When I accompanied my 85-year-old father to a doctor’s appointment not long ago, his primary care physician brushed off his complaints about chronic back pain, as well as my observations about his failing memory and balance problems. It’s normal at his age, he told me. When asked about the 14 different medications and supplements he’s on, the PCP quickly scanned several pages in the electronic record but decided not to make any changes since other specialists prescribed them for good reason. He mentioned that he wasn’t comfortable overruling another physician, though he also wouldn’t take any action on his own, like supplying him with a walker.
My dad, sadly, is not the only elderly patient to take so many medications — and to have his doctor dismiss his concerns about them with a shrug. The problems start early in the drug treatment process: Frequently excluded from clinical trials are the very older adults the medications are meant to help — and whose changing physiology causes them to metabolize drugs differently. Similarly, some doctors fail to recognize when standard medication doses are only appropriate for much younger patients.
We medicalize the natural process of aging, then look down on the patients who come seeking treatment.
Yet medication-related problems are estimated to be one of the top five causes of death in those 65 and older, and a major cause of confusion, depression, falls, disability and loss of independence. One in three seniors who take five or more medications will have at least one bad drug reaction each year; two-thirds will require medical attention. And those over 65 are 2.5 times more likely to visit an emergency room for an adverse drug reaction than younger individuals.
Such deep-seated failings in the delivery of medicine to elderly patients are indicative of a larger problem in health care: ageism. We medicalize the natural process of aging, then look down on the patients who come seeking treatment while not adequately preparing the doctors they visit to address their particular needs. The U.S. population is getting older, and without a major change in the values, training and attitude of the mainstream health care community, more and more of us will be harmed when we seek care as senior citizens.
Ageism “permeates the attitudes of medical providers, the mindset of older patients, and the structure of the health care system, having a potentially profound influence on the type and amount of care offered, requested, and received,” according to research by geriatricians Karin Ouchida and Mark Lachs for the American Society on Aging.
An analysis of National Health and Retirement study datafound that 1 in 5 adults over 50 experiences age-related discrimination in heath care settings; 1 in 17 said they experience it frequently. This bias is associated with new or worsening disability, poorer mental and physical health, and use of fewer preventive health services.
Other studies found age-based discrimination to be common in diagnostic procedures and in the types of treatment offered to patients, especially in cardiology, oncology and stroke care. Compared with younger patients, older adults were less involved in their own health care decision-making and doctors were less tolerant, less respectful and less optimistic.
Even government health agencies like the CDC frequently lump everyone over 65 into one homogenous group. But these individuals’ remaining lifespans could easily exceed 20 or 30 years, and they’re no more alike than are infants and tweens or kindergarteners and high schoolers.
These stereotypes matter. Many physicians, as well as older adults themselves, believe pain, fatigue, depression and dependency are a “normal” part of aging. These older patients are less likely to seek health care for themselves, and if they do, risk being undertreated. Ailments like poor hearing or cognitive decline can brand a patient as noncompliant or “difficult.” Studies show providers communicate differently with older adults than with younger ones. They’re less patient, less engaged and provide less information. And too often, treatable conditions like chronic pain or arthritis are dismissed as just a part of old age.
As we age, care becomes more complex, and more fragmented. The National Council on Aging points out that most adults over 65 have at least one chronic condition, and 77 percent have at least two. Yet these diseases are often poorly managed, leaving vulnerable patients to juggle multiple medical appointments, tests and medications, and feel overwhelmed and ill-informed, according to leading aging experts.
The American Geriatrics Society estimates that 30 percent of people 65 and older need care from a geriatrician — a primary care physician with advanced training in the care of older people. But these doctors are in short supply. As of 2018, only about 3,600 of the 6,900 certified geriatricians were practicing, leaving a serious gap in elder care, with an estimated shortfall of close to 27,000 full-time providers by 2025. Primary care doctors, who can manage some of the chronic conditions common among seniors, such as diabetes and high blood pressure, are at times turning older patients away.
One root cause is the lack of medical training to attend to the special demands of older patients. Medical schools routinely offer rotations in specialties like pediatrics, cardiology, surgery and emergency medicine. But geriatrics? Often not on the list.
Medical students don’t want to specialize in elder care, which is frequently considered a poor stepchild to other specialties, according to Louise Aronson, a geriatrician and author of “Elderhood: Redefining Aging, Transforming Medicine, Reimagining Life.Caring for older people isn’t seen as cool.
It’s probably because no one really wants to think about growing older and dying, she told me by phone. “Many people think old age is a bad thing, and depressing. That’s true of many medical students and physicians, too.”
Most doctors still receive the same training as they did when many more people died before they got old. While researching her book, Aronson, a professor of medicine at the University of California, San Francisco, discovered that medical school curricula even at the top schools still emphasized the same core rotations. If geriatrics was mentioned at all, it was as an elective course.
Whatever the reasons for the antipathy toward older patients, society — and the medical industry in particular — can’t ignore the population data. By 2035, adults 65 and older are expected to outnumber children in the U.S. for the first time. Most of those 79 million elders will need health care at some point. Already, though people over 65 are 15 percent of today’s population, they account for 39 percent of hospitalizations.
The medical establishment should recognize that older patients offer valuable lessons to practitioners.
Some hopeful signs of change are slowly emerging. More hospitals are establishing senior-specific emergency departments, which use nurse practitioners who are trained to assess older patients for cognitive function, medication interactions, depression and appropriate home support. Some health systems are also creating a culture of “age-friendly care,” emphasizing holistic approaches and what matters to the person, rather than subjecting them to every available invasive intervention.
Indeed, the medical establishment should recognize that older patients offer valuable lessons to practitioners. These include managing complexity, demonstrating patience, effective listening, fostering inclusivity — and treating people with dignity and respect, regardless of their number of years on the planet.