Chapter 4 – Age
4.1 Acknowledging Age Bias in Medicine
Laurie Belknap DO and Camilla Curren MD
Understanding Age Bias
Barbara is a 90-year-old woman who recently moved to a rural Ohio town to be closer to her youngest son. She is independent and healthy, and until a year ago lived alone in a cabin in the Colorado Rocky Mountains. The elevation and isolation of the cabin became problematic as Barbara aged, and her family became concerned about access to health care. The only hospital was a regional care facility about 45 minutes away.
After relocating to Ohio, Barbara decided to establish care with a primary care physician She scheduled her appointment in an outpatient Family Medicine office. When she arrived in the waiting area, the receptionist spoke to her in a very loud voice even though Barbara has no problems with hearing. Barbara laughed when the receptionist mistakenly assumed that her son was her husband. The medical assistant escorted her back to the examination area and asked what medications Barbara was taking. Barbara replied that she uses Natural Tears for dry eyes, but that she has never taken any medications. The medical assistant asked repeatedly for medications and dosing. “Perhaps she just doesn’t remember,” she said to the patient’s son.
The physician was pleasant and polite, but also seemed a bit frustrated with Barbara’s visit. “I just don’t know how I will be able to bill this since there is nothing wrong with you,” she told Barbara. “Medicare won’t pay if you are healthy.” Barbara was not sure what to offer in order to help the physician but felt as though she was pressured to have some kind of physical ailment. “I think I need a tetanus shot,” she said, remembering that her daughter in law had mentioned that she might need one when they spoke the day before. “And I need to see an eye doctor about my vision,” even though Barbara had already seen an ophthalmologist a few months before leaving Colorado. That seemed to make the physician happy, and so Barbara left the office after receiving a tetanus shot and a referral to an eye doctor for presumed decreased vision.
What messages are being sent to Barbara about her health through her experience with the providers? What actions, by the providers were the result, either directly or indirectly, of attitudinal bias? How did provider bias impact the care that Barbara received? What might the primary care practice have done differently that could have improved Barbara’s care?
Aging and Bias in the Medical Community
Ageism is a term used to describe stereotyping that can ultimately lead to discrimination against older people. While ageism may vary in different cultures, causes for bias against older people can be multifactorial and socially complex, and may possibly originate in childhood or early clinical training experiences.1 Health care providers may further be predisposed to the development of ageism due to increased exposure to chronically ill or medically fragile patients at the end of life.2
In fact, bias against the elderly may be the strongest and most socially acceptable bias.1 In one study, groups of nursing students and working nurses exhibited negative implicit attitudes towards older people, though nursing students had less implicit attitudinal bias than working nurses.3 In another study, evidence was found to suggest that mental health providers believed that mental illness was a normal part of aging and that older adults would not benefit from psychotherapy.4 Medical care providers with more experience had decreased negativity in attitudes toward older patients, but this article also suggests that clinical experience and level of training are not predictive of a provider’s attitude toward the elderly.2
Anti-aging bias among healthcare providers can affect decisions regarding the evaluation and treatment options that are offered to older adults and could result in disparities in health care for the elderly.4,5
The Medical Impact of Bias Against Older Persons
The presence of attitudinal bias in the medical community can transcend the confines of the profession and impact patient care at many levels according to a recent literature search. While several studies have looked at the impact of ageism among primary care providers2,5 others have demonstrated age-related bias among other providers including rehabilitation professionals.6 The cause of bias may be multifactorial.1 Several factors are theorized as being contributory to physician or health care provider preconceptions about aging and older adults.
One study suggested that a lack of general knowledge or decreased understanding of normal aging processes among primary care physicians can result in inadequate or improper patient care.2 The degree of contribution of knowledge deficit to bias seems to depend upon the age of the provider, as well as on his or her ethnicity and/or race. The contribution of ethnicity and race to the development of bias against the aging has been termed in one study “cultural ageism.”7 Another study investigated the presence of beliefs about declining memory as an age-related change across the lifespan. High school aged students, college students; middle-aged and older adults in the community were studied. The findings supported the author’s hypothesis that high school students and younger participants had more stereotypical and less accurate views of memory decline with aging than did the other groups.8
There are many other common misperceptions about older people. Common beliefs include the ideas that older adults are unable to adapt to change or learn new information, that they are often bored, irritable or angry, or that they become more religious with age. One study found that the vast majority of the time, these assumptions are incorrect.2 In addition, healthcare providers often assume that older people are not sexually active, or are not interested in sexual activity. But one article suggests that this is simply not true and that one half to two-thirds of older adults are sexually active. This study also suggests that the biggest limitation to sexual activity is the lack of a partner, especially for older women.9 Older patients may not be appropriately counseled about or screened for sexually transmitted infections due to erroneous provider assumptions about their sexual activity.9,10
Hearing loss is also commonly associated with aging by healthcare personnel.
