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Ageism in American Health Care

An 85-year-old man is experiencing some pain in his right knee so he goes to the doctor for a check up. The doctor examines his knee and says, “I can't really find anything wrong with it. Maybe at your age you should expect this. After all you are 85 years old.” The man says to doctor, “I could buy that, except that my left knee is 85 years old too and it doesn't hurt at all.”

I heard this as a joke many years ago, but it appears there may be some truth behind it.

The U.S. Senate Special Committee on Aging recently held a hearing entitled “Ageism in the Health Care System: Short Shrifting Seniors?”

Daniel Perry, executive director of the Alliance for Aging Research testified on the Alliance's latest report: “How American Health Care Fails Older Americans.”

Perry said older patients too often do not receive preventive treatments such as vaccines and screening tests that could prevent diseases from becoming life threatening. In fact, the report finds that due to insufficient research on older patients, there is very little clinical agreement what constitutes normal lab results in older people.

“Lack of generally accepted standards of care for older patients means older patients are more likely to face inappropriately invasive procedures, such as multiple heart surgeries, while others may be denied a life-saving surgery out of the mistaken concern that the patient's age alone rules them out for certain procedures,” Perry testified.

Perry told the Senators that medical neglect of the aged often begins even before illness strikes. It starts with the failures to screen older people for the early signs of disease. “Very few screening guidelines have been developed that even refer to people over 65, even though the vast majority of fatal heart attacks and cancer deaths occur after that age. We are still waiting for the research to show whether common health screening protocols for measuring cholesterol or colorectal cancer exams catch problems early enough in the elderly to save lives.”

“The bias that underlies these shortcomings would be unacceptable even if the elderly were a small percentage of the patient population in our country,” Perry admonished. "But currently Americans over 65 comprise half of all physician time. By 2030, almost 25% of the entire U.S. population will be in this age group. Ageist assumptions that distort the quality of healthcare for such a large and growing group hurt everyone, because they lead to premature loss of independence on a giant scale; they increase mortality, disability and depression in older adults who might otherwise lead productive, satisfying and healthier lives.”

Robert Butler, MD and professor of Geriatrics, Mount Sinai School of Medicine, also presented compelling testimony on the under-representation of older persons in clinical trials. Clinical trial is the process established to test the safety and efficacy of new drug treatments.

“Unfortunately,” Butler testified, “people 65 and over are woefully underrepresented in or even excluded from these trials, despite the fact that they are the ones who generally take the most medications. The result is a lack of understanding of how drugs and treatments will work in older persons, which can lead to adverse reactions and inappropriate dosages or treatments and the misperception that older people cannot tolerate or benefit from new drugs and procedures.” As Congress debates the addition of a prescription drug benefit for Medicare beneficiaries, Butler said, it becomes increasingly important that we have a proper understanding of how drugs affect the older population.

Ironically a reason researchers exclude older persons is they often have multiple conditions that make it harder to interpret results. He pointed out that in fact complicated medical histories are the norm and that we must learn something about older people as they live and age.

The Senate also heard testimony on how the nation's mental health care system fails older Americans. Joel E. Streim, MD, president of the American Association for Geriatric Psychiatry said, “Research has shown that depressed older adults have worse clinical outcomes for a variety of conditions that are highly prevalent in late-life: hip fractures, heart attacks and cancer. Depression increases mortality rates after heart attacks and among elderly residents of long-term care facilities. In fact, depression is a stronger predictor of mortality among heart attack victims than a second heart attack. After surgical repair of hip fractures, depressed patients have poorer recovery rates during rehabilitative care compared to those who are not depressed. Among cancer patients, those who are depressed have worse pain control, increased hospitalization rates, poorer physical function and poorer quality of life. Persons over 65 have the highest suicide rate of any age group; among those over 85, the rate is twice the national average.”

Despite this Streim said, “Mental health care services in our country are designed for young and middle-aged adults in good physical health, ignoring the unique needs of older adults who typically have concurrent medical conditions that complicate their care. Instead of a system that provides coordinated care to manage the complex interactions of psychiatric and medical conditions — and the multiple medications used to treat them — older adults are subject to a system of fragmented care that falls far short of what we should consider to be a minimum standard of care. Even Medicare — with its primary mission of funding health care for seniors — carries the bias against mental health care that afflicts the nation's health care system more generally. Most mental health services under Medicare require a 50% copayment as opposed to the 20% copayment for treatment of all other medical conditions. That's not just an insurance carrier's coverage decision — it's the law.”

Congratulations to the Senate Committee on Aging for examining these inequities in our nations' health care system. Let's hope they take action to reverse them.