Ageism in Rheumatologic Care: Ensuring Equity and Quality for Older Adults

The opening line of most medical documentation often reads, “Patient is a [xx]-year-old presenting for evaluation of…”. This standard practice of categorizing patients primarily by their age shapes our perception, subtly perpetuating a divisive labeling approach. In rheumatology, patient age is as pivotal as identifying erosive changes when determining treatment strategies for rheumatoid arthritis (RA).(1) However, there is a concerning trend: the older the patient, the less likely they are to receive disease-modifying antirheumatic drugs (DMARDs), even when they are functionally and cognitively capable and would benefit from the standard of care.(1, 2) This may represent ageism.

The World Health Organization (WHO) defines ageism as stereotyping (how we think), prejudice (how we feel), and discrimination (how we act) directed towards individuals based on their age. Ageism is widespread in our society and can manifest in several ways.(3) It can be internalized, leading to negative feelings about one’s own aging process. It can be interpersonal, where people treat others differently based on age, sometimes through careless comments or deliberate actions. Additionally, ageism can be structural, where discrimination against older adults is embedded within institutions, policies, and practices. The psychosocial impacts of ageism include increased feelings of isolation, helplessness, and frustration. Older adults might feel their concerns are not taken seriously, leading to mistrust in the healthcare system and decreased adherence to treatment regimens.

Ageism magnifies negative health impacts, including reduced lifespan, prolonged disability, and accelerated cognitive decline.(4) Although ageism can affect people of all ages throughout their lives, the negative impacts on health are greater in older individuals.(3) Alarmingly, one in two people worldwide hold ageist attitudes towards older adults.(5) With the U.S. population aging rapidly—those aged 65 and older are projected to rise from 17% in 2022 to 23% by 2050—the number of older adults living with rheumatologic diseases is also increasing. Older adults often face additional challenges such as limited mobility, chronic pain, and other geriatric syndromes (e.g., falls, frailty, depression, cognitive impairment). Inadequate treatment possibly rooted in ageism further exacerbates these poor health outcomes.

The economic burden of ageism on the US healthcare system is also substantial. A staggering $63 billion or 15% of total healthcare expenditure related to the eight most expensive health conditions affecting older adults was attributed to ageism, after adjusting for age and sex.(6) For musculoskeletal disorders alone, excessive costs of $2.1 billion were attributed to age discrimination and $4.4 billion to negative age stereotypes. This financial strain affects both patients and the healthcare system at large.

In this article, we aim to raise awareness among our colleagues about the pervasive yet often overlooked issue of ageism. The implications of ageism within the field of rheumatology need recognition. While research from other fields offers valuable insights, we must focus more on understanding and addressing ageism in rheumatologic care from both a clinical and patient perspective. We hope this discussion, with the perspective from an older adult with rheumatic disease (Lawrence ‘Rick’ Phillips), will illuminate the path toward better, more equitable care for all patients.

As a patient, Rick notes that “ageism happens (in healthcare) when people treat older [adults] with limited opportunities based primarily on age”. During his rheumatologic care journey, Rick recalls that “a rheumatologist once asked how long I expected to live. He indicated that would help define what care was appropriate. [The rheumatologist] seemed perplexed when I said age 200. The thing is, he was wondering why I was asking about changing biologic medication. At my age (51), he was perplexed as to why I was asking about more aggressive treatment. Why? I asked because I do not want my joints to hurt. I asked if that was uncommon for people of any age. No, he said he supposed not.”

Ageism in Rheumatologic Care: Manifestation and Detrimental Effects

Ageism in rheumatologic care can manifest in various ways, often starting with stereotypes and misconceptions.(7) At the individual level, self-directed ageism can influence treatment choice by affecting older adults’ perceptions and attitudes towards aggressiveness and/or long-term side effects of medications. Furthermore, internalized ageism can decrease participation in behaviors known to enhance health outcomes, such as exercise and mind-body practices.(8) Conversely, this may lead older adults to engage in risky health behaviors, including unhealthy eating, excessive drinking, or smoking, ultimately reducing their overall quality of life.

