Fighting Bias in Healthcare: Ageism & Nursing Homes

Did you know that discrimination in healthcare is a major cause of poor health outcomes among socially disadvantaged communities in the US? Studies have shown that racial minorities receive inadequate healthcare and are more likely to have their health concerns dismissed in healthcare interactions. The same is true of patients with obesity.

According to a 2020 study of more than 2,000 adult participants, one in five Americans have experienced discrimination in the medical system. While attention has been raised about barriers to receiving quality healthcare in recent years, age-related prejudice still often goes unchecked.

Ageism is discrimination against older people that can manifest in stereotypes, prejudiced beliefs, and discriminatory actions towards others based on their age.

According to the World Health Organization (WHO), a profound number of people are ageist: half of the global population. This staggering statistic reveals how prevalent discrimination against older adults is and how insidious. Psychologists have called it the last socially acceptable form of discrimination.

So, it is no surprise that healthcare workers are not immune to ageism. A lack of knowledge about the aging process, ingrained stereotypes, and ageist attitudes toward older adults result in reduced quality of care they provide older patients.

Over the last few decades, ageism awareness has slowly grown. In 1990, the United Nations General Assembly designated October 1 as the International Day of Older Persons to raise awareness of issues that concern the older population.

More recently, the American Society on Aging created Ageism Awareness Day, which also falls in early October each year, to highlight ageism specifically.

Dr. Lakelyn Eichenberger, gerontologist and caregiver advocate at Home Instead, an organization that helps older adults age in place, explains the impact of ageism, the subtle ways it can be perpetuated, and what needs to happen to reduce ageism and its harmful effects in long-term care environments.

In addition to her work at Home Instead, Dr. Lakelyn Eichenberger serves as chair of the board of directors at the Dreamweaver Foundation, member of the board of directors at the National Alliance for Caregiving, vice chair at the Alzheimer’s Association Dementia Care Provider Roundtable and the American Heart Association Sweethearts Program.

She earned her doctorate in gerontology from the University of Nebraska – Omaha, with a research focus on dementia family caregivers and in-home respite care. Dr. Eichenberger is an outspoken advocate for older adults and has made major media appearances, including on Dr. Phil in 2020.

“I think the reason [ageism] is so prevalent is because it’s just ingrained in our society,” Dr. Eichenberber says. “Unfortunately, ageism is something that we’re almost kind of raised to just be accustomed to. It’s built into the media and perpetuated in so many different ways.”

According to the WHO, children as young as four become aware of ageist stereotypes that oversimplify and generalize older adults’ characteristics, attributes, and behaviors.

Examples include beliefs such as older folks:

• All have cognitive impairment
• Lead lonely lives
• Are all friendly and vulnerable
• Don’t know how to use technology
• Are all sexually inactive

As with any form of prejudice, painting a group of people with a broad brush is not only a moral issue, it’s a serious source of harm.

According to the WHO, ageism affects individuals in the following ways:

• It is linked to poorer physical, sexual, and reproductive health
• It affects the ability to recover from disability
• It is associated with premature death
• It is associated with poorer mental health, especially depression
• It can increase risky health behaviors (e.g., eating an unhealthy diet, smoking)
• It causes a lower quality of life and contributes to social isolation and loneliness

As a result of experiencing prejudice from outside sources, some older adults may internalize negative stereotypes of ageism, which can contribute to declining health and reduce openness to engage in new learning opportunities.

Ageism is observable in countless contexts from the workplace, to family and friendship dynamics, to portrayals of older adults in the media. Unfortunately, healthcare is another avenue in which older adults can experience its effects—and it’s one of the most measurably harmful in terms of its impact.

According to the US Department of Health and Human Services, people aged 65 and older have almost a 70 percent chance of needing some type of long-term care services and support, either provided at home, in the community, or in a care facility.

“As people age, they utilize more healthcare. It’s the highest healthcare usage years of their lives,” Dr. Eichenberger says.

Unfortunately, interactions with healthcare professionals can be a major source of ageism among older adults as their interactions with the healthcare system increase: “For instance, at a [doctor’s] appointment, if the older adult is there with an adult child, the provider might talk directly to the adult child and not to the older adult, assuming that maybe the older adult wouldn’t understand what they’re talking about,” Dr. Eichenberger says.

Demeaning language toward older adults, sometimes called “elder speak,” is a common form of ageism in nursing homes and clinical settings. According to a study from 2017, elder speak includes use of:

• Inappropriate terms of endearment (e.g., Grandma, honey, sweetie, etc.)
• Child-like terms such as nicknames (e.g., Susie for Susan), or shortening words for baby talk (e.g., nightie for nightgown)
• Tag questions, in which a question posed to an older adult indicates the desired response (e.g., “You’re ready for breakfast now, aren’t you?”)
• Reflective speech (e.g., “Take your medicine for me”)
• Collective pronoun substitutions, which emphasize an older adult cannot act independently (e.g., “Are we ready for our bath?”)

The same study examined transcripts of 80 video recordings of staff-resident communication collected during nursing home care activities. It found that nursing home staff used elderspeak in 84 percent of the transcripts during bathing, dressing, oral care, and other activities.

While generally well-intentioned, many older adults find these speech patterns demeaning. Researchers found that nursing home residents may react with depression, avoidance, assumption of dependent behavior, and restiveness to care.

