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Ageism in Healthcare
- Gerald C H Koh (8 September 2006)
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Whose ageism?
- Iona Heath (12 September 2006)
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Changing ageist practice - clinical leadership plays a key role
- S H Guptha, P Owusu-Agyei, Consultant Physician and Clinical lead in Stroke (14 September 2006)
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Geriatricians and stroke
- Desmond O'Neill, DR Collins, Consultant Geriatrician and Stroke Physician (16 September 2006)
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Gerald C H Koh, Asst Prof Yong Loo Lin School of Medicine, National University of Singapore
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Dear Editor, My deepest respect to Fairfield and Rothwell for doing this study and to BMJ for publishing it.[1] Their findings echo those found in a past BMJ paper that reported many ICUs in UK had age-based admission criteria.[2] Both papers highlight an important social issue that affects healthcare systems: ageism. Ageism has been defined by sociologists as discrimination on the basis of age and the mistaken belief that older persons benefit less from medical interventions.[3,4] Why do physicians and healthcare systems discount the demonstrated ability of older patients to benefit from interventions and continue to deprive them of beneficial treatment? Is it because of an underlying attitude that the elderly are a financial burden to society or simple ignorance? Ageism is a pervasive problem in society with its roots deeply entrenched in stereotypical attitudes towards older persons that are taught to us through society, media, and even the negative attitudes that some older persons may hold of themselves. For anti-ageist practice to become firmly established as a central part of good medical practice, careful but concrete steps must be taken. We must have a deeper appreciation of the ageist attitudes of society that run much deeper than the level of personal values and individual concerns. It must take into account the wider issues of culture, gender, race, and society’s structural issues.[5] As healthcare providers, we must continue to keep vigilant against ageist attitudes and policies that may creep into our daily practice. Dr Gerald C H Koh, Assistant Professor National University of Singapore, 117597, cofkohch@nus.edu.sg References: 1. Jack F Fairhead and Peter M Rothwell. Underinvestigation and undertreatment of carotid disease in elderly patients with transient ischaemic attack and stroke: comparative population based study. BMJ 2006;333:525-527. 2. Escher M, Perneger TV, Chevrolet JC. National questionnaire survey on what influences doctors' decisions about admission to intensive care. BMJ 2004;329:425. 3. Formosa M. Exposing ageism. BOLD (Quarterly Journal of the International Institute on Ageing). 2001;11:15-23. 4. Feraro K. Cohort Changes in Images of Older Adults. The Gerontologist. 1992;32:296-304. 5. Palmore EB. Ageism: Negative and Positive. New York: Springer. 1990. Competing interests: None declared |
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Iona Heath, general practitioner Caversham Group Practice NW5 2UP
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I have misgivings about this paper and about the suggestions of ageism in the accompanying editorial. In the introduction, we learn that lower rates of treatment in older people “might legitimately reflect … patients’ choice”. However, the conclusions of the abstract assert “a willingness to have surgery” on the part of elderly patients and in the discussion section of the main paper we are told that the low rate of endarterectomy in patients of 80 and above is ”unlikely to have been due … to patient choice”. Neither of these statements is supported by a reference. In the methods section, we are told that “all patients were interviewed and examined so that the potential appropriateness of carotid surgery could be determined”. However, we are not told how appropriateness was determined and from whose perspective.
