Ageist messages are prevalent in healthcare and can significantly worsen health outcomes, particularly in people with cancer. Nonetheless, many cancer navigators and other providers are left wondering what they can do to address this ageist discrimination and improve care experiences and outcomes, according to Sarah H. Kagan, PhD, RN, AOCN, APRN, FAAN, FGSA, gerontology clinical nurse specialist in the Joan Karnell Supportive and Palliative Care Program in the Abramson Cancer Center at Pennsylvania Hospital, Penn Medicine. The answer, she said, lies in providing person-centered and age-friendly care.
“We’re all bombarded with ageist messages like, ‘older people burden our society with overuse of healthcare,’” she said at the AONN+ Virtual Midyear Conference. “Despite having both international age-friendly community movements and a national age-friendly health systems movement, we’re not as far as we need to be in making cancer care age-friendly.”
The truth is, we do live in an aging society. Currently, 16% of the US population is over the age of 65 years (although in many areas of the country that proportion is much greater). The majority of cancer diagnoses occur in older people, and the majority of people surviving cancer are older. But according to Dr Kagan, contrary to popular belief, chronological age does not directly influence health status.
However, the reality is, ageism remains prevalent in cancer care (even when it’s unintentional), and the care provided is, by and large, not age-friendly.
“The paradox here is that chronological age doesn’t worsen health; ageism does,” she said. “In fact, if there is one thing that I’d ask us all to think about giving up, it’s identifying people by their chronological age, because it’s actually not relevant to health status.”
Person-Centered Care
According to Dr Kagan, person-centered care is about “engaging our inner patient.”
“All of us are people who need, seek, and receive healthcare,” she said. “We can typically empathize with anxiety around receiving care; we might even recall times when we felt powerless, and I believe we all hope for that clinician who’s going to ‘get us.’”
Person-centered care first emerged in the care of people living with dementia, but it is still not widely used in cancer care.
“But nursing and other supportive care fields have an opportunity to really bring person-centered care into cancer care,” she said.
Importantly, person-centered care and patient-centered care are not one and the same, and the difference is important. The main goal of patient-centeredness is a functional life for the patient, whereas the main goal of person- and family-centeredness is a meaningful life for the patient (not simply a functional life).
Age-friendly care is a broader term that reframes care for older people and builds on dismantling ageism, but that also requires person- and family-centeredness. Importantly, age-friendly care in cancer is not simply geriatric oncology, she noted.
What Is Ageism?
According to Dr Kagan, ageism is discrimination based on perceptions of age, but in reality, it is far more complex than that. It can be both positively and negatively intended (or completely unintended), and it can be implicit or explicit in nature. It can exist in individuals, institutions, and cultures, and in healthcare it is typically unacknowledged.
“Quite honestly, ageism is not widely acknowledged in society, and sadly, we have a lot of evidence showing that it’s really ubiquitous in healthcare,” she said. “It’s the last widely accepted form of discrimination in our society; all you have to do is look at the birthday card choices for anyone over the age of 40.”
Research shows that ageism negatively affects health. Internalized ageism (termed negative age-related self-stereotyping) is common around the world and is one of the primary sources of ageism responsible for negative health outcomes.
According to Dr Kagan, there are generally 3 different ways in which ageism is expressed on either an individual or institutional/structural level: negative with intent to harm (ie, verbal or financial abuse, physical harm), ambivalent and beneficent with implied intent to protect (ie, “elder speak,” coddling), and emerging from the elder and entailing elder identity (ie, negative stereotypes, practices that exclude elders).
She noted that the first category is rarely seen in healthcare, but ageism with implied intent to protect is quite commonly seen. “This can often take the form of ‘elder speak,’ as though we’re speaking to a small child,” she said. “Small children don’t like it, so there’s no reason to expect that older people will appreciate that form of communication.”
Negative self-stereotyping is also often seen in cancer care (eg, “I’m too old for that,” or “At my age, I could never”). On an institutional/structural level, this type of ageism is seen in age restrictions on clinical trials or even clinical programs.
Additionally, ageism costs billions of dollars each year to the US healthcare system. “We can do something about this if we take an anti-ageist stance and work toward an age-friendly world, age-friendly communities, age-friendly healthcare, and age-friendly interactions,” said Dr Kagan.