“I think it’s not necessarily a bad thing to simplify what you’re talking about, especially when it comes to healthcare because it can be very complicated, but it can be done in a respectful manner,” Dr. Eichenberger says.

While every individual is different and some might not resent the use of certain terms or behaviors, the key is for healthcare professionals to recognize and respect the agency of the patient or resident—no matter how long or short the provider-patient relationship will last—Dr. Eichenberger says.

“We need to ask them, how would you like me to refer to you? Is it, [for example] Mrs. Eichenberger?…or do you have a nickname that you would prefer me to call you instead of honey or sweetie?” Dr. Eichenberger explains.

The effects of prejudice don’t start and end with how older people are spoken to. When a healthcare practitioner acts on ageist stereotypes, it can measurably affect a person’s quality of care and compromise their health.

“[Healthcare workers] sometimes look at [older adult patients] as a lump sum. Anyone who is 65 and older, they may look at them as a statistic as opposed to an individual,” Dr. Eichenberger says. “That can…come through in our practice and our interactions with older adults.”

A 2020 review of more than 1,000 health associations across 45 countries found that ageism predicted significantly worse health outcomes in 95.5 percent of the studies.

“[An older adult] might kind of brushed off like, ‘Oh, you know, you have a little memory loss, but that’s okay. That happens to everyone as we get older,’ but we know that dementia [and] cognitive impairment are not a normal part of aging,” Dr. Eichenberger says.

Memory loss can be a sign of dementia, but it can also be indicative of depression, an infection, or side effects of medication. So, while the source of memory loss is sometimes irreversible, in other cases, it can be improved via treatment.

Either way, determining the underlying health condition is essential. If the healthcare practitioner writes off a patient’s cognitive impairment as untreatable without a thorough investigation, the patient may lose out on life-changing—or even life-saving—treatment.

One 2020 study estimated the annual cost of ageism to the healthcare system is $63 billion, which experts say is partly due to underdiagnosis and misdiagnosis.

This theme can be observed in countless other healthcare scenarios. Dizziness, falls, delirium, decreased appetite and failure to thrive may be dismissed as a “normal part of aging” when they are actually signs of acute illness in older adults.

As Dr. Eichenberger says, sweeping these symptoms under the rug can lead to missed opportunities to address treatable illnesses and serious complications.

Ageism can also present when healthcare practitioners withhold information or limit patients’ control over their own healthcare planning: “Sometimes cancer treatments are very intensive and so [healthcare providers] might assume…‘Well, they’re too old. This treatment’s too intense, so we’re not even going to offer it to them.’”

The reverse scenario is also problematic, Dr. Eichenberger says. Sometimes, healthcare professionals gloss over details about a treatment when communicating with an older patient and insist on pursuing an intensive therapy that the patient may not want, if they had been given all the facts.

“Not all older adults want to engage in those treatments and cures because it could negatively impact their quality of life,” Dr. Eichenberger says. “…[It’s crucial to] make that [provider-patient] connection and understand what is important to the individual, not make assumptions.”

In 2016, the WHO started a global campaign to combat ageism by identifying gaps in research and making recommendations to agencies in the public and private sectors for combating ageism.

In addition to recommending the creation of legislation to prevent discrimination, the organization points out that educational interventions from the primary school level up to university can play a major role in preventing ageism among new generations of learners.

“There’s an opportunity to educate [further] about the aging process,” Dr. Eichenberger says. “I would challenge any educator no matter where you’re teaching…How are you educating about the aging process?”

While students in healthcare disciplines are commonly taught about elder abuse and neglect, the pervasiveness of age-based discrimination in healthcare settings suggests an educational gap when it comes to more subtle forms of ageism.

One recent review on studies of ageism among nursing students found that while student nurses generally portray positive attitudes towards old age, ageist beliefs, and discriminatory behaviors are still observable. It also found that a significant percentage of the student nurses were not interested in studying elderly care or gerontology.

Researchers recommend training programs for future care professionals that give students more diverse perspectives on aging to help counteract ageist stereotypes and overgeneralizations.

According to Dr. Eichenberger, the more diverse perspectives and stories that healthcare students receive about aging, the more they will break down stereotypical beliefs about aging and learn to view older patients as individuals instead of statistics.

“I think that person-centered care training is starting to become more mainstream, where, again, you focus on the person; they’re at the center of the care,” Dr. Eichenberger says.

“[We should ask], ‘How can we as providers…help make the last third of their life the highest quality of life possible?’ So I think reframing education to at least include a little bit more of that lens would be helpful.”

Healthcare centers and nursing homes can also do their part. One study on ethical challenges in nursing homes suggests that institutions should hold regular ethics meetings for staff members to discuss their everyday interactions with patients. This would help providers identify unrecognized ageism in their interactions and begin to reduce it.

As individuals, we also each shoulder the responsibility to continuously evaluate their own prejudice.

“Sometimes even just like a self-reflection activity on how you view your own aging journey [is helpful]. Do you have any biases that are ageist about yourself?” Dr. Eichenberger asks.

“…Because I think, again, ageism really starts with us as a society. If we’re able to kind of reflect on it throughout our own life course, it can help us be more mindful of those older adults we’re caring for, but then hopefully will help us have a successful aging journey as well.”