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Ageism and its clinical impact in oncogeriatry: state of knowledge and therapeutic leads

Ageism and its clinical impact in oncogeriatry: state of knowledge and therapeutic leads Journal name: Clinical Interventions in Aging Article Designation: Review Year: 2015 Volume: 10 Running head verso: Schroyen et al Clinical Interventions in Aging Dovepress Running head recto: Ageism in oncogeriatry open access to scientific and medical research DOI: http://dx.doi.org/10.2147/CIA.S70942 Open Access Full Text Article Rev I ew Ageism and its clinical impact in oncogeriatry: state of knowledge and therapeutic leads Sarah Schroyen Abstract: Cancer is a major health problem that is widespread in elderly people. Paradoxically, older people suffering from cancer are often excluded from clinical trials and are undertreated when Stéphane Adam 2,3 compared to younger patients. One explanation for these observations is age stigma (ie, stereotypes Guy Jerusalem 1 linked to age, and thus ageism). These stigmas can result in deleterious consequences for elderly Pierre Missotten people’s mental and physical health in “normal” aging. What, then, is the impact in a pathological University of Liège, Psychology of context, such as oncology? Moreover, health care professionals’ attitudes can be tainted with age- Aging Unit, University of Liège, Laboratory of Medical Oncology, ism, thus leading to undesirable consequences for patients. To counter these stigmas, we can apply CHU Sart Tilman Liege, Department some possible interventions emerging from research on normal aging and from social psychology, of Medical Oncology, Liège, Belgium such as intergenerational contact, activation of positive stereotypes, self-affirmation, and so on; these tools can improve opinions of aging among the elderly people themselves, as well as health care professionals, thus affecting patients’ mental and physical health. Keywords: oncogeriatry, clinical approaches, stigmatization, ageism Introduction Cancer is a very common disease; in Europe, 3.45 million new cases of cancer were diagnosed in 2012 and 1.75 million people died from the disease in that same year. A significant proportion of cancer patients are elderly because age is a risk factor for many diseases, including cancer: it is estimated that in 2030, 70% of diagnosed cancers in the United States will affect patients .65 years old. Paradoxically, the psychosocial needs of elderly people with cancer remain unknown. Indeed, even if geriatric oncology programs have been developed (geriatric assessments, individual treatment, prevention, and so on), it is not enough; the perception of aging among health 4–6 professionals, including physicians, is still negative. Moreover, elderly patients are often excluded from clinical trials – between 1996 and 2002, 68% of people included in clinical trials for cancer were aged 30–64 years old, whereas only 8.3% of people were 65–74 years old (this represents, respectively, 3% and 1.3% of incident cancer patients in each age group). Many reasons are provided to justify the exclusion of elderly individuals from clinical trials, such as avoiding attrition (mortality, relocation, health decompensation), minimizing confounding variables associated with comorbidities, avoiding lengthier study processes, and so on. This observation, and the specific concern for a small Correspondence: Sarah Schroyen subgroup of patients (the youngest patients and/or those who display the best health) Unité de Psychologie de la Sénescence, Département Psychologies et cliniques has a double clinical consequences: 1) available data cannot be applied generally to des systèmes humains, Université de all elderly people with cancer given the nature of the physiological changes that occur Liège (ULg), Traverse des Architectes (B63c), B-4000 Liège, Belgium with more frequent comorbidities, the patients’ heterogeneous health statuses, etc; and Tel +32 436 697 45 2) it is difficult to develop specific guidelines for the treatment of elderly patients. In Fax +32 436 634 01 email sarah.schroyen@ulg.ac.be any guideline elaboration, it seems important to base treatment decisions on biological submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 117–125 Dovepress © 2015 Schroyen et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further http://dx.doi.org/10.2147/CIA.S70942 permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Schroyen et al Dovepress age and not chronological age; we are not equal in terms of that physicians recommend chemotherapy for breast cancer aging – physiological, social, and cognitive changes can in 99% of cases among people 55 years old, but only 60.4% appear and they are specific to each individual. From this among people 76 years old whose clinical situations are the perspective, scales like the Comprehensive Geriatric Assess- same. Moreover, 71% of physicians justified their decisions ment or Multidisciplinary Geriatric Assessment can be used based on tumor characteristics, whereas only 14% based it to assess the health status and comorbidities of elderly cancer on the patient’s age. Similarly, a UK survey showed that patients. From the same line of thinking, it is essential that the intensity of cancer treatment is influenced by age in 49% elderly cancer patients’ cases are discussed and taken on by of early-stage cases and 51% of advanced-stage cases. In multidisciplinary teams in order to obtain a global view of comparison, comorbidities influence only 37% of recom - the patients’ situations. General rules for the oncological mendations in the early stages and 31% in the advanced treatment have to be frequently adapted. The treatment has stages. Another recent study showed that mortality increases to be much more personalized when compared to that of a with age among women with breast cancer, and the authors younger patient population. For instance, the adjustment suggest that undertreatment can explain this observation. of some parameters (hemoglobin level, drug selection, the Indeed, young and old patients are not evenly treated; in the dose, and so on) during chemotherapy can be implemented in case of breast cancer treatment, older patients have a lower 12 19 order to suit an elderly population. The patient’s character- probability of receiving standard care. istics play a relatively high role when compared to younger Yet it should be remembered that “advanced” age alone patients, where the treatment is mainly decided based on should not be a contraindication for treatments that can 13–15 the tumor’s characteristics. Alternative local treatments increase a patient’s quality of life or significantly extend such as radiotherapy can be a first option in elderly patients a patient’s survival. Consequently, although it is unde- if a much higher mortality rate related to comorbidities is niable that some health changes appear with age (more expected with surgery. The life expectancy can be an argu- frequent comorbidities, reduction of immune function, ment against the use of some adjuvant therapies. For instance, etc), these changes are not a contraindication for receiving relapses in chemotherapy in high-risk endocrine-sensitive treatment; instead, they point to the need to adapt them to breast cancer frequently occur after 5 years of follow-up, elderly people. This is particularly true given the lack of and second-line endocrine therapy can still allow for several evidence that elderly people are too weak to tolerate che- years of disease stabilization in the metastatic setting. Life motherapy, radiotherapy, or surgery; in other words, this 12,20,21 expectancy and comorbidities also influence the aggressive - is a stereotype. Concerning radiotherapy, a study of ness of the treatment of prostate cancer, which is frequently nonagenarians showed that they exhibited good tolerance diagnosed in older men as the disease, in general, grows (89% ni fi shed the treatment and had an average of 13 months slowly; endocrine therapy can also allow for disease control of survival after radiotherapy). Finally, a study showed that for some time. the survival rate following intracranial tumor surgery was not It is important to note that systemic oncological treat- related to the patient’s age (in contrast, the histology or per- ments are becoming more and more expensive. Coverage formance score, for instance, was associated with survival). by the national health care system in our country, Belgium, Along the same lines as the previously cited examples, it has is not only based on the benefits observed according to been observed that elderly people receive fewer conservative tumor characteristics and line of therapy, but sometimes also and reconstructive procedures such as breast reconstruction; according to patient characteristics (such as performance in equivalent clinical situations, future physicians recom- status), while taking into account eligibility criteria in the mended breast reconstruction in 95% of cases for patients registration trial. Currently, age has not been used in our under 31 years old, in comparison to only 65% of cases in country for reimbursement, but excluding older patients adds patients over 59 years old. These data call on health care the risk that coverage by insurance is declined because of the professionals to ask themselves some questions. How can lack of evidence-based proof of similar benefits in a patient one explain such different attitudes toward older people if population excluded from the trial. not by stigmatization linked to age (ie, negative stereotypes This discrimination against elderly patients is not limited associated with aging, and thus ageism: “One boob less after to research; it is observed in the clinic too. Older patients age 59…what’s the difference?!”)