AARP Bulletin November 2003 cover story
Dorothy Rinehimer of Wilkes-Barre, Pa., vividly recalls the day in 1997 her late husband Bob returned from a visit to their family doctor with the news that an X-ray had turned up a spot on his right lung.
"The doctor told him there was no point in doing anything because he was nearly 87 and, at his age, any tumor would be small and slow-growing," Rinehimer, 92, recently told the AARP Bulletin.
But just two years later, after another X-ray and a biopsy, Rinehimer was on the operating table. Mark Katlic, M.D., the thoracic specialist who removed the lower right lobe of his lung, believes the family doctor waited too long to refer Rinehimer for surgery. "The doctor thought surgery was too risky for a man that age and that the patient was so old he would eventually die of other causes," Katlic says.
After the operation, Rinehimer lived four more years, playing golf almost daily until he died of pneumonia unrelated to his cancer this past March. "Without surgery," Katlic told the Bulletin, "Mr. Rinehimer wouldn't have lived those four years, that's for sure."
Rinehimer was shortchanged—at least until he came under Katlic's care—by a health care system that's unfairly, and often steeply, tilted against older Americans. Indeed, ageism—the term for discrimination against older people coined more than 30 years ago by Robert N. Butler, M.D., the founding director of the National Institute on Aging—still permeates virtually every aspect of the U.S. health care system.
Just as Rinehimer was falsely judged by his family doctor to be too old to handle cancer surgery, older Americans routinely receive second- or even third-class medical care at the hands of health care professionals who harbor a wide range of ageist assumptions and beliefs.
Often, says Christine Cassel, M.D., the president and CEO of the American Board of Internal Medicine, "The doctor's attitude is, 'At your age, I don't want to put you through this.' "
Over the past three decades, Butler has seen little change in the widespread bias against older people within the U.S. health care system.
"The ageist view of older people has persisted despite a significant body of evidence, dating back to the 1960s, that older people can tolerate powerful drugs and interventions to treat cancers and other diseases," says Butler, who now heads the New York-based International Longevity Center-USA. "There is no reason to assume that a person would not benefit from a drug or treatment based simply on his or her age."
Nonetheless, to a troubling degree, that's exactly what happens in the U.S. health care system. Numerous studies and surveys show that older patients are too often subjected to some inappropriately invasive procedures, such as multiple heart surgeries, or denied life-saving surgeries and other forms of state-of-the-art care.
Nowhere is the latter shortcoming more evident than in the nation's intensive care units (ICUs). People 65 and older account for more than half of all ICU days, and patients over 75 account for seven times more ICU days than those under 65. Yet a recent study by Wes Ely, M.D., of Vanderbilt University Medical Center, found unmistakable evidence of age bias in ICUs.
"Although older ICU patients could potentially require more interventions and consume more health care resources," Ely wrote, "recent studies have shown that older patients actually receive less-aggressive care than do younger patients."
SIGNPOSTS OF DISCRIMINATION
The signposts of age discrimination in the nation's health care system are nearly ubiquitous and, often, disturbing in their implications:
Older people are often denied the kind of preventive care routinely provided to others. "Many disease prevention techniques that are routine for children and many older adults are just not a regular part of practice when it comes to older patients," concludes a recent report from the Alliance on Aging Research, a nonprofit organization in Washington. Example: Even though flu vaccinations could prevent up to 80 percent of all deaths from influenza-related complications (such as pneumonia) among older Americans, two-thirds go without flu shots each year.
Why? Dennis O'Mara, the associate director for adult immunization at the Centers for Disease Control and Prevention (CDC), points to the order of priorities in the offices of busy doctors. "The focus tends to be on curative medicine and management of chronic disease," he says. "Prevention comes in a poor third."
Older people are less likely to be screened for life-threatening diseases. Although three-fourths of the more than 500,000 Americans who die of cancer each year are over 65, they are less likely than younger people to be screened for the disease, according to the American Cancer Society. Studies show that a wide range of other diseases and conditions often go unscreened and undetected, including osteoporosis, glaucoma and even hearing loss. Earlier this year, the CDC found that nine of 10 adults over age 65 go without the appropriate screenings.
"I see older women all the time who have never had a Pap smear or a mammogram," says Stuart M. Lichtman, M.D., a geriatric oncologist at North Shore University Hospital on Long Island, N.Y.
Similarly, on the mental health front, primary care doctors often miss signs of clinical depression and suicidal thoughts in older people—even though people over 65 have the highest suicide rate of any age group. In fact, 70 percent of older adults who commit suicide have seen their doctors sometime in the preceding month, and 39 percent have seen their doctors within one week before taking their own lives.
