Ageism in health care is more common than you might think, and it can harm people

Ashley Milne-Tyte

npr.org

Originally posted 7 March 24

A recent study found that older people spend an average of 21 days a year on medical appointments. Kathleen Hayes can believe it.

Hayes lives in Chicago and has spent a lot of time lately taking her parents, who are both in their 80s, to doctor's appointments. Her dad has Parkinson's, and her mom has had a difficult recovery from a bad bout of Covid-19. As she's sat in, Hayes has noticed some health care workers talk to her parents at top volume, to the point, she says, "that my father said to one, 'I'm not deaf, you don't have to yell.'"

In addition, while some doctors and nurses address her parents directly, others keep looking at Hayes herself.

"Their gaze is on me so long that it starts to feel like we're talking around my parents," says Hayes, who lives a few hours north of her parents. "I've had to emphasize, 'I don't want to speak for my mother. Please ask my mother that question.'"

Researchers and geriatricians say that instances like these constitute ageism – discrimination based on a person's age – and it is surprisingly common in health care settings. It can lead to both overtreatment and undertreatment of older adults, says Dr. Louise Aronson, a geriatrician and professor of geriatrics at the University of California, San Francisco.

"We all see older people differently. Ageism is a cross-cultural reality," Aronson says.

The info is here.

Here is my summary:

This article and other research point to a concerning prevalence of ageism in healthcare settings. This bias can take the form of either overtreatment or undertreatment of older adults.

Negative stereotypes: Doctors may hold assumptions about older adults being less willing or able to handle aggressive treatments, leading to missed opportunities for care.

Communication issues: Sometimes healthcare providers speak to adult children instead of the older person themselves, disregarding their autonomy.

These biases are linked to poorer health outcomes and can even shorten lifespans.  The article cites a study suggesting that ageism costs the healthcare system billions of dollars annually.  There are positive steps that can be taken, such as anti-bias training for healthcare workers.

New evaluation guidelines for dementia

The Monitor on Psychology

Vol. 54, No. 3

Print Version: Page 40

Updated APA guidelines are now available to help psychologists evaluate patients with dementia and their caregivers with accuracy and sensitivity and learn about the latest developments in dementia science and practice.

APA Guidelines for the Evaluation of Dementia and Age-Related Cognitive Change (PDF, 992KB) was released in 2021 and reflects updates in the field since the last set of guidelines, released in 2011, said geropsychologist and University of Louisville professor Benjamin T. Mast, PhD, ABPP, who chaired the task force that produced the guidelines.

“These guidelines aspire to help psychologists gain not only a high level of technical expertise in understanding the latest science and procedures for evaluating dementia,” he said, “but also have a high level of sensitivity and empathy for those undergoing a life change that can be quite challenging.”

Major updates since 2011 include:

Discussion of new DSM terminology. The new guidelines discuss changes in dementia diagnosis and diagnostic criteria reflected in the most recent version of the Diagnostic and Statistical Manual of Mental Disorders (Fifth Edition). In particular, the DSM-5 changed the term “dementia” to “major neurocognitive disorder,” and “mild cognitive impairment” to “minor neurocognitive disorder.” As was true with earlier nomenclature, providers and others amend these terms depending on the cause or causes of the disorder, for example, “major neurocognitive disorder due to traumatic brain injury.” That said, the terms “dementia” and “mild cognitive impairment” are still widely used in medicine and mental health care.

Discussion of new research guidelines. The new guidelines also discuss research advances in the field, in particular the use of biomarkers to detect various forms of dementia. Examples are the use of amyloid imaging—PET scans with a radio tracer that selectively binds to amyloid plaques—and analysis of amyloid and tau in cerebrospinal fluid. While these techniques are still mainly used in major academic medical centers, it is important for clinicians to know about them because they may eventually be used in clinical practice, said Bonnie Sachs, PhD, ABPP, an associate professor and neuropsychologist at Wake Forest University School of Medicine. “These developments change the way we think about things like Alzheimer’s disease, because they show there is a long preclinical asymptomatic phase before people start to show memory problems,” she said.

The info is here.