? are undertreated when compared to younger patients. For The concept of ageism was introduced by Butler in instance, based on clinical vignettes, Protière et al showed 1969 with reference to revulsion toward the elderly, disease submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Dovepress Ageism in oncogeriatry 27–29 and infirmity, fear of helplessness, uselessness, and death. they developed considerably more cardiovascular issues. Consequently, elderly people are often seen as weak, intoler- This negative impact is even demonstrated on mortality rate: ant of change, and cognitively impaired. In other words, the with a 23-year follow-up, these authors showed (control- prevailing view of elderly people today is negative, tinted ling for objective and subjective health parameters, race, with ageism and youth culture. This view masks the great age, and socioeconomic status) that subjects with a negative cultural, social, physiological, and psychological heteroge- perception of aging lived an average of 7.5 years less than neity of seniors. A gripping example of such stigmatiza- subjects with a positive perception. One explanation sug- tion is given by a television show where participants have gests that these effects are linked to their daily attitudes in to eliminate “the weakest link” in the chain – that is, the life: people with a negative view of aging were less likely weakest member of the team. Participants who were more to engage in good health behaviors (eg, a healthy diet, using than 50 years old were excluded, not because of their poorer seatbelts, engaging in physical exercise, minimizing alcohol potential for the game but because they were older. No such or tobacco consumption, etc) over the course of 20 years, dur- discrimination was found for sex, or the ethnicity or racial ing which they were followed up. Conversely, other studies category. Evidence of this negative view of aging has been have proven that positive stereotypes of aging have a good found by different studies. The most widely cited reason for impact on recovery; older persons with a severe disability discrimination in Europe is age – more specifically, being were 44% more likely to fully recover the ability to perform over (only) 55 years old (4% in 2012), followed by sex and in four daily activities (bathing, dressing, transferring, and ethnic origin (3%). walking) when they held positive stereotypes compared with Given the observed discrimination in oncology (clinical when they held negative stereotypes. trials and treatments), we can wonder what the consequences Other studies have analyzed the immediate effect (within of such ageism are for patients themselves and for health a few minutes) of negative stereotype activation (implicit professionals. In this paper, we aim to describe the negative or explicit) on elderly people. According to internalization impact of ageism in geriatric oncology, including data from theory, stereotypes are part of one’s identity and are pres- “normal” aging. Before concluding, we will describe some ent in all circumstances. Levy et al studied the effect of therapeutic leads for patients and professionals, which could subliminal exposure to positive or negative words linked to potentially be applied in geriatric oncology to reduce the aging. In their experiment, subjects had to fixate on a cross deleterious effect of ageism. on a computer screen; below or above it, words with nega- tive connotations (eg, “senile”, “dependent”, etc) or positive Self-stereotyping connotations (eg, “enlightened”, “insightful”, etc) for elderly Having a negative view of elderly people is not without people were flashed for a very short time, preventing the iden - consequences when one becomes older. Before we analyze tic fi ation or recognition of words (thus, stereotype perception these consequences for patients in oncology, it would be was not conscious). Participants had to indicate, as fast as valuable to observe ageism’s impact in a nonpathological possible, the position of the flashed word with the help of context: many studies have demonstrated an injurious effect two buttons (up versus down). This subliminal activation was on older people’s physical and mental health. This effect preceded and followed by various tasks. The results showed has been shown by two types of studies: 1) longitudinal that elderly people’s exposure to negative stereotyped words studies ascertaining the impact of positive or negative per- impaired their memory capabilities and led to their feeling ceptions that elderly people have of aging; and 2) empirical that their memory was less efc fi ient than in the case of elderly studies showing the immediate effects (within a few minutes) people exposed to positive stereotypes. More surprisingly, on elderly people of the activation (implicit or explicit) of the stereotypes triggered an increase in the participants’ positive or negative stereotypes. cardiovascular response to stress, led to a more negative Holding negative stereotypes can have many deleterious perception of their health, and resulted in a decline in the 34,35 effects on one’s physical health over the long term. This is will to live among the elderly subjects. These results are the conclusion that has been suggested by many studies with in the same vein as stereotype activation based not on stereo- the help of longitudinal follow-up. Indeed, individuals with type internalization, but on the stereotype threat paradigm. an initial negative impression of aging tended to have poorer According to this paradigm, people feel anxiety when they memory capabilities, they described themselves as having confirm stereotypes about their own group. For instance, worse physical health with age (over a 28-year period), and when elderly individuals are told that their memory will be submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Schroyen et al Dovepress tested, it provokes anxiety because it activates the negative particularly vulnerable to such ageist stereotypes because stereotype of “memory decline with advancing age”. Indeed, they are constantly exposed to ill elderly people (“An elderly Abrams et al showed that subjects exposed to negative person is an individual with bad physical and/or mental aging stereotypes had decreased intellectual performance health”; Adam et al, unpublished data, 2014). Therefore, (including on memory tasks) when compared to a neutral they are likely to hold negative attitudes toward older people group. Moreover, they took more time to do the tasks and (eg, viewing them as unable to adapt, boring, untidy, etc), 37 41,42 their level of anxiety was higher. including older people in oncology. When we see the negative consequences of ageism in a This negative vision of aging (with pejorative attitudes nonpathological context, we can reasonably ask ourselves toward old people) is not without consequences for older whether this impact applies in the specific context of geriat - people themselves. Indeed, when elderspeak speech is used, ric oncology. Indeed, if the perception that we have of our elderly people can feel powerless and experience lower self- own age affects our physical and mental health in normal esteem; the message they receive is, “You have difficulties aging, then in a context where health is already affected by hearing me and understanding me”. An experiment can be a disease, we might suppose that patients will be even more described by way of illustration – young and older partici- sensitive to the view they have of themselves and of their pants have a map in front of them and they have to listen to age. Very few studies of this specific context exist, but their someone giving them directions in elderspeak. Their task results confirm the negative impact of ageist stereotypes. is very simple: they have to trace the route according to the For example, a recent study of patients of 80 years old and directions. After that, they have to judge their own commu- over suffering from a chronic disease (eg, heart disease, nicative skills. The results showed that, when exaggerated arthritis, diabetes, or cancer) showed that these patients more prosody was used, the older participants completed fewer frequently linked their disease’s origin to their advanced age maps correctly, made more deviations from the correct route rather than to unhealthy behaviors, genetics, etc. The stereo- and made negative assessments of their own communica- type “to be old is to be ill” has negative consequences: the tive skills (see experiment 2). Consequently, elderspeak more patients believe it and the more physical symptoms they simply reinforces stereotypes (people confirm that they do perceive, the poorer their health maintenance behaviors and not clearly understand the instructions they are given); a 38 43 the higher the probability of mortality at a 2-year follow-up. negative feedback loop is thus created. Another effect of Another recent study of patients’ age perception, conducted this kind of communication is shown by studies including with elderly people (median age: 63 