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Desmond O’Neill, Refashioning the uneasy relationship between older people and geriatric medicine, Age and Ageing, Volume 51, Issue 4, April 2022, afab281, https://doi.org/10.1093/ageing/afab281
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Abstract
A notable feature of most medical specialties is close joint working between patient advocacy groups and specialist societies in furthering improvements in policy and services. While growing old is not a disease, nor too is being a child, and the engagement of advocacy and international bodies such as UNICEF with paediatricians is well established and recognised. Yet almost eight decades after the founding of geriatric medicine, it is clear that this type of relationship does not hold for the advocacy bodies representing those we serve, as well as the wider constituency of older people.
Geriatricians are an extraordinary resourceful and imaginative group, and a more effective promotion of our role as guardians of the longevity dividend is vital to a more positive and mutually beneficial relationship with older people and society. This will require a redirection of our focus to a more critical stance on our origins as a discipline, our relationship with ageing across the lifespan and with older people and a fuller engagement with the broader concepts of gerontology in training and research to develop a refreshed articulacy for, the opportunities arising from gerontologically attuned healthcare.
Key Points
A gap exists between geriatric medicine and older people both in general and through their advocacy organisations.
Geriatricians need to develop insight into how this has arisen, in particular association with the problematisation of later life.
Greater engagement with critical and cultural gerontology is needed to formulate effective strategies for synergy with older people.
The Reframing Aging Project provides a helpful template for better joint working between geriatricians, advocacy and academia.
Commentary
And so each venture is a new beginning, a raid on the inarticulate
TS Eliot, East Coker from the Four Quartets
A notable feature of most medical specialties is close joint working between patient advocacy groups and specialist societies in furthering improvements in policy and services. While growing old is not a disease, nor too is being a child, and the engagement of advocacy and international bodies such as UNICEF with paediatricians is well established and recognised. Yet almost eight decades after the founding of geriatric medicine, it is clear that this type of relationship does not hold for the advocacy bodies representing those we serve, as well as the wider constituency of older people.
The yearly reports on health and older people from AgeUK, the major advocacy body for older people in the UK, make no mention of geriatric or gerontological expertise [1]: a similar absence is evident in the narrative on health on AGE Platform Europe, the European advocacy group on ageing https://www.age-platform.eu/policy-work/healthy-ageing. Even the important 2021 report from the World Health Organisation on ageism as a negative social determinant of health [2], although drawing heavily on the literature of gerontology and geriatric medicine in its reference lists, makes no mention of these sources of gerontological literacy and activism as agents of change in addressing the scourge of ageism. Older people and their families are also resistant to engaging with geriatric medical care [3, 4].
To many geriatricians this may seem puzzling in the face of the recognised effectiveness of geriatric medicine and associated gerontological healthcare disciplines such as gerontological nursing in responding to many aspects of age-related disease and disability across a range of services [5–7]. In addition, geriatric medicine has acted as a focus of resistance to the widespread evidence of ageism in generic medical and surgical care that undermines care for older people [8], as well as in combatting exclusion of older people in research of interventions of prime relevance to them [9].
Soul-searching is clearly required to tease out how this divergence arises from those we consider ourselves to serve, and points to the necessity of ensuring a stream of critical reflection within the discipline as to its origins, internal conflicts and contradictions, as well as pathways to generating future synergy with older people and wider society. It is likely that a key contributor to the hiatus arises from the atypical development of the specialty in many countries, promoted by governments in the face of sustained opposition from rival medical specialties. The cost of this process has been the linkage of geriatric medicine to the problematisation of old age in terms of government policies that tend to view later life as a problem [10] rather than an extraordinary societal achievement [11].
As noted by Susan Pickard, the discourse of geriatric medicine has unwittingly helped to shape society’s perceptions of older people by situating them in a broader discourse that ‘stressed the danger old age potentially posed to the rest of (civilised, productive) society whilst indicating that their professional skills could directly ameliorate these effects’ [10]. While geriatricians focus on the amelioration, the public and other disciplines preferentially perceive the implied failure model of ageing, with geriatric medicine suffering from guilt by association.
In addition, the emphasis of the specialty on efficiency in acute hospital-based care, as reflected in prioritisation of acute hospital care within the discipline in many countries [12], raises the issue as to whether geriatricians have truly set their sights on a vision of care for the broad range of care needs of older people, particularly those in the community and nursing homes [13]. Even in terms of hospital settings, our professional integrity is challenged by a lack of robust and consistent stance on standards for rehabilitation for older people who have lost function, either through the presenting illness or the effects of a hospital stay, as well as by tolerance of the intellectual and professional muddle represented by ‘step-down’, intermediate care [14] and ‘reablement’ [15].
It is also likely that geriatricians harbour unconscious ambivalence and negativity towards ageing [16]. While we have moved significantly from the negativity expressed by the early pioneer of geriatric medicine, Ignatz Nascher, in 1914—‘We realize that for all practical purposes that the lives of the aged are useless, that they are often a burden to themselves, their family and the community at large. Their appearance is generally unesthetic, their actions objectionable, their very existence often an incubus to those who in their humanity or duty take upon themselves the care of the aged’—there have been many signals of insensitivity and potential negativity from geriatricians towards ageing over the decades [10].
