By Liz Seegert
Ageism is real and pervasive in healthcare.
And, it comes at a price. It affects older people’s wellbeing, their physical and mental health, and increases the need for and cost of care.
Twenty percent of older patients have reported experiencing ageism in healthcare encounters. A review of the impact of ageism on older people’s health concluded that in 85 percent of the examples, clinicians were less likely to offer procedures and treatments to older people, compared with younger patients, regardless of likelihood of benefit.
Ageism exacts a high financial toll. Researchers found the one-year cost of ageism on overall health for people 60 and older in the U.S. was $63 billion—one of every seven dollars for the eight most expensive health conditions—directly accounting for 17.04 million cases of these conditions. It also increases cardiovascular stress among older people, increases risk of cardiovascular events, and affects a person’s cognitive health.
“When older individuals are randomly assigned to a negative age-stereotype condition, it impairs health outcomes, such as memory performance and balance, compared to those in a neutral or positive-age-stereotype condition. And when randomly exposed to age discrimination in the form of patronizing speech, they performed significantly worse on a cognitive task than those not exposed to patronizing speech,” notes Yale psychologist and ageism researcher Becca Levy, author of Breaking the Age Code: How Your Beliefs About Aging Determine How Long and Well You Live.
A recent World Health Organization report on ageism concludes that, “Often people fail to recognize the existence of such institutional ageism because the rules, norms and practices of the institution are longstanding, have become ritualized and are seen as normal.”
However, ageism in healthcare and by health professionals is not inevitable. Studies of ageism among nursing students pointed to nursing’s essential role in elder care, and concluded that nursing professionals’ attitudes and behavior help define the quality of care provided. “Training programs for future care professionals have a responsibility to educate from a non-stereotypical perspective based on current societal needs.”
Changing Perceptions of Care
Camille Fitzpatrick is a retired clinical professor of nursing who taught adult gerontology primary care to nursing and medical students at UC Irvine from 1986 to 2021, originally at the School of Medicine and later at the Sue & Bill Gross School of Nursing. The gerontology concentration is now integral to the school’s Family Nurse Practitioner qualification.
Fitzpatrick has been working to change nurses’ perceptions of older people for decades. “Unfortunately, many students don’t see gerontology as sexy,” she says.
It’s not as financially lucrative as some other specialties, so someone really needs to have a passion for it. However, gerontology is also incredibly rewarding and challenging because it often involves very complex care. “You look at the older adult as a patient, not an old person, and they have different needs, just like your cardiac patient has different needs than someone who is physically fit and active,” she explains.
Other nurse leaders are also doing their part to combat ageism. Ellen Flaherty, vice president of the Dartmouth Health Geriatric Center of Excellence, and a past president of the American Geriatrics Society, has spent much of her career helping early-career nurses reframe their perceptions about caring for aging patients. Flaherty’s research and practice focuses on an interprofessional approach to primary care through the Geriatric Interprofessional Team Transformation in Primary Care (GITT-PC) model using the Age-Friendly Health Systems framework.
“I tell them one of the reasons we love geriatrics is that it’s peeling the onion. It’s always complicated, and complicated from a social perspective as well. But I don’t think that’s the general perception of nurses or other professionals coming into the field,” she says.
Flaherty believes that nurse educators “absolutely” must be training students in geriatrics, because more training and education leads to more people thinking about what a career in this field might look like.
Dartmouth is working to get more students interested in the field of gerontological nursing through modules around end-of-life care, and having conversations about serious illness, all the while trying to stay person-centered at every step. “There’s tremendous opportunity to really get to understand what does matter most to older adults,” Flaherty explains.
Finding a Connection with Older People
When she started out as a nurse practitioner in internal medicine at Harvard Community Health in 1976, Fitzpatrick didn’t know much about caring for older people. Geriatrics was part of internal medicine, but not a distinct specialty. She remembers older people coming in to see the residents. “They were just craving human contact, and I just loved it.” She’s always been drawn to vulnerable populations, and caring for older people “just fit.”
It wasn’t long before caring for older adults became a driving force in her life and career, as did efforts to educate and encourage other medical and nursing professionals to take up the mantle of geriatrics.
Fitzpatrick, who now lives in San Diego and volunteers her knowledge of geriatrics in support of San Diego County’s Medical Corps Services, said she always encountered students who described the profound impact an older person, usually a grandparent, had on their lives, which prompted them to concentrate in aging.
“I have been fortunate to have had several students who have gone into geriatrics and, and it’s wonderful. It feels like mission accomplished. My attitude was, even if they don’t change their mind to specialize in geriatrics, they at least were exposed to my passion.”
Clinical Professor Emeritus Camille Fitzpatrick has now retired from UC Irvine and the Sue & Bill Gross School of Nursing, but is still championing the right of older people to specialized gerontological care.
One of the best aspects of geriatric care is how highly interdisciplinary the field is.
Camille Fitzpatrick
One of the best aspects of geriatric care is how highly interdisciplinary the field is, according to Fitzpatrick, because it involves social workers, physical therapists, medical assistants, and other specialties, in addition to physicians and nurses.
“We look at how the person lives, functions, how to read older people’s behavior by looking at the bigger picture,” she says.
For example, did they forget to bring their hearing aids to an appointment? It’s not a cognition problem, it’s a hearing problem. “I have always taught nurses to focus on the geriatric ‘F’ word—function. We want to make sure that people are functioning to their highest level.”
