Ageism Revisited

My long-established patient—an active, retired professional in her 70s with few health problems—provides feedback to me during a recent wellness visit. She states that the staff in my practice had treated her condescendingly and disrespectfully, seemingly because of her age. I am surprised to hear this because my staff members are especially professional and several have experience caring for older relatives. An increasing number of older patients are being seen in my practice, and this feedback is concerning to me. How can I improve staff communication skills with older patients?

Between the 2010 and 2020 censuses, the U.S. population 65 years and older increased from 40.3 million to 55.8 million and now represents almost 17% of the U.S. population.¹ This nearly 40% increase was more than double the increase from 2000 to 2010 (15%) and is attributed to the influx of the baby boomer population (i.e., individuals born between 1946 and 1964).¹ This population currently accounts for approximately 60% of the older population; this number will increase as the rest of the cohort ages, simultaneously growing with a racially diverse aging population.¹ In many medical practices, older adults already comprise a large proportion of the patient population.² Best serving the health needs of these patients requires an intentional approach to the care of older individuals, free of ageist assumptions.

Ageism refers to a pattern of prejudice, discrimination, and marginalization that is strongly associated with multiple negative effects on the physical and mental health of older individuals.^3–5 Ageism can take many forms, verbally or with body language, ranging from overt mistreatment and abuse to the conveyance of condescension or even dislike. Although much attention has been given to overt abuse of older people, more than 90% of individuals 50 years or older report experiencing ageism routinely or even every day, predominantly in the form of language and behaviors that convey hostility, a lack of value, or narrow stereotypes of older adults.⁶ These repeated negative interactions may be subtle or not intentionally discriminatory but are nevertheless strongly associated with poor physical and mental health in older adults.⁶ Women, members of minority populations, and patients with perceived impairments or disabilities are at increased risk of all forms of ageism and its multiple negative effects on overall health.^6–8

Even well-intentioned health care professionals can inadvertently convey ageism. Common examples of disrespectful behavior include asking for information from companions rather than the patient and discussing symptoms in front of patients while ignoring them. This dismissive conduct conveys the assumption that all older adults have cognitive deficits. Other examples include patronizing behavior, baby talk, and excessive reassurance.^6,9,10

Several organizations and multiple publications provide guidance on communicating appropriately with older patients and their families or caretakers. Some resources include the local chapter of the AARP, the Area Agency on Aging, and other advocacy organizations for older individuals.³ Some of these recommendations, however, may be insufficiently aligned with the expectations and behaviors of older patients, specifically baby boomers.¹¹ The aging population is a large and heterogeneous group with myriad individual life experiences and diverse health care needs and priorities.^11–14 Among this group, many older adults value independence, autonomy, wellness, and positive physical appearance.

Compared with earlier generations, older adults are currently more likely to be health conscious and motivated to proactively optimize their long-term health and successful aging, including considering alternative medicine and unconventional approaches to health care.^11,15,16 Many older individuals use the internet and social media resources to obtain health information, and they are likely to have investigated issues before consulting a physician—and to provide a review of their experience following the office visit.^11,17,18 These characteristics go well beyond the once widely held stereotype of passive older patients ceding authority to their physicians.

Communicating effectively requires reconsidering conventional recommendations for communication with older individuals^2,11,18,19 (Table 1^2,20–22). Speaking slowly and clearly, maintaining appropriate eye contact and body language, and adapting to any sensory, physical, or cognitive problems remain integral for all patients, but these considerations may not sufficiently address concerns.

Effective communication with all older patients requires attention to a patient's individuality and avoidance of negative assumptions about health and lifestyle.^2,11,18 The advice to ask, don't assume is especially relevant. Physicians should avoid any language or behavior that suggests their older patients are frail, cognitively impaired, or otherwise unable to manage their own affairs, including health care decisions. They should avoid any comment, tone, or body language that their older patients might perceive as disrespectful, condescending, or pitying—even if not intended as such. A common example is using the term still in questions about ability to conduct activities of daily living, thus implying that such abilities are in doubt or will inevitably be lost soon. It is better to ask, How do you organize daily food preparation? than Can you still cook? Patients should be asked for their opinions about symptoms, health care concerns, possible diagnoses, and potential strategies to manage symptoms and optimize current and future health. Physicians should tactfully gauge the extent to which patients value control over their lifestyle and health care decisions. Offering suggestions and a choice of options is likely to be more successful than mandating a course of action and initiating a power struggle with a patient.

Despite the significance of ageism, little evidence-based guidance is available on ways to reduce its occurrence and to improve communication between older patients and health care staff.^4,18 Comprehensive reviews of diverse programs and interventions report that incorporating experience working with older individuals along with providing information on the realities of aging and use of appropriate communication styles resulted in the greatest short-term improvement in attitudes and comfort when interacting with this population.^4,19 The most effective aspect of these interventions was to increase knowledge of healthy aging and counter negative stereotypes of all older individuals as frail or dependent.^4,19 Increasing knowledge of the realities of aging is also reported to reduce anxiety about the aging process in oneself and others, reduce reluctance to engage with older individuals, and enhance positive attitudes toward the aging population in health care personnel.^7,10

The scenario presented does not mention a specific statement or overt ageism but could have resulted from a range of possibly subtle signals, for example, a clash between the staff member's perception of the patient as a “little old lady” and the patient's self-image as a healthy, vigorous, capable woman. In striving to be supportive and empathic, the staff member may have used language, tone, or gestures that conveyed an assumption that the patient had limitations or frailties because of her age. The patient may have been sensitized to negative stereotypes of older women through previous experiences and overreacted to well-intentioned, but inappropriate, comments.

Improving communication and preventing future episodes of unintended ageism require developing ways to increase staff members' knowledge of the changing picture of aging in the United States and providing opportunities for positive interactions with older people. This knowledge should include information on the demographic changes nationally and in the practice population to illustrate the growing significance of the proportion of the older population—increasingly comprising baby boomers—to the practice and the community it serves. A discussion of perceptions and stereotypes of older adults can segue into consideration of personal perspectives, attitudes, and experiences with older individuals as patients, family members, friends, or acquaintances.

Positive intergenerational contacts are especially valuable in addressing ageism, and staff members who have limited experience interacting with older people should consider ways to increase contacts with older members of the community. Current patients may be helpful in suggesting opportunities for staff to interact with individuals from other generations to improve understanding and appreciation of different perspectives on aging.

Editor’s Note: Dr. Walling is an associate medical editor for AFP.