A. Ageism and health law, policy and practice

The federal government is responsible for the Canada Health Act[112] but each of the provinces and territories is responsible for the administration of health care coverage and the overall distribution of health resources within health care and to different populations. Ageism in health care can be seen in many forms including the absence of services for older adults; age based decisionmaking in health and age rationing; making decisions about the quality of older people’s lives; paternalism; forced decisions; and gender bias. Ageism can be evident in the allocation of health care resources, the respective burdens of the individual and spouse or partner, other family and the state.

It has been noted that as an institution of society, the health system perpetuates ageist assumptions. Thus, cultural conceptions of older people can legitimate differential treatment and this can be perpetuated in the delivery of health care.[113] There is a growing international literature on the paternalistic and ageist ways that older adults are treated within health care systems. Renowned gerontologists Kane and Kane note

“Older people are always singled out as the most expensive demographically defined group of health care users. It is a cliché for journalists and many health policy authorities to remark to remark the X percent of people over the age of 65 account for XX percent of the health care dollar. Indeed older people do use disproportionately more care than do their younger counterparts as well they should. People accumulate chronic diseases as they age and some diseases have their onset in later life…. The unreflective repetition of this almost tautological claim about the high use of health care by older people (somewhat like the high use of health care by sick people) does verge on ageism. “[114] [emphasis in the original]

In “Time for Action”, the Ontario Human Rights Commission highlighted health care as one of the important areas in which older adults can face significant discrimination with profound effects on health, quality of life and their longevity. Here we see the intersection of multiple “isms”, predominantly ageism, sexism and ableism, but also heterosexism, and racism. Older adults note they are often treated differently by some in the health care system:

“it’s like health care at 60. They don’t want to be bothered with you. You’re a drag on society and doctors don’t have time. They just don’t want to take the time with an older person. And it gets back to health care. Every time they have to cut healthcare back, the seniors seem to get it . . . . We’re just living week to week to week. “[115]

There is a general concern expressed in many Canadian jurisdictions that the acute care system has failed to adapt to the changing needs of a changing population, in essence creating a “structural ageism”. In other words, when health care is shaped as a traditional service designed around isolated episodes of care within well-defined specialties and agencies, it cannot fully meet the needs of increasing numbers of older patients, especially those with chronic, multiple and recurrent medical problems.[116]

At both an individual level and a structural level it has been recognized that in healthcare, old persons are often treated differently. At a practice level, that ageism may involve withholding information, services, or treatment, or it may involve taking older persons’ complaints or symptoms less seriously and attributing them to old age.[117] Research on health care professional attitudes in acute and rehabilitative care show a fair amount of agreement about subtle and not so subtle ageisms. Physicians, for example often provide inadequate treatment to the elderly.[118] They give more respect and support, as well as more detailed medical information to younger patients.[119] They also solicit more information from younger patients.[120]

In a review of the health care literature and ageism, Dovios (2006) noted older people receive more medication prescriptions than younger people for equivalent symptoms.[121] Anxiety medication use by Canadians more than doubles from 65 years of age on, and the hypnotic medication use more than triples. This has particular significance given that 40% percent of all emergency department visits by older adults are medication-related.[122] Some physicians may rely on prescription medications as a substitute for taking time with an older patient, overlooking preventive care, good screening and diagnosis.

The Commission also points to the systemic effects of limited benefits coverage of health care system on older adults: Medicare does not cover all medically-related and dental health services. Instead, these must be paid by the individuals or from private insurance plans (which may have restrictions on coverage). This impact may be especially acute for older women. Similarly, there are inadequate facilities for chronic care, partly because the current health care system tends to focus on acute care facilities. Funding for long term care, complex continuing care, and rehabilitation (which are three key need areas for older many adults) is less a priority and funding adequacy is less developed in the current system.

The ways in which current health care funding is allocated disproportionately affects older women. Older women are much more likely than older men to have chronic conditions. Women are more likely to go into nursing homes, as they tend to live longer than men in general and older women tend to outlive their spouses. Many older women can expect to live twenty or thirty years as widows.

Prevention and rehabilitation tend to be viewed as less important with advancing age; and health care providers may feel that age limits for the access to medical services are acceptable and justifiable. [123] Kane and Kane draw a distinction between “disparity” (unfairness, inequality) and variation in health care practice. Legitimate reasons, unrelated to age, such as underlying conditions or ability to survive the treatment can make some distinctions between older persons and some younger persons with the same conditions justifiable.[124] Yet it is always important to be willing to test the underlying assumptions.

