How to spot ageism in healthcare (and why it’s still so common) | with Assoc. Prof. Rachel Ambagtsheer

Ageing is something every one of us will experience, but ageism – the stereotypes, assumptions and biases tied to age – still shapes how people are treated in everyday life. In this episode of Let’s Talk Health, host Natalie Cook is joined by Senior Research Fellow and public health academic Associate Professor Rachel Ambagtsheer to explore why ageism often goes unnoticed, how it can show up in healthcare settings, and what we can all do to challenge it.

To learn more about the Challenging Ageism short course, visit https://www.torrens.edu.au/studying-with-us/study-options/short-courses/challenging-ageism 

In this episode, we cover:

• What ageism actually means and where the term originated
• How stereotypes, prejudice and discrimination based on age show up across the lifespan
• Why ageism is often called “the last acceptable ism”
• The role of culture, intergenerational contact and societal norms in shaping attitudes to ageing
• How ageism appears in healthcare, aged care and clinical decision-making
• What “benevolent ageism” looks like (and why it’s still harmful)
• How self-directed ageism affects confidence, mobility, mental health and physical decline
• Why age-based screening cut-offs can disadvantage older adults
• Strategies for recognising and calling out ageism in clinical appointments
• How families can advocate for older relatives without taking away their autonomy
• The health, social and economic impacts of ageism on individuals and communities
• Practical actions anyone can take to challenge ageism in daily life
• Rachel’s research into shifting attitudes and the impact of her “Challenging Ageism” short course

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Transcript

Natalie Cook: 0:15

Welcome to Let's Talk Health. I'm your host, Natalie Cook, Director of Innovation, Industry and Employability in Health and Education at Torrens University Australia. On this podcast, you'll hear from experts who'll share their knowledge to help you make more informed choices about your health. Joining me today is someone who has spent her professional career researching aging, frailty, and more recently attitudes towards aging in particular. Rachel Ambagtsheer is a senior research fellow at the Centre for Public Health, Equity and Human Flourishing and a public health academic at Torrens University Australia. Rachel, thanks for joining me. Thanks, Nat. Pleased to be here. So you're a public health researcher. How did you even get into public health in the first place?

Rachel Ambagtsheer: 0:57

I actually started life as a geographer, believe it or not, and got into planning of health systems and all the rest of it. And I was drawn into ageing. I've actually been researching ageing for about 30 years now in total. And I think part of the reason why I did that is I lived with my grandparents. So they weren't my primary carers, but they lived with us or next to us for most of my childhood and actually most of my teenage years. And so I actually had a really close connection to my grandparents growing up. And I think that really shaped me in a lot of respects. So there was a personal, I think, reason why I kind of got into aging and saw them navigating health and age care systems and things in the beginning. But you know, I think more broadly, we're all aging. You know, aging is basically living. It's another word for living, if you think about it. If you weren't aging, you wouldn't be living. And so it's a truly universal experience. And I think, as in particular, I started progressing through life, became older, etc., all the rest of it. I think it took on what much more of a personal kind of question for me is what does it mean to age well? And how do we achieve quality of life as we age? And that's something that really fascinated me and has held my fascination that whole time.

Natalie Cook: 2:16

It's interesting, just that your personal experience was that you lived with your grandparents, which is not that common. And I made a I guess a broad statement saying, particularly in Western cultures, because I feel like there are different cultures around the world where senior people, age, uh older relatives, whatever, are held in a different level of respect than perhaps we do. Is that a fair statement when I say that?

Rachel Ambagtsheer: 2:38

I think that's definitely a fair statement. And I think you only have to look to our own neighbourhood. So Aboriginal Torres Strait Islander culture in particular is one in which traditionally elders have been revered, and that's very common in what we kind of call collectivist type or communities where people live together in close contact with each other. And I think that intergenerational contact really does give you a respect for older people, um, which you know is missing unfortunately from a lot of our modern westernized culture in many respects.

Natalie Cook: 3:17

It's interesting. I mean, of course, we're aging from the day we're born, right? Yes, so that's what living is. I know my mum has always said, well, you don't want to fear getting older because the alternative's not that great. Absolutely. Embrace it, you know. Yes. So age isn't, I'll admit, this is a word that I probably only learnt, I'm gonna say maybe even a year ago. What does it mean?

