Ageism as a New Negative Phenomenon in Health Care (Case Study)

Ageism as the new negative phenomenon in health care services. (Casuistry) For the first time, the term ageism was used in 1960 by physician Robert Butler, who defined it as a process of systematic stereotypes and discrimination against people because they are old. In discussing aging, the same author stated that aging is a natural part of the human life cycle and that although we have started to study death, we have somehow skipped one period: the long time interval preceding death. He himself attributed this neglect precisely to ageism, noting that older people are often seen as universal victims because they share certain negative attributes, including senility. Yet if a person is not subject to premature death, age is the destiny of every human individual. In some respects, we can even say that age leads us toward death. (Aronson, 2015) The coherent concept of ageism was later presented in 1969, referring to hostility toward old age, illness, frailty, fear, helplessness, but also uselessness and death, because older people are often considered weak, intolerant of change, and suffering cognitive impairments. Evidence of this negative view of aging has been and continues to be presented by various studies. For this reason, we can say without hesitation that the most often cited reason for discrimination in Europe is age—more precisely, the stage near the end of life. (Schroyen, 2015) Studying ageism, we find that it is a social phenomenon that significantly harms older individuals by putting them aside and similarly devaluing the worth of their experience and knowledge. (Ferreira, 2015) Older individuals are assigned low value, underestimated, rejected, mocked, made less significant, and regarded as a burden on society. They need a lot, but give little. (Lešková, 2009) Older people encounter ageism in many forms and at both regular and irregular intervals. Their experiences with age stigma can range from less benevolent experiences, in which they receive so-called unwanted help, to more hostile ones, in which they face rejection. (Chasteen, Lindsey, 2015) Age stereotypes, for example, are among the most tolerated forms of social discrimination in Canada and the USA. These discriminatory attitudes and assumptions can negatively affect many aspects of life, especially when these assumptions are internalized and accepted as reality. (Genoe, White, 2015, Štefaňák, 2009) Negative conceptions of aging permeate most of society, and the growing body of evidence likewise indicates that negative views of aging are persistent and can have harmful effects both for individuals and for society. (Miche, 2015) According to Irving, evidence of ageism can be seen at every step. In a New York Times editorial, Karpf said: “Older adults are likely seen as a burden and a burden in terms of resources.” This type of gerontophobia is harmful precisely because we have internalized it. Ageism is described as a set of prejudices toward our future selves. This fact also indicates that age is defining our own identity. (Irving, 2015) It is true that there is strong evidence that older adults differ physiologically from younger adults, yet among older individuals there is great variability in health, functional status, life priorities, and medical preferences. Nevertheless, for example, in the United Kingdom, within health policy it is assumed that old age inevitably brings incapacity. (Aronson, 2015) Trentham, in relation to ageism, also points out that seniors remain markedly frustrated in their attempts to influence state policy. Social media often exclude seniors from various public discussions, which in essence is also an expression of ageism. (Trentham, 2015) On a societal level, negative views of aging appear as age stereotypes that lead to prejudice and discrimination toward older individuals. On an individual level, a negative outlook on one’s own aging is associated, among other factors, with poor health, poor life comfort, and even shorter survival. (Kotter-Grühn, 2015) It is clear that manifestations of ageism in society contribute to the worsening of older individuals’ health, and therefore such expressions of age discrimination should be minimized not only in society but also in the context of health-care delivery, because only then can we successfully carry out comprehensive rehabilitation of the older person. Comprehensive rehabilitation is, by contrast, a mutually coordinated, interconnected and at the same time goal-directed process that includes not only therapeutic rehabilitation but also vocational, educational, and social-psychological rehabilitation. We see the removal of age discrimination in health care as a strong strengthening of social-psychological rehabilitation.

