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Duke Medical Ethics Journal

Unveiling the Hidden Bias: Ageism’s Impact on Healthcare and Its Ripple Effects

By Julia Williams

In 1975, Robert Butler coined the term ageism as the perception of older persons as “senile, rigid, and old-fashioned in mortality and skills” [3]. It is no surprise to anyone that we, as the general public, view the elderly in a different light. This is not to say that this view is prejudiced or discriminatory; rather the stark differences in how we view the older generation provide the opportunity for ageism to arise, especially in our healthcare system. As recently as 10 years ago, people in the US above the age of 65 made up a minority of the population but accounted for an exponentially larger total healthcare cost [3]. Although currently a minority, we must recognize that it is projected that by 2030, 71 million adults are expected to be 65 years or older [2]. With this age group being the largest healthcare group, the prevalence and impact of ageism becomes quite significant. Furthermore, unlike other -isms that are isolated towards specific groups, ageism is bound to impact all who live long enough. By drawing attention to the avenues through which ageism presents itself in our healthcare system, we, as a society, can take proactive steps towards more inclusive training and policies. 

“The importance of open, honest, and unbiased communication between a patient and a healthcare professional is invaluable to diagnosis and treatment and thus, overall medical experience. Ageism can break down these communication ideals and cause the pathway to providing excellent and necessary healthcare to fail.”

This is not to say that the occurrence of ageism is always mal-spirited or intentional, as in many cases it appears unconsciously [3]. This implicit bias causes more alarm amongst healthcare policy workers because it makes the root of ageism in the medical setting harder to pinpoint and thus mitigate. Many recent surveys have illustrated common trends that healthcare professionals are grounded in a desire to do good towards older adults but their behaviors inevitably deprive patients of their autonomy [1]. One such theory of ageist tendencies toward older people from healthcare professionals is encapsulated by the “Terror Management Theory” [3]. This theory explains how the idea of ageism is closely associated with the human desire to dissociate from reminders of one’s own inevitable death [2]. Through this avoidance and ego-protective mechanism, negative attitudes and behaviors towards the elderly are reinforced [3]. This explanation of age anxiety is not targeted at solely healthcare professionals but the impacts of these ageist attitudes play the largest role in providing quality care and medical attention to the older population. As a result, the main areas in which ageism is most apparent and detrimental in our healthcare system are discriminatory communication and lack of emotional engagement, less respect for patient autonomy and patronizing environments, avoidance and neglect of preventative and extensive medical procedures, and lastly, severe elderly underrepresentation in clinical research [1]. 


The importance of open, honest, and unbiased communication between a patient and a healthcare professional is invaluable to diagnosis and treatment and thus, overall medical experience. Ageism can break down these communication ideals and cause the pathway to providing excellent and necessary healthcare to fail. A 2005 study video recorded doctor-patient interactions and an alarming amount of footage portrayed doctors not smiling and looking away from the elderly patient [3]. This survey also analyzed these older patients’ satisfaction with their medical interaction and a vast majority were negative as many blamed the interaction on “poor bedside manner” [3]. This sort of prejudiced speech was present not only in doctors but also in nurses. Whereas the general trend showed doctors utilizing passive communication, nurses conveyed a largely patronizing tone toward elderly patients when conducting workups [3]. Additionally, a 2004 study illustrated that the names of older patients are significantly less likely to be remembered than younger patients [3]. When older patients recognize that their healthcare team is not as invested in their care, they are discouraged by the outcomes they might get from their care. 


Another crucial responsibility of healthcare professionals is to uphold patient autonomy as this is the pillar that empowers patients to actively participate in their own care. Ageism has inhibited the ability of older patients to obtain maximum autonomy over their care. Autonomy has been shown to decrease among older patients due to the stereotype that older people cannot make sound, reasonable decisions about their own care. Circling back to Robert Butler’s echoing words about the term ageism, we are greatly inclined to see older patients are more incompetent than a standard, young patient. This attitude has encouraged a “dependency-support script” which describes a greater willingness to help someone who displays compliant reliance rather than free will, as observed in a study in the 1980s [3]. Findings from this study show how healthcare professionals are far more positively responsive to the dependent behaviors of elderly patients than to expressions of independence [3]. Although healthcare professionals’ hesitation to give older patients full independence can stem from good intentions, the presumption that this restricted autonomy applies to all patients at or above the 65-year-old mark is a very dangerous overgeneralization. 


