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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.
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