Expert Commentary

The impact of ageism on health and health care: A research roundup and explainer

Ageism against older people results in negative health outcomes for individuals and society, research shows. But momentum is building for policies that take aim at age-based discrimination at the state and federal level.

(kat7214 from Pixabay)

From failures to include older adults in clinical trials for treatments meant for older patients to internet tropes like #OKBoomer, ageism is so ubiquitous in Western society that unabashedly ageist acts often go unrecognized and unaddressed. Ageism can be structural, interpersonal, or self-directed, and it encompasses age-based thoughts (stereotypes), feelings (prejudice) and actions (discrimination).

Ageism can be overt, subtle, or even unconscious. Older adults often encounter comments, jokes, and representations of older people that perpetuate negative stereotypes and refer to them as a monolithic group, despite wide diversity in experiences and health status among older people. New research by Julie Ober Allen, an assistant professor and ageism researcher in the health and exercise science department at the University of Oklahoma, and her colleagues finds that encounters with “everyday ageism” — jokes about getting old on birthday greeting cards, for example, or comments made about older drivers — have a significant impact on health.

Older adults “are systematically disempowered, devalued and excluded from many aspects of contemporary society,” Allen said during a July 27 panel discussion on ageism convened online as part of the Journalists in Aging Fellowship Program, which helps reporters improve their aging-related coverage. “… Many examples [of everyday ageism] are perceived as humorous or considerate or even complimentary, yet they strip older adults of their individuality, and they’re used to justify treating them with less respect and fewer rights.”

Ageism may serve as a source of chronic stress in the lives of older adults, Allen explained during the panel discussion. Alternatively, older adults who believe that loneliness and depression are a normal part of aging might be less likely to seek care, take medications as prescribed, and adhere to their health care providers’ recommendations. Older adults who experience ageism in a health care setting might also be less likely to seek care.

And I’m not just talking about their interactions with their health care providers, but also with the front office staff, with the ways that messages around them are framed and even things like systemic issues, such as procedures for making health care appointments,” Allen said.

A systemic problem

In the United States, ageism resulted in more than $63 billion in excess health care costs in 2018 alone, according to a 2020 article in The Gerontologist. Medical ageism among health care providers has been found to lead to both the overtreatment and undertreatment of disease and negative experiences that discourage older adults from seeking care. For example, negative attitudes about aging, such as the idea that depression is a normal part of getting older, often result in older people feeling demeaned or brushed off.

“Older people are more likely to have high health care needs, so you would think that the health care system would be built uniquely to serve them, but it’s not,” says Kevin Prindiville, executive director of Justice in Aging, a national legal advocacy organization. “You talk to doctors about their training in medical school, and very little of that training is specific to the needs and unique concerns of older adults. Yet when they’re out practicing medicine, they’re finding that many of the people they’re working with and serving are older people, so there’s a misalignment there.”

“Older people are more likely to have high health care needs, so you would think that the health care system would be built uniquely to serve them, but it’s not.”

— Kevin Prindiville, executive director of Justice in Aging.

At the individual level, median survival is seven and half years longer for people with a positive outlook on growing older, compared with people who internalize negative beliefs about aging, according to a longitudinal study by Yale psychologist Becca Levy and her colleagues. Decades of research by Levy and her team, employing a variety of methods to measure how negative attitudes about aging affect health, has shown that internalizing negative stereotypes about aging increases the risk of dementia, heart attack, mental illness and more.

These issues are particularly acute in Western society — with its youth-obsessed culture and “anti-aging” industries — but ageism is present elsewhere as well. More than half of the world’s population is ageist against older adults, according to the World Health Organization’s Global Report on Ageism, which also found that ageism is more prevalent in developing countries, and that women, minority groups, and people with lower levels of education are more likely to experience its adverse health effects.

Despite the ubiquitous and deeply ingrained nature of ageism, however, research also suggests that ageist views can be changed through education and increased intergenerational contact.