If we look at social expectation theory, we see that this theory assumes that a person’s appearance influences how individuals evaluate themselves; therefore, ageism can create in older individuals a sense of lower self-worth. Research results also attest to this phenomenon. In a study completed in 2015 by Sabik, 244 African American, Black and European American women aged 60 and above participated. Body appreciation substantially mediated the relationship between age discrimination and psychological well-being, primarily in Western culture, and this discrimination was associated with lower psychological well-being. Older women in the African American sample did not link higher age with their psychological well-being. (Sabik, 2015) In 2014, a study was carried out to determine the role personality traits and empathy play in the development of ageist attitudes. A noteworthy finding was that respondents who showed greater anxiety and fear about the process of aging were more prone to forming ageist attitudes themselves. (Alan, Johnson, Emerson, 2014) Today, ageism intersects to a large extent with gender discrimination. The term gendered ageism appears, especially in employment. Jyrkinen studied managers’ attitudes in private companies and the third sector and presented claims that women encounter ageism in the workplace in a much greater degree than men. Gendered ageism can occur at many levels of professional development and involves comments about female roles, appearance, sexuality, and even menopause. (Jyrkinen, 2014) Another study explored the relationship between changes in perceived discrimination and changes in depressive symptoms among older people. The relationship between perceived age discrimination and depressive symptoms was analyzed longitudinally along with tests assessing whether self-perception of aging mediates the association. Changes in perceived discrimination were significantly associated with changes in the increase in depressive symptoms over time. Perceived age discrimination is strongly linked to increased depressive symptoms. The findings indicate the importance of identifying perceived discrimination and negative self-perceptions of aging and of how the negative effects of age discrimination may influence self-perceptions of aging and become risk factors for the development of depressive symptoms at the end of life. (Richardson, H, Richardson, J, Virginia, E, 2015) Holding on to negative stereotypes about aging can have many harmful effects on physical health in the long term, including life expectancy. Schroyen states that based on longitudinal observation, he can say with certainty that subjects with negative perceptions of aging live on average 7.5 years less than individuals with positive perceptions of aging. Some studies cited by Schroyen even showed that positive aging stereotypes have a beneficial effect on health restoration in comprehensive rehabilitation; among older people with severe health impairments there was a 44% greater probability of fully recovering in daily activities—bathing, dressing, transferring, and walking, among others—when they were exposed to positive stereotypes. (Schroyen, 2015)

Ageism in Health Care

In 2014, Skirbvekk and Nortvedt published a study examining the ethical aspects of health care among clinicians in treatment and treatment-priority setting for older patients in Norway. Physicians’ and nurses’ views were analyzed using qualitative methods. They conducted 21 in-depth interviews and 3 focus-group interviews in hospitals and general practitioners’ offices. All study participants—nurses and doctors—reported that care of older patients differs from care of younger patients, and even that treatment for older patients has lower priority than treatment for younger age groups. They attributed this phenomenon to various performance targets and budgetary constraints. (Skirbekk, Nortvedt, 2014) When we see such negative consequences of ageism in a non-pathological context, we can reasonably ask whether this influence also applies in the specific context of geriatric oncology. In fact, if one accepts that our perception of aging affects our physical and mental health in normal aging processes, then when physical health is already compromised by illness, we can assume patients will be even more sensitive to assumptions about being of advanced age. (Schroyen, 2015) Sumway and Hamstra also view age discrimination as a phenomenon that increasingly appears in health care, including among oncology patients. Older patients with cancer are less likely to receive surgery or radiotherapy. For rectal cancer, patients over 65 are less often referred for preoperative radiotherapy, even though reducing local recurrence is recognized as standard care even for advanced-age patients. Particularly concerning is the fact that age discrimination is especially prevalent among men with prostate cancer. Some physicians note that for men over 75 with prostate cancer, treatment carries high risk, and thus 67% of them receive primary androgen deprivation therapy (ADT) or no treatment. (Shumway, Hamstra, 2015) It is worth noting that a significant share of patients with cancer are older people, because age is a risk factor for many diseases, including cancer. It is estimated that by 2030, up to 70% of diagnosed cancers in the United States will be in the over-65 age group. The perception and treatment of older oncology patients by health-care workers, including physicians, remain persistently negative. It is also proven that older patients are often excluded from clinical studies. From 1996 to 2002, 68% of patients in cancer-related clinical studies were between 30 and 64 years old, while only 8,3% were between 65 and 74 years of age. There are, of course, many legitimate reasons offered to justify excluding older individuals from clinical studies, such as high mortality, relocation, medical decompensation, and so on. Data from major cancer studies therefore cannot generally be applied to older people, mainly due to the nature of physiological changes associated with aging. In addition, it is important to note that systemic cancer treatment remains more expensive and increasingly expensive. For this reason, for example, the national health-care system in Belgium for cancer treatment is based not only on tumor type and treatment line, but also on patient characteristics, including eligibility criteria for treatment based on median survival. Discrimination against older patients thus does not stop at research but is observable also in clinical practice. It has been shown that for breast cancer chemotherapy, physicians recommend treatment to 99% of patients under 55 years of age, but only 60.4% of patients over 70, even when clinical situations are the same or highly comparable. In addition, 71% of physicians justify their decision based on tumor characteristics and 14% based on high age. Similar research in the UK found that the intensity of cancer treatment is influenced by age in 49% of cases. (Schroyen, 2015)