years) suffering from a people with dementia: elderspeak enhances resistance to care chemotherapy-treated cancer, showed that people who felt (eg, grabbing objects, crying, saying no, pushing away, etc) in younger than their chronological age had a tendency to main- comparison to normal adult communication and to silence. tain their sense of humor, highlight the importance of family, There is no direct study on the effect of elderspeak in the have positive thoughts, and stay engaged in life; these factors context of geriatric oncology. The only study close to this are prognostic of good physical and mental health. field showed that high use of ageism among professionals, as perceived by patients suffering from breast cancer (prob- Influence of ageism on health ably noticed partly because of elderspeak), was associated professionals’ attitudes and with more physical pain, poorer mental health, and decreased patient–professional relations general satisfaction with their care. In the same vein, older The negative consequences of ageism are not limited to breast cancer survivors who had negative beliefs about elderly people themselves; they also have an impact on the symptom management perceived that their health care pro- attitudes of those who deal with these people, including health viders had negative attitudes, or they reported experiencing care professionals. This impact, generally subconscious, difficulties communicating about their symptoms and had a is explained primarily by the general negative attitudes of lower quality of life. society. It may be manifested in “elderspeak” (or “baby talk”) This direct influence of the attitudes of health care profes - communication; this kind of speech is characterized by speak- sionals on the changes in seniors’ physical and psychological ing slower and/or louder, using simplified sentences, etc, health is confirmed by studies of normal aging. In one, when talking to an elderly individual. This attitude is based residents of a nursing home were asked to do a jigsaw puzzle. on the stereotype that elderly people have hearing issues and In the first group, help was provided by, for instance, sug - impaired cognitive functions. Health care professionals are gesting where to put pieces (“You can do it like this”); the submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Dovepress Ageism in oncogeriatry second group was only encouraged verbally (“Yes! You’re explored. However, we can suggest some methods based making progress!”); and the third group was given neither on internalization theory and the stereotype threat paradigm help nor encouragement. The results indicated that helping arising from normal aging studies. an elderly person contributed to decreased performance and In line with internalization theory, experimental stud- self-confidence in completing this task, and increased the ies have shown the positive effect of subliminal activation feeling of difficulty associated with it. In other words, good (perception without awareness) of positive aging stereotypes intentions can have deleterious effects; when we want to help on elderly people’s physical and psychological health. For an elderly person, we have to be careful not to help him or her instance, participants walk faster, have better cardiovascular 27,34,50 too much. Another example shows that negative stereotypes measures, and have better memory performance. If these create artificial dependency. In their experiment, Coudin results seem difficult to apply in a clinical context, we can and Alexopoulos included three conditions: by listening to assume that our everyday vocabulary refers to an image of a text, elderly subjects were exposed to positive stereotypes aging; for instance, using words such as “confused”, “incom- (eg, “Older persons represent a huge market and therefore petent”, or “decline” in reference to elderly people triggers contribute to the economic growth of our society”), or nega- negative stereotypes and has a detrimental impact on them tive stereotypes (eg, “Aging is characterized by a loss of some (eg, elderspeak). Conversely, words such as “improving”, important social roles that contribute to the devaluation of “learned”, and “advise” have a positive resonance and thus older adults”); there was also a control condition with no can have positive effects on communication with elderly text to listen to. Then, participants were asked to solve a people or on their anxiety. very complicated puzzle in 10 minutes; they could ask for In line with the stereotype threat paradigm, multiple help by honking a horn. The results showed that exposure methods emerge from the literature on normal aging and to negative stereotypes was associated with more dependent social psychology. Stereotype threat is observed when behaviors – the subjects asked for help more frequently than negative stereotypes are explicitly presented to subjects; in the positive or neutral conditions. Thus, when negative their performance deteriorates when compared to when no stereotypes, such as “Elderly people are dependent and need allusion to stereotypes is made. Some studies of normal help”, are revealed through health care providers’ behaviors, aging suggest that intergenerational contact works against it contributes to a decline in the elderly subjects’ perfor- the effects of ageism on the elderly. Indeed, an experiment mance. This has clinical implications: if we want to help a observed that in the face of stereotype threat (eg, explain- patient, is this help really necessary? Are we not creating ing that mathematical abilities decline with age just before an artificial dependency instead of improving his or her a mathematical challenge), anxiety is diminished if elderly abilities? These examples (elderspeak, excessive help, and participants have positive contact with their grandchildren, so on) illustrate that our behavior is not always adapted to or when they simply imagine talking with a younger person the elderly and that the psychosocial needs associated with before this stressful task. Thus, in the specific realm of aging are not always taken into consideration. geriatric oncology, it is possible that imagining talking with a younger person might help reduce elderly people’s anxiety Countering the stereotypes: before a stressful event (eg, surgery, first chemotherapy, suggestions for intervention any treatment, etc). Similarly, a study tested the efficacy of After reviewing the negative consequences of ageism, intergenerational reminiscence for seniors (ie, evocation of one obvious fact comes to mind: it is essential to develop memories of grandchildren); after the intervention, those therapeutic solutions to counter the negative influence of seniors reported less loneliness and a better quality of life. stereotypes. Fortunately, some therapeutic leads are given in This technique would also be interesting way to test elderly the literature; some of them relate directly to elderly people people with cancer to see if it can enhance their quality of who are the victims of these stereotypes, whereas others are life. For instance, during medical care or preparation before designed for professionals and other people working with a treatment, you can speak with the patient with the aim the elderly. of evoking good memories that he or she can have with his/her grandchildren. At the patient level Two concepts from social psychology have attracted our To our knowledge, specific therapeutic indications against attention: “self-afr fi mation” and “counter-stereotype”. These ageism in oncogeriatry at the patient level have not yet been two concepts allow people to avoid a stereotype threat. submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Schroyen et al Dovepress To understand the concept of “self-affirmation”, it is were found; 2) the stereotype condition, in which it was important to realize that people are motivated to maintain explained that older people have less efficient memories the integrity of their self. Thus, when the self is threatened, than younger people; and 3) the control condition, in which they must cope with it; self-affirmation is a form of indirect no information was provided regarding age differences in psychological adaptation. For a person, it refers to focusing memory. The results on a memory task showed that all on an important aspect of his or her life that is irrelevant to participants in the counter-stereotypes group (younger and the threat, or engaging in an activity that is disconnected older) recalled more words than those in the other condi- from the threat and that highlights some important value for tions, but only in the case of subjects with more education. him or her. Some studies (for a review, see McQueen et al ) Subjects with lower education levels recalled fewer words in have shown that stereotype threat can be neutralized by self- the stereotype and counter-stereotype conditions than in the affirmation. For instance, when women are told that their control condition. Thus, this study suggested that the counter- math intelligence will be tested, this represents a stereotype stereotype approach is efc fi ient (in some cases) in combating threat (“Women are bad at math”), and so their performance stereotype threat (when the stereotype is applicable to the is worse than if they were told that the purpose of the study group in question – in this case, older participants) and ste- was to get people’s