Rachel Ambagtsheer: 3:39

I'm glad you asked me that. That's a really good question. Um, so the origins of ageism actually date back essentially ancient Greece. You can look back and find philosophers saying horrible things about ageing if you go back far enough. Absolutely. They're really interesting. Um, but ageism as a term was only coined in the late 1960s. And there's a funny story about it, actually. So the guy who coined it was a psychiatrist called Robert Butler, and he was being interviewed by a journalist who was later to go on and be famous for uncovering the Watergate scandal. So Carl Bernstein was the journalist who was interviewing him as a young starting-out journalist. And Robert Butler was reflecting on a housing development that was being developed in his local neighbourhood and saying that it was a housing development specifically for older people. And there was huge pushback from the community that didn't, you know, didn't want a dedicated housing community for older people in their neighbourhood, you know, the not in my backyard type people. And what he saw, he likened to a form of racism. You know, he said this is almost like racism, but directed towards older people. And, you know, hence the term ageism was born. And what's fascinating about that is that Robert Butler was raised by his grandparents. They were poor chicken farmers, and they raised him, and he grew up with this amazing appreciation for their tenacity and their resourcefulness and their hard work. And he took that into his professional life as a psychiatrist. So he was kind of tuned in to notice, perhaps, the things that he saw around him. But we've been throwing the term ageism around quite a bit. What do we mean by the term officially? Um, it actually refers to stereotypes, prejudice, and discrimination towards ageing or based on age. That's essentially what the World Health Organization definition is, relates to how we think, feel, and behave around ageing in a negative way when we're talking about ageism.

Natalie Cook: 5:51

And does negative always have to be overtly negative? And I'm thinking of uh I think it was last year there was in the press about a football club that as part of their end-of-year celebrations, they all got dressed up as old versions of themselves, you know, and they're very stereotypical in the way they presented with walking sticks and the great hero and so on.

Rachel Ambagtsheer: 6:10

Absolutely, that is ageism. But um, this is a really interesting question because I get the same, um, it's the same kind of vibe when we talk about birthday cards as an example. So if you ever want a really good example of ageism, just walk into a news agent and have a look across the rack or wait till your 50th birthday or 40th birthday or and wait for all the jokes about the nursing home and your teeth falling out and you know, um candles being able to be seen from Mars and all the rest of it. And um, essentially people kind of say, well, we're just having a joke. What's wrong with that? And the answer is it's fine to have a joke in its place, but what it does is kind of entrench that idea that it's okay to joke about and stereotype older people. And, you know, what that ends up doing is it drives ageism underground, which is where it has been for a long time. Um, it's actually called, um, it's been called the last acceptable ism. So it's it's actually because people don't recognise it as discrimination because it's so much around us, so pervasive in our everyday world. And so, you know, we know about sexism, we know about racism, we know about homophobia. Um, these are all isms, if you like, that gradually over time society and culture have become more aware of and they've put things in place to address them. And that's why they say ageism is the last ism, because we're not even at a point where many people would even recognise it as a form of discrimination, let alone want to do something about it.

Natalie Cook: 7:51

Uh absolutely. And I think when you Yeah, when you use that language, it's just a joke. I think we've we can all relate to other isms that you go, that is not okay. Yeah, yeah. It is still okay in this space. And you're right, it is there's a stereotype that goes with those jokes.

Rachel Ambagtsheer: 8:08

Yes, once upon a time it would have been perfectly normal, and I'm using the word normal inverted commas, say to walk into a mine site and there be pictures of naked women everywhere, as an example, or a work site, you know. Um uh it may have been perfectly acceptable to joke about a different culture, and you know, um we we've all seen various manifestations of racism over time that at various times would have been deemed acceptable by the standards of the time, but has since moved on. And I honestly think we're going to look at ageism in the future exactly the same way. So the things that we take for granted now and the things we joke about, I think one day will be just as outdated and inappropriate as those other isms, and which is not to diminish the isms. I think there's still a lot of work to be done on sexism, racism, and homophobia, ableism is another one, all the rest of it, but they are uh more widely recognised, and there's been much more work done on them, I would say, comparatively than with ageism.

Natalie Cook: 9:24

And in terms of when I guess almost uh for want of a better word, the victims of ageism is at a particular age.