The most detrimental application of ageism in the medical sphere is the limited proactiveness and extensiveness of diagnoses and treatments for older patients. Not only have studies directly observing negligent behavior in hospital settings supported this, but the structure of our healthcare policies for older patients has been equally revealing of diminished care for older patients. Large discrepancies have been shown in breast cancer care between younger women and older women. A study from the early 2000s shows how only 7% of physicians in the study conducted breast examinations on older female patients on a routine basis. Although an older study and we can hope that these numbers have increased on a wide-spread scale, the significantly low statistic is indicative of the preventative care differences solely based on the age of the patient [3]. This is recently seen with the way that the UK's National Health Service Breast Cancer Screening Program is structured. In this program, regular mammography is offered only to women under the age of 65 but was recently extended to the age of 70 [3]. Another study in 2006 approached breast cancer care bias through a different lens–physicans’ recommendation of invasive treatment for older patients compared to younger patients. Younger patients are significantly more likely to be recommended for breast-conservation therapy, whereas a higher percentage of older patients were recommended for modified radical mastectomy [3]. On the premise that prognosis and breast cancer stages between the two different age groups were relatively equal, the treatment recommendations were not as equal. Although such radical treatments might have been necessary for older women, many were recommended this invasive procedure before exploring other more accommodating and yet still effective treatments. 

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Ageism in this regard has also been researched with cardiovascular accidents (CVA) and strokes, common diseases especially in older patients. A 2007 study summarizes how older persons are less likely to receive care consistent with current guidelines for CVA. This is not to say that healthcare professionals are denying preventative care to older patients, but it is evident that ageist attitudes have given physicians an excuse to not exude full care and dedication to providing the most proactive and noninvasive treatment. However, physicians are not all to blame for this gap in healthcare for older patients. Health insurance plans all across the world become far more restrictive covering preventative tests and procedures for older people. In Belgium, patients over 85 years old are largely considered as “not worthy of care” [3]. In Greece, policies for inpatient stroke care enforce that patients over 65 are sent to admission to a general internal medicine ward rather than a neurology specialty service [3]. Similar restrictions are placed on elderly healthcare U.S. policies. Medicare benefits tend to provide for a maximum of 100 days of reimbursement, creating an incentive for facilities to keep patients in rehabilitation settings for this full-time period, regardless of whether it is beneficial [3]. Additionally, fall risk screening and home safety assessments are not covered by Medicare, nor is comprehensive outpatient geriatric care. While it is worthwhile to address the positive impact that Medicare has made to improve healthcare for older patients and thus tackle ageism, there are still areas of improvement that, with reform, can exponentially increase the health outcomes of older people. 


The last major avenue in which we see ageism plays a significant role is through the exclusion of the elderly in clinical research and trials for new drug development. A recent study of participant inclusivity in clinical drug trials for cancer and coronary artery disease strikingly shows how persons over the age of 65 are largely underrepresented [3]. This exclusivity has contributed to “double discrimination”: a term describing how without clinical evidence supporting the use of novel treatments in the older population, the chance is greatly reduced that older patients will receive these treatments [3]. This directly correlated with the trends shown in decreased recommendations of innovative and noninvasive treatments for older patients. 


Overall, the consequences of ageism include decreased access to care, inadequate care, longer hospitalization stays, and decreased patient satisfaction. These issues in our healthcare have contributed to poorer quality of life and even decreased survival rates for our older population [1]. Shedding light on these issues and the implications of ageism is crucial to stimulate discussion of action to provide solutions. The majority of scholarly opinions have pushed for greater training programs that directly address the healthcare of older patients and ageism in the medical sphere [2]. By strengthening the toolkit that the future generation of healthcare professionals has, our society can build a more sustainable age-friendly healthcare system. This ideal healthcare system would include increased inclusion of older adults in clinical trials, more appropriate preventative measures for the elderly, and enhanced communication to increase older patients’ satisfaction [1]. Likewise, healthcare policies need to be reevaluated to be explicitly more inclusive to protect the healthcare rights of the aging population. Although such positive changes have been seen with the Patient Protection and Affordable Care Act (ACA) of 2010 and further geriatric care reforms, ageism still claims a negative role in our healthcare system. By unveiling this hidden bias and continuing to address exactly how ageism is apparent, we can take steps towards improvement.

Review Editor: Laila Khan-Farooqi
Design Editor: Eugene Cho
  1. Palsgaard, P., Maino Vieytes, C. A., Peterson, N., Francis, S. L., Monroe-Lord, L., Sahyoun, N. R., Ventura-Marra, M., Weidauer, L., Xu, F., & Arthur, A. E. (2022). Healthcare Professionals' Views and Perspectives towards Aging. International journal of environmental research and public health, 19(23), 15870.

  2. Watt, Windy. “What Is Ageism in Healthcare, and What Can We Do About It?” GoodRx, GoodRx, Accessed 10 Mar. 2024. 

  3. Wyman, Mary, et al. “Chapter 13 Ageism in the Health Care System: Providers, Patients, and Systems.” Contemporary Perspectives on Ageism, SpringerOpen, pp. 193–212. 

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