impressions of the problem. However, reotype activation (when the stereotype does not apply to the when a self-afr fi mation paradigm is applied (eg, participants group – in this case, younger participants). Concerning this have to write a paragraph on a value that is personally impor- last point, there are other ways to avoid the use of stereotypes tant to them), the stereotype threat disappears; self-afr fi ming in the general population, and some specific approaches can women who autoaffirmed performed at the same level as be suggested for professionals. women in the control condition. Moreover, this concept can be used to enhance the acceptance of health messages At the professional level (in this case, the “threat” is to be in bad health). For instance, Similarly to the patient level, there are no therapeutic instruc- Sherman et al selected 60 students – 30 which drank cof- tions to combat ageism specifically in geriatric oncology. fee, and 30 of which did not. These students had to read a We can suggest some group and individual interventions to (fake) scientic fi article on the probability of developing breast reduce health professionals’ stereotypes of aging and thus cancer due to drinking coffee. The results showed that when improve their communication with patients. a self-affirmation paradigm was used, the coffee drinkers In a group setting, training sessions can be set up for were more likely to accept the message than were those in health care professionals to make them fully aware of how the control condition, and they were also more likely to do stereotypes affect their behavior, and to inform them of so than the students who did not drink coffee. The impact the consequences that these behaviors can have on elderly of this technique in geriatric oncology should be analyzed; patients. To highlight the importance of such training, one self-afr fi mation just after the explanation of a treatment such study showed that physicians have developed a more positive as chemotherapy or radiotherapy could enhance acceptance attitude toward elderly patients since 2000, whereas nurses’ of this treatment. At another level, it might promote adher- attitudes have become less positive. This difference may be ence to a specific diet, which is very important in parallel to due to more comprehensive education on aging in medicine. cancer treatment. Likewise, education and support during practice experience The second concept emanating from social psychology, enhance positive attitudes toward elderly patients among the “counter-stereotype”, consists of intentionally activating medical students. Similarly, another study showed that a ideas or creating mental imagery in opposition to stereotypes gerontology education course given to students in the social (eg, create a mental image of an old man running). This services decreased their anxiety about working with older approach is based on the assumption that counter-stereotypes people and reduced their ageism. Moreover, a training will challenge stereotypes in information processing. In geri- program that includes information on the aging process atric oncology, a possible counter-stereotype could be that and simulation of the role of older adults resulted in better older people have the same probability as younger people of attitudes toward elderly people and increased knowledge tolerating cancer treatments such as chemo- or radiotherapy. of aging; 4 weeks after the training program, these results This process has been tested in the area of memory decline: were still observed. Regarding communication, the harmful participants (from 21–80 years old) were divided into one of effects of elderspeak can be improved by specific training three conditions: 1) the counter-stereotype condition, where for nursing staff. One example of communication training, they were told that no age-related differences in memory which included information about elderspeak and its negative submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Dovepress Ageism in oncogeriatry effects, as well as practice with effective communication Their reports revealed stronger stereotypes for the group who skills, resulted in a significant reduction in elderspeak. had to suppress their preconceptions in the first task than for A similar reduction was observed in a study carried out in the control group who never had to control their stereotypes. three nursing homes immediately after the intervention, but Thus, we must be careful about using this method; more stud- this effect was also observed 2 months later. ies must be done before it can be applied in the clinic. Regarding interventions with individual professionals, we can describe some approaches (such as the patient-level In a practical way approaches) that are based on studies from social psychol- Considering all this literature, applications of these find - ogy. First, the concept of self-affirmation cited earlier can ings in daily life could take several forms, the most obvious also be used to battle prejudices; when their self-image has being the systematic training of all health care professionals been bolstered through self-afr fi mation, people express fewer (medical and paramedical) on aging, with a specific aware - prejudices against other people (eg, people express more ness regarding our attitudes and the impact of our negative positive feedback for a Jewish job candidate after writing aging view on older patients. This training could be done about their values). Another means of working against using theoretical information, as well as using videos and stereotypes is perspective-taking – in other words, describ- role playing in order to make a stronger bond between theory ing a situation from someone else’s point of view (eg, an and clinical practice. It will allow participants to see how elderly man). Perspective-taking leads participants to see stereotypes can be easily integrated into daily care through an overlap between their self-image and the image of the their vocabulary (evoking negative stereotypes) or acts (for out-group (in this example, older people), thereby reduc- instance, assuming the individual cannot eat or wash him or ing the accessibility and application of stereotypes. Some herself alone). This kind of technique has already been suc- authors suggest that certain techniques that do not require cessfully applied among health care professionals (nurses, 67 63 much effort may also be applicable. More specifically, in particular) in order to diminish “baby speak”. the authors found that if students are exposed to admirable Otherwise, integration of an aging specialized psycholo- members of a stigmatized group and disliked members of gist in an oncogeriatry department can be a useful initiative. their own group, it triggers a modification of the social For instance, this psychologist could realize a systematic context and thus a shift in the students’ attitudes. More screening of the view of aging that patients possess about specifically, when exposed to a picture of an admired elder themselves. Patients with a clearly negative vision could be (eg, Mother Teresa or Albert Einstein), participants implicitly followed individually or in group sessions. The content of this associate positive words with advanced age more quickly; intervention can take several forms, for example, by activating however, no effect was found for explicit measures. positive stereotypes or highlighting important values in these Blair describes two ways of combating stereotypes: individuals (ie, the self-afr fi mation technique). These different counter-stereotypes, as we saw earlier; and stereotype sup- clinical approaches have not yet been validated in the specic fi pression. Stereotype suppression is based on a very simple context of oncogeriatry. Additional studies have to be done principle: subjects must try to control their stereotypes about in order to determine the extent of the positive effects of each a group to prevent their judgment from being influenced. technique, but also to identify the most adequate patient prol fi e This procedure is illustrated in the following experiment: for each approach. In a more global way, we could question students were shown a photograph of a male skinhead and the terminology used during caring of the elderly – being sent asked to describe a typical day for him. One group was told to the “geriatric department”, being addressed to a “geriatri- that our impressions are often biased by our stereotypes and cian”, receiving a “senior menu”, etc; all of these terms refer they had to try to avoid preconceptions. The control group to old age and consequently activate associated stereotypes. did not receive any specific instructions. The authors found All of this daily vocabulary can be considered as pointless that subjects produced fewer stereotyped descriptions when detail, but the impact of stereotypes should lead us to further they were asked to suppress their stereotypes. However, this questioning. In order to measure the effect of such terminol- methodology can provoke a “rebound effect”: when subjects ogy, additional studies have to be done. are told to suppress their stereotypes, they may reappear later with greater intensity. This was observed in the second Conclusion part of the experiment; another male skinhead’s photograph Ageism is constantly present in daily life (in the media, in our was shown and subjects were asked to perform the same attitudes, etc), and it can be subconscious. It influences interac - task, but this time without any instructions for either group. tions with elderly people and can have negative consequences submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Schroyen et al Dovepress 43,48 5. Sheikh RB, Mathew E, Rafique AM, Suraweera RSC, Khan H, for them. Moreover, as we age, our conceptions of aging Sreedharan J. 