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Ageism in Post-Acute and Long-Term Care: Is That Possible?

      I have worked in nursing homes since I was 17 years old, and despite many years of loving my work with older adults, I recently began to wonder whether I could be ageist. It is hard to share that thought publicly — not just because I value dignity, respect, and inclusivity, but because I’m a social worker. Is it possible that I could be harboring ageist attitudes and beliefs without even knowing it? With my curiosity piqued, I delved into exploring what it means to be ageist and the ways that I could unconsciously be contributing to this problem.
      In 1969, geriatrician Robert Butler coined the term “ageism,” which he defined as “a combination of prejudicial attitudes toward older people, old age, and aging itself; discriminatory practices against olders; and institutional practices and policies that perpetuate stereotypes about them” (quoted in Ashton Applewhite, This Chair Rocks: A Manifesto Against Ageism, Networked Books, 2016). Researchers at Yale University estimated that ageism is responsible for “17.04 million cases of the eight most expensive health conditions” per year in the United States, amounting to $63 billion annually (Yale News, Nov. 13, 2018, https://bit.ly/3KcBPde).
      Ageism affects people of all ages, including children. Nobody is born ageist, but it starts young. According to Jill Vitale-Aussem in her book Disrupting the Status Quo of Senior Living: A Mindshift (Health Professions Press, 2019), “research suggests that children develop negative stereotypes about old age in early childhood, around the same time that attitudes about race and gender begin to form.” From these early years, we learn to stereotype those who aren’t our peers — from “old people” to “people our parents’ age” — and we even learn early on to stereotype those younger than us, such as calling kids who cry or appear scared “babies.” We hear and see these stereotypes repeated in TV shows, on birthday cards, and through the jokes we tell. Such everyday stereotypes take root in our society and begin to affect the way we unconsciously think about those of other ages.
      As Ms. Vitale-Aussem acknowledges in her book, “Once you learn about ageism and pay attention to it, you realize it is absolutely everywhere. Now I can’t stop seeing it!” I identify with that statement, and I’m growing in my capacity to notice ageist attitudes, statements, policies, and rules in the world around me.
      For those of us working in post-acute and long-term care settings, unconscious ageism is something that can slip by us unnoticed — after all, many of us love working with older adults, and the last thing we believe is that we are ageist. To help unpack my own ageism, I found the following three concepts helpful.

      Age as a Social Experience

      The first concept is that while aging is a biological process, age is a social experience. In her book This Chair Rocks, Ms. Applewhite says, We have “a conception of old age as a biomedical problem to which there might be a scientific solution. What was lost was a sense of the life span, with each stage having value and meaning.” What this comes with, she says, is a sense of shame about growing older as though it’s something to hide, cover up, fix, or medicate. As a society, we assign social roles to older adults that don’t necessarily reflect their internal identities, which may feel ageless. Simply because people biologically age, we are acculturated to silence their voices and question their opinions, which in turn may diminish what might otherwise be a rewarding social experience.
      In terms of our work in PALTC, I think we need to consider our beliefs, or perhaps assumptions, about purpose and whether we believe that just because someone lives in a nursing home they no longer desire to have purpose, or purposeful work, or meaningful things to do, that they instead merely need to fill their time.

      Generational Speak

      The second concept is that ageisms are baked into our interactions with anyone in a different age group — from our language to our expectations about how each “generation” should behave. Take, for instance, the stereotypes we have around “millennials,” or “Gen Z,” or “boomers,” many of which are regularly debated in the media. Although there are historical changes that do affect generations, sociologists recognize that generational frameworks are more likely to reinforce social stereotypes than provide useful descriptions of social groups. As Louis Menand writes in a 2021 piece in the New Yorker, “there is no empirical basis for claiming that differences within a generation are smaller than differences between generations” (Oct. 11, 2021, https://bit.ly/3JbaKH9).
      It’s only when we become aware of this socialization that we can make conscious choices to reframe our thinking and language. This includes how we speak with people who live in nursing homes. Ms. Applewhite writes, “Condescension alone actually shortens lives. What professionals call ‘elderspeak’ — the belittling ‘sweeties’ and ‘dearies’ that people use to address older people — does more than rankle. It reinforces stereotypes of incapacity and incompetence, which leads to poor health, including shorter life spans ... Nursing home residents with severe Alzheimer’s have been shown to react aggressively to infantilizing language.”