The effects of age related discrimination in areas such as health care are tangible, and discrimination is a life stressor. People who report experiencing discrimination also experience more mental health problems. Women who had experienced age discrimination have significantly lower positive well-being than men who had experienced age discrimination. [125]

Ageism may be manifested at any stage and within any type of health care. Some types are directed directly at older adults. Others are structural, affecting older adults and those who care and support them. Ageism can arise in the context of health care consent, as well as in the context of the protection of those who care for older adults in the health care system. It can arise in the context of health care policy in key areas such as home care.

Noel Simard has commented that paternalism is an insidious expression of ageism, widely seen among health professionals. It is expressed by a condescending attitude and infantilizing approach that considers advanced age as a debilitating disease that places older persons at the same level as small children or the mentally incompetent, unable to make sensible decisions regarding their health or well-being. [126]

There is a propensity in society to confuse the aging process with the disease process. That is, people tend to be more familiar with pathological aging (when things go wrong) than they are with healthy aging. The belief that continual decline is inevitable leads to disease or symptom management rather than health promotion or proactive intervention.[127] Symptoms are misdiagnosed in older adults because these are written off as part of the ‘normal aging process’.

Older adults are less likely to be referred for screening and treatment. For example, American data suggest that as many as nine of every ten adults over the age of 65 go without the appropriate screenings.[128] The Alliance for Aging Research notes: “Those numbers are startling considering that 80% of all fatal heart attacks and 60% of all cancer deaths afflict men and women age 65 and older, indicating that there is great need for aggressive screening measures within this age group”. [129] There is also a general tendency in health care to assume that older adults will not benefit from particular treatments, rather than find out from research and other clinical evidence whether that is actually the case.

Once an older patient encounters a health problem, studies show that physicians often use the person’s age, not his or her functional status, as a factor in determining the appropriate treatment. This means far fewer older patients receive interventions that can save their life or improve its quality. Their functional health, not their age, should remain the determining factor when deciding whether surgery is appropriate.[130]

. Structural ageism

(a) Omission from clinical trials

The systematic exclusion of older adults from clinical trials has been identified as one of the most flagrant examples of ageism.[131] Although older adults are the heaviest users of many prescription drugs because bodies wear out, they have historically been excluded from clinical drug trials through overt age cut-offs or less explicit exclusions based on co-morbidity and frailty. The use of specific age limits appears to be chosen arbitrarily.[132] Most trials (even those that specifically target therapies frequently used by older adults) try to actively exclude people with multiple diseases and conditions in the trial group. There are a number of practical and economic factors underlying this omission of older adults in clinical trials. Including them can complicate the data analysis and interpretation. However, very importantly from a marketing perspective, it dampens the effects sought (i.e. the drugs’ efficacy may come off in a less positive light). The effect of the lack of older adults in the clinical trials means that they become de facto laboratory rats once the drugs are on the market. Health care consent to the medications becomes illusory because there is little if any information on how the drugs work on older adults.

While some of the explicit exclusion of older adults from clinical trials has diminished over the years, it is still there. A survey of Spanish research, for example, indicated that in the 1990s, 36% to 40% of the intervention studies submitted had an upper age limit. This number decreased to 19% in 2007. Non-intervention trials (where a group of people receive no care or medication), by way of contrast, rarely had upper age limits.

Today in the United States, the Food and Drug Administration now requires the population being targeted for a particular drug’s use to be included in the drug trials. Nonetheless, the more complex cases and persons are still winnowed out.[133] International work shows some physicians are reluctant to enrol older patients in trials, citing concerns about coexisting conditions, the toxic effects of treatment, ineligibility, poor compliance, and lack of social support.[134] Thus it is often not chronological “age” per se that leads to the ageism in health care, but a number of interrelated factors that are associated with aging, as well as a lack of social effort to see if it is possible to address the underlying factors used to exclude older adults in the first place.

(b) Treatment and under treatment

Gender and age discrimination can intersect in areas such as health care treatment. Older adults often experience a fatalistic attitude among health care providers as expressed in the statement “Well, you are going to die of something …”. This often leads to a lack of consideration of whether there are some treatments from which the older person will benefit. The issue is not that the person will die (as all people will), but what efforts are made to support a reasonable quality of life for t