The Age Trajectory of Happiness

Kratz, F., & Brüderl, J. (2021, April 18).

https://doi.org/10.31234/osf.io/d8f2z

Abstract

A large interdisciplinary literature on the relationship between age and subjective well-being (happiness) has produced very mixed evidence. Virtually every conceivable age-happiness trajectory has been supported by empirical evidence and theoretical arguments. Sceptics may conclude that the social science of happiness can only produce arbitrary results. In this paper we argue that this conclusion is premature. Instead, the methodological toolbox that has been developed by the modern literature on causal inference gives scholars everything they need to arrive at valid conclusions: the causal inference toolbox only must be applied by happiness researchers. We identify four potential sources of bias that may distort the assessment of the age-happiness relationship. By causal reasoning we derive a model specification that avoids these  biases.  For  an  empirical  illustration,  we  use  the  longest  running  panel  study  with information on happiness, the German Socio-Economic Panel (1984-2017; N persons=70,922; N person-years =565,703). With these data we demonstrate the relevance of the four biases and how combinations of different biases can reproduce almost any finding from the literature. Most biases tend to produce a spuriously U-shaped age trajectory, the most prominent finding from the literature. In contrast, with our specification we find a (nearly monotonic) declining age-happiness trajectory.

Summary and Conclusions

How aging affects happiness is an important research question for the social and behavioral sciences. Our literature review demonstrates that many conflicting age trajectories have been reported in the literature. As this state of research is quite unsettling for the science of happiness, we  discuss—informed  by  recent  advances  in  the  methodology  of  causal  analysis—model specifications used by researchers in this field. Altogether, we identify four main biases that may distort the age trajectory of happiness. By using the German SOEP data, we show that distortions may be huge producing even qualitatively different conclusions. We demonstrate that by using different combinations of mis-specifications it is possible to generate (almost) every trajectory that has been reported in the literature. With a model specification that avoids these four biases, we find an age-happiness trajectory that declines slowly over adulthood (altogether about half a scale point). The decline comes to a halt and we observe even a small increase (about one tenth of a scale point) during the golden ages. Afterwards, in old age a very steep decline in happiness sets in.

The research is here.

Older adults across the globe exhibit increased prosocial behavior but also greater in-group preferences

Cutler, J., Nitschke, J.P., Lamm, C. et al. 

Nat Aging 1, 880–888 (2021).

https://doi.org/10.1038/s43587-021-00118-3

Abstract

Population aging is a global phenomenon with substantial implications across society. Prosocial behaviors—actions that benefit others—promote mental and physical health across the lifespan and can save lives during the COVID-19 pandemic. We examined whether age predicts prosociality in a preregistered global study (46,576 people aged 18–99 across 67 countries) using two acutely relevant measures: distancing during COVID-19 and willingness to donate to hypothetical charities. Age positively predicted prosociality on both measures, with increased distancing and donations among older adults. However, older adults were more in-group focused than younger adults in choosing who to help, making larger donations to national over international charities and reporting increased in-group preferences. In-group preferences helped explain greater national over international donations. Results were robust to several control analyses and internal replication. Our findings have vital implications for predicting the social and economic impacts of aging populations, increasing compliance with public health measures and encouraging charitable donations.

Main

Prosocial behaviors have critical individual and societal impacts. Emerging evidence suggests that older adults might be more prosocial than younger adults on measures including economic games learning about rewards for others, effortful actions and charitable donations. In line with this, theoretical accounts of lifespan development, such as socioemotional selectivity theory, propose that motivation for socially and emotionally meaningful behaviors increases as a result of age-related differences in goals and priorities. However, most research has tested participants from western, educated, industrialized, rich and democratic populations. It is unknown whether increased prosociality is shown by older adults across the world. Moreover, although some studies point to increased prosocial behavior, others find no association or even heightened negative behaviors, including greater bias toward one’s own emotions, increased stereotyping of outgroups and less support for foreign aid. Together these findings suggest that age might be associated with both increased positive helping behaviors but also heightened self-serving and in-group preferences.

The research is here.