“We have found evidence that that these [ageist] processes can occur unconsciously, and if people don’t know it’s happening, it’s harder to challenge it and fight it,” Levy, author of Breaking the Age Code: How Your Beliefs about Aging Affect How Long and Well You Live, tells The Journalist’s Resource. “But on the other hand, our research has found that it is possible that these age beliefs are malleable, and they can be changed. So, I think there is definitely room to increase awareness of these negative beliefs and find ways to overcome them.”

Policy efforts at the federal level

In broad economic terms, the consequences of ageism are astronomical, with one study by AARP estimating unrealized gross domestic product growth in the U.S. at $850 billion for 2018, due to discrimination against a burgeoning population of older workers. That figure could reach $3.9 trillion by 2050, according to the report. As a result, older Americans are increasingly experiencing housing vulnerability and homelessness, which greatly exacerbates negative health outcomes, says Justice of Aging’s Prindiville.

Although the proportion of people over age 65 is growing quickly in the United States, policies to address issues that are common among people in this age group have historically been low priority at the state and federal level. Some research even suggests that aging-related policies can have the unintended consequence of intensifying age discrimination. Recently, however, the federal Centers for Medicare and Medicaid Services (CMS) rolled out proposed changes to section 1557 of the Affordable Care Act, which includes anti-discrimination provisions for protected groups, including older adults and people with disabilities.

Other policy work at the federal level is focused on making it easier for older people to receive the same medical care in their homes that they are entitled to receive in nursing facilities under Medicaid, explains Prindiville. These efforts are modeled on the success of advocacy groups for younger people with developmental disabilities who have worked to transition care for that population from institutions to homes and community-based programs.

“We’re looking to make a similar shift for other people with disabilities and for older adults,” Prindiville tells The Journalist’s Resource. “There is a coalition of people working on this in DC, and there are coalitions that are growing and building at the state level.”

States Undertake Master Plans for Aging

A few months before the start of the COVID-19 pandemic, California embarked on a campaign to collect input about aging-related issues and supports from stakeholders, policymakers and the public. This information-gathering effort kicked off a process to develop a 10-year master plan to prepare the state to better serve its fastest-growing population segment. Now, two years into implementation, the far-reaching California Master Plan for Aging is propelling an aging-related policy agenda in the state, says Prindiville, a member of the advisory committee that worked on the plan.

“Having the master plan has helped educate the state administration and different government agencies and departments about the aging population in California, has helped identify particular needs and priorities, and then has helped those agencies develop more specific action they can take for a community that otherwise, sometimes, is overlooked,” he says.

Other states are following California’s lead. The governors of New York and New Jersey have signed executive orders aimed at beginning similar planning efforts. The nonprofit Center for Healthcare Strategies is working with a coalition of 10 states — Colorado, Illinois, Indiana, Minnesota, North Carolina, North Dakota, Oregon, South Carolina, Tennessee, and Vermont — on master plans for aging.

“At the state level, sometimes it’s difficult to get momentum to take political and policy action on aging issues because they’re not seen as hot button political issues,” says Prindiville. “The master plans provide a vehicle and a framework to help a state get organized and to start to educate and elevate some of the issues.”

Research roundup

Recent research has examined the prevalence and health effects of ageism and negative age beliefs, as well as the efficacy of various policies and direct interventions, including intergenerational interactions or “cogeneration.” Below are summaries of seven curated peer-reviewed studies on ageism and health, including two by Levy and her team and one systematic review that she participated in as part of the WHO campaign.

Among the key findings in this research roundup:

  • People with positive beliefs about aging live longer than those who internalize negative beliefs and stereotypes about getting older.
  • Negative beliefs about aging increase a person’s risk of experiencing a cardiovascular event, such as angina attacks or stroke, later in life.
  • More than 95% of studies that have examined the connection between ageism and health over the past 25 years have found that ageism results in worse health outcomes.
  • In the U.S., 1 out of every 7 dollars (15.4%) spent on the eight most-expensive health care conditions among people ages 60 and older is linked to ageism.
  • Research suggests 93.4% of people ages 50-80 regularly experience some form of ageism in their daily lives.
  • Educating people about the aging process and providing opportunities for younger people to interact with older people are effective ways of reducing negative attitudes toward older people.

