Strategies to identify and address ageism in ourselves, others, and institutions

Kelly M. Trevino, PhD, Associate Attending Psychologist, Department of Psychiatry and Behavioral Sciences, Memorial Sloan Kettering Cancer Center, US

Dr. Robert N. Butler famously defined ageism as the “process of systematic stereotyping or discrimination against people because they are old.”1,2  More recently, the World Health Organization defined ageism as a multifaceted social phenomenon that includes stereotypes (thoughts), prejudice (feelings), and discrimination (actions or behaviors) directed towards others or oneself based on age. 3,4   While ageism can be directed toward individuals of all ages, this article focuses specifically on ageism toward older adults.  Ageism is common and a relatively accepted form of stereotyping and discrimination that has negative implications for older adults’ physical and mental health. 5,6 Therefore, identifying and combatting ageism in ourselves, others, and institutions is an important component of improving care for older adults with cancer.

Combating Ageism in Ourselves

For those of us committed to geriatric oncology, considering our ageist stereotypes can be difficult.  However, we are exposed to the same negative societal messages about aging as our colleagues, family, and friends. These negative messages can lead to implicit stereotypes that are outside our conscious awareness and, in fact, contradictory to our personal beliefs.

If bias against older adults can be outside conscious awareness, how can we detect ageism in ourselves?  First, be attentive for comments and behaviors with an ageist undertone.  Have you ever made comments like, “I’m having a senior moment” or “You look good for your age?”  How do you feel about your wrinkles and gray hair and why?  These questions are not intended to be judgmental or scolding but to help us reflect on our internalization of negative stereotypes of older adults.

For a quantitative assessment of implicit bias toward older adults, consider taking the Implicit Association Test (IAT) for Age (https://implicit.harvard.edu/implicit/takeatest.html). 7   The IAT is designed to measure the strength of our associations between a concept (old and young) and evaluations (good and bad). The IAT requires rapid responses in order to assess biases outside our awareness. The impact of these implicit biases on our behavior may be small.  However, we cannot effectively combat ageism in others and our institutions unless we are aware of our own personal biases.

Awareness of our personal biases prompts us to change how we think and speak about older adults.  The Reframing Aging Initiative was started in 2012 by eight aging organizations to address ageism by changing how we think and communicate about aging (https://www.reframingaging.org/).  For example, consider replacing catastrophic (e.g., “tidal wave” and “tsunami”) and conflict-oriented words (e.g., “battle” and “fight”) with affirmative statements such as “as people live longer and healthier lives…”  Avoid “other-ing” terms such as “seniors” and “elderly” that place older adults in an out-group. The World Health Organization recommends neutral language such as “older person” or “older adult.”3 These changes in language may seem subtle but the shift from referring to older adults as a problematic outgroup to members of society with valuable skills and abilities is at the core of combating ageism.

Combating Ageism in Others

Confronting ageism in others can feel adversarial and uncomfortable.  The Reframing Aging Initiative identifies common assumptions triggered by references to aging that can lead to ageist speech and actions (https://www.frameworksinstitute.org/wp-content/uploads/2020/05/aging_apt_ystt.pdf).  Understanding these assumptions helps us respond in a way that directly addresses the underlying bias.  As noted above, older adults are often seen as “other” or as an opposing group.  This view can trigger “zero sum logic” or the assumption that giving resources to older adults requires taking resources from another group.  Aging is also often viewed as a process of deterioration and loss of control for which nothing can be done, a negative and fatalistic approach to aging.  This deterioration is often attributed to individual choices which excludes collective or policy-level changes as possible solutions.

The Reframing Aging Initiative identifies three values that address the common assumptions underlying ageism: Justice, Ingenuity, and Building Momentum.  Referring to these values when responding to ageist speech and actions challenges the core assumptions driving ageism.  Justice is a widely shared value that all people should be treated equally.  Reminding others that older adults are not currently treated as equals taps into the value of justice and can lead to productive discussion of how to reshape systems and processes to fully include older adults.  The value of justice challenges views of older adults as “other” and directs the conversation toward building systems and processes that enhance equity across age.

Of course, identifying ways to make change can be difficult which leads to the second value – Ingenuity. Ingenuity emphasizes that we are problem-solvers with the ability to rethink and improve our approach.  Ingenuity challenges the assumption that aging is the result of individual choices for which collective solutions are not possible.  Rather, as ingenious problem-solvers, we can find creative ways to create a more just society and capitalize on the longer and healthier lives of older adults.

The third value of Building Momentum highlights that aging is a process that includes positive attributes and personal growth.  From this perspective, older adults are a growing resource and we, as individuals and teams, can capture this momentum for the benefit of society.  Framing conversations from this perspective challenges the assumption that aging is characterized primarily by deterioration and dependency.

The Reframing Aging Initiative provides additional guidance for talking effectively with others about aging based on the values of Justice, Ingenuity, and Building Momentum here: https://www.frameworksinstitute.org/wp-content/uploads/2020/05/aging_apt_faq.pdf

Combating Ageism in Institutions

As medical and psychosocial providers for older adults with cancer, we are familiar with the ways healthcare institutions fail to consider the needs of older adults.  Common challenges are the exclusion of older adults from clinical trials, inappropriate medication use and polypharmacy, insufficient involvement of caregivers, lack of geriatric training in healthcare professionals, and specialist-based care that can lead to fragmented care plans.8 The degree to which these challenges are due to ageism and/or other factors is unclear.  However, the outcome is often that older adults do not receive the care they need.  The members of the SIOG Nursing and Allied Health Interest Group are experts in the solutions to these problems so I will not describe them here.  However, I will speak to the frustration that comes with institutions that are slow to recognize problems and even slower to change.  My simple advice is – keep “beating the drum.”  Keep advocating for institutional change that will promote justice and ingenuity to build momentum toward equity for older adults.  Each time an individual combats ageism, progress is made.  When we all combat ageism, societal change becomes possible.

References

  1. Butler RN. Age-Ism: Another form of bigotry. The Gerontologist. 1969;9(4_Part_1):243-246. doi:10.1093/geront/9.4_Part_1.243
  2. Butler RN. Psychiatry and the elderly: An overview. The American Journal of Psychiatry. 1975;132(9):893-900. doi:10.1176/ajp.132.9.893
  3. World Health Organization. Global Report on Ageism. 2021. https://www.who.int/teams/social-determinants-of-health/demographic-change-and-healthy-ageing/combatting-ageism/global-report-on-ageism
  4. Officer A, de la Fuente-Núñez V. A global campaign to combat ageism. Bull World Health Organ. 2018;96(4):295-296. doi:10.2471/BLT.17.202424
  5. Chang ES, Kannoth S, Levy S, Wang S-Y, Lee JE, Levy BR. Global reach of ageism on older persons’ health: A systematic review. PLoS One. 2020;15(1):e0220857. doi:10.1371/journal.pone.0220857
  6. Levy BR, Slade MD, Chang E-S, Kannoth S, Wang S-Y. Ageism amplifies cost and prevalence of health conditions. The Gerontologist. 2018;60(1):174-181. doi:10.1093/geront/gny131
  7. Giasson HL, Chopik WJ. Geographic patterns of implicit age bias and associations with state-level health outcomes across the United States. European Journal of Social Psychology. 2020;50(6):1173-1190. doi:https://doi.org/10.1002/ejsp.2707
  8. Inouye SK. Creating an anti-ageist healthcare system to improve care for our current and future selves. Nature Aging. 2021/02/01 2021;1(2):150-152. doi:10.1038/s43587-020-00004-4