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Yale J Biol Med. 2013;86(1):41–47. professionals risk, for instance, concluding that a confused 9. Townsley CA, Selby R, Siu LL. Systematic review of barriers to the elderly patient is too cognitively impaired to understand what recruitment of older patients with cancer onto clinical trials. J Clin Oncol. 2005;23(13):3112–3124. is going on. Conversely, in a young patient, the same observa- 10. Hurria A, Browner IS, Cohen HJ, et al. Senior adult oncology. J Natl tion will be linked to the stress of the oncological consultation. Compr Canc Netw. 2012;10(2):162–209. Therefore, countering ageism needs to be taken seriously into 11. Penson RT, Daniels KJ, Lynch TJ. Too old to care? Oncologist. 2004; 9(3):343–352. consideration in clinical practice. We have seen some therapeu- 12. Balducci L. Management of cancer in the elderly. Oncology (Williston tic approaches for this purpose, but more studies are needed in Park). 2006;20(2):135–143; discussion 144, 146, 151–152. 13. 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Ageism and its clinical impact in oncogeriatry: state of knowledge and therapeutic leads

Clinical Interventions in Aging , Volume 10 – Dec 31, 2014

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Journal name: Clinical Interventions in Aging Article Designation: Review Year: 2015 Volume: 10 Running head verso: Schroyen et al Clinical Interventions in Aging Dovepress Running head recto: Ageism in oncogeriatry open access to scientific and medical research DOI: http://dx.doi.org/10.2147/CIA.S70942 Open Access Full Text Article Rev I ew Ageism and its clinical impact in oncogeriatry: state of knowledge and therapeutic leads Sarah Schroyen Abstract: Cancer is a major health problem that is widespread in elderly people. Paradoxically, older people suffering from cancer are often excluded from clinical trials and are undertreated when Stéphane Adam 2,3 compared to younger patients. One explanation for these observations is age stigma (ie, stereotypes Guy Jerusalem 1 linked to age, and thus ageism). These stigmas can result in deleterious consequences for elderly Pierre Missotten people’s mental and physical health in “normal” aging. What, then, is the impact in a pathological University of Liège, Psychology of context, such as oncology? Moreover, health care professionals’ attitudes can be tainted with age- Aging Unit, University of Liège, Laboratory of Medical Oncology, ism, thus leading to undesirable consequences for patients. To counter these stigmas, we can apply CHU Sart Tilman Liege, Department some possible interventions emerging from research on normal aging and from social psychology, of Medical Oncology, Liège, Belgium such as intergenerational contact, activation of positive stereotypes, self-affirmation, and so on; these tools can improve opinions of aging among the elderly people themselves, as well as health care professionals, thus affecting patients’ mental and physical health. Keywords: oncogeriatry, clinical approaches, stigmatization, ageism Introduction Cancer is a very common disease; in Europe, 3.45 million new cases of cancer were diagnosed in 2012 and 1.75 million people died from the disease in that same year. A significant proportion of cancer patients are elderly because age is a risk factor for many diseases, including cancer: it is estimated that in 2030, 70% of diagnosed cancers in the United States will affect patients .65 years old. Paradoxically, the psychosocial needs of elderly people with cancer remain unknown. Indeed, even if geriatric oncology programs have been developed (geriatric assessments, individual treatment, prevention, and so on), it is not enough; the perception of aging among health 4–6 professionals, including physicians, is still negative. Moreover, elderly patients are often excluded from clinical trials – between 1996 and 2002, 68% of people included in clinical trials for cancer were aged 30–64 years old, whereas only 8.3% of people were 65–74 years old (this represents, respectively, 3% and 1.3% of incident cancer patients in each age group). Many reasons are provided to justify the exclusion of elderly individuals from clinical trials, such as avoiding attrition (mortality, relocation, health decompensation), minimizing confounding variables associated with comorbidities, avoiding lengthier study processes, and so on. This observation, and the specific concern for a small Correspondence: Sarah Schroyen subgroup of patients (the youngest patients and/or those who display the best health) Unité de Psychologie de la Sénescence, Département Psychologies et cliniques has a double clinical consequences: 1) available data cannot be applied generally to des systèmes humains, Université de all elderly people with cancer given the nature of the physiological changes that occur Liège (ULg), Traverse des Architectes (B63c), B-4000 Liège, Belgium with more frequent comorbidities, the patients’ heterogeneous health statuses, etc; and Tel +32 436 697 45 2) it is difficult to develop specific guidelines for the treatment of elderly patients. In Fax +32 436 634 01 email sarah.schroyen@ulg.ac.be any guideline elaboration, it seems important to base treatment decisions on biological submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 117–125 Dovepress © 2015 Schroyen et al. This work is published by Dove Medical Press Limited, and licensed under Creative Commons Attribution – Non Commercial (unported, v3.0) License. The full terms of the License are available at http://creativecommons.org/licenses/by-nc/3.0/. Non-commercial uses of the work are permitted without any further http://dx.doi.org/10.2147/CIA.S70942 permission from Dove Medical Press Limited, provided the work is properly attributed. Permissions beyond the scope of the License are administered by Dove Medical Press Limited. Information on how to request permission may be found at: http://www.dovepress.com/permissions.php Schroyen et al Dovepress age and not chronological age; we are not equal in terms of that physicians recommend chemotherapy for breast cancer aging – physiological, social, and cognitive changes can in 99% of cases among people 55 years old, but only 60.4% appear and they are specific to each individual. From this among people 76 years old whose clinical situations are the perspective, scales like the Comprehensive Geriatric Assess- same. Moreover, 71% of physicians justified their decisions ment or Multidisciplinary Geriatric Assessment can be used based on tumor characteristics, whereas only 14% based it to assess the health status and comorbidities of elderly cancer on the patient’s age. Similarly, a UK survey showed that patients. From the same line of thinking, it is essential that the intensity of cancer treatment is influenced by age in 49% elderly cancer patients’ cases are discussed and taken on by of early-stage cases and 51% of advanced-stage cases. In multidisciplinary teams in order to obtain a global view of comparison, comorbidities influence only 37% of recom - the patients’ situations. General rules for the oncological mendations in the early stages and 31% in the advanced treatment have to be frequently adapted. The treatment has stages. Another recent study showed that mortality increases to be much more personalized when compared to that of a with age among women with breast cancer, and the authors younger patient population. For instance, the adjustment suggest that undertreatment can explain this observation. of some parameters (hemoglobin level, drug selection, the Indeed, young and old patients are not evenly treated; in the dose, and so on) during chemotherapy can be implemented in case of breast cancer treatment, older patients have a lower 12 19 order to suit an elderly population. The patient’s character- probability of receiving standard care. istics play a relatively high role when compared to younger Yet it should be remembered that “advanced” age alone patients, where the treatment is mainly decided based on should not be a contraindication for treatments that can 13–15 the tumor’s characteristics. Alternative local treatments increase a patient’s quality of life or significantly extend such as radiotherapy can be a first option in elderly patients a patient’s survival. Consequently, although it is unde- if a much higher mortality rate related to comorbidities is niable that some health changes appear with age (more expected with surgery. The life expectancy can be an argu- frequent comorbidities, reduction of immune function, ment against the use of some adjuvant therapies. For instance, etc), these changes are not a contraindication for receiving relapses in chemotherapy in high-risk endocrine-sensitive treatment; instead, they point to the need to adapt them to breast cancer frequently occur after 5 years of follow-up, elderly people. This is particularly true given the lack of and second-line endocrine therapy can still allow for several evidence that elderly people are too weak to tolerate