Rachel Ambagtsheer: 9:32

Is it actually throughout your whole lifespan? That's an interesting one because people tend to assume perhaps because of the use of the word age, they think that only older people experience ageism. Whereas in fact you can experience it right through your entire lifespan. So people can be discriminated against because they're younger, just as equally as older. But the stereotyping and prejudice tends to take on different forms and be based on different established prejudice out there. We see this most obviously if I give you the example of the generations, baby boomers, Gen X, Gen Y, millennials, I think I've skipped one there and gone back, uh, Gen Alpha. There's all these widely held wisdom, you know, stereotypes about who those people are and how they think, how they behave in the workplace, uh, and all the rest of it, which, when you think about it, is actually stereotyping a group of people based entirely on when they were born and not recognising that there's a huge heterogeneity, a huge difference within those groups with respect to personality and experience, and everyone's an individual and they sh they should be treated as such. The workplace in particular is a good example of where we see this. Older people might be stereotyped as being, you know, not as proficient with technology, can't learn new skills, so that old adage of can't teach an old dog new tricks. Conversely, younger people, and speaking to some of my friends in that Gen R Z group who may be entering the workforce or navigating that period in their lives, they might have a rich experience, they might have great perspectives to offer, but sometimes they're seen as naive or incapable just because they're younger. I had that experience myself. I don't know if you did, but often as a younger person, when I first worked in government bureaucracy, I would find that I would be the person who was sitting at the meeting not saying anything because I was junior. And um I I think it works both ways, older and younger.

Natalie Cook: 11:42

Isn't that interesting? And you're right. I'm hearing in my mind that each younger generation has got, you know, hey, boomer. You don't have tech skills or it's interesting, isn't it? And you're right, and so much in the workplace, I imagine the healthcare sector could be a challenge in this area.

Rachel Ambagtsheer: 11:59

It is, uh absolutely. And by healthcare, I would be including the health and aged care sector. I know some people make a distinction between the two and others don't, but those systems and services that older people interact with all the time, and I'm going to speak here to older people quite a bit because that's my particular experience. I think because they spend a lot of time in those environments. So if we think about those health and age care environments, historically that's where health professionals often would see older people, often when they were in a sick and vulnerable state. And that that state might be temporary. Um, they may, you know, um, we all think back to whenever you've been in hospital, and you could probably relate, regardless of age, you know, it's a time when you're not feeling at your best. Historically, over time, you know, medical professionals, etc., perhaps one of the reasons why ageism was so entrenched in the health and age care sector was because there was a particular way of interacting with older people that wasn't representative of the experiences of older people as a whole. However, it is a sector in which historically ageism has been rife, and we do know that it's been very well established. I think it would be over-generalising to suggest that that is the case everywhere and in every service. You know, obviously there's some great services out there and some quite progressive places, but it's still a huge issue, and that's been raised lately in all the investigations into the aged care sector, ageism was raised in that regard as well.

Natalie Cook: 13:34

And I can imagine I'm imagining as well, sort of almost a condescending way of working with older people who might have cognitive decline, but they might not. But this almost assumption that once you're older you don't have the capacity to understand the prince of the decisions or whatever's happening with your or that you're deaf. Yes.

Rachel Ambagtsheer: 13:54

As an example, right? Is another example that gets used a lot. And I think, you know, there's actually a word for that now. It's actually called benevolent ageism. And it's a form of ageism that, you know, we particularly see within the aged care sector that whole, how are you today, my duck? Um, you know, would you like to go for a walk outside? So that infantilizing of older people. And it's called benevolent ageism because it it's said to come from a well-meaning place, a protective place, but you can see that what it does is stereotype older people as being in need of that approach, yeah, right? Without investigating with them, without talking one-on-one with the older person. It's just an assumption.

Natalie Cook: 14:46

So there's obviously an onus people of people working in the sector to be better educated and aware of what they're doing. Is there anything that the health consumers, like the person that's experiencing, can do or their family can do to help sort of map navigate it better or mitigate it?