But the simple fact that the population is aging is not responsible for ageism; it is a product of cultural forces, not demographics. Importantly, ageism doesn’t just make people ill; it actually makes people feel purposeless and depressed. “I want navigators to recognize that they can really remedy that,” she said.
Beneficial Effects of Anti-Ageism
Research has shown that thinking positively about our age actually creates an epigenetic benefit. Anti-ageism has also been shown to increase motivation among older people.
“If people are helped to take ageism apart and think positively about themselves as they grow older, they’re actually likely to be more motivated to take care of themselves, to be physically active, and to engage with others,” she noted. This is important, since other research shows that some health effects of ageism may be modifiable or even reversible.
Particularly in the field of healthcare, education has been shown to reduce ageism and increase interest in working with older people. Although some are skeptical about changing the culture of ageism in the United States, even more research has shown that anti-ageist healthcare is possible, practical, and cost-effective.
Age-Friendly Health Systems is a national healthcare quality initiative working to disseminate the “4Ms” framework to US hospitals and clinics. “The 4Ms are designed to hit the places where current healthcare, including cancer care, breaks down,” she explained.
The 4Ms
The 4Ms of age-friendly cancer care—What Matters, Mobility, Mentation, and Medication—are meant to drive care improvement by attaching clinical screening tools to each “M.”
“Age-friendly cancer care is about taking the 4Ms and being person- and family-centered, being holistic, anchoring everything in an understanding of what matters, and creating an overarching plan to ensure success through universal screening, focal assessments, targeted referrals, and consistent evaluation, not just at the individual level, but at the program level,” said Dr Kagan. “This is as much about data analytics as it is about the person, because if we don’t know that we’re touching every person, how do we know that every person is getting what they need?”
She said that relying on “what matters” is the key to building caring and effective therapeutic relationships, because every person has wishes, hopes, and desires; cancer doesn’t change that.
“Just as much as a serious illness conversation, asking what matters can be so profoundly valuable,” she noted, but navigators should keep in mind that “what matters” is complex and shifts as life evolves.
According to Dr Kagan, every patient encounter should begin with asking the patient what matters, in the form of questions like, “What matters to you today/in this encounter?” “What are your goals for your healthcare?” “What gives you a sense of purpose in your life?”
Match the “what matters” conversation to a frailty screen, she advised. Screening for frailty helps to appraise risk, so an accepted frailty screen should be used on all patients, and patients who screen as frail should be referred for further assessment, evaluation, and intervention planning (Dr Kagan’s institution utilizes the Flemish Triage Risk Screening Tool in their assessment).
“Frailty screens are incredibly valuable, and most are easily integrated into navigator assessments,” she noted.
Goals of care conversations are the most frequently noted assessment domain in the “what matters” element of age-friendly cancer care, but personal wishes and dreams, health and general literacy, and communication preferences are other important domains. “Quite honestly, knowing what you’d like for lunch is sometimes an important element of what matters,” she added.
Key referrals to help follow up on gaps in addressing “what matters” include referrals to nurses, social workers, chaplains, and palliative care teams.
“Asking what matters is a habit that takes some work,” she said. “But I encourage you to be the first to ask.”
Screening for mobility (focusing on getting people more mobile as well as prehabilitation and rehabilitation), mentation (identifying and treating depression, dementia, and hearing impairment), and medication (reviewing medication lists to identify polypharmacy and potential inappropriate medications) should follow a similar format and should also be accompanied by key referrals when necessary.
“These aspects of care can really transform patient safety, patient experience, and patient outcomes,” she said.
Reshaping Navigation
In dismantling ageism and turning toward person- and family-centered cancer care, Dr Kagan encourages navigators to reject “gate-keeping” as a model for navigation and healthcare and instead opt for a “gate-opener” approach. Replace “Do they need it?” thinking with “Why would they not need it?” For example, asking, “Why would this patient not need physical therapy?” can serve to create routine support for mobility.
Live the maxim that age is just a number, she encouraged. Limit the mention of age except where necessary for record keeping, and use the self-check: “Would I believe/think/do this if this person were young?”
Change the language you use at work and at home (instead of “elderly,” simply use person/people or “older adult/people” when necessary), Dr Kagan added, and finally, challenge the people around you to change theirs.