“They think we are all deaf,” says Lois, age 75, “but I can hear just fine.” Her reflection is supported by one study, which suggests health care providers often assume hearing loss is associated with normal aging. And while hearing can decline with age and can even contribute to profound sensory impairment that increases social isolation, it is not inevitable or usually untreatable.11,12
Physician and Provider-Patient Relationships: The Cost of Attitudes About Aging
Despite known implicit biases among medical students and healthcare professionals, there can be a clear dissociation between implicit bias and explicit attitudinal and behavioral measures.13,14 What we say or do may differ from what we believe, but the relationship between elderly people and their health care providers can be significantly impacted by implicit or explicit bias.
“They all think we are demented,” says one elderly woman. “I like my doctor’s office, but they always act like I am forgetful. “ Her point is supported by evidence that age-related memory decline is likely due to decreased cortical volume which can result from disease or chronic conditions. Interestingly, cumulative years of education has been shown to have a protective effect on cortical volume with preservation of memory.15
A literature search supports other patients’ observations that mental health professionals may believe that mental illness is normal in aging.4 Given this misconception, accurate diagnoses or appropriate treatments may be overlooked by the physician. One study confirmed that, despite the knowledge that depression and suicide is a major national health problem, physicians were less willing to treat older or retired patients despite recognizing suicidal ideation.16 Healthcare professionals’ perceptions of older adults could also be disadvantageous to seniors in need of less critical mental health care. The same symptoms of mental health issues were judged to be clinically less severe in older adults than in younger patients according to one study.4 Another study suggested that primary care physicians were less likely to treat depression and suicidal ideation in older patients, despite adequate recognition of the presence of either condition.16 The underutilization of mental health services by seniors is likely a result of many factors, but bias among mental health providers or primary care physicians may be a contributing cause.4
Yet another study found that there is age bias often found in physician recommendations for physical activity for arthritis management in adults5, with physicians consistently recommending exercise to younger patients but not conveying that standard advice to their older.ones.5
Bias in Interprofessional Relationships
Bias by colleagues against older physicians “begins earlier than you think it does”, according to Pat Ecklar, MD, a retired Columbus internist with 40 years of experience in treating adults of all ages, including many senior patients. Dr. Ecklar previously served as the internal medicine residency director for Mt. Carmel Health and is now a faculty member at the OSU College of Medicine. Ecklar points out that remaining competent and up-to-date on medical care advances is incumbent upon all physicians, but that these skills are sometimes questioned by learners and colleagues when the physician is over 50 years of age. Similarly, studies indicate that physician cognitive performance17 and stress tolerance18 decline with aging, although the overall effects on patient care are difficult to determine due to the complex mix of factors that go into clinical care provision.17 Nonetheless, the relevance of the older physician as clinician or medical teacher may be questioned by patients and learners who define medical care and competence more narrowly, according to Ecklar. And calls for proven competency maintenance through simulation or other means have been made by various medical societies where older physicians are concerned.18 Nonetheless, Ecklar points out that the breadth of experience of older physicians is often valuable to colleagues as well, and that some seek the advice of more experienced clinicians. And Beverly Laubert points out that, at a recent conference of Ohio Medical Directors, older physicians were front and center embracing telehealth, advanced technologies, and inclusive language to benefit the care of older patients.
Interprofessional Perceptions of Older Doctors w/ Drs. Pat Ecklar and Laurie Belknap – YouTube Video
Strategies to Reduce the Effects of Bias
Strategies to reduce attitudinal bias and its effects among healthcare providers should begin early in training, if not in elementary and middle schools, and should be approached in several ways according to Beverly Laubert, Ohio’s Long-Term Care Ombudsman. Several studies suggested that cross-cultural education about elderly people and aging would be beneficial to reduce negative attitudes about aging and to benefit interactions with older adults.4,7 Older people should blend in as an unremarkable part of the community, and aging should be normalized, according to Laubert. One recent study found that although primary care providers did not appear to have negative bias toward older people, knowledge of normal aging was lacking2 Laubert points out that all physicians should be learning more about taking care of aging patients as the geriatric population percentage increases; this increased patient volume will not be able to be managed by geriatric specialists alone. . The same study also suggested that educational interventions to improve knowledge of age-related physiological changes, as well as training to improve physician competencies in working with a multidisciplinary team, were successful in helping primary care providers deliver a holistic approach that improves care for seniors.2
Findings from medical education literature suggest personal bias can be reduced, and resulting patient care can be improved.1 Most of the studies described learning methods primarily focused on the recognition of implicit personal bias in providers and provision of training to reduce these influences on provider actions and decision making.
The positive impact of faculty role modeling was also noted in one study, with a benefit to trainee shown by faculty members exemplifying enthusiasm for providing geriatric care.1,19 The same study showed that students are given the opportunity to participate in service learning with seniors and then to apply their experiences in subsequent classroom activities not only learned from their experiences but also recognized the individuality of the seniors and experienced personal attitudinal or emotional growth.20
Laubert, Ecklar, and the seniors interviewed for this chapter agree that “treating everyone the same” and ignoring age-related bias negates the individuality and special traits of seniors that would otherwise allow them to age as they have lived the rest of their lives– and to maintain maximal health.
Strategies to Reduce the Effects of Bias with Beverly Laubert and Dr. Laurie Belknap – YouTube Video
Dr. Pat Ecklar talks with Dr. Laurie Belknap about Healthy Older People in Our Society – YouTube Video