These include continuing use of the descriptor ‘elderly’ in department names and literature, professional reticence in engaging with nursing home care and continuing to carry out studies on older people without reference to the lifespan. This is exemplified in repeated studies on loneliness among older populations without reference to prevalence and impacts on the general population. Given that loneliness in most western societies peaks in late adolescence and early adulthood, such studies miss out on an opportunity to tease out measures to combat loneliness at all ages: this stream of literature also compounds the problematisation of later life by falsely characterising later life as a primary locus of loneliness [17]. A similar situation arises with studies of older drivers, among the safest demographic on the road, but frequently misrepresented as a threat to the public in research by geriatricians and gerontologists [18].
Escaping from this challenging paradigm within which our practice has been established must become a key priority for geriatric medicine. The ever-growing longevity dividend of our collective ageing is threatened by ageism, gerontological illiteracy and a negative framing of ageing in the public domain—the much vaunted concept of citizens’ assemblies provided a salutary insight into this from Ireland where the focus was almost entirely on the potential burden of healthcare and pensions and not on what had been gained in terms of our increase in life-span and its individual and societal enrichment.
Knitting the narratives of the gains and losses of later together is a recognised challenge, rendered more complicated by the dominance of the failure narrative of ageing on one side, and the positivist emphases of paradigms of active and successful ageing [19] on the other, which neglect how our existential vulnerability becomes more pronounced as we age [20]. Older people have long been recognised as harbouring internalised ageism [21], and advocacy organisations for older people may themselves shy away from the task of incorporating our universal vulnerabilities and co-dependencies into a balanced discourse of the longevity dividend. The mission statements of many geriatric medicine societies emphasise improved health for older people but rarely if ever acknowledge the longevity dividend, including the fresh opportunities arising from later life in challenging circumstances including nursing home care [22].
The most important priority is to place the value of the longevity dividend at the heart of our mission, strategy and practice, moving it from the implicit and unarticulated to explicit and centre stage. This will require action at several levels, and in particular a stronger engagement by geriatricians with critical and cultural gerontology, both of which seek to tease out a broader view of what it means to be older, focus on the meaning of ageing and later life, help us to escape from the strictures of our professional paradigms and emphasize the richness of later life [23].
Changing course may seem daunting, but there are a number of encouraging developments. The WHO Programme on Ageing has prioritised changing how we think, feel and act towards age and ageing as the first of four key actions for the Decade of Healthy Ageing 2020–2030 [24]. There have been some episodic developments in joint working between advocacy groups and gerontology and geriatric medicine, such as the report on frailty from the British Geriatrics Society, Royal College of General Practitioners and AgeUK [25]. The essence of this project has been the recognition of the need to find a narrative, or narratives, of ageing that meets the needs and expectations of both older people and those that serve them, incorporating appropriately the advances in our knowledge from the broad range of sciences about ageing. This is exemplified neatly in the wish of older English people in the frailty project that instead of being described as a frail older person, we should talk of an older person living with frailty [25].
Developing this trend further is assisted by a ground-breaking example from the USA, where eight organisations including advocacy, gerontology and geriatric medicine came together to change the often negative narrative on ageing in the project Reframing Aging https://www.reframingaging.org/ [26]. Developed through an iterative process with the stakeholders, the reframing of our language is enormously powerful (Table 1) and merits incorporation into all of our discourse and discussion internally and externally.
