MR. C, 81, was admitted to an acute care facility for a scheduled total hip arthroplasty. Before the surgery, Mr. C worked part-time in the accounting office he'd started over 45 years ago, now managed by his son. He was completely independent in his activities of daily living. He lived with his wife of 57 years in a one-story single-family home.

Following surgery, Mr. C was discharged to his home to continue his rehabilitation. One week later, he fell while walking to the bathroom. His wife reported the fall to the physical therapist, who reviewed with Mr. C appropriate hip precautions. Two days later, Mr. C experienced urinary incontinence and confusion. When the nurse visited, she told his wife that these were unfortunate consequences of aging and that some incontinence and confusion were common among people in their 80s.

As another week passed, Mr. C continued to experience incontinence and confusion. When he had another fall, Mrs. C called 911 and he was taken to the local ED.

Mr. C's situation is, unfortunately, not uncommon. His decline following surgery was due to physiologic complications, not normal changes of aging, as suggested by his home health caregivers. Ageism, defined as stereotyping or discrimination aimed at older adults1 and a lack of knowledge about normal changes of aging and presentation of illness in older adults, clouded the lens of the healthcare providers who were providing Mr. C's care. This article outlines how to recognize and avoid ageism to keep patients safe.

Understanding ageism

Ageism by healthcare professionals is manifested through attitudes and actions that can harm older patients, as in the case of Mr. C. Current research findings suggest that ageism is common in healthcare. Skirbekk and Nortvedt used qualitative methods to examine the attitudes of healthcare providers, including physicians and nurses, toward treatment and priority setting for patients.2 From the interviews of 21 providers and three focus groups, the researchers found that the age of a patient was taken into consideration by physicians and nurses when prioritizing patient needs. Additionally, older adults with chronic illnesses who still had care needs were given low priority for nursing care.

Older adults represent 13% of the total population in the United States, but account for over 40% of U.S. hospitalizations.3 Nurses in most healthcare settings care for, or at least encounter, older adults regularly. Yet many view working with older adults as undesirable and a "last resort" for employment.3 Klein and Lu found that occupational therapists who worked with older adults felt "stigmatized" by their peers because their work was viewed as less challenging and requiring less skill and intellect than caring for other populations.4 Negative experiences with older adults in healthcare settings, as well as inadequate preparation in caring for older adults, can lead to ageist attitudes among care providers.

Ageism can negatively affect the care a nurse provides to older adults by clouding the nurse's assessment, which can lead to overlooking or misinterpreting critical findings. Too often, nurses, healthcare providers, family members, and even older adult patients are quick to attribute signs and symptoms of illness to the normal aging process, often missing an important indicator that needs to be addressed. Nurses who work with older adults need to understand that illness can present differently in older adults than in younger patients.

For the community-dwelling older adult, ageism may result in a lack of preventive services such as immunizations being encouraged or even offered. The impact of ageism is also shown in clinical trials: Those over 65 are typically not included, even when older adults are likely to receive most of the medications being studied.5

Presentation of illness

Certain physical changes are hallmarks of aging. Because of these changes, disease can present differently in a person over age 65 than in a younger adult or a child. Some normal aspects of aging can mimic signs and symptoms of disease, while other changes can mask early clinical manifestations of illness. This can lead to overtreatment of a relatively healthy older person or misdiagnosis of an acute disorder that requires treatment.6

One example is age-related memory loss, which is often worsened by stress.6 Failure to recognize this as a normal change of aging might prevent the nurse from adequately teaching older patients.

Common indicators of illness in older adults don't necessarily coincide with those of younger adults. An example is an uncomplicated urinary tract infection (UTI), which may not present with the usual signs and symptoms of dysuria, frequency, and urgency; in an older adult, UTI commonly presents as a sudden onset of confusion.6 This shouldn't automatically be interpreted as a normal change of aging but rather assessed as an early sign of illness. Early recognition lets treatment begin while recovery is still possible.6

Recommendations

Researchers have found that knowledge of the aging process decreases ageism, and greater compassion is associated with less ageism.7 Nurses need to examine their own biases toward older adults and participate in continuing education to learn more about the aging process and the unique needs of older adults.8

Nurses can benefit from interacting with active older adults to recognize that not all older adults are sick and frail and that many older adults have full and rich lives. Ideally, these interactions would start much earlier in life through intergenerational learning opportunities, which can modify ageist attitudes. Alcock et al. found through an ethnographic study that youth and older adults who participated together in weekly activities changed their attitudes toward other generations and built a stronger sense of community.9

Nurses who work with older adults need support, not only through education, but also from administrators. Because these nurses often feel slighted by their peers and feel that their work isn't as significant as care in other settings, recognitions and incentives are needed to honor their hard work.10

Administrators need to ask specifically about a nurse's interest in working with older adults, and perhaps consider using a tool to gauge the nurse's attitudes toward aging, such as Palmore's Facts on Aging Quiz. (See http://www2.webster.edu/~woolflm/myth.html.) Making a commitment to hire nurses who are interested in geriatrics may boost the skill level, collegiality, and compassion of the nursing staff.

A good outcome

Mr. C was diagnosed with pyelonephritis, possibly the result of an untreated UTI. He was admitted and treated with I.V. antibiotics and physical therapy. At discharge, he was no longer incontinent or confused, and he felt stronger. He continued physical therapy in an outpatient setting and was looking forward to returning to his part-time job in time for tax season.

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