CGPR: What is ageism?

Dr. Clarfield: Ageism is stereotyping, prejudice, and discrimination due to age. It’s analogous to other forms of discrimination like racism or sexism. Older people receive unfair treatment by younger people, bias that on the face of it seems illogical since most of the young will hopefully become old. Ageism manifests in various ways. For example, an older worker might be denied employment after a certain age, not because of incapacity but due to prejudice. This is despite evidence that older workers can be more reliable and loyal, although on average less familiar with technology than many of their younger counterparts (Blomé MW et al, Int J Occup Saf Ergon 2020;26(1):112–120). “Benevolent” ageism occurs when an older person’s independence is overridden by others’ concerns, like children deciding to revoke a parent’s driver’s license. While sometimes stemming from genuine worry, this approach also reflects a disrespect for the older adult’s autonomy and independence, unless they are severely cognitively impaired.

CGPR: How does ageism affect mental health?

Dr. Clarfield: Normal aging can result in less “backup” energy or strength and a loss of abilities in physical and mental domains. Older adults might not be able to do as much as they used to or may take longer to recover from physical activities or illnesses. Being reminded of this by a patient’s family or by society, when it’s irrelevant or relatively unimportant, can detract from an older person’s sense of self and independence. Older adults experiencing ageism are more likely to experience lower levels of psychological well-being (Kang H and Kim H, Gerontol Geriatr Med 2022;8:23337214221087023). Ageism can diminish a person’s sense of self-respect, autonomy, and empowerment. Everyday ageism, such as making comments about “senior moments,” is associated with depressive symptoms even though such comments often are not intentionally discriminatory (Allen JO et al, JAMA Netw Open 2022;5(6):e2217240). Additionally, when older adults hear or use such terms, they internalize the idea that cognitive decline is a given. Older adults might become less confident in their mental abilities, which could lead to poorer performance on cognitive tasks (Barber SJ, J Appl Res Mem Cogn 2020;9(3):274–285).

CGPR: How can clinicians help combat ageist stereotypes?

Dr. Clarfield: Start by building empathy for older adults—work to discover their past achievements and experiences. A trick I use is asking patients to tell me what they did when they were in their prime. Everybody has an interesting story, be it running a large company or enduring serious trauma. Interest in a patient’s history shifts perception from seeing just an “old person” to recognizing that person and their lifetime of experiences. We doctors tend to not ask enough of a social history, even though it can take only a minute or two. However, it’s so important to acknowledge a patient’s social identity before addressing their medical conditions. This process helps quickly build a better therapeutic alliance between the clinician and patient. In clinical education, it’s vital to highlight when ageist attitudes appear. I often ask trainees: “Have you asked the [older] patient what they think?” I also ask patients: “What bothers you the most?” We should prioritize the patient’s primary concern rather than just addressing the most critical medical issues, dealing with the most life-threatening items on the problem list and moving down.

CGPR: People may be dismissive of depression in older adults, seeing it as a normal response to approaching the end of life. How should clinicians adapt their approach to depression in older adults?

Dr. Clarfield: Depression is a complex condition that can include anhedonia, anxiety, self-loathing, and an inappropriate sense of diminished self-worth, which can’t be dispelled by reminiscing about past achievements. Depression is an illness, not a normal response to aging, and requires treatment through therapy, medications, or even ECT. It’s also crucial to distinguish between depression and grief, as the latter, however painful, is not an illness but a normal and natural response to real loss. In the face of profound loss, such as the death of a lifelong partner, the most we can offer is empathy and companionship; we can’t cure the pain, but we can share in it, providing comfort just by being present. In Judaism, for example, the tradition of shiva (seven days of family and communal accompaniment for the bereaved) provides a framework for multidimensional support, emphasizing presence over words. The act of sitting quietly with the bereaved can be more comforting than any words. For our part, the psychiatrist’s role is to be with the patient during the acute phase of their loss and beyond, without demands, helping in their gradual recovery.

CGPR: Positive beliefs can improve mental health and negative beliefs can hurt mental health. What works when you want to change a patient’s beliefs about age?

Dr. Clarfield: Changing beliefs might not always be possible, but guiding people to adapt to them can be effective. Commiserating with patients often helps. I may share a quote by Bette Davis: “Old age ain’t no place for sissies.” This usually brings a smile and a nod of agreement, acknowledging the inevitable challenges that come with aging—the loss of independence and abilities. It’s important to validate these losses without dismissal or denial. Yet the focus should then shift to what remains, to the strengths and joys still present in their lives. One can help redirect their attention to a loving wife, devoted children, a hobby, or a job. For example, if a patient is grieving the loss of a spouse but is also a talented guitarist, encourage them to keep playing. Sometimes people don’t do enough of what they like and what they can.

CGPR: You’re giving them permission to live the good life.

Dr. Clarfield: Yes! When patients are distraught, I ask them what they like to do and allow them to incorporate activities into their life that they enjoy, even if it means watching a movie alone.