When research findings contradict clinical experience, they demand careful scrutiny. My experience of talking to older people over many years is that many, although certainly not all, begin to lose their enthusiasm for hospital treatment of any sort after the age of 80, let alone for invasive surgery with a significant, albeit small, risk of harm. I note that in this study the gold standard was a decision made by the patient after discussions with surgeons who were not involved in the study. Ageism is undoubtedly operating in the distribution of healthcare resources in the UK but we should not forget that it can also occur when patients are persuaded to accept treatments that do not accord with their own values and aspirations. There is a real danger that locating ageism within rates of prophylactic surgery will distract attention from the much more pervasive expressions of ageism which are to be found in the lack of funding for the care of frail older people in England and particularly those suffering from dementia. Competing interests: None declared |
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S H Guptha, Consultant Physician Peterborough and Stamford NHS Hospitals Trust, P Owusu-Agyei, Consultant Physician and Clinical lead in Stroke
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We read with interest the findings of Fairhead and Rothwells study.[1] We discovered that amongst patients admitted with acute stroke, brain imaging was performed only in a small proportion of older adults. The most common misconceptions were that imaging older adults after an acute stroke would not change management and therefore it would be a waste of resources. After the appointment of a clinical lead in stroke, there has been a sustained effort at changing this practice by a continuing audit cycle, development of local acute stroke guidelines, regular teaching sessions regarding the importance of appropriate prescribing of anti-platelet agents, risk of haemorrhage with indiscriminate use of anti- platelet agents, consequences of recurrent stroke and importance of its prevention especially in the older adult. We are glad that this effort has improved brain imaging in older adults in our hospital. Table: Rate of brain imaging in patients admitted with acute stroke in the years 1997,1998 and 2003 Age 1997 1998 2003 Upto 40yrs 67% 50% 100% 41 – 50 yrs 90% 100% 100% 51 – 60 yrs 84% 96% 91% 61 – 70 yrs 68% 78% 83% 71 – 80 yrs 34% 67% 89% 81 – 90 yrs 25% 56% 78% 91 yrs and above12% 31% 68% Reference: 1. Jack F Fairhead and Peter M Rothwell. Underinvestigation and undertreatment of carotid disease in elderly patients with transient ischaemic attack and stroke: comparative population based study. BMJ 2006; 333: 525-527 Competing interests: None declared |
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Desmond O'Neill, Consultant Geriatrician and Stroke Physician Stroke Service, Adelaide and Meath Hospital, Dublin 24, Ireland, DR Collins, Consultant Geriatrician and Stroke Physician
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The paper and editorial on investigation into stroke and ageism are important additions to the literature on ageism as a source of inequity in access to healthcare (1, 2). One of the missing pieces of information is the specialty or sub-specialty of the physicians providing secondary care in the Oxford study. Allowing for selection bias in admissions, there is evidence that care under a neurologist or geriatrician can be associated with a higher levels of investigation in stroke, or avoidance of harmful therapy (3). Nursing styles and team work in stroke care in geriatric medicine wards has been demonstrated to be more appropriate than in general medicine and stroke unit care (4), and the use of Acute Care of the Elderly principles has been shown to be an effective basis for the development of stroke unit care (5). It is notable that the UK and the Ireland have evolved models of stroke unit care with clinical leadership from both geriatricians and neurologists, in conjunction with rehabilitationists. This unique combination allows for the introduction of gerontological principles and models of care that facilitate care for an age-related disease, as well as balancing advocacy against ageism with a biopsychosocial approach. The effectiveness of the gerontological approach to medical care has been demonstrated for acute general medical admissions (6): it is vital that the advantages of this dual approach are developed and expanded in stroke care. 1.Fairhead JF, Rothwell PM. Underinvestigation and undertreatment of carotid disease in elderly patients with transient ischaemic attack and stroke: comparative population based study. BMJ 2006;333:525-527 2. Young J. Ageism in services for transient ischaemic attack and stroke. BMJ 2006;333:508-509 3. Duffy BK, Phillips PA, Davis SM, Donnan GA, Vedadhaghi ME; Stroke in Hospitals: an Australian Review of Treatment investigators. Evidence-based care and outcomes of acute stroke managed in hospital specialty units. Med J Aust. 2003;178:318-23. 4. Pound P, Ebrahim S. Rhetoric and reality in stroke patient care. Soc Sci Med. 2000;51:1437-46 5. Allen KR, Hazelett SE, Palmer RR, Jarjoura DG, Wickstrom GC, Weinhardt JA, Lada R, Holder CM, Counsell SR. Developing a stroke unit using the acute care for elders intervention and model of care. J Am Geriatr Soc. 2003;51:1660- 7 6. Ellis G, Langhorne P. Comprehensive geriatric assessment for older hospital patients. Br Med Bull. 2005;71:45-59. Competing interests: None declared |
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