A Quick Start Guide to Reframing Ageing
| Instead of These Words and Cues: . | Try: . |
|---|---|
| ‘Tidal wave,’ ‘tsunami’ and similarly catastrophic terms for the growing population of older adults | Talking affirmatively about changing demographics: ‘As people live longer and healthier lives . . .’ |
| ‘Choice,’ ‘planning,’ ‘control’ and other individual determinants of aging outcomes | Emphasizing how to improve social contexts: ‘Let’s find creative solutions to ensure we can all thrive as we age . . .’ |
| ‘Seniors,’ ‘elderly,’ ‘ageing dependents’ and similar ‘other-ing’ terms that stoke stereotypes | Using more-neutral (older people) and inclusive (‘we’ and ‘us’) terms |
| ‘Struggle,’ ‘battle,’ ‘fight,’ and similar conflict-oriented words to describe aging experiences | The Building Momentum metaphor: ‘Aging is a dynamic process that leads to new abilities and knowledge we can share with our communities . . .’ |
| Using the word ‘ageism’ without explanation | Defining ageism: ‘Ageism is discrimination against older people due to negative and inaccurate stereotypes . . .’ |
| Making generic appeals to the need to ‘do something’ about ageing | Using concrete examples like intergenerational community centres to illustrate inventive solutions |
| Instead of These Words and Cues: . | Try: . |
|---|---|
| ‘Tidal wave,’ ‘tsunami’ and similarly catastrophic terms for the growing population of older adults | Talking affirmatively about changing demographics: ‘As people live longer and healthier lives . . .’ |
| ‘Choice,’ ‘planning,’ ‘control’ and other individual determinants of aging outcomes | Emphasizing how to improve social contexts: ‘Let’s find creative solutions to ensure we can all thrive as we age . . .’ |
| ‘Seniors,’ ‘elderly,’ ‘ageing dependents’ and similar ‘other-ing’ terms that stoke stereotypes | Using more-neutral (older people) and inclusive (‘we’ and ‘us’) terms |
| ‘Struggle,’ ‘battle,’ ‘fight,’ and similar conflict-oriented words to describe aging experiences | The Building Momentum metaphor: ‘Aging is a dynamic process that leads to new abilities and knowledge we can share with our communities . . .’ |
| Using the word ‘ageism’ without explanation | Defining ageism: ‘Ageism is discrimination against older people due to negative and inaccurate stereotypes . . .’ |
| Making generic appeals to the need to ‘do something’ about ageing | Using concrete examples like intergenerational community centres to illustrate inventive solutions |
A Quick Start Guide to Reframing Ageing
| Instead of These Words and Cues: . | Try: . |
|---|---|
| ‘Tidal wave,’ ‘tsunami’ and similarly catastrophic terms for the growing population of older adults | Talking affirmatively about changing demographics: ‘As people live longer and healthier lives . . .’ |
| ‘Choice,’ ‘planning,’ ‘control’ and other individual determinants of aging outcomes | Emphasizing how to improve social contexts: ‘Let’s find creative solutions to ensure we can all thrive as we age . . .’ |
| ‘Seniors,’ ‘elderly,’ ‘ageing dependents’ and similar ‘other-ing’ terms that stoke stereotypes | Using more-neutral (older people) and inclusive (‘we’ and ‘us’) terms |
| ‘Struggle,’ ‘battle,’ ‘fight,’ and similar conflict-oriented words to describe aging experiences | The Building Momentum metaphor: ‘Aging is a dynamic process that leads to new abilities and knowledge we can share with our communities . . .’ |
| Using the word ‘ageism’ without explanation | Defining ageism: ‘Ageism is discrimination against older people due to negative and inaccurate stereotypes . . .’ |
| Making generic appeals to the need to ‘do something’ about ageing | Using concrete examples like intergenerational community centres to illustrate inventive solutions |
| Instead of These Words and Cues: . | Try: . |
|---|---|
| ‘Tidal wave,’ ‘tsunami’ and similarly catastrophic terms for the growing population of older adults | Talking affirmatively about changing demographics: ‘As people live longer and healthier lives . . .’ |
| ‘Choice,’ ‘planning,’ ‘control’ and other individual determinants of aging outcomes | Emphasizing how to improve social contexts: ‘Let’s find creative solutions to ensure we can all thrive as we age . . .’ |
| ‘Seniors,’ ‘elderly,’ ‘ageing dependents’ and similar ‘other-ing’ terms that stoke stereotypes | Using more-neutral (older people) and inclusive (‘we’ and ‘us’) terms |
| ‘Struggle,’ ‘battle,’ ‘fight,’ and similar conflict-oriented words to describe aging experiences | The Building Momentum metaphor: ‘Aging is a dynamic process that leads to new abilities and knowledge we can share with our communities . . .’ |
| Using the word ‘ageism’ without explanation | Defining ageism: ‘Ageism is discrimination against older people due to negative and inaccurate stereotypes . . .’ |
| Making generic appeals to the need to ‘do something’ about ageing | Using concrete examples like intergenerational community centres to illustrate inventive solutions |
In a broader context, it would be helpful for geriatricians to develop a stronger identification with ageing through the lifespan, not just in giving better perspectives to research in topics such as loneliness and driving, but also teasing out the benefits of ageing into later life across the generations, as well as influencing the factors that shape healthy life expectancy throughout the life-course [27]. This is particularly relevant given growing concern that increased social and economic inequality through austerity and social policy in the USA and UK has reversed a hitherto positive trend of healthy life expectancy [28, 29]. Solidarity with all other stakeholders promoting equity of socioeconomic well-being across all ages can only add to the credibility and integrity of geriatric medicine with the population at large and is mirrored in the potential for activism in other areas such as climate change.
As busy clinicians already engaging with a very broad and dynamic range of clinical services, this may seem like adding yet another burden to a packed agenda. Yet geriatricians are an extraordinary resourceful and imaginative group, and a much more effective promotion of our role as guardians of the longevity dividend [30] is vital to a more positive and mutually beneficial relationship with older people and society. This will require a redirection of our focus to a more critical stance on our origins as a discipline, our relationship with ageing across the lifespan and with older people and a fuller engagement with the broader concepts of gerontology in training and research to develop a refreshed articulacy for the opportunities arising from gerontologically attuned healthcare.
Declaration of Conflicts of Interest
None.
Declaration of Sources of Funding
None.
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