Supported Decision Making With People at the Margins of Autonomy

A. Peterson, J. Karlawish & E. Largent (2020) 

The American Journal of Bioethics

DOI: 10.1080/15265161.2020.1863507

Abstract

This article argues that supported decision making is ideal for people with dynamic cognitive and functional impairments that place them at the margins of autonomy. First, we argue that guardianship and similar surrogate decision-making frameworks may be inappropriate for people with dynamic impairments. Second, we provide a conceptual foundation for supported decision making for individuals with dynamic impairments, which integrates the social model of disability with relational accounts of autonomy. Third, we propose a three-step model that specifies the necessary conditions of supported decision making: identifying domains for support; identifying kinds of supports; and reaching a mutually acceptable and formal agreement. Finally, we identify a series of challenges for supported decision making, provide preliminary responses, and highlight avenues for future bioethics research.

Here is an excerpt:

Are Beneficiaries Authorized to Enter into a Supported Decision-Making Agreement?

The need for supported decision making implies that a beneficiary has diminished decision-making capacity. But there is a presumption that she is still capable to enter into a supported decision-making agreement. What justifies this presumption?

One way to address this challenge is to distinguish the capacity to enter into a supported decision-making agreement from the capacity to make the kinds of decisions enumerated in the agreement. For example, it is recognized in U.S. law that people who lack capacity to make medical decisions at the end of life may still have capacity to assign a surrogate decision maker (Kim and Appelbaum 2006). This practice is justified because the threshold of capacity required to appoint a surrogate is lower than that to consent to more complex decisions. Similarly, the kinds of decisions enumerated in supported decision-making agreements will often be complex and could result in unfortunate consequences if poor decisions are made. But the decision to enter into a supported decision-making agreement is relatively less complex. Moreover, these agreements are often formalizations of ongoing, trusting relationships with friends and family intended to enhance a beneficiary’s wellbeing. Thus, the threshold of capacity to enter into a supported decision-making agreement is justifiably low. People with marginal capacity would reasonably satisfy this threshold.

This response, however, raises questions about the minimum level of decision-making capacity required to enter into a supported decision-making agreement. The project of supported decision making would benefit from future scholarship that describes the specific decisional abilities that show a person with dynamic impairments can (or cannot) enter into a valid supported decision-making agreement.

The article is here.

Aging in an Era of Fake News

Brashier, N. M., & Schacter, D. L. (2020).
Current Directions in 
Psychological Science, 29(3), 316–323.

Abstract

Misinformation causes serious harm, from sowing doubt in modern medicine to inciting violence. Older adults are especially susceptible—they shared the most fake news during the 2016 U.S. election. The most intuitive explanation for this pattern lays the blame on cognitive deficits. Although older adults forget where they learned information, fluency remains intact, and knowledge accumulated across decades helps them evaluate claims. Thus, cognitive declines cannot fully explain older adults’ engagement with fake news. Late adulthood also involves social changes, including greater trust, difficulty detecting lies, and less emphasis on accuracy when communicating. In addition, older adults are relative newcomers to social media and may struggle to spot sponsored content or manipulated images. In a post-truth world, interventions should account for older adults’ shifting social goals and gaps in their digital literacy.

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The focus on “facts” at the expense of long-term trust is one reason why I see news organizations being ineffective in preventing, and in some cases facilitating, the establishment of “alternative narratives”. News reporting, as with any other type of declaration, can be ideologically, politically, and emotionally contested. The key differences in the current environment involve speed and transparency: First, people need to be exposed to the facts before the narrative can be strategically distorted through social media, distracting “leaks”, troll operations, and meme warfare. Second, while technological solutions for “fake news” are a valid effort, platforms policing content through opaque technologies adds yet another disruption in the layer of trust that should be reestablished directly between news organizations and their audiences.

A pdf can be found here.

What is the ethics of ageing?

Christopher Simon Wareham
Journal of Medical Ethics 2018;44:128-132.