CGPR: Can you provide an example of common blind spots you see when clinicians treat older adults?

Dr. Clarfield: Ageism can lead clinicians to focus primarily on an older patient’s medical conditions, disregarding important components of their identity. Recently, a student presented a patient to me: “A 95-year-old man presented with acute congestive pulmonary edema secondary to…” I then asked about the patient’s social history, and the student reported that the patient lived in Beer Sheva and worked as a taxi driver. When I went to the bedside, I asked the patient where he was born. He told me he was born in Poland and came to Israel in 1949. When I asked where he was during the Second World War, the patient recounted that he survived five death camps, then proceeded to tell me the rest of his story. The student then asked me how he could have missed all of this—I explained that it was because he didn’t ask. Older patients all have a younger person inside them with experiences, accomplishments, and struggles. Just ask! When you teach a student this once, they don’t make the mistake again.

CGPR: Any other clinical examples of ageism?

Dr. Clarfield: Do not resuscitate (DNR) orders can be sensitive, especially regarding patients with cognitive decline. The presumption should be of capacity to decide unless proven otherwise, rather than assuming incapacity due to age or appearance. This approach respects a patient’s autonomy and recognizes that capacity is not binary; a patient may have the capacity to make health care decisions like DNR consent but struggle with financial affairs, for example. Clinicians must navigate these nuances, offering patients the respect to make their own choices, including mistakes, provided they aren’t severely impaired. This approach aligns with how autonomy is respected in younger adults facing similar decisions. The concept of ageism complicates this. Positive ageism, or overprotective behavior, stems from good intentions but can undermine an older person’s independence (Ben-Harush A et al, Eur J Ageing 2016;14(1):39–48). Contrary to negative ageism, which discriminates against older adults, positive ageism errs on the side of caution to prevent harm. I prefer to call it “parentalism.” You’re treating someone like they’re a child when they’re not, even if their judgment is impaired. Ageism can be patronizing and disrespectful to an older person’s judgment and views of risk.

CGPR: How does ageism affect a clinician’s approach to an older adult’s physical complaints? Are psychiatric contributors overlooked, or are somatic complaints dismissed as “just aging”?

Dr. Clarfield: Recurrent physical symptoms are often (but not always!) due to the somatization of depression (Li X et al, Front Psychiatry 2023;14:999047). It becomes tricky in older adults because they often have good physical reasons to have back pain, headaches, and abdominal pain. In younger people, when they endorse these symptoms and their scans come back normal, it’s easier to jump to a psychological underpinning. In older people, you often find imaging results that appear to explain the back pain but may well be primarily a somatization. Anxiety in old age is also a common symptom of depression. Digging deeper, you may find that patients with anxiety are not sleeping, have less of an appetite, etc. When you treat depression, the anxiety and the physical symptoms go away or at least no longer bother the patient. They may still have back pain, but it becomes tolerable.

CGPR: What else should clinicians look for in depression and anxiety to distinguish symptoms from normal aging?

Dr. Clarfield: Most older people have good reasons to be sad. If you live long enough, you’ll lose something serious. Still, clinicians should not dismiss depression as natural for older adults simply because they are closer to death or are having more physical difficulties. Depression cannot be dismissed, regardless of age. Ask about a patient’s sleep, weight changes, sexual appetite, love for life, and self-esteem. Ask whether they are still engaging in enjoyable activities. I consider depression as a possibility especially when patients stop activities that they had previously enjoyed throughout life. You can also more formally ask questions from the Geriatric Depression Scale. If you determine your patient is reacting to a difficult situation, then they don’t require medication, just support. When younger people lose their job and they’re upset, it’s clear they need a job and not an antidepressant. In older age it becomes trickier. In some patients, you may start with a trial of an antidepressant for a couple of months, then try a second antidepressant if they don’t improve. If there’s still no change after the second antidepressant, you can reevaluate the origin of the patient’s symptoms and modify your approach accordingly. For example, you may offer interpersonal psychotherapy to an older adult going through a life transition.

CGPR: What are some of the more serious consequences of ageism?

Dr. Clarfield: Studies suggest that up to 10% of adults over the age of 65 experience abuse in some form (Patel K et al, Cureus 2021;13(4):e14375). That’s ageism writ large. Keep your ears open, looking for hints and suggestions that elder abuse might be occurring. Sometimes elder abuse occurs primarily because caregivers are frustrated and at the end of their tether, such as when an otherwise good parent loses control and slaps their child. Supporting the caregiver, rather than taking a punitive approach, is a better solution in cases like this. But sometimes children, spouses, or even acquaintances act in a malignant manner toward an older adult, taking advantage of their vulnerabilities—just as truly abusive parents do to their children. Older people are scammed all the time. Fraud is a type of malignant ageism and differs from more typical elder abuse. It constitutes taking advantage of older adults, stealing from them, or changing the will of someone who has mild cognitive impairment. Clinicians should never forget that this can happen and be alert to it.

CGPR: Thank you for your time, Dr. Clarfield.