Figure 1 and 2: Cancer disease treatment

Figure 3: Reasons for refusal of chemotherapy

Other studies have shown that in older patients, pain is treated inadequately not only in oncology. These studies, however, did not address why so many older people continue to experience pain, such as back pain. It is possible that health-care providers focus on pain treatment around acute problems or measurable assessments, such as biomarkers or disease severity scales. Because of insufficient data on the causes of inadequate back pain treatment in older people, qualitative studies identified concrete obstacles that are essential for identifying future intervention targets. The core obstacle is the development of negative attitudes and prejudices by health-care staff. (Makris, 2015) Back pain is the most common type of musculoskeletal pain reported by older adults and the second most common complaint for which patients visit primary care. The goal of the study conducted in 2015 was to understand the views and perspectives of older adults regarding care-seeking for back pain treatment. The study used data from a diverse sample of 93 older adults (median age 83) who reported back pain in the previous three months. From the study it is clear that interactions between older patients and health-care providers can influence older adults’ willingness to undergo treatment or seek treatment. Data analysis revealed several possible reasons for inadequate care, and the narratives show that the nature of interactions with providers contributes to participants’ central attitudes toward strategies for seeking further follow-up care. Participants were very often exposed to the providers’ belief that back pain is inevitable at older ages (this was stated by 74% of interview participants and 75% of focus group participants). The nature of interaction with health-care providers contributed to participants’ core attitudes toward strategies for seeking additional care. This meant that participants often said their provider was not willing to listen to their concerns, or was not willing to consider different treatment alternatives. Many participants felt that providers either had nothing to offer, or were not willing to offer anything new. This approach created negative associations in patients around further back pain treatment. The study author states that the findings suggest that the patient-provider interaction can act as a strong deterrent to future health-care seeking. The provider was identified as a significant obstacle in comprehensive rehabilitation of older individuals. This finding underscores the need to address the issue by improving communication between patient and provider in a model of care for the senior that will be based on shared understanding of treatment goals and, where possible, shared priorities, while also offering new paths for integrated interventions. The importance of patient-provider interactions and their impact on treatment outcomes opens space for the introduction of the term “therapeutic alliance.” The research emphasizes the importance of creating effective partnership, including the need to improve communication skills of health professionals and willingness to involve older adults in their own care toward creation and revision of shared goals. (Makris, 2015) The research study, whose results were published in 2015, showed that increased mortality with age can be traced in women with breast cancer and that this phenomenon is caused by undertreatment. Still, it is important to remember that “advanced” age by itself should not be a contraindication to treatment that can improve a patient’s quality of life. This also applies given the lack of evidence that older people tolerate chemotherapy, radiotherapy, or surgery less well. As for radiotherapy, it has been shown that older individuals demonstrate very good tolerance. Other studies found that postoperative survival is not age-dependent. In addition, it was found that older individuals often receive only conservative treatment, for example in breast cancer, where physicians do not recommend subsequent reconstructive procedures. Physicians recommend breast reconstruction in 95% of patients under 31, compared to only 65% in patients over 59. The question therefore arises—how can such different attitudes toward older people be explained except by age-related stigma? (Schroyen, 2015) According to Kagan and Melendez, ageism in health and nursing care poses a major threat to health and society. Studying the phenomenon of ageism suggests that age discrimination negatively influences health and leads to poor experiences of citizens in health care. Society faces a future in which we will unavoidably need to understand an aging society and confront ageism by developing adaptable model-based programs that prevent ageism or at least limit it. (Kagan, Melendez‐Torres, 2015)

Case Study Diagnostic history: Ján P. Occupation: toolmaker, retired at 63; Alcohol: drinks alcohol occasionally, 2–3 cigarettes per day, does not drink coffee; Initial diagnosis: Instability, gait disorder, VAS LS spine; Final diagnosis established after three years: Mixed gait disorder on the basis of spinal lumbar stenosis, multiple cerebral infarct lesions, diabetic polyneuropathy, celiac disease, suspected but not yet biopsy-confirmed small intestinal lesions; Drug and food allergies: denies; Current long-term medications: Agen 1/2-0-1/2, Prenessa 1-0-0, Insulin Lantus 0-0-16 j, Gabagamma 0-0-1, Thiogamma 1-0-0, Melyd 1-0-1/2, Stadamet 1-0-1.; Therapy: Infusion treatment.