Rachel Ambagtsheer: 15:00

I think so. It's a really interesting space because public awareness of ageism, as I've suggested, is still really low. And even as I said, health service provider awareness of ageism isn't always all that great either. So it's an emerging space. I think what I would say is you can call it out if you even recognise that it's happening. So I don't think I've mentioned, but there is actually two forms of ageism that are really important distinctions. One is self-directed ageism. So it's actually the ageism that you feel about your own ageing and how you think and feel about that and how that colours your world, and actually leads to some really significant negative outcomes for older people. But the other is other directed ageism, and that's where, as it sounds, ageism that's directed towards others or how you think about others aging. And um, what's interesting about that is if you think about it, the healthcare encounter, when you sit down with a health service provider and an older person goes in or older patient, perhaps, it's an encounter between two people who have both self levels of self-directed ageism, so they have their own thoughts and feelings about ageing, potentially, but also other directed ageism, so they have thoughts about others, other people's ageing, which the health service provider would have. And not to say that it's necessarily negative, but certainly coloured by their experiences and often not even obvious to them. So navigating all of that to realise that in a way you're being discriminated against or talked down to or condescended to, you know, the older person might come away with a vague feeling of something not being right, but not being able to put their finger on it. And there was a survey done of older Australians who said that of those who'd reported experiencing ageism, and I think they say it's around 50%. Yikes, okay. Um, that they there was a large percentage that just didn't know what to do about it. So even those who do recognise it don't know what to do. And I think that the main thing is if you feel that you can call it out, that's what I'm working towards is equipping people with the skills and tools to be able to recognise ages and when it's happening and call it out, whether they're doing it to themselves or whether they're seeing it in front of them, or in fact stopping themselves from doing it to someone else completely, perhaps inadvertently and without realising it. But yeah, recognising it is one and calling it out in terms of saying, Well, hey, I'd really love to have this treatment, but I haven't heard you speak about it. Like I've read up about on the internet, but I'd love to know more about it. Is that something that I could have access to? Because we know in healthcare in particular, sometimes ageism actually looks like an assumption that the old person won't benefit from the treatment, so I won't actually offer it or speak to them about it because they're too old to benefit from it, you know, and so it's all of that kind of stuff.

Natalie Cook: 18:19

Once over the age of X, then this trick but then when you come down to a person-to-person level, it's really it's quite confronting actually, the the whole concept of it and the the impact.

Rachel Ambagtsheer: 18:30

Yes. Well, if I can just give you an ex another specific example. Um in my professional life, I work a lot on the issue of screening. And of course, when you think about it, there's a lot of age limits for screening. So there's the whole of government screening, you mean things like bowel screening. Exactly, bowel cancer screening, breast cancer screening, and I also do a lot of work on frailty screening and dementia screening. Um but the cancer screening in particular is one that I hear again and again from older people. Once they hit around about 74, then often the official policy would be recommended not to continue screening. Now, this is nuanced because what they're meant to do is look at the individual and say, let's look at this on their merits. But these ideas are all based around groups of people, right? And how much life expectancy are you going to have at 75 on average? And are you going to benefit from a cancer treatment if we find it? Are you going to live long enough to benefit from it? Well, some people do, right? And others don't. So why not look at the person as an individual rather than make decisions based on an age cutoff? And a good provider will do that person-centered care. But these are age limits that are baked into policy for reasons of resource allocation and whatever lend themselves to situations where the older person maybe just doesn't get offered a screening with no conversation ever again.

Natalie Cook: 20:04

So obviously you I can hear a passion for this. Yes. Also it's your job and it's your research. Where's your research headed at the moment?

Rachel Ambagtsheer: 20:15

What I'm really interested in, as I kind of alluded to, is how does ageism appear when it's in a healthcare setting? What does it look like and how do people experience it and feel it? But also, much more importantly, what can we do about it? So I think through this work, it'd be fair to say I've become quite an advocate for raising public awareness about ageism and the things we can do to kind of tackle it. And so one of the things that I've been doing at Torrens is to develop a challenging ageism course, which is just a simple online one-hour course. It's free. And the idea was to make it available to the general public because I think we have so much work to do just in terms of raising everyone's awareness, is actually something we should care about. And so my work has been focused on doing things like developing the course and then evaluating it to see whether we can actually change attitudes through an hour course. Not very long time, but we found that we could, you know, significantly shift attitudes to ageing within that time. Now that's just a pilot study at the moment, but we're hoping to get more funding to be able to look at the longer-term effects of this and how would you scale out this kind of thing, scale it up and make it more accessible? Because I think more people really need to have access to this kind of information.

Natalie Cook: 21:39

Are there health impacts for us as a population or are there economic impacts?