Longevity Increased by Positive Self-Perceptions of Aging
Becca Levy, Martin Slade, Suzanne Kunkel and Stanislav Kasl. Journal of Personality and Social Psychology, August 2002.

This was the first longitudinal study that connected negative health outcomes with individuals internalizing negative beliefs about growing old. Levy and her team relied on a comprehensive survey of residents from the town of Oxford, Ohio, which has a population of about 15,000 and is home to Miami University, and studied the effects of their perceptions about aging as they got older, for up to 23 years. They found that participants who held positive beliefs about aging “lived 7.5 years longer” compared with those who had internalized negative stereotypes.

The research included 660 individuals aged 50 and older who participated in the community-based survey known as the Ohio Longitudinal Study of Aging and Retirement (OLSAR). These participants were first recruited to take the OLSAR by a professor at Miami University starting in 1975, and participants were interviewed in six waves. Levy and her team conducted the survival analysis by matching the OLSAR data to mortality data from the National Death Index.

Although the study’s findings were in keeping with previous research showing that self-perceptions of stigmatized group identities, such as those related to race and gender affect behavior and functioning for people in those groups, the researchers theorized that self-perceptions of aging operate differently.

“Unlike race and gender stereotypes, which individuals encounter while developing group self-identities, individuals acquire age stereotypes several decades before becoming old,” they write. “Thus, younger individuals are likely to automatically accept age stereotypes without questioning their validity.”

In a follow-up longitudinal study, Levy and her team found that negative age beliefs acquired earlier in life significantly increased the likelihood that a person would experience a cardiovascular event later in life. The 89 cardiovascular event types studied included angina attacks, congestive heart failures, and strokes.

Global Reach of Ageism on Older Persons’ Health: A Systematic Review
E-Shien Chang; et al. PLoS One, January 2020.

This systematic review, conducted in conjunction with the World Health Organization’s Global Campaign to Combat Ageism, included more than 7 million participants in 422 studies from 45 countries on five continents over a span of 25 years. 

“Ageism led to significantly worse health outcomes in 95.5% of the studies and 74% of the 1,159 ageism-health associations examined,” the researchers write. “The studies reported ageism effects in all 45 countries, 11 health domains, and 25 years studied, with the prevalence of significant findings increasing over time (p < .0001).”

The study specifically examines “individual ageism” which refers to the “impact of culture-based negative age stereotypes and negative self-perceptions of aging on the health of older persons.” The review, which draws on the Stereotype Embodiment Theory developed by Levy, finds that ageism is more prevalent in less developed countries and that people with less education are more likely to experience the adverse health effects of ageism.

Ageism Amplifies Cost and Prevalence of Health Conditions 
Becca Levy; et al. The Gerontologist, February 2020.

This was the first study to examine the financial costs of ageism in terms of its health effects. The study, conducted by Levy and her team at the Yale School of Public Health, concludes that ageism resulted in $63 billion in excess health costs related to the eight most-expensive conditions (cardiovascular disease, chronic respiratory disease, musculoskeletal disorders, injuries, diabetes mellitus, treatment of smoking, mental disorders, and non-communicable diseases) for people ages 60 and older in 2018. In other words, 1 out of every 7 dollars (15.4%) spent on those conditions was linked to ageism, after adjusting for age, sex, and overlapping costs.

“This is greater than the total amount the United States spent on health care costs of morbid obesity for the same year,” the researchers write.

The costs were further broken down; $11.1 billion was attributed to age discrimination, $28.5 billion was attributed to negative age stereotypes, and $33.7 billion was linked to negative self-perceptions of aging. The study authors also estimated that ageism was responsible for 17.04 million cases of those eight most-expensive health conditions in 2018. The highest expenses were attributed to cardiovascular disease.

The research combined the results of previous ageism-health studies with 2013 data on health care spending from the Institute of Health Metrics and Evaluation. The research team used a variety of statistical checks to reduce the likelihood of health affecting ageism, as opposed to the other way around.