che- years of disease stabilization in the metastatic setting. Life motherapy, radiotherapy, or surgery; in other words, this 12,20,21 expectancy and comorbidities also influence the aggressive - is a stereotype. Concerning radiotherapy, a study of ness of the treatment of prostate cancer, which is frequently nonagenarians showed that they exhibited good tolerance diagnosed in older men as the disease, in general, grows (89% ni fi shed the treatment and had an average of 13 months slowly; endocrine therapy can also allow for disease control of survival after radiotherapy). Finally, a study showed that for some time. the survival rate following intracranial tumor surgery was not It is important to note that systemic oncological treat- related to the patient’s age (in contrast, the histology or per- ments are becoming more and more expensive. Coverage formance score, for instance, was associated with survival). by the national health care system in our country, Belgium, Along the same lines as the previously cited examples, it has is not only based on the benefits observed according to been observed that elderly people receive fewer conservative tumor characteristics and line of therapy, but sometimes also and reconstructive procedures such as breast reconstruction; according to patient characteristics (such as performance in equivalent clinical situations, future physicians recom- status), while taking into account eligibility criteria in the mended breast reconstruction in 95% of cases for patients registration trial. Currently, age has not been used in our under 31 years old, in comparison to only 65% of cases in country for reimbursement, but excluding older patients adds patients over 59 years old. These data call on health care the risk that coverage by insurance is declined because of the professionals to ask themselves some questions. How can lack of evidence-based proof of similar benefits in a patient one explain such different attitudes toward older people if population excluded from the trial. not by stigmatization linked to age (ie, negative stereotypes This discrimination against elderly patients is not limited associated with aging, and thus ageism: “One boob less after to research; it is observed in the clinic too. Older patients age 59…what’s the difference?!”)? are undertreated when compared to younger patients. For The concept of ageism was introduced by Butler in instance, based on clinical vignettes, Protière et al showed 1969 with reference to revulsion toward the elderly, disease submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Dovepress Ageism in oncogeriatry 27–29 and infirmity, fear of helplessness, uselessness, and death. they developed considerably more cardiovascular issues. Consequently, elderly people are often seen as weak, intoler- This negative impact is even demonstrated on mortality rate: ant of change, and cognitively impaired. In other words, the with a 23-year follow-up, these authors showed (control- prevailing view of elderly people today is negative, tinted ling for objective and subjective health parameters, race, with ageism and youth culture. This view masks the great age, and socioeconomic status) that subjects with a negative cultural, social, physiological, and psychological heteroge- perception of aging lived an average of 7.5 years less than neity of seniors. A gripping example of such stigmatiza- subjects with a positive perception. One explanation sug- tion is given by a television show where participants have gests that these effects are linked to their daily attitudes in to eliminate “the weakest link” in the chain – that is, the life: people with a negative view of aging were less likely weakest member of the team. Participants who were more to engage in good health behaviors (eg, a healthy diet, using than 50 years old were excluded, not because of their poorer seatbelts, engaging in physical exercise, minimizing alcohol potential for the game but because they were older. No such or tobacco consumption, etc) over the course of 20 years, dur- discrimination was found for sex, or the ethnicity or racial ing which they were followed up. Conversely, other studies category. Evidence of this negative view of aging has been have proven that positive stereotypes of aging have a good found by different studies. The most widely cited reason for impact on recovery; older persons with a severe disability discrimination in Europe is age – more specifically, being were 44% more likely to fully recover the ability to perform over (only) 55 years old (4% in 2012), followed by sex and in four daily activities (bathing, dressing, transferring, and ethnic origin (3%). walking) when they held positive stereotypes compared with Given the observed discrimination in oncology (clinical when they held negative stereotypes. trials and treatments), we can wonder what the consequences Other studies have analyzed the immediate effect (within of such ageism are for patients themselves and for health a few minutes) of negative stereotype activation (implicit professionals. In this paper, we aim to describe the negative or explicit) on elderly people. According to internalization impact of ageism in geriatric oncology, including data from theory, stereotypes are part of one’s identity and are pres- “normal” aging. Before concluding, we will describe some ent in all circumstances. Levy et al studied the effect of therapeutic leads for patients and professionals, which could subliminal exposure to positive or negative words linked to potentially be applied in geriatric oncology to reduce the aging. In their experiment, subjects had to fixate on a cross deleterious effect of ageism. on a computer screen; below or above it, words with nega- tive connotations (eg, “senile”, “dependent”, etc) or positive Self-stereotyping connotations (eg, “enlightened”, “insightful”, etc) for elderly Having a negative view of elderly people is not without people were flashed for a very short time, preventing the iden - consequences when one becomes older. Before we analyze tic fi ation or recognition of words (thus, stereotype perception these consequences for patients in oncology, it would be was not conscious). Participants had to indicate, as fast as valuable to observe ageism’s impact in a nonpathological possible, the position of the flashed word with the help of context: many studies have demonstrated an injurious effect two buttons (up versus down). This subliminal activation was on older people’s physical and mental health. This effect preceded and followed by various tasks. The results showed has been shown by two types of studies: 1) longitudinal that elderly people’s exposure to negative stereotyped words studies ascertaining the impact of positive or negative per- impaired their memory capabilities and led to their feeling ceptions that elderly people have of aging; and 2) empirical that their memory was less efc fi ient than in the case of elderly studies showing the immediate effects (within a few minutes) people exposed to positive stereotypes. More surprisingly, on elderly people of the activation (implicit or explicit) of the stereotypes triggered an increase in the participants’ positive or negative stereotypes. cardiovascular response to stress, led to a more negative Holding negative stereotypes can have many deleterious perception of their health, and resulted in a decline in the 34,35 effects on one’s physical health over the long term. This is will to live among the elderly subjects. These results are the conclusion that has been suggested by many studies with in the same vein as stereotype activation based not on stereo- the help of longitudinal follow-up. Indeed, individuals with type internalization, but on the stereotype threat paradigm. an initial negative impression of aging tended to have poorer According to this paradigm, people feel anxiety when they memory capabilities, they described themselves as having confirm stereotypes about their own group. For instance, worse physical health with age (over a 28-year period), and when elderly individuals are told that their memory will be submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Schroyen et al Dovepress tested, it provokes anxiety because it activates the negative particularly vulnerable to such ageist stereotypes because stereotype of “memory decline with advancing age”. Indeed, they are constantly exposed to ill elderly people (“An elderly Abrams et al showed that subjects exposed to negative person is an individual with bad physical and/or mental aging stereotypes had decreased intellectual performance health”; Adam et al, unpublished data, 2014). Therefore, (including on memory tasks) when compared to a neutral they are likely to hold negative attitudes toward older people group. Moreover, they took more time to do the tasks and (eg, viewing them as unable to adapt, boring, untidy, etc), 37 41,42 their level of anxiety was higher. including older people in oncology. When we see the negative consequences of ageism in a This negative vision of aging (with pejorative attitudes nonpathological context, we can reasonably ask ourselves toward old people) is not without consequences for older whether this impact applies in the specific context of geriat - people themselves. Indeed, when elderspeak speech is used, ric oncology. Indeed, if the perception that we have of our elderly people can feel powerless and experience lower self- own