Research also suggests that negative attitudes stem from a lack of positive contact between group members. Positive contact with older adults is associated with less ageism, with the strongest effect observed for close relationships such as friendships. This exposure allows for individual identities to become more salient with a richer, more holistic view of individuals.12

In 2016, the World Health Organization adopted the first global strategy and plan of action on ageing and health, which spans a fifteen year period and calls for a global campaign to combat ageism.13 The campaign seeks to inform the public about the individuality of older persons, influences on health, and aspects of healthy aging. The program mandates changes in societal attitudes, more accessible environments, and changes to health care systems that align with the needs of older people.

If all healthcare workers – not only geriatric practitioners – are attuned to these needs, patients are treated holistically, with both medical and psychosocial needs accounted for. I had the pleasure of hearing the colorful stories of many patients and getting to know them as human beings rather than “objects of care.” Patients leaving the hospital showed so much gratitude, and each day I walked away feeling fulfilled. While it may not be for everyone, I can understand why geriatricians are ranked as the subspecialty with the highest job satisfaction – and maybe this should be another selling point for a career that is overlooked in a profession where burnout is so prevalent.14

On that windy day in Dublin, I stopped for a moment when I saw the man’s hat blow off on the platform, and I ran around the enclosed part of the parking lot until I could enter it. I picked up his hat and handed it to him through the gap of the iron fence.

“Thank you, God bless you,” the man said.

When I came back around to the platform, I chatted with him for a few moments until the next tram arrived and he shook my hand. I will not forget how appreciative he was of such a small gesture. I can only hope that when I am in that man’s shoes someday, others would take the time to do the same.

 

References

  1. Bratt, Christopher, Dominic Abrams, Hannah J. Swift, Christin-Melanie Vauclair, and Sibila Marques. 2018. “Perceived Age Discrimination Across Age In Europe: From An Ageing Society To A Society For All Ages.”. Developmental Psychology54 (1): 167-180. doi:10.1037/dev0000398.
  2. Butler, R. N. 1969. “Age-Ism: Another Form Of Bigotry”. The Gerontologist9 (4 Part 1): 243-246. doi:10.1093/geront/9.4_part_1.243.
  3. “Frailty And The New Ageism – Evidence Network”. 2019. Ca. https://evidencenetwork.ca/frailty-and-the-new-ageism/.
  4. Wiseman, David. 2007. “Patient Characteristics That Impact Healthcare Resource Allocation Choices: Relative Impact Of Mental Illness, Age, And Parental Status”. Journal Of Applied Social Psychology37 (9): 2072-2085. doi:10.1111/j.1559-1816.2007.00251.x.
  5. Nelson, Todd D. 2005. “Ageism: Prejudice Against Our Feared Future Self”. Journal Of Social Issues61 (2): 207-221. doi:10.1111/j.1540-4560.2005.00402.x.
  6. “Ageing And Health”. 2019. Int. http://www.who.int/en/news-room/fact-sheets/detail/ageing-and-health.
  7. Officer, Alana, Mira Leonie Schneiders, Diane Wu, Paul Nash, Jotheeswaran Amuthavalli Thiyagarajan, and John R Beard. 2016. “Valuing Older People: Time For A Global Campaign To Combat Ageism”. Bulletin Of The World Health Organization94 (10): 710-710A. doi:10.2471/blt.16.184960.
  8. Moberg, David O., and Todd D. Nelson. 2003. “Ageism: Stereotyping And Prejudice Against Older Persons”. Contemporary Sociology32 (5): 563. doi:10.2307/1556464.
  9. Sheets, Debra. 2013. “Jan Baars. Aging And The Art Of Living. Baltimore, MD: John Hopkins University Press, 2012.”. Canadian Journal On Aging / La Revue Canadienne Du Vieillissement32 (4): 454-455. doi:10.1017/s0714980813000548.
  10. “Psychiatry And The Elderly: An Overview”. 1975. American Journal Of Psychiatry132 (9): 893-900. doi:10.1176/ajp.132.9.893.
  11. Lytle, Ashley, and Sheri R Levy. 2017. “Reducing Ageism: Education About Aging And Extended Contact With Older Adults”. The Gerontologist59 (3): 580-588. doi:10.1093/geront/gnx177.
  12. Jonson, H. 2012. “We Will Be Different! Ageism And The Temporal Construction Of Old Age”. The Gerontologist53 (2): 198-204. doi:10.1093/geront/gns066.
  13. “Global Campaign To Combat Ageism”. 2019. World Health Organization. https://www.who.int/ageing/ageism/campaign/en/.
  14. O’Neill, Desmond. 2011. “Dialogue At Davos For An Aging World”. Journal Of The American Geriatrics Society59 (8): 1540-1541. doi:10.1111/j.1532-5415.2011.03504.x.

 


 

DANE WANNIARACHIGE is a fourth-year medical student at Trinity College Dublin in Ireland. He is interested in medical journalism, healthcare policy, and geriatric medicine and holds a master’s degree in Journalism and a Bachelor of Medical Science degree from Western University in London, Ontario, Canada. He has written for the Canadian Medical Association Journal, Evidence Network, and the Windsor Star. Currently, he is a co-editor-in-chief of the Trinity Student Medical Journal.

 

Spring 2019  |  Hektorama  |  Doctors, Patients, and Diseases