Is ageism undermining your ED’s medical decisions?
Imagine: it’s 6 a.m. and you go off shift in an hour. EMS brings in a 95-year-old female with abdominal pain. You go in to eyeball her and order a work up. On exam, she has a Murphy’s sign.
Aside from signing the patient out at 7 a.m. and letting your colleague handle the disposition, what do you think?
Is she a candidate for cholecystectomy?
And, if you believe that she is not, are you basing that opinion solely upon her age?
Would your opinion differ if she were 75-years-old? Maybe 55-years-old? Or even 35-years-old?
Patient 2: This is a 98-year-old male with c/o dense right hemiplegia, receptive aphasia and inability to swallow. The family understands that he has most likely had a major stroke. They would like you to advise them in a preliminary way what the best course will eventually be: aggressive rehabilitation or nursing home/hospice.
What is your first reaction? Is this reaction based upon his age? Would it differ if he were 78, 58 or 38?
As an emergency medicine resident, I did a clinical rotation in England. One day, a paramedic approached me.
“I just want you to know we have an elderly woman outside in the ambulance. She’s nearly dead. I’ll come get you when she has expired so you can pronounce her. We’re not going to bother to bring her in.”
Although not always so flagrant as this, ageism undermines many medical decisions.
I remember calling a neurosurgeon when we had an intubated elderly patient with a subarachnoid hemorrhage.
“She’s 80-years-old! What do you want me to do?” he asked.
“Well, I can’t send her home on a vent,” I responded.
As emergency physicians, we are well aware that few physicians (if any) are happy to hear from us in the middle of the night.
Who among us has not at one time or another dreaded calling an admitting physician about an elderly person who needed dialysis, cardiac catheterization, or surgery?
It seems there’s a pervasive collective opinion that elderly patients should be kept comfortable and be allowed to die.
I recently had the perspective of the family member advocating for a super elderly patient, my 98-year-old mother.
Even those among us who may not have had children of their own have studied the milestones of infancy and childhood. First an infant rolls from front to back; much later from back to front. Learning to walk, talk, feed oneself and toilet train are milestones with wide variations in when each child achieves each milestone, but ultimately most master the task.
In late March, my mother had a stroke. She was 98 at the time and left with a dense right-sided hemiplegia, inability to speak or swallow and complete dependency. My mother was unable to stand, transfer or turn over in bed. She could not walk at all. Her speech was incomprehensible. She had to be fed, her mouth wiped during feeding and a new bib worn for each meal. She was diapered and not aware of when she needed to use the bathroom. She had lost all of the childhood milestones.
At 98-years-old, how many might opine nursing home until demise or hospice placement? Many of us might think the prognosis to be very poor in someone of this age.
In the hospital, we had meetings with doctors, nurses, therapists, neurologists and, most importantly, the discharge planning lady. Thoughtful minds disagreed on what would be best for my mother: nursing home/hospice or a rehabilitation facility versus returning home with care. Ultimately, Mom clearly enunciated through her expressive aphasia: “I want to go home. Now!”
The first two weeks at home, we re-considered that decision daily. Perhaps a rehab facility would have been a better choice. Nursing agencies were low staffed following the effects of the pandemic. We had no control early on at the people provided. Although credentials were the same for all, like milestones, there was a wide variation in abilities, bedside manner and enthusiasm.
I recall sending one woman home shortly after she arrived diaphoretic, unable to take instruction, or even sit down to talk, unwilling to speak to my mother and apparently in withdrawal. Another nurse’s aide simply failed to show up. When confronted by phone, she said she had heard my mother was “dead weight” and she didn’t want to injure her back. Another aide simply walked out after a couple of hours without even saying goodbye. She had never cared for a stroke patient and felt uncomfortable.
On the day I called the discharge planner to say we should perhaps consider a facility, my mother’s long-time visiting nurse stepped up to the plate with the names of independent (non-agency) nurse’s aides whom she knew to be available and who are very good. Within a very short period, we had a team of six dedicated caregivers: two in the day, one at night.
The team had lessons from the physical therapist on what exercises she should do daily. They had instruction from the speech therapist on daily tasks for both speaking and swallowing. They searched cookbooks for tasty pureed meals. There were endless lists of supplies and equipment needed and we ensured my mother had all that was required.