At the interpersonal level, healthcare provider bias critically translates into disparities in care. Although chronologic age alone does not provide a true indicator of an older adult’s health status, it may deter the standard of care.(1) Among older adults with a new diagnosis of late-onset rheumatoid arthritis (RA), less than a third were initiated on some form of disease-modifying antirheumatic drug (DMARD), despite their general safety and efficacy in this population.(2) Ageism may contribute to undertreatment since healthcare professionals with less favorable stereotypical beliefs regarding aging were more focused on the risks of medical intervention rather than their benefits when counseling older adults with rheumatic diseases.(9)

Rick emphasizes “I understand the options when they are offered. I cannot understand why some physicians want to make those decisions for me without my input. Doctors do not live in my experience. Give me the options, and I will decide how to proceed”.

Another common but flawed belief is that pain and disability are natural parts of aging, resulting in the underdiagnosis and undertreatment of rheumatologic conditions in older adults.(10) This misconception can cause delayed diagnosis and treatment, leading to disease progression and a decreased quality of life.

At the institutional or policy level, older adults are often excluded from clinical trials leading to a dearth of evidence bases for age-friendly care and clinical practice guidelines. A systematic review showed that a third of clinical trials involving patients with rheumatoid arthritis and osteoarthritis had arbitrary age limitations.(11) Addressing the underrepresentation of older adults in research was recognized as a priority, and the National Institute on Health implemented a policy to require researchers to include individuals of all ages in clinical research.(12) The 5Ts framework (Targets, Team, Tools, Time, and Techniques) enhances the inclusion of older adults in clinical research by addressing specific barriers and promoting a more inclusive approach.(13) By setting clear inclusion goals, assembling multidisciplinary teams, utilizing age-sensitive tools, allocating sufficient time, and implementing tailored techniques, researchers can create a conducive environment that respects and accommodates the unique needs of older adults.

Time, communication, and complexity: factors exacerbating ageism in rheumatology

Healthcare professionals are often unable to spend sufficient time understanding the unique needs of older patients, which exacerbates existing issues related to ageism. Older patients may have hearing or vision impairments necessitating more time and effort to ensure effective communication. Cognitive impairment can also impact assessment and subsequent time it takes to communicate management approaches in a way that both the older patient and their caregiver(s) understand. Rushed consultations can lead to misunderstandings, challenged trust or therapeutic alliance, and poorer health outcomes.

Multimorbidity in older patients can lead to reduced effectiveness of DMARD therapy and atypical presentations of adverse drug effects.(14, 15) Additionally, their treatment goals and preferences may differ from those of younger adults, making a one-size-fits-all approach inappropriate and highlighting the need for a patient-centered and age-friendly approach.(16) Rick believes “rheumatologists should see older patients as people first, patients second, and only then older mixed in with other things in our chart and history.” Because without thorough, individualized assessments, rheumatology health care professionals risk suboptimal treatment outcomes.

Emotional and psychological needs are often overlooked. Issues such as isolation, depression, or anxiety can profoundly impact older patients’ well-being, requiring time, empathy, and interdisciplinary collaboration to address.(16) The connection and communication styles between healthcare professional(s) and their older patient are critical, especially Rick points out when navigating “the challenging business of interacting with doctors and other healthcare providers.” The patient’s care experience begins the moment they enter a practice and as Rick shares: “ageism starts at the front desk and ripples right through a practice.” In today’s world, where electronic health records and portal messages are increasingly relied upon, the clinical staff play crucial roles as messengers and gatekeepers of information. Rick emphasizes that effective communication from both office staff and clinicians is essential when caring for older adults: “Talking to me like I’m a child makes me want to avoid visiting the doctor altogether. I advise your staff to avoid losing patients out the back door based on their interaction at the front door”. Rick is referring to “elderspeak”, a communication style that involves using simplified vocabulary, exaggerated intonation, and a condescending tone with older adults, often stemming from implicit ageism.(17) While it may be used with good intentions, elderspeak can come across as patronizing and may undermine patient-provider trust, exacerbate social isolation and lead to resistance to care.

