There is a very subtle bias that can impact all populations regardless of race or gender.  This bias is commonly known as “ageism”, and it refers to the discrimination of patients because of nothing more than their age.  This bias can, and often does, negatively impact both the emotional and physical health of older patients by contributing to cognitive decline, more hospital stays, and disability.  It also carries a price for providers as well.

As the nation’s population continues to age, opportunities for ageism to occur in healthcare will continue to increase as well.  If you consider that the U.S. Census bureau estimates that by the year 2060 almost 25 percent of Americans will be 65 or older with the number of 95-plus individuals tripling, you have a good idea of the potential scope of this challenge.  In fact, credible research suggests that one in five adults over the age of 50 have experienced discrimination in a healthcare setting. If nothing changes, this population will continue to be at risk for stereotyping, prejudice (implicit or explicit) and substandard practices in all areas of healthcare.

Various studies bear this out.  One, for example, showed that younger patients tend to wait less time in the ED for assessments than older and frailer patients, who wait longer for the same attention and care. This delay in delivering care was attributed to no other reason than the age or frailty of the patients. Given that seniors have a greater number of ED visits than their younger counterparts, the potential negative impact on their health of having to wait for care cannot be underestimated.

In addition to risks to their physical health, their receiving often-dehumanizing treatment in the ED and other areas of healthcare can also cause emotional damage to older patients. This behavior includes infantilizing seniors through “elderspeak” (such as calling an older patient “dear”), discounting or disregarding their opinions and input, or simply dismissing them outright because “they are old.” You can see this in the following examples reported by patients and caregivers:

• The doctor said to me, “Well, you know, she’s old.” And then I blew up. I said, “Her age has nothing to do with this. She is in pain, she can’t walk, she hurts.” (Caregiver)
• When you’re older, they don’t expect you to know anything . . . and they discount you immediately. (Patient)
• Talked down to you as if you’re a child. That’s right, yes. You’re a responsible adult. You understand perfectly well what’s going on. They should treat you as such. (Patient)
• There’s a stigma to dealing with older seniors . . . that we’re going to die anyway. So, minimal service. (Patient)

Provider staff can also create an environment that implicitly tolerates age discrimination by having attitudes such as “every patient over the age of 65 should be an automatic no code” or “we should be saving the resources for the young”.

One impact of ageism in a provider setting is that it can influence the range of diagnostic tests and treatments offered and/or provided to seniors. It also can lead to providers making assumptions such as an older person with poor hearing being cognitively impaired or chronic conditions such as neuropathy being dismissed as “it’s part of being old.” On the other hand, some conditions may be overtreated, which can cause unnecessary harm and emotional distress.  It also may increase the probability that they will engage in risk-taking behaviors that could further negatively impact their health.  And last, but certainly not least, age bias has been associated with an earlier death – by some estimates over seven years on average.

Older people are often left out of clinical trials, which can make it more difficult for researchers to identify the benefits and risks of medications that may be marketed to seniors (and their doctors).

Providers are not immune to the financial and operational impact of ageism.  A study by the Yale School of Public Health found that this bias led to excess costs of $63 billion for a broad range of health conditions during one year in the United States. The researchers also found that ageism was responsible for 17.04 million cases of the eight most expensive health conditions in one year among those 60 and older. Among the health conditions examined were cardiovascular disease, mental disorders, and chronic respiratory disease.

What health care providers can do

Most experts agree that trying to eliminate all bias would be akin to trying to “get people not to breathe”.  Providers can, however, adopt approaches and techniques to achieve positive outcomes in addressing age and other biases.  Some of these include the following:

• Include potential bias factors as part of a provider’s morbidity and mortality conferences to better identify when, how, and what could have prevented the bias and its influence on treatment decisions
• Make the effort – and train staff – to always practice evidence-based medicine and how to better recognize when their unconscious bias and stereotypes about age and other factors (often multiple biases are present, for example race and age) may be a factor in treatment or diagnostic decisions
• Take time to see the patient as an individual rather than as a member of a group prone to generalizations and try to understand their point-of-view, life experience and day-to-day stresses
• Adapt communications to compensate for the fact that many seniors have reduced hearing and visual acuity or may need additional time to process information being given them about their condition and treatment plan – this includes being sure to ask the right questions
• Learn to recognize when verbal or body language during provider-patient interactions may be giving subtle cues of bias – these include “elder-speak” and talking to a caregiver rather than to the patient when also in the room
• Develop and implement an ongoing continuing education module on working with elderly patients (if a provider does not already have one)
• Identify and correct individual provider and staff misconceptions that contribute to age bias — these include such false beliefs such as older patients can’t understand as well as younger ones or that older ones may not follow through on after-care plans
• Audit the ED and other treatment areas to identify ways to make them more “elder friendly” such as offering patient advocates or other volunteers (especially important if no family members are present), having larger type materials, and ensuring areas are well-lit

It is important to recognize the existence of age and other biases and avoid taking a “not at my hospital” approach to dealing with this important issue. Admitting that any type of bias exists in a healthcare setting is neither easy nor comfortable. But doing so on an ongoing, objective basis is critical to the health and well-being of patients across the country.  Their lives literally depend on it.