Objectives: Older adults utilize health care systems to a higher frequency than younger groups, and are more vulnerable to system bias regarding ageing and expectations of old age. This narrative review attempts to outline the available literature regarding how various health support systems perceive the older adult, with an Australian focus.
Conclusions: Perspectives on ageing are generally negative regardless of the health industry. Possible contributors to this include elements of death anxiety, inadequate education and inadequate occupational exposure during training.
Population ageing is the outcome of the history of a country’s fertility, mortality and migration rates. Although Australia’s population profile has been ageing continuously for the past 150years, the rate at which this is occurring has been greatest in the years post 2010, as the baby boom generation born in the late 1940s and early 1950s will have passed age 65. On an individual basis, concepts of ageing have changed within just one generation, in virtually every domain: 65 is no longer the age of retirement, it is no longer unusual for people to live past the age of 90, and financial decisions have to encompass a far wider range of potential scenarios. The older person no longer necessarily needs to retire, to live in a nursing home, or to suffer dementia – all of which were previously taken for granted as inevitabilities.
There is arguably only one constant in ageing, however, and that is increasing dependence on health systems. As people age, there is an increased risk of chronic disease, with concurrent increased access to health services. For the older person trying to find direction as they age, it is therefore critically important to consider the role of health systems in defining ageing. An elderly person does have several sources of health support, from the general practitioner and practise nurse to the hospital emergency director and the residential care manager. Each of these sources come from well-established models of clarifying pathology in the elderly – recognizing mental illness, recognizing frailty, managing polypharmacy and appropriate end-of-life decisions. What is not always clear from these agencies is what is an appropriate model for what constitutes ‘healthy ageing’ beyond the absence of pathology. Whilst they provide vital sources of support, each of these agencies can also have significant levels of bias regarding ageing, which can affect how they interact with the older person, and, summarily, interfere with care and social functioning.
Doctors
Doctors or medical students have, in numerous studies, shown generally unfavourable attitudes to ageing.2Medical students, in particular, are consistently shown to have a negative attitude towards older people, with geriatric medicine considered an unpopular career choice as being ‘low tech’, with multiple chronic problems.3 The lack of opportunity for private practice is a significant factor in the lack of engagement. On a more positive note, participants in these and other studies who had been exposed to geriatric medicine through a clinical posting, or a geriatric medicine course during training had a better understanding and more positive attitude.
Nursing
The role of nursing in aged care involves high patient proximity in situations such as residential facilities; however, a professional background in nursing also can lead to work in areas such as policy development or other social supports.
A study of registered nurses in Australia and the United Kingdom (UK) found that registered nurses in both countries had misconceptions and used negative stereotypes about the ageing process and older people, particularly in the way they underestimated and devalued the capacities and capabilities of older people.5 It identified a need for education on ageing and older people, in both the pre-employment and post-employment periods.
A 2014 literature review examined the knowledge and understanding of the ageing process and attitudes to older people of nurses in emergency care departments (EDs).6 Older people coming into EDs may present with an acute episode and, at the same time, with a range of complex and comorbid conditions. The research shows that ED nurses are not always prepared to consider or accept that a ‘quick fix’ may not be possible and that a more holistic approach might be required to meet the needs of older people in this setting. Another key finding is that managerial style, past experiences and the centrality of the curative approach of the medical model in health care service delivery were factors that also influenced nurses’ negative attitudes towards older people.
Psychology
Starting from Freud’s 1905 consideration that it was worthless providing the elderly with psychotherapeutic interventions, there has been a relatively late engagement with ageing from the psychological community. However, the appraisal of ageing itself from the industry has yielded more significant findings – despite a failure to translate into therapeutic approaches.
A total of 604 practising psychologists were surveyed using the Reactions to Ageing Questionnaire (RAQ). The strongest significant predictors of attitudes to ageing were respondents’ age and positive attitudes toward conducting therapy with older clients. Training and contact with older clients did not have a significant impact.
A South Australian review of 441 students, academic faculty and practitioners from the disciplines of psychology and social work created a comprehensive recent picture of attitudes to ageing from persons who will constitute a considerable part of the older person’s support network.8 Students (and, unfortunately, lecturers) were found to be relatively indifferent to learning about older adults, although positive ageism was more prominent for practitioners.
Other allied health clinicians
Research involving allied health professionals in Australian health care settings report similar findings: generally negative attitudes, formed around ageist stereotypes and knowledge deficits, that significantly influence practice, and potentially the quality of care.
Research among allied health professionals indicates that physiotherapists and occupational therapists hold neutral to slightly more positive attitudes to older people than nurses or doctors, although both professional groups lack knowledge about the ageing process and older people. Occupational therapists (OT) were similar to physiotherapy students in attitudes and knowledge. OT students and clinical educators responded to questions more positively than physiotherapy students. Surprisingly, clinical educators had no better knowledge of ageing than students.
Discussion
Perspectives on ageing have been generally reported as negative regardless of the health industry is assessed. The studies suggest a dearth of data regarding Australian medical institutions, but also interesting methodological issues regarding the study of these structures.
It is worth briefly commenting on the wide range of instruments used to assess attitudes to ageing between these studies, given the disparate methodologies behind their design (despite the relatively uniform outcomes). Some of these instruments were intended to measure explicit knowledge of, and attitudes towards, the ageing process and older people: Reactions to Ageing Questionnaire; Facts about Aging Quiz and Aging Semantic Differential. These measures have been criticized due to their reliance on honest self-report. Implicit measures (such as the Implicit Association Test, used in the Chonody 2014 study), show a surprisingly poor correlation with the explicit measures.
Terror Management Theory (an existential theory based on the writings of Ernest Becker) posits that death anxiety is never completely escapable but rather suppressed by ‘avoiding reminders of death or developing particular attitudes against people or actions that serve as reminders of their own mortality. This suggests an expected causality between measures like the Death Anxiety Scale or Fear of Old People subscale (from the Ageing Anxiety Scale) and the associated Attitudes to Ageing Scale. Studies, such as the Nash 2014 study, identified fear of older people being associated with death anxiety – that is, that ‘people have negative attitudes to older adults because they bring to mind the reality that they themselves will become old, and being old is regarded as an undesirable state’.
With regards to the outcomes, whilst there is conflicting information regarding medical and allied disciplines with regards to their attitudes to ageing, there is repeated comment regarding the failure of educational institutions to instil a positive approach to ageing in their students, recognized in a poor progression in attitudes from the commencement of training to enter the workforce. Simple exposure to older persons does not seem sufficient, but an expectation of working with older persons together with a positive attitude towards outcomes in working with the older persons requires a theoretical framework that does not appear to have been yet developed. Perhaps updated data regarding ageing, such as ongoing publications from the Harvard Ageing studies or centenarian studies, could inform such approaches.
It is clear that there is still much to be learned regarding the inherent bias towards ageing in medical support structures, and, regrettably, much of what we are already aware of is likely to be an understatement, due to overreliance on explicit measures and self-report. It is proposed that evidence-based models of ageing can assist in addressing the fine line between idealist notions and frank ageism. Until agencies are able to determine a clear picture of how ageing can be celebrated, and how this concept can be taught, latent bias and impaired patient care are inevitable.
Dr Jeyasingam is the former head of the Faculty of Old Age Psychiatry NSW and Senior Clinical Lecturer with Sydney University. He is the author of "Psi", a mental health novella. His website is www.profectuspsych.com.au