Rachel Ambagtsheer: 21:44

There are all of the above. So ageism has been associated with a whole range of negative outcomes for older people and for societies. They include things like early death, poorer mental and physical health, poorer quality of life, and then for societies, this is an area that need to do more research about the economic costs of ageism in the United States alone, estimating millions and millions of dollars added to the cost of hospitalisations, etc., by the worsening impact overlaid over the top of all of that. Now, we don't understand always the mechanisms by which that occurs. Like, how is it that if you think about ageing in a negative manner, that may take years off your life eventually? And I think we get into some really interesting realms. I wish I had all day to talk about it, but the psychology of okay, well, I'm getting older, that I'm a bit creaky, that's just a natural part of aging. I won't get out there, I won't move, I won't do those things because, well, I'm getting old, and that's what you do when you get old. Now, what we do definitely know from frailty research is if you stop moving, you will go downhill physically, mentally, all of it really quickly. Wow. And so you can see how, in theory, that thought process of, well, I won't do it because I'm too old, or this is just a normal part of aging, I won't get out there and exercise, or whatever, whatever thought process you have, I'm too old to socialise. Maybe I'll just hang out at home on my own. You know, so all of the mental and social stuff that comes along with that can then tip you over into, you know, depression, uh, isolation, and these we know for sure are contributing factors to things like frailty, which then end up in falls, hospitalization, residential care admission, you name it.

Natalie Cook: 23:56

In terms of just what any person can do, they don't work in healthcare, they're not adopted, what can we do?

Rachel Ambagtsheer: 24:02

I think educate yourself. It sounds like a really obvious one that I almost don't want to say it, but I think to be able to recognise ageism, you need to know what it is and what it looks like, and and sometimes almost how it hides in our everyday assumptions. For me, it's small everyday actions, so like questioning a joke, even if it's just in your own mind, maybe you don't feel brave enough to challenge someone who gives you a birthday card that says, Congratulations, you're ready for the nursing home. But you could too. You could say, Oh, this is a bit ageist, isn't it? Even if it's a joke. Yeah. Seems like a bit of a cliche, but it is that tiny step. If everybody takes it, then we'll get there as a society because we've done it with the other isms. And, you know, if this is the last ism, then we should definitely make it a priority to progress on it into the future. So if you're in a workplace and you see a colleague say something racist to another colleague, don't be silent, call it out, report it, or whatever it is. And I think we do need to get to that point where ageism is in the same place. But sadly, I think we are a way off, but certainly, you know, this is the place to start.

Natalie Cook: 25:15

And for people that are supporting older relatives, navigating their way through the systems and experiencing it.

Rachel Ambagtsheer: 25:22

I think you could stick up for them as well, you know, and don't firstly though, don't assume that they can't stick up for themselves. But if, for example, a classic example that we often hear about in healthcare is someone goes in with their older parent into the doctor and they're jointly having a consultation, and the doctor is addressing all their comments to the daughter or son in the room rather than the older person, even though the older person is the subject of the consultation. So if you notice that happening as a daughter or son, you could say, well, hang on, it's actually mum's the patient here, you can talk directly to her.

Natalie Cook: 26:07

If someone wanted to test their own awareness slash levels of ageism, where would they find the is the short course still available?

Rachel Ambagtsheer: 26:16

The short course is absolutely still available. So you do just um do a Google search for challenging ageism and torrents and you would find it. Uh, and I believe we have links to a self-ageism check in there. Anything else you'd like to share or make sure that we know? I think just for me, the essential take-home message from this whole conversation is just that ageing is universal, but ageism doesn't have to be. We talked about it and discussed it, you know, ageing is just living, everyone's doing it. So, why should we put up with ageism? All of us, unfortunately, will experience it at some point in our lives. So we shouldn't put up with it. So I do think again, it requires a change in attitude on both a small and a huge scale, but we can only start where we are, which is in our own backyard. I think even just having these conversations, really important, and having those water cooler type conversations, or what do we call it, barbecue, round the Barbie. That's a good place to start. That's as good a place as any.

Natalie Cook: 27:23

Thank you so much. I think even if someone listening hears this and that's their spark to change perspective, then it's been a really valuable conversation, but really fascinating. Thank you so much for your time, Rachel. Thank you, Nat. Hopefully we see less of those AGIST birthday cards actually adding around the traps after this. Thanks. And a disclaimer the information discussed in this podcast is for general information purposes only and is not intended as medical advice. The content should not be relied on as a substitute for professional health care. And if you have any concerns about your health, please do consult a qualified healthcare professional.