age affects our physical and mental health in normal esteem; the message they receive is, “You have difficulties aging, then in a context where health is already affected by hearing me and understanding me”. An experiment can be a disease, we might suppose that patients will be even more described by way of illustration – young and older partici- sensitive to the view they have of themselves and of their pants have a map in front of them and they have to listen to age. Very few studies of this specific context exist, but their someone giving them directions in elderspeak. Their task results confirm the negative impact of ageist stereotypes. is very simple: they have to trace the route according to the For example, a recent study of patients of 80 years old and directions. After that, they have to judge their own commu- over suffering from a chronic disease (eg, heart disease, nicative skills. The results showed that, when exaggerated arthritis, diabetes, or cancer) showed that these patients more prosody was used, the older participants completed fewer frequently linked their disease’s origin to their advanced age maps correctly, made more deviations from the correct route rather than to unhealthy behaviors, genetics, etc. The stereo- and made negative assessments of their own communica- type “to be old is to be ill” has negative consequences: the tive skills (see experiment 2). Consequently, elderspeak more patients believe it and the more physical symptoms they simply reinforces stereotypes (people confirm that they do perceive, the poorer their health maintenance behaviors and not clearly understand the instructions they are given); a 38 43 the higher the probability of mortality at a 2-year follow-up. negative feedback loop is thus created. Another effect of Another recent study of patients’ age perception, conducted this kind of communication is shown by studies including with elderly people (median age: 63 years) suffering from a people with dementia: elderspeak enhances resistance to care chemotherapy-treated cancer, showed that people who felt (eg, grabbing objects, crying, saying no, pushing away, etc) in younger than their chronological age had a tendency to main- comparison to normal adult communication and to silence. tain their sense of humor, highlight the importance of family, There is no direct study on the effect of elderspeak in the have positive thoughts, and stay engaged in life; these factors context of geriatric oncology. The only study close to this are prognostic of good physical and mental health. field showed that high use of ageism among professionals, as perceived by patients suffering from breast cancer (prob- Influence of ageism on health ably noticed partly because of elderspeak), was associated professionals’ attitudes and with more physical pain, poorer mental health, and decreased patient–professional relations general satisfaction with their care. In the same vein, older The negative consequences of ageism are not limited to breast cancer survivors who had negative beliefs about elderly people themselves; they also have an impact on the symptom management perceived that their health care pro- attitudes of those who deal with these people, including health viders had negative attitudes, or they reported experiencing care professionals. This impact, generally subconscious, difficulties communicating about their symptoms and had a is explained primarily by the general negative attitudes of lower quality of life. society. It may be manifested in “elderspeak” (or “baby talk”) This direct influence of the attitudes of health care profes - communication; this kind of speech is characterized by speak- sionals on the changes in seniors’ physical and psychological ing slower and/or louder, using simplified sentences, etc, health is confirmed by studies of normal aging. In one, when talking to an elderly individual. This attitude is based residents of a nursing home were asked to do a jigsaw puzzle. on the stereotype that elderly people have hearing issues and In the first group, help was provided by, for instance, sug - impaired cognitive functions. Health care professionals are gesting where to put pieces (“You can do it like this”); the submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Dovepress Ageism in oncogeriatry second group was only encouraged verbally (“Yes! You’re explored. However, we can suggest some methods based making progress!”); and the third group was given neither on internalization theory and the stereotype threat paradigm help nor encouragement. The results indicated that helping arising from normal aging studies. an elderly person contributed to decreased performance and In line with internalization theory, experimental stud- self-confidence in completing this task, and increased the ies have shown the positive effect of subliminal activation feeling of difficulty associated with it. In other words, good (perception without awareness) of positive aging stereotypes intentions can have deleterious effects; when we want to help on elderly people’s physical and psychological health. For an elderly person, we have to be careful not to help him or her instance, participants walk faster, have better cardiovascular 27,34,50 too much. Another example shows that negative stereotypes measures, and have better memory performance. If these create artificial dependency. In their experiment, Coudin results seem difficult to apply in a clinical context, we can and Alexopoulos included three conditions: by listening to assume that our everyday vocabulary refers to an image of a text, elderly subjects were exposed to positive stereotypes aging; for instance, using words such as “confused”, “incom- (eg, “Older persons represent a huge market and therefore petent”, or “decline” in reference to elderly people triggers contribute to the economic growth of our society”), or nega- negative stereotypes and has a detrimental impact on them tive stereotypes (eg, “Aging is characterized by a loss of some (eg, elderspeak). Conversely, words such as “improving”, important social roles that contribute to the devaluation of “learned”, and “advise” have a positive resonance and thus older adults”); there was also a control condition with no can have positive effects on communication with elderly text to listen to. Then, participants were asked to solve a people or on their anxiety. very complicated puzzle in 10 minutes; they could ask for In line with the stereotype threat paradigm, multiple help by honking a horn. The results showed that exposure methods emerge from the literature on normal aging and to negative stereotypes was associated with more dependent social psychology. Stereotype threat is observed when behaviors – the subjects asked for help more frequently than negative stereotypes are explicitly presented to subjects; in the positive or neutral conditions. Thus, when negative their performance deteriorates when compared to when no stereotypes, such as “Elderly people are dependent and need allusion to stereotypes is made. Some studies of normal help”, are revealed through health care providers’ behaviors, aging suggest that intergenerational contact works against it contributes to a decline in the elderly subjects’ perfor- the effects of ageism on the elderly. Indeed, an experiment mance. This has clinical implications: if we want to help a observed that in the face of stereotype threat (eg, explain- patient, is this help really necessary? Are we not creating ing that mathematical abilities decline with age just before an artificial dependency instead of improving his or her a mathematical challenge), anxiety is diminished if elderly abilities? These examples (elderspeak, excessive help, and participants have positive contact with their grandchildren, so on) illustrate that our behavior is not always adapted to or when they simply imagine talking with a younger person the elderly and that the psychosocial needs associated with before this stressful task. Thus, in the specific realm of aging are not always taken into consideration. geriatric oncology, it is possible that imagining talking with a younger person might help reduce elderly people’s anxiety Countering the stereotypes: before a stressful event (eg, surgery, first chemotherapy, suggestions for intervention any treatment, etc). Similarly, a study tested the efficacy of After reviewing the negative consequences of ageism, intergenerational reminiscence for seniors (ie, evocation of one obvious fact comes to mind: it is essential to develop memories of grandchildren); after the intervention, those therapeutic solutions to counter the negative influence of seniors reported less loneliness and a better quality of life. stereotypes. Fortunately, some therapeutic leads are given in This technique would also be interesting way to test elderly the literature; some of them relate directly to elderly people people with cancer to see if it can enhance their quality of who are the victims of these stereotypes, whereas others are life. For instance, during medical care or preparation before designed for professionals and other people working with a treatment, you can speak with the patient with the aim the elderly. of evoking good memories that he or she can have with his/her grandchildren. At the patient level Two concepts from social psychology have attracted our To our knowledge, specific therapeutic indications against attention: “self-afr fi