Abstract

Applied ethics is home to numerous productive subfields such as procreative ethics, intergenerational ethics and environmental ethics. By contrast, there is far less ethical work on ageing, and there is no boundary work that attempts to set the scope for ‘ageing ethics’ or the ‘ethics of ageing’. Yet ageing is a fundamental aspect of life; arguably even more fundamental and ubiquitous than procreation. To remedy this situation, I examine conceptions of what the ethics of ageing might mean and argue that these conceptions fail to capture the requirements of the desired subfield. The key reasons for this are, first, that they view ageing as something that happens only when one is old, thereby ignoring the fact that ageing is a process to which we are all subject, and second that the ageing person is treated as an object in ethical discourse rather than as its subject. In response to these shortcomings I put forward a better conception, one which places the ageing person at the centre of ethical analysis, has relevance not just for the elderly and provides a rich yet workable scope. While clarifying and justifying the conceptual boundaries of the subfield, the proposed scope pleasingly broadens the ethics of ageing beyond common negative associations with ageing.

The article is here.

Is utilitarian sacrifice becoming more morally permissible?

Ivar R.Hannikainen, Edouard Machery, & Fiery A.Cushman
Cognition

Volume 170, January 2018, Pages 95-101

Abstract

A central tenet of contemporary moral psychology is that people typically reject active forms of utilitarian sacrifice. Yet, evidence for secularization and declining empathic concern in recent decades suggests the possibility of systematic change in this attitude. In the present study, we employ hypothetical dilemmas to investigate whether judgments of utilitarian sacrifice are becoming more permissive over time. In a cross-sectional design, age negatively predicted utilitarian moral judgment (Study 1). To examine whether this pattern reflected processes of maturation, we asked a panel to re-evaluate several moral dilemmas after an eight-year interval but observed no overall change (Study 2). In contrast, a more recent age-matched sample revealed greater endorsement of utilitarian sacrifice in a time-lag design (Study 3). Taken together, these results suggest that today’s younger cohorts increasingly endorse a utilitarian resolution of sacrificial moral dilemmas.

The article is here.

Here is a portion of the Discussion section:

A vibrant discussion among philosophers and cognitive scientists has focused on distinguishing the virtues and pitfalls of the human moral faculty (Bloom, 2017; Greene, 2014; Singer, 2005). On a pessimistic note, our results dovetail with evidence about the socialization and development of recent cohorts (e.g., Shonkoff et al., 2012): Utilitarian judgment has been shown to correlate with Machiavellian and psychopathic traits (Bartels & Pizarro, 2011), and also with the reduced capacity to distinguish felt emotions (Patil & Silani, 2014). At the same time, leading theories credit highly acclaimed instances of moral progress to the exercise of rational scrutiny over prevailing moral norms (Greene, 2014; Singer, 2005), and the persistence of parochialism and prejudice to the unbridled command of intuition (Bloom, 2017). From this perspective, greater disapproval of intuitive deontological principles among recent cohorts may stem from the documented rise in cognitive abilities (i.e., the Flynn effect; see Pietschnig & Voracek, 2015) and foreshadow an expanding commitment to the welfare-maximizing resolution of contemporary moral challenges.

Oregon Emphasizes Choices At Life's End

By Kristian Foden-Vencil

Oregon Public Broadcasting

Originally published March 8, 2012

Terri Schmidt, an emergency room doctor at Oregon Health and Science University, can't forget the day an elderly man with congestive heart failure came into the hospital from a nursing home.

The man hadn't filled in a medical directive form, so, by law, Schmidt had to provide all the medical care possible.

"I intubated the man. I did very aggressive things. It didn't feel right at the time," says Schmidt. "There was just this sense in my mind that this is a 92-year-old very elderly person with bad heart failure. And about 15 minutes later, when I was able to get ahold of the family.  They said, 'You did what?  We talked about this! He didn't want it. We had a big conversation in his room about a week ago.'"

Oregon has been in the forefront of trying to make sure a person has as much control over the end of his or her life as possible. The state pioneered a form known as a POLST, for Physician Orders for Life-Sustaining Treatment, that has been adopted by 14 states and is being considered in 20 more. The form offers many more detailed options than a simple "do not resuscitate" directive.  

That's good for Helen Hobbs, who is 93 and lives in an assisted living facility in Lake Oswego. Age has bent Hobbs low and she uses a walker, but she is very clear-headed on this topic.

"You know, death is part of your life. You know you're going to get there someday so let's make it as pleasant as possible," Hobbs said. "I mean, would you like to stay in an unconscious condition for years while people kept you alive with feeding and hydration tubes? No."