Intersectionality of Ageism with other ‘isms’

Ageism is a significant social determinant of health, often intersecting with other forms of discrimination, such as racism and sexism, to exacerbate healthcare disparities, particularly for older adults with chronic conditions like rheumatic diseases.(18, 19) Policies and practices reflecting bias systematically disadvantage marginalized groups, while ageism perpetuates stereotypes and biases against older adults.(20) This intersection of discriminatory factors creates barriers to accessing quality healthcare. Theories like “double jeopardy” and “cumulative inequality” elucidate how the interplay of these forms of discrimination leads to compounded, detrimental effects on health outcomes.(21) For instance, older adults from minority backgrounds may encounter prejudices that lead to misdiagnoses, insufficient treatment, and mistrust in the healthcare system, resulting in more severe disease activity and progression.(22–24) Gender bias can also add another layer of discrimination, as healthcare professionals might dismiss or underestimate the symptoms of rheumatic diseases in older women.(25, 26) These overlapping -isms further restrict access to necessary medications, specialist consultations, and comprehensive management, ultimately leading to poorer health outcomes and increased chronic conditions. Addressing these issues effectively requires promoting comprehensive healthcare practices that ensure all older adults receive equitable, culturally competent care.(18, 22, 27)

Strategies to Mitigate Ageism in Rheumatologic Care

In the global report on ageism, the World Health Organization has outlined strategies for combating ageism. (5) Education and awareness are key in combating ageism within healthcare and ourselves.(5)

At the patient level, providing older adults with resources and education about their rheumatic disease condition enables them to advocate effectively for themselves. Understanding their diagnosis and treatment options empowers them to engage in informed discussions with their healthcare providers. Older adults with rheumatic diseases should be encouraged to share their functional goals, thereby opening up conversations with the rheumatology healthcare team about optimal treatments.

At the clinic level, rheumatology healthcare professional training programs should focus on recognizing and countering ageist attitudes. This involves avoiding broad generalizations about older adults and understanding that chronological age does not necessarily reflect physiological age. Leading national and international organizations combating ageism emphasize the need for language and imagery free of assumptions and judgment. Terms that stigmatize or dramatize aging, such as “elderly,” “senior,” or “demographic cliff,” should be avoided, as well as any portrayal of older adults as having less worth, such as suggestions of over-utilizing healthcare.(28) Instead, as a healthcare community, we should provide a balanced perspective on both the opportunities and challenges presented by demographic changes. The geriatric 5Ms framework—Medication, Mobility, Mentation, Multicomplexity, and what Matters most—provides a holistic approach to understanding older adults as individuals with distinct complexities, functional abilities, psychosocial needs, and care objectives.(16, 29) Rheumatology healthcare professionals who are knowledgeable about the 5Ms tend to have more favorable and nuanced views about aging.(9) Applying the 5Ms to assess social determinants of health can also help identify how structural racism intersects with ageism.(29) By acquiring the knowledge and skills to tackle age-related discrimination and inequality, rheumatologists can provide more empathetic and personalized care.

Collaborative care from a multidisciplinary team including rheumatologists, geriatricians, pain management specialists, clinical psychologists, PharmDs, physical therapists, and occupational therapists can help create a comprehensive treatment plan. Such a holistic approach ensures that all aspects of an older patient’s health are considered, including their preferences and goals of care, leading to more effective and personalized care.

With age, Rick noted that “increasingly, the doctors have to interact and do so seamlessly. I rely on that, and for the most part, that interaction requires me to remind each team member to react to other team members’ notes. I am finding that doctors who cannot interact well with the rest of my team are more of a liability than an asset”.

At the institutional level, policy and systemic changes are necessary to institutionalize the fight against ageism. Advocating for healthcare policies that promote the inclusion of older adults in research is essential to develop evidence-based age-friendly/appropriate guidelines that can help ensure that age is not a barrier to receiving appropriate care. Moreover, older adults should be recognized as important stakeholders in the process of developing age-friendly healthcare systems to reduce “othering” – an imaginary boundary between our present and future selves – and improve interpersonal and inter-generational collaboration.

Rick himself is an active patient advocate and has “written CMS and asked that rheumatologists receive better reimbursement. (Because) a rheumatologist will not find any better supporters than their older client base”.

Conclusion

Ageism in rheumatologic care poses significant challenges. By recognizing the unique needs of older adults, fostering interdisciplinary collaborations, implementing policy changes, and leveraging innovations in care, we can ensure that all patients, regardless of age, receive the equitable and quality care they deserve.

As Rick reflected on his rheumatologic care, a person aging with rheumatic disease, “I want to be in partnership with my care team. But they must understand they are my care team, and I will be the leader. Each of us has a role on that team. My role is to make decisions about my care, given the options. Their part is to give me the options and be sure I understand the risks. I employ them to help me understand the options and evaluate the risks”.