More Gerontology Nurses Needed
The need for nurses with advanced knowledge about caring for older adults is only growing. People 65 and older make up about 17.3 percent of the U.S. population, but by 2050, they will comprise over 22 percent. In just about a decade, older people will outnumber those under 18 for the first time, the Census Bureau projects. And, the Population Reference Bureau estimates that by 2060, the number of Americans 65 and older will nearly double from 52 million (2018 data) to 95 million.
It’s not just that there are more older adults, thanks to the aging of the baby boomers. Lifespan has also increased. Despite the Covid pandemic, more people are living into their eighties and nineties, with multiple chronic conditions, thanks to the many advances in care and treatment.
This trend is not just happening in the United States—worldwide, the 65+ population is increasing steadily, thanks to improved access to healthcare, better sanitation and nutrition, lower fertility rates and reduced infant and child mortality.
However, despite the older adult population growth, there is still a serious shortage of geriatric specialists, even while demand increases. Currently, there are about 7,100 certified geriatricians in the U.S. who care for those needing more specialized care—about 30 percent of the 53 million people 65 and older. That works out to about 36.4 providers per 100,000 older adults. The ratio is even lower in rural areas. Issues like differences in compensation and age bias make it difficult to recruit primary providers to this specialty.
It’s an opportunity for nurses, especially nurse practitioners, to step up, according to healthcare consultant and former nurse Jennie Chin Hansen, past CEO of the American Geriatrics Society, and former president of AARP. But first, it means eliminating age bias among these care professionals. “There’s just this overlay of ageism, and this permeates throughout healthcare,” she says.
That societal barrier has also affected the nursing curriculum and the medical curriculum. By the time people focus on caring for older people, they seem so different and so complex with comorbidities and functional issues and the matrix of cognitive issues. “It’s overwhelming for some people,” Hansen explains.
One way to help address the shortage of geriatric care professionals is to train all healthcare providers to care for older patients, in the way that geriatric nursing is part of the Family Nurse Practitioner program at the Sue & Bill Gross School of Nursing. This should include diverse older populations with a range of health conditions, writes Becca Levy in Breaking the Age Code. She notes that while all medical schools in the U.S. require pediatric training, less than 10 percent require geriatric training. And, “Less than 1 percent of nurses are formally trained to work with older adults.”
Caring for the Most Vulnerable
Between 2000 and 2007, Fitzpatrick teamed up with gerontologist Laura Mosqueda, MD (now at University of Southern California, (USC)) to provide clinical care to older adults in Orange County. They became expert in caring for older people with large numbers of serious chronic illnesses, like Alzheimer’s and heart disease. Family members were often involved, so their patients became not just the person, but everybody who loved them. That required a little bit of listening and a lot of looking at body language, observation, how people are responding, how people are jumping in, Mosqueda explains.
“Camille just has a natural ability to do that. It’s a real combination of the art and science of medicine,” says Mosqueda. “She does her homework, she knows her stuff. And she has a big heart, and all of those things combined into being a good clinician and a good teacher.”
The trust and respect they had for each other allowed them to serve their patients and students to the best of their ability. The kind of work that she and Fitzpatrick did and still do is often not the most expensive thing. It was often not the sort of sexiest, coolest thing. But it was the thing that was going to make the biggest impact on that person’s life for the better, Mosqueda explains.
“The world would be a better place in all kinds of ways if we had more Camilles in the world,” says Mosqueda. “She’s just a delightful person. People really want to work with her. And students want to do well because of her. She inspires all of us to do better.”
Age Bias on the Road
Fitzpatrick has also helped to tamp down age bias through her research and education on older adults and driving. “There are age-related changes that don’t make us necessarily unsafe, but may make us more cautious, for example, driving at night.” She developed a clinical guide to assessing driving in older adults in conjunction with the state of California, and even made a YouTube video about driver safety for Leisureworld in Florida.
“It’s not the nurse practitioner or the physician’s responsibility to take away a driver’s license. It’s their responsibility to evaluate,” Fitzpatrick explains. Her goal is to help clinicians figure out how to help their older patients maintain their independence for as long as possible. Not everyone over 65 or 70 has driving issues, but serious concerns like dementia should be reported to the DMV, she says.
Caring for older people takes specialized knowledge, the ability to tackle multiple problems at once, and someone who is unfazed by complexity. It takes a person who understands that the pieces are always moving, and that a condition isn’t just a “Costco recipe,” says Hansen.
“You have to tweak and adjust. It’s a partnership like no other, and the reward that you have for giving the best care based on who that person is and what you know, and bring to the table so that their life is better,” she adds.
There’s no doubt that taking care of geriatric patients is complicated and less financially rewarding than many other specialties, Fitzpatrick says. “But the big thing is, I always got back more than I gave out. It is just such a blessing and honor to be able to take care of these folks who have done so much and I just want to give back and get back.” It seems like Fitzpatrick and successive gerontology nurseeducators still have their work cut out for them, as research by Levy and others document. Higher, avoidable healthcare costs, missed treatment opportunities, poorer outcomes, and worse mental health could all be avoided, or at least minimized, if providers could remove ageism from the mix. It’s hard to break some of the myths, Fitzpatrick admits. “All we can do is role model and just be the best we can.