Hobbs outlined her end-of-life medical decisions a couple of years ago, after a serious surgery. She used Oregon’s form. It is signed by her doctor, so it's legally enforceable.

The entire story is here.

Lawsuit Accuses Company Of Fraudulently Cycling Patients Through Nursing Homes, Hospice Care

By Jordan Rau

Kaiser Health News Staff Writer

Originally published January 4, 2012

A national hospice company improperly cycled patients through nursing homes and hospice with a goal of making as much profit as possible from Medicare, according to a whistleblower lawsuit announced this week.

Federal attorneys also sued the hospice company, AseraCare, alleging it milked Medicare’s hospice benefit by pressuring its employees to enroll people into hospice who weren’t dying and resisted discharging them despite evidence they weren’t deteriorating. One hospice patient who should have been immobile from end-stage heart disease was healthy enough to go to his granddaughter’s graduation and a berry-picking excursion with a friend, the government charges.

For years, some critics of Medicare’s hospice benefit have said that the way the government pays providers gives them financial incentives to abuse the system. The suits against AseraCare, a Fort Smith, Ark.-based hospice company operating in 19 states, follow several other suits against big hospice companies but go further in their allegations that the company coordinated its use of nursing care and hospice care to maximize Medicare reimbursements.

The entire story is here.

My psychoanalyst’s twisted final session

Once a legend in his field, he was clearly losing his grip. Still, why did he have such a hold on me?

By Simon Yisrael Feuerman

Published by Salon.com

It was with some trepidation that I called Dr. M.

I had read his articles in various psychoanalytic journals and heard his name tossed around at conferences and institutes. He was one of the princes of psychoanalysis and supervision, a member of the old school. He knew people who had been analyzed by Freud and was a colleague of some of the last century’s bad/good boys of psychoanalysis – Hyman Spotnitz, Lou Ormont, Ethel Clevans, Phyllis Meadow.

Nineteen years I had been with a previous analyst and supervisor with whom I had an irreparable break. Nineteen years may sound like a long time for most people, but in the rarefied world of New York psychoanalysis, 19 years is merely a beginning.

Finally, I had made the phone call. And now I was at Dr. M’s Upper West Side office for my interview. I had built a practice that was already sizable, but would I rate for his famous supervision group?

I had arrived about 10 minutes early and expected to read in the waiting room until the appointed hour. By tradition, an analyst will open his door precisely at the right time, neither early nor late.

To my surprise, he came out 10 minutes before our appointment time. Anticipating a silent rebuke I quickly said, “I apologize for coming early.”

“I apologize for seeing you early,” he said. “Come in.”

He had a shock of white hair. He was handsome. Looking at him in that dimly lit hallway in the late spring of 2009, I was taken aback. Why, he must be 90 years old, at least. (He was 89.) His body sent my body a message: I am dying. But at the very same time the vigor in his booming voice said something else entirely. It took hold of me. I was confused: While on the one hand he looked as though he might be nearing the end of his life — the office was dusty, his pants were hiked up too high, subtle but telltale signs of a man losing touch — his voice said, “Beginnings!” New life.

He talked, I talked. I talked, he talked. We had a rhythm. He seemed to be building an enthusiastic lather about having me as his newborn as though he were a man of 30 being given a baby to hold outside the delivery room. There was, you could say, a kind of love in the air.

And it made me somewhat uneasy. In fact, I was quite certain that I had made a mistake. I wanted to run away fast. I did not want to be in this man’s group. Perhaps I feared that I would have to face his death and my own here. I wanted to go to a group that promised me everlasting life. I did not want a dying analyst. I was looking for potency, vitality, virility. I had quite a bit myself, but sought it in others too.

As if magically sensing my turmoil, he stood up. “Enough for today,” he barked. “I would like you to join my group, but say in about nine months. Not before.”

I was astonished. Was he a master, I thought, one of these wonder-worker analysts who can read the mind and even ride like a bronco, two wildly opposing winds of thought in a man? Such things were possible in my world. I had great faith in analysts and their mad magic, their alchemy, their abilities to turn lead into gold and ambivalence and even death into life.

The rest of this interesting story is here.