BMJ  2007;334:316 (10 February), doi:10.1136/bmj.39111.694884.94

Views & reviews

Personal views

Out with "the old," elderly, and aged

¹ Department of Medical Gerontology, Trinity Centre for Health Sciences, Adelaide and Meath Hospital, Dublin

In his analysis of the challenge of simultaneously assisting and engaging in a respectful way with groups of differing status in society, the sociologist Richard Sennett reflected on why respect—which, unlike food, costs nothing—is in such short supply.¹ One answer lies in the language we use. Listening to the wishes of clients and patients with disability or of a different ethnicity has led to a more sensitive use of language in encounters with people from these groups.

Older people, who not only are key clients of health services but also experience ageism as a widespread and potent barrier to adequate health care,² have clearly signalled their wishes to be addressed in respectful terms. In a Europe-wide survey they have articulated a preference for "older" or "senior" as the defining adjectives for their demographic grouping.³ They also said which terms they deemed unacceptable: "elderly," "aged," and "old," with a particularly forceful rejection of elderly. This is echoed by the Human Rights Commission of the United Nations, which has outlined clearly in the International Covenant on Economic, Social and Cultural Rights why the descriptor "older" should be used.⁴

Yet the terms used to describe older people vary markedly in the biomedical literature and official policy documents. Perhaps the most common undesirable usage is that of "elderly," a term that in any other context is invariably pejorative: who wants to buy an elderly car or travel in an elderly aeroplane? Although a few commentators have outlined the importance of avoiding the more egregious forms of ageist terminology in clinical usage,⁵ the use of "elderly" in the biomedical (and indeed gerontological⁶) literature needs to be reconsidered, for further important reasons.

Two main phenomena of ageing in later life may be obscured by the use of terminology that is simultaneously pejorative and reductionist. The first is that the many positive aspects of ageing in later life, such as wisdom, experience, enhanced creativity, strategic skills, and maturity, are often overlooked in an ageist society, and such qualities are a critical component of successful ageing. Are the late great works of Verdi, Matisse, and Bellow the works of "elderly" or "older" artists? The second is the greater variability between individuals: populations of older people are more complex and heterogeneous than younger cohorts,⁷ and the corresponding complexity of their healthcare needs are ill served by negative collective phrases such as "elderly" rather than the more dispassionate "older."

In scientific terms the greatest risk is that what commentators really mean by "elderly" is a well meaning but misguided attempt to envelop the major clinical issue of frailty into a term that applies to all older people. Frailty is an important factor in functional decline, morbidity, and mortality for some older people, and much progress has been made in defining the phenotype, risk factors, manifestations, and outcomes of frailty as a clinical syndrome.⁸ However, most older people are not frail,⁹ and the proportion of older people who are disabled is dropping.¹⁰ Therefore, further understanding of the syndrome of frailty is not well served by a population descriptor that implies that all older people are affected by frailty. A better approach would be to promote clinical skills that selectively identify frail older people in preventive, community, and hospital care, as well as skills and pathways to improve care of this vulnerable group.¹¹

These considerations are enough to prevent treating the proposal for a rational and respectful terminology as a tiresome manifestation of the outer reaches of political correctness. Indeed, those who feel that concerns over terminology are a distraction from developing better services for older people would do well to heed the insights of influential social commentators and philosophers. Susan Sontag has illustrated the corrosive influence of negative social attitudes on service provision,¹² while Jürgen Habermas has outlined the importance of understanding and engaging with the social discourse from whence empirical research arises, emphasising the importance of communicative action as the driver of strategic and instrumental action.¹³

Editors of medical journals could usefully discuss whether or not they would promote the same sensitivity and precision in portraying older people as they would do with people from ethnic minorities and those with disability and to begin to describe older people in a way that respects their complexity, contribution, and civic engagement. Indeed, above and beyond avoiding the word "elderly," journal editors could look into the future and reflect on whether they might anticipate future thinking on what it means to be an older person. Perhaps the sharpest stimulus is the realisation that most of us will live to be older people and that we all have a stake in ensuring that the matrix within which our care system is embedded is sensitive to the increasing heterogeneity of our needs. Moving from the sense of a group that is separated from us by time and by pejorative descriptors towards an identification with our own future might be promoted by an imaginative turn of phrase: could "us as we age" be a useful starting position?

Older people have clearly signalled their wishes to be addressed in respectful terms

References

1. Sennett R. Respect: the formation of character in an age of inequality. London: Penguin, 2004.
2. Tonks A. Medicine must change to serve an ageing society. BMJ 1999;319:1450-1.[Free Full Text]
3. Walker A. Age and attitudes: main results from a Eurobarometer survey. Brussels: Commission of the European Communities, 1993.
4. United Nations Committee on Economic, Social and Cultural Rights. The economic, social and cultural rights of older persons. Geneva: UN High Commissioner for Human Rights, 1995.
5. Cayton H. The alienating language of health care. J R Soc Med 2006;99:484.[Free Full Text]
6. Palmore E. Ageism in gerontological language. Gerontologist 2000;40:645.[Free Full Text]
7. Nelson EA, Dannefer D. Aged heterogeneity: fact or fiction? The fate of diversity in gerontological research. Gerontologist 1992;32:17-23.[Abstract]
8. Walston J, Hadley EC, Ferrucci L, Guralnik JM, Newman AB, Studenski SA, et al. Research agenda for frailty in older adults: toward a better understanding of physiology and etiology: summary from the American Geriatrics Society/National Institute on Aging Research conference on frailty in older adults. J Am Geriatr Soc 2006;54:991-1001.[CrossRef][ISI][Medline]
9. O'Hanlon A, McGee A, Barker M, Garavan R, Hickey A, Conroy R, et al. Health and social services for older people II (HeSSOP II): changing profiles from 2000 to 2004. Dublin: National Council on Ageing and Older People, 2005.
10. Manton KG, Gu X, Lamb VL. Change in chronic disability from 1982 to 2004/2005 as measured by long-term changes in function and health in the US elderly population. Proc Natl Acad Sci USA 2006;103:18374-9.[Abstract/Free Full Text]
11. Bandinelli S, Lauretani F, Boscherini V, Gandi F, Pozzi M, Corsi AM, et al. A randomized, controlled trial of disability prevention in frail older patients screened in primary care: the FRASI Study. Design and baseline evaluation. Aging Clin Exp Res 2006;18:359-66.[Medline]
12. Sontag S. Illness as Metaphor. London: Penguin, 2002.
13. Habermas J. The theory of communicative action. Cambridge: Polity Press, 1984.

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