Improving Geriatric Care by Combating Ageism

The Role of Ageism in Clinical Decision-Making: A Review of the Literature

Ageism, defined as prejudice or discrimination against individuals based on their age, is an often-overlooked yet pervasive issue in clinical practice. While healthcare providers aim to deliver equitable care, unconscious biases and stereotypes about older patients can subtly influence diagnostic and treatment decisions. This review explores the role of ageism in clinical decision-making, the consequences of such biases, and strategies to mitigate their impact on healthcare outcomes.

1. Understanding Ageism in Healthcare

What is Ageism?

Ageism in healthcare manifests as assumptions about a patient’s needs, abilities, or prognosis based solely on their chronological age. These assumptions often stem from stereotypes, such as perceiving older adults as frail, resistant to change, or less deserving of aggressive treatment.

Prevalence of Ageism in Medicine

• Studies estimate that up to 50% of older adults experience ageism in clinical settings.
• A systematic review found that ageist attitudes influence decisions across various medical specialties, including oncology, cardiology, and psychiatry.
• Source: https://pubmed.ncbi.nlm.nih.gov/31463593/

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2. How Ageism Influences Clinical Decision-Making

1. Diagnostic Oversights

Age-related stereotypes may lead clinicians to attribute symptoms to "normal aging" rather than investigating underlying pathologies. For example:

• Cognitive Symptoms: Memory issues may be dismissed as "senility," delaying diagnoses of reversible conditions such as depression or vitamin deficiencies.
• Pain Complaints: Older adults reporting pain may be undertreated due to assumptions about higher pain tolerance.

2. Treatment Decisions

1. Exclusion from Aggressive Therapies:

• Older patients are often deemed ineligible for invasive procedures, such as surgeries or chemotherapy, despite evidence suggesting comparable benefits to younger individuals.
• In cardiology, studies have shown that older adults are less likely to receive interventions like coronary artery bypass grafting.
• Source: https://www.ahajournals.org/doi/full/10.1161/CIRCULATIONAHA.120.046568

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1. Polypharmacy Concerns:

• While polypharmacy is a legitimate concern, it sometimes results in the under-prescription of necessary medications due to fears of adverse reactions.

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3. Communication Barriers

• Physicians may adopt a paternalistic approach, speaking more to caregivers than the older patient. This undermines patient autonomy and shared decision-making.

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3. Consequences of Ageism in Clinical Care

1. Poor Health Outcomes

Ageism can lead to delayed or inadequate treatment, increasing morbidity and mortality rates in older populations.

2. Reduced Quality of Life

Neglecting the psychosocial aspects of care, such as mental health and mobility, diminishes the quality of life for older patients.

3. Increased Healthcare Costs

Inadequate care can result in preventable hospitalizations, emergency room visits, and longer recovery periods, driving up healthcare costs.

4. Psychological Impact

Experiencing ageism erodes self-esteem, leading to depression, anxiety, and reduced trust in healthcare providers.​

4. Evidence from the Literature

1. Oncology

Older patients are often excluded from clinical trials, leading to gaps in evidence for optimal cancer treatments. Despite tolerating chemotherapy as well as younger patients, older adults frequently receive less aggressive treatment.
Source: https://www.cancer.gov/news-events/cancer-currents-blog/2021/older-adults-cancer-clinical-trials

2. Cardiology

The underuse of life-saving interventions, such as stents or defibrillators, in older adults highlights persistent biases. Many clinicians overestimate surgical risks based on age alone, ignoring functional status and comorbidities.
Source: https://www.ahajournals.org/doi/full/10.1161/CIR.0000000000000702

3. Geriatric Psychiatry

Mental health conditions, including depression and anxiety, are often underdiagnosed in older adults. Misconceptions about aging lead to the assumption that such issues are inevitable rather than treatable.
Source: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4932072/​

5. Factors Contributing to Ageism

1. Lack of Geriatric Training

Medical education often inadequately addresses geriatric care, leaving providers unprepared to meet the unique needs of older adults.

2. Cultural Stereotypes

Societal views that equate aging with decline perpetuate ageism in healthcare settings.

3. Systemic Pressures

Time constraints and financial incentives in healthcare systems can lead to rushed decisions and biases against complex cases, which older patients often represent.​

4. Implicit Bias

Unconscious attitudes influence clinical judgments, even among well-intentioned providers.​

6. Strategies to Address Ageism in Clinical Decision-Making

1. Education and Training

• Incorporating geriatric care into medical curricula helps providers understand the physiological and psychological aspects of aging.
• Regular workshops on implicit bias can make clinicians aware of age-related stereotypes.

2. Comprehensive Geriatric Assessments (CGA)

• CGAs evaluate an older patient’s functional status, comorbidities, and social support, guiding tailored treatment plans.

3. Shared Decision-Making

• Involving older patients in their care decisions respects autonomy and ensures treatments align with their goals and preferences.

4. Advocacy and Policy Changes

• Mandating the inclusion of older adults in clinical trials ensures evidence-based care for this population.
• Healthcare policies should discourage discriminatory practices, such as automatic age-based exclusions from treatments.

5. Addressing Systemic Barriers

• Increasing the availability of geriatric specialists and resources can improve care for older patients.

6. Promoting Research

• Encouraging studies on the effects of ageism in various medical specialties can provide insights into effective interventions.

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7. The Role of Healthcare Professionals

1. Self-Awareness

• Clinicians should regularly reflect on their biases and seek feedback from peers to improve decision-making.

2. Holistic Approach

• Recognizing that chronological age is just one factor among many in assessing a patient’s health and prognosis.

3. Empathy and Communication

• Building trust through open, respectful communication fosters better patient-provider relationships.

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8. Conclusion

Ageism in clinical decision-making is a critical issue with far-reaching consequences for patient care and outcomes. By acknowledging and addressing biases, healthcare professionals can ensure equitable treatment for older adults, honoring their dignity and improving their quality of life. The path forward requires a collaborative effort between medical education, policy reform, and individual accountability.