Diagnostic interview: “I never had problems with my legs; it came suddenly, and three years ago my condition began to deteriorate rapidly. Then began my journey full of suffering and misunderstanding from health workers. At my first visit to the family doctor, I was told by the doctor: I think this is a natural part of aging, nothing can be done about it now… This idea that my suffering was inevitable in old knees tormented me, I could not sleep, and psychological problems also joined, such as irritability and fear of the future. At my personal request, the family doctor sent me for neurological examination, which found nothing serious, at least not in the sense of why my legs hurt so much and why I was losing stability when walking. I started to understand my situation as my body being worn out and that every old person has to suffer this way. At the orthopedic examination I met with the same approach. I remember the conversation clearly: “Look at me, I can’t walk, what do you think, what am I to do? I’m in a desperate situation…” The doctor replied: “How old are you actually?” I said seventy, and he said: “What do you expect? You are an old man, you have to get used to that, your best years are behind you…” It was always the same thing. You have to reconcile yourself with old age. I have reconciled with that, but can no one help me so that I don’t suffer like this? My walking was becoming increasingly unstable, I could no longer step over the threshold to the living room, my weight kept dropping, I became emaciated and weak and feeble. I developed diarrhea and loss of appetite, I felt bloated. I ate only to stay alive. Later, it was before Easter; I went out into the garden to get some fresh air, I couldn’t maintain my stability, I fell, and lay on the ground until my son found me—about twenty minutes. Because of the fall I fractured three ribs, and then was hospitalized in surgery, where they gave me medicines and infusions. I don’t want pills, I want to know what is wrong with me! That was my plea to the health workers. It is not enough for me to hear that I am old, is it? At that moment in the hospital bed I felt a wish to die, to leave this world, especially when the doctor again explained that I no longer can go out into the garden on my own. You’re already your age, Mr. Ján… realize that, those were the words I often heard from doctors. I saw the physician who was my attending doctor about five minutes a day. I needed to talk with someone, with a professional, someone I could tell about my worries. Will this get worse? Is this really related to age? After my hospitalization, my eldest daughter assumed my care. Under pressure on the doctor she arranged another hospitalization in neurology, where I lay for ten days. I assumed that my illness was something I would likely have to learn to live with. The constant weight loss also worried me, but the doctor explained that with age muscle mass declines automatically, that is why I lost weight, and that this is individual—some people lose more muscle, some less. Gradually they began creating in me a picture of a future life in a wheelchair, saying that this would be the best solution for the future. I managed the pain somehow, but why this huge instability when walking? The doctors obviously attributed this to age and certain age-related changes in my spine and brain; they even linked it to diabetes, although I had that under control. A change in how they approached me came abruptly. I do not know if it was divine intervention or mere chance. Before that, however, I should mention one more illness of mine, if I may call it that. I had never dealt with this, and when I showed it to doctors, they merely shrugged their shoulders and ignored it, so I ignored it too. I had tiny blisters under my elbows that sometimes itched intensely, I scratched them until they bled; there were days it was fine, but sometimes I could not stand it, especially at night I scratched continuously. My middle daughter also had this problem, but after examinations she was finally diagnosed with celiac disease. Exactly then I was still in that same neurology ward. My daughter came and insisted on speaking with the chief physician; she told him it seemed that we have celiac disease in the family and asked whether all my problems, which were being attributed to age, might be caused in part by celiac disease. From that moment I started to feel a change in how I was being treated. Suddenly there was a possibility of a diagnosis that was not age-related. Blood was taken for antibodies, I think that is the gluten test. Doctors around me joked: choose what you will eat more easily—potatoes or flour. I said, potatoes, because I knew if celiac disease was confirmed, I would not be able to eat anything made from flour. Then I did feel relief—not because I would be glad to have celiac disease, every disease is bad, but because in my own mind I had always suspected that my age was being blamed unjustly and that I should have been sent for further tests. The anti-gluten antibodies were positive, and yet I still had to undergo a biopsy of the small intestine. The doctor told me that after starting a gluten-free diet they expect overall improvement in my condition because celiac disease is systemic, but I will never be completely healthy again. I do not know how severely my small intestine is damaged; they said there are several degrees of damage, and whether it will ever heal. And whether some of my symptoms will subside when I start the diet, I do not know for certain. It is true, the neurologist explained, that the current form of celiac disease, especially in adults, behaves like a chameleon and is truly difficult to detect. I somehow believe them, because when this hypothesis was brought to the hospital by my daughter, they acted very quickly… They looked at my elbows and asked when I had lost this much weight and whether food still tasted good. But what hurts me most is that I was often rejected as a patient because of my age. Do you think a 70-year-old person is that old? I think not. At neurology, I met a young doctor who was willing to speak with me openly and honestly. He was a wonderful person—very compassionate and kind—and I am grateful he was available to me, even for a short time, and during our conversation did not mention or allude to my age so often. He explained age-related changes that in my case seemed to have occurred perhaps somewhat earlier than in others, because it is true that we all age differently, and he also asked about my personal life, whether I had personal concerns and problems and whether I was often getting irritable; he explained that the mind also plays its part and that I should downplay some things and not take them too seriously. This, however, was only one positive experience with a doctor during three years of my treatment…”