By the end of the April, my mother could bear weight and stand with the assistance of two nurse’s aides; she could feed herself with her right hand; and started walking with her walker an hour a day with three caregivers (one on either side holding gait belt and one behind with a wheelchair).
She still did not exhibit many pre-mortem activities: she would not wear her eyeglasses, read or watch television. She had abandoned her IPAD and had no interest in Facebook or emails.
At the end of May, she had been studied by a mobile van that did swallowing studies and she advanced to a soft mechanical diet and thin liquids. She no longer needed the wheelchair for short trips to the bathroom or dining table; and she asked to be taken to the bathroom regularly. Mother started wearing her eyeglasses and reading; she began watching television again.
She also has taken an interest in appearance and insisted on having her hair done. She entertained friends over tea in her living room. In June, we celebrated her 99th birthday as well as her remarkable (miraculous) progress. By then, she required only one caregiver to walk along as she used her walker.
In June she started having episodes of biliary colic. There were at least 12 episodes in six weeks. None of her doctors recommended cholecystectomy. She was admitted twice and a surgeon was not consulted during either admission. When I asked the GI doctor, she said she doubted any surgeon would operate on a patient her age. Her medical doctor agreed.
We faced a challenge — in Florida the laws about prescribing narcotics are Draconian. As a result, most doctors don’t. When Mom had biliary colic, she clearly had 10/10 pain and we had little to offer. There was also the risk of eventually developing a common bile duct stone, ascending cholangitis, sepsis and death if we did nothing.
A surgeon friend sent me a retrospective study of surgery in the “super elderly” (over 90 years old) that showed very favorable results. 
We consulted a local eminent surgeon who agreed to perform laparoscopic cholecystectomy. The cardiologist took me aside to say he would have to write “very high risk” on the medical clearance. I told him to do what he had to do.
The surgery was performed in 15 minutes to minimize the time of general anesthesia. She did very well without any complications. Recovery was very swift.
As for the milestones she achieved once in childhood and lost in March, as of August, we are down to only one day and one night caregiver. She walks well with the walker without assistance. She feeds herself, toilets, reads, watches TV, reads her emails, goes on Facebook, speaks articulately at least 70% to 80% of the time and is back to her old self of making her wishes very clear. She knows and tells us if she doesn’t want a caretaker to continue, where to put her flowers, complains if a cushion is out of place. She notices every detail and wants everything pristine and meticulous. She demanded removal of the hospital bed and is back in her own bed.
The elderly population is growing logarithmically. “The first Baby Boomers reached 65 years old in 2011,” said Dr. Luke Rogers, chief of the Census Bureau’s Population Estimates Branch. “Since then, there’s been a rapid increase in the size of the 65-and-older population, which grew by over a third since 2010. No other age group saw such a fast increase.” 
An NIH-funded study shows that America’s 65-and-over population is projected to nearly double over the next three decades, from 48 million to 88 million by 2050.
Ageism needs to be recognized by physicians. I recently spoke with an internist who told me he is clearing more and more over 90-year-olds for surgery because they are active and healthy and in pain. One anesthesiologist recently worked on a hip replacement in an active 101-year-old.
Many of the super elderly are still doing their pool aerobics, participating in social events and living very active lives.
In 2019, the American Journal of Public Health published a review and meta-analysis to reduce agism, “Ageism is the stereotyping, prejudice, and discrimination against people on the basis of their age. Research has shown that ageism directed toward older adults has a negative impact on their health, well-being, and quality of health care received.” 
We are the front line. Whether we acknowledge it or not, we set the hospital course for each patient when we make the disposition after our work up.
It’s up to us to consider the patient and not the age. Presented with a person who has been leading an active, healthy life, who now has a serious health challenge, our decision to refer for aggressive management must be based on factors other than their age.
As the surgeon said about my mother, “She says she is 99, but her body is 76.”
- “Are They Too Old for Surgery? Safety of Cholecystectomy in Superelderly Patients (>Age 90), Busavo Iroiah et al, Permanente Journal, 2017, 21: 16-013. Published online 2017 Apr 14, doi: 10.7812/TPP/16-013.
- 65 and Older Population Grows Rapidly as Baby Boomers Age, United States Census Bureau, June 25, 2020, Release No CB20-99.
- “Interventions to Reduce Ageism Against Older Adult: A Systematic Review and Meta-Analysis,” David Burnes et al, American Journal of Public Health, August 2019.