"Because of the disconnect between primary care and mental health care," says Joel E. Streim, M.D., president of the American Association for Geriatric Psychiatry, "older adults seen by their primary care physicians are too often misdiagnosed or improperly treated."
Older people are routinely overtreated, undertreated or even mistreated by health care professionals with little or no training in geriatrics. Physicians, out of ignorance or unconscious bias, may discount or misattribute certain problems to natural aging rather than disease, says Ron Adelman, M.D., the director of Cornell University's Center for Aging Research and Clinical Care.
"When physicians believe that depression, confusion and urinary incontinence are all part of normal aging," Adelman says, "they're not going to investigate it, they're not going to diagnose it, and they're not going to intervene."
Proven medical interventions for older people are often ignored, leading to inappropriate or incomplete treatment. A case in point: chemotherapy. Even though older patients in good health can tolerate chemotherapy as well as younger patients, they are less likely to get it. A raft of recent studies show that primary-care physicians often do not refer older people to oncologists out of the mistaken belief that they can't tolerate chemo or don't want it.
Two of three doctors surveyed by the American Society of Aging last year, in fact, said that undertreatment of older cancer patients is common.
Other studies show that many older patients are denied such therapies as mechanical ventilation, pulmonary artery catheters and hemodialysis. Yet other studies show that many older patients do not get clot-dissolving medications during heart attacks or beta blockers on hospital discharge that might prevent irreversible damage to the heart.
Older people are consistently underrepresented in—or even excluded from—clinical trials. One study showed that only 9 percent of the participants in breast cancer trials were 65 and over, even though women in that age group account for nearly half of all breast cancer cases.
A MATTER OF LIFE AND DEATH
Why do older people get such short shrift in the health care system? The root of the problem, the Alliance report says, has to do with "the lack of training in the basis of good geriatric medicine" among the nation's health care professionals.
Consider a recent survey of students at the Johns Hopkins University School of Medicine. More than 80 percent of them said they would admit a 10-year-old girl with pneumonia to intensive care and treat her aggressively, but only 56 percent said they would do the same for an 85-year-old woman.
In the worst cases, says Dan Perry, executive director of the Alliance on Aging Research, the age bias growing out of the lack of training can be "a matter of life and death."
Up until two years ago, Robyn Dickey's 84-year-old mother worked part time and lived on her own in Arkansas. One day she fell and hit her head. At the hospital, doctors said they suspected she had Parkinson's disease and began treating her with powerful drugs.
As her condition deteriorated, Dickey's mother was given ever-higher doses of drugs. Soon she was strapped in a wheelchair, at times hallucinating.
"'I know it's hard,'" Dickey recalls a doctor telling her, "'but once they get old, this is what you can expect.'"
One day a nurse took Dickey aside and gave her the name of a geriatric specialist. The specialist examined her mother and, after concluding that she probably didn't have Parkinson's, advised the family to remove her from the facility. He slowly weaned her off the medications, which, he later concluded, had caused a series of strokes.
"My mother was in and out of seven facilities during this ordeal," Dickey told the Bulletin. "The sad thing is that in every one of these facilities, we heard similar stories."
THE SHAPE OF THINGS TO COME
Earlier this year the U.S. Senate Special Committee on Aging held the first congressional hearing ever on age bias in the health care system, with testimony from Butler, Perry and others. "This built-in bias in our health care system prevents seniors from receiving the care they need," John Breaux of Louisiana, the committee's ranking Democrat, told his colleagues.
"The bias isn't 'I don't like older people,' " says Carl Eisdorfer, M.D., a geriatric psychiatrist and director of the University of Miami's Center on Aging. "The bias is more like, 'An older patient is much more difficult and time-consuming to treat, and I've got 20 other people in the waiting room and need to be at the hospital in two hours.' "
Many doctors, under intense financial pressure from managed care plans and companies and low Medicare reimbursements, try to pack the maximum number of appointments into a day and may not have the time and training to adequately assess the needs and problems of older patients.
It's just more evidence, Butler says, that "the whole health care system is negative and prejudicial toward the older patient."
But perhaps that will change as society asks the question that William Faxon Payne of Nashville, Tenn., a retired radiologist who nearly died when his post-surgery sepsis (blood poisoning) went undiagnosed, uses to frame the issue:
"Why should an older person not expect to have the same treatment as someone half his or her age?"
Elizabeth Pope is a freelance writer in Portland, Maine.
by Elizabeth Pope