      Ageist Design

      The third concept is that of ageist design. In their nature of being places to care for adults, long-term care facilities are often designed with ageist notions. As Ms. Vitale-Aussem notes, our “institutional culture” of ageism persists “in every level of living and even in the most beautiful of buildings. It’s a culture that purports to honor aging but continues, in many situations, to operate based on processes and policies infused with paternalism, ageism, and antiquated thinking.” These spaces often assume a lack of agency for residents — the purpose is for staff to “take care of” the people who live there, not to support or enhance their independence. However, a sense of agency, dignity, and meaningful purpose is important at any age — it doesn’t go away.
      As Ms. Vitale-Aussem points out, even the electronic medical record is designed with ageist assumptions and categories intended to “manage risk” instead of protecting individual agency. What could easily be labeled a “behavioral problem” from a dropdown menu may actually be an understandable reaction to an environment designed to take away a resident’s agency; in such cases, it’s the environment that needs modification, not the resident.
      As I consider the psychosocial assessments that I’ve done over many years, I feel a sense of regret that I was not aware of my own internalized ageisms. I no doubt placed limitations on people because of their age and by virtue of the fact that they were in the nursing home.

      What We Can Do

      I see this as the ultimate question: How do we create a nonageist or age-inclusive culture in facilities that are designed to do the opposite? Based on the works I’ve noted in this article, I have compiled action steps for counteracting ageism. As Ms. Vitale-Aussem writes, “these are not just aesthetic changes that can be accomplished with updating décor and buying new equipment ... the changes that we need are in the way we think, speak, and interact.”
      • Look at your own biases and attitudes about aging by looking “for ways in which you are ageist instead of looking for evidence that you aren’t” (Applewhite).
      • Question your assumptions. You aren’t sure whether something is ageist or not? Consider whether it would be appropriate if used for someone your own age — would you use words like “spry” or “cute” to describe your own peers? (Applewhite).
      • Avoid qualifiers like “for your age ...” or using of the word “elderly” (Applewhite).
      • Avoid asking people how old they are — this often isn’t relevant information (Applewhite). Also consider whether you make any assumptions when you learn of a person’s age. Do you relegate them to a particular category or group?
      • Consider starting a consciousness-raising group around ageism in your facility. According to Ms. Applewhite, “consciousness-raising is a tool that uses the power of personal experiences to unpack unconscious prejudices and to call for social change” (see the resources list with this article).
      • Create cultures of inclusivity that involve tackling ageism alongside sexism and racism (Vitale-Aussem).
      • Consider the ways in which “managing risk” unconsciously translates into denying residents their agency. Ms. Vitale-Aussem recommends eliminating words like “refused” and “noncompliant” and using words that support a human being making a choice.
      • Create communities, not facilities — ask the residents and staff what community means to them (Vitale-Aussem).
      • Reconsider your admission processes, assessments, and questions. So much of what we ask is about the past, but why don’t we ask about the future? What would they like to learn, discuss, focus on? These questions promote what Ms. Vitale-Aussem calls an “evolving sense of self” and can help residents find new purpose and meaning in their lives.
      • Consider the ways that staffing can help create age-inclusive communities. When possible, hire people who truly want to work in PALTC and want to learn. Create a culture where the staff feel like they are part of something bigger. Consider forming a resident hiring committee so residents can have a say as well. For more ideas, see Leslie Pedtke’s book What Living as a Resident Can Teach Long-Term Care Staff: The Power of Empathy to Transform Care (Health Professions Press, 2017).
      To increase our capacity to understand ageism and to implement some of these strategies, it’s also important to acknowledge the complexity of our current environment — that we are constantly managing risk, liability, and responsibility. It’s difficult to balance regulations at the federal and state levels and hundreds of policies and procedures, not to mention the impact and long-term implications of the last three years living and working in a pandemic.
      But regardless of these challenges, what I’ve ultimately learned in my work is this: it’s important to initiate conversations about difficult topics like ageism and really listen to what other people share. Talk to people about their frustrations, disappointments, and successes. Offer support when people get discouraged. And remember that change happens slowly — keep going!

      Resources

      Ms. Hector is an author, speaker, and educator specializing in clinical operations for the interdisciplinary team, process improvement and statistical theory, Nonviolent Communication, risk management and palliative care, among other topics. She is a member of the Editorial Advisory Board for Caring for the Ages. She is passionate about nursing homes and supporting staff to care for the most vulnerable people in their communities.

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