Experiences of Everyday Ageism and the Health of Older US Adults
Julie Ober Allen; et al. JAMA Open Network, June 2022.

This study made use of data from the University of Michigan National Poll on Healthy Aging that was collected in December 2019 from a nationally representative sample of 2,035 people aged 50-80. The analysis found that 93.4% of respondents regularly experienced at least some form of everyday ageism in their daily lives.

“Everyday ageism” was broken down into three groups: exposure to ageist messages; ageism in interpersonal interactions; and internalized or self-directed ageism.

Participants with lower levels of education, lower income, retirees not working for pay and people living in rural areas reported higher levels of everyday ageism than their counterparts. Older adults who spent more time online, watching television and reading magazines also reported being exposed to higher levels of everyday ageism, according to the study.

These higher levels of everyday ageism were associated with all four physical and mental health indicators the researchers examined — fair or poor physical health, number of chronic health conditions, fair or poor mental health, and depressive symptoms.

Interventions to Reduce Ageism Against Older Adults: A Systematic Review and Meta-Analysis
David Burnes; et al. American Journal of Public Health, August 2019.

This was the first systematic review and meta-analysis to assess the relative effects of interventions aimed at reducing ageism, the effectiveness of which remain poorly understood, according to the WHO’s global ageism report. Three types of interventions designed to reduce ageism among youths and adults were assessed — education providing information and addressing misperceptions about the aging process, intergenerational contact and combined education and intergenerational contact.

The review looked at 63 studies, including five randomized controlled trials, with a total of 6,124 participants, with most of the studies conducted in the United States. The research team found that ageism interventions had a significant effect on participants’ attitudes, knowledge and comfort level in interacting with older adults, but had no significant effect on anxiety about one’s own aging or interest in working with older adults (in the fields of geriatrics or gerontology). Interventions that included both education and contact between older and younger generations had the largest effects on attitudes. The effects were strongest among women and adolescent and young adult groups.

The paper also notes that “studies that examined the effect of ageism interventions among older adults themselves were lacking.”

Disparate Inclusion of Older Adults in Clinical Trials: Priorities and Opportunities for Policy and Practice Change
Angelica P. Herrera; et al. American Journal of Public Health, April 2010.

This paper looks at the issue of under-representation of older adults in clinical trials through a policy lens, reporting on the severity of the problem through a review of past research and outlining potential policy solutions.

Older people are sometimes excluded from clinical trials if they have multiple diseases, or they may have lower-functioning organs, such as the kidneys, which are important for drug processing. The result of this exclusion is underrepresentation. For example, two out of three cancer patients are older than 65, but only about 25% of participants in clinical trials for cancer treatments are in that age group, according to a 2003 study.

“Clinical trial participation of older adults is also low in research on Alzheimer’s disease, arthritis, epilepsy, incontinence, and cardiovascular disease,” the researchers write. “These failings may limit generalizability, provide insufficient data about positive or negative effects of treatment among specific populations, and hinder much-needed access to new treatments.”

The study recommends the development of standardized protocols for recruiting clinical trial participants, establishing guidelines for the inclusion of older people based on physiological rather than chronological age, using age-friendly methods of communication, making trial participation less costly and improving education and federal monitoring.

Ageism and Psychological Well-Being Among Older Adults: A Systematic Review
Hyun Kang and Hansol Kim. Gerontology and Geriatric Medicine, April 2022.

The authors of this paper reviewed 13 quantitative studies of the relationship between ageism and the mental health of older adults. The study confirmed that an increase in experiences of ageism has a negative effect on older adults’ psychological well-being, but it also identified some important mitigators.

According to the research, older adults with a “high level of psychological well-being,” especially those who were proud of their age group, were more optimistic about aging and their future, were more self-confident about their bodies, were flexible in setting goals, and were more resilient to the negative effects of ageism on their mental health. 

The researchers conclude that, overall, studies on the efficacy of interventions to combat the harmful effects of ageism are lacking. “Significant scholarly attention should be given to ageism,” they write, “considering its importance and universality, as it encompasses every generation and the growth of the population of older adults.”

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