Diagnostic conclusion: The case study indicates that interaction between patient and health-care provider can often be so discouraging that an older patient may not seek further medical care at all. Mr. Ján P., in his interview, essentially spoke from his perspective about the quality of interactions between an older patient and a health-care provider. It is possible that Mr. Ján P. developed a high sensitivity to remarks about his age, and for that reason longed for different behavior and different attitudes from the treating staff. We even observed that the patient developed a near-aversion to statements concerning aging and advanced age.

Conclusion

The ability to cope with disability differs for each person and is related to the circumstances under which disability occurred. (Bienertová, 2014) It is clear that very often attitudes of an individual in whom disability emerges are also shaped by the behavior of intact individuals, who marginalize disabled persons through their behavior. (Bienertová, 2012) Intact persons—thus, people coming into contact with the older person—unquestionably include the treating staff. The modern patient, and therefore the senior as well, should nevertheless be a partner who participates in the nursing process itself, should co-decide about his or her health, and should have his or her needs and rights ensured. (Vaňharová, Mauritzová, 2015) With the term “ageism in health care,” we refer to the overt and subtle ways in which older people can be treated unfairly and treated by health-care providers, or are exposed to undignified treatment simply because they are of advanced age. We know that ageism or negative age-based stereotypes are directly associated with unfavorable or even incorrect treatment outcomes. Despite efforts to combat the negative perception of seniors, the negative impact of ageism on the physical and psychological health of older people persists. (Makris, 2015, Štefaňák, 2013) Most studies conducted on this topic recommend that people working in health care should be educated in gerontology, develop accurate knowledge about the process of aging, and increase their interest in working with older adults. (Coffey, 2015) William Hazlitt described prejudice as “the child of ignorance.” While removing prejudice may be a utopian matter, the first step to overcoming ageism in medicine is recognition of the problem. (Aronson, 2015) The quality of coherent health care for a growing population of older adults should include psychosocial intervention aimed at rejecting ageism, which in the context of what we have learned appears to be a strong social barrier that makes comprehensive rehabilitation of the older person difficult. Older adults speak of interaction quality as a significant factor in decisions about potential future care. The overall findings suggest that older adults within provided care seek behavior and attitudes from health professionals that contribute to improved communication between patient and health-care provider specifically in the context of so-called therapeutic alliance, which should not be colored by ageist attitudes or prejudices toward advanced age. Therapeutic alliance between treating staff and the older person appears to us as the right path within comprehensive rehabilitation of the older individual, with first-contact medical and nursing staff becoming part of this comprehensive rehabilitation. Patient-senior interaction with health-care providers, founded on a therapeutic alliance based on rejecting age discrimination, sensitive approach, and a holistic view of the senior’s medical history, will contribute to comprehensive rehabilitation of the older person in the context of positive psychosocial influence.

Author: Mgr. Katarína Kotradyová, PhD. OZ Deti slnka References

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