mation” and “counter-stereotype”. These ageism in oncogeriatry at the patient level have not yet been two concepts allow people to avoid a stereotype threat. submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Schroyen et al Dovepress To understand the concept of “self-affirmation”, it is were found; 2) the stereotype condition, in which it was important to realize that people are motivated to maintain explained that older people have less efficient memories the integrity of their self. Thus, when the self is threatened, than younger people; and 3) the control condition, in which they must cope with it; self-affirmation is a form of indirect no information was provided regarding age differences in psychological adaptation. For a person, it refers to focusing memory. The results on a memory task showed that all on an important aspect of his or her life that is irrelevant to participants in the counter-stereotypes group (younger and the threat, or engaging in an activity that is disconnected older) recalled more words than those in the other condi- from the threat and that highlights some important value for tions, but only in the case of subjects with more education. him or her. Some studies (for a review, see McQueen et al ) Subjects with lower education levels recalled fewer words in have shown that stereotype threat can be neutralized by self- the stereotype and counter-stereotype conditions than in the affirmation. For instance, when women are told that their control condition. Thus, this study suggested that the counter- math intelligence will be tested, this represents a stereotype stereotype approach is efc fi ient (in some cases) in combating threat (“Women are bad at math”), and so their performance stereotype threat (when the stereotype is applicable to the is worse than if they were told that the purpose of the study group in question – in this case, older participants) and ste- was to get people’s impressions of the problem. However, reotype activation (when the stereotype does not apply to the when a self-afr fi mation paradigm is applied (eg, participants group – in this case, younger participants). Concerning this have to write a paragraph on a value that is personally impor- last point, there are other ways to avoid the use of stereotypes tant to them), the stereotype threat disappears; self-afr fi ming in the general population, and some specific approaches can women who autoaffirmed performed at the same level as be suggested for professionals. women in the control condition. Moreover, this concept can be used to enhance the acceptance of health messages At the professional level (in this case, the “threat” is to be in bad health). For instance, Similarly to the patient level, there are no therapeutic instruc- Sherman et al selected 60 students – 30 which drank cof- tions to combat ageism specifically in geriatric oncology. fee, and 30 of which did not. These students had to read a We can suggest some group and individual interventions to (fake) scientic fi article on the probability of developing breast reduce health professionals’ stereotypes of aging and thus cancer due to drinking coffee. The results showed that when improve their communication with patients. a self-affirmation paradigm was used, the coffee drinkers In a group setting, training sessions can be set up for were more likely to accept the message than were those in health care professionals to make them fully aware of how the control condition, and they were also more likely to do stereotypes affect their behavior, and to inform them of so than the students who did not drink coffee. The impact the consequences that these behaviors can have on elderly of this technique in geriatric oncology should be analyzed; patients. To highlight the importance of such training, one self-afr fi mation just after the explanation of a treatment such study showed that physicians have developed a more positive as chemotherapy or radiotherapy could enhance acceptance attitude toward elderly patients since 2000, whereas nurses’ of this treatment. At another level, it might promote adher- attitudes have become less positive. This difference may be ence to a specific diet, which is very important in parallel to due to more comprehensive education on aging in medicine. cancer treatment. Likewise, education and support during practice experience The second concept emanating from social psychology, enhance positive attitudes toward elderly patients among the “counter-stereotype”, consists of intentionally activating medical students. Similarly, another study showed that a ideas or creating mental imagery in opposition to stereotypes gerontology education course given to students in the social (eg, create a mental image of an old man running). This services decreased their anxiety about working with older approach is based on the assumption that counter-stereotypes people and reduced their ageism. Moreover, a training will challenge stereotypes in information processing. In geri- program that includes information on the aging process atric oncology, a possible counter-stereotype could be that and simulation of the role of older adults resulted in better older people have the same probability as younger people of attitudes toward elderly people and increased knowledge tolerating cancer treatments such as chemo- or radiotherapy. of aging; 4 weeks after the training program, these results This process has been tested in the area of memory decline: were still observed. Regarding communication, the harmful participants (from 21–80 years old) were divided into one of effects of elderspeak can be improved by specific training three conditions: 1) the counter-stereotype condition, where for nursing staff. One example of communication training, they were told that no age-related differences in memory which included information about elderspeak and its negative submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Dovepress Ageism in oncogeriatry effects, as well as practice with effective communication Their reports revealed stronger stereotypes for the group who skills, resulted in a significant reduction in elderspeak. had to suppress their preconceptions in the first task than for A similar reduction was observed in a study carried out in the control group who never had to control their stereotypes. three nursing homes immediately after the intervention, but Thus, we must be careful about using this method; more stud- this effect was also observed 2 months later. ies must be done before it can be applied in the clinic. Regarding interventions with individual professionals, we can describe some approaches (such as the patient-level In a practical way approaches) that are based on studies from social psychol- Considering all this literature, applications of these find - ogy. First, the concept of self-affirmation cited earlier can ings in daily life could take several forms, the most obvious also be used to battle prejudices; when their self-image has being the systematic training of all health care professionals been bolstered through self-afr fi mation, people express fewer (medical and paramedical) on aging, with a specific aware - prejudices against other people (eg, people express more ness regarding our attitudes and the impact of our negative positive feedback for a Jewish job candidate after writing aging view on older patients. This training could be done about their values). Another means of working against using theoretical information, as well as using videos and stereotypes is perspective-taking – in other words, describ- role playing in order to make a stronger bond between theory ing a situation from someone else’s point of view (eg, an and clinical practice. It will allow participants to see how elderly man). Perspective-taking leads participants to see stereotypes can be easily integrated into daily care through an overlap between their self-image and the image of the their vocabulary (evoking negative stereotypes) or acts (for out-group (in this example, older people), thereby reduc- instance, assuming the individual cannot eat or wash him or ing the accessibility and application of stereotypes. Some herself alone). This kind of technique has already been suc- authors suggest that certain techniques that do not require cessfully applied among health care professionals (nurses, 67 63 much effort may also be applicable. More specifically, in particular) in order to diminish “baby speak”. the authors found that if students are exposed to admirable Otherwise, integration of an aging specialized psycholo- members of a stigmatized group and disliked members of gist in an oncogeriatry department can be a useful initiative. their own group, it triggers a modification of the social For instance, this psychologist could realize a systematic context and thus a shift in the students’ attitudes. More screening of the view of aging that patients possess about specifically, when exposed to a picture of an admired elder themselves. Patients with a clearly negative vision could be (eg, Mother Teresa or Albert Einstein), participants implicitly followed individually or in group sessions. The content of this associate positive words with advanced age more quickly; intervention can take several forms, for example, by activating however, no effect was found for explicit measures. positive stereotypes or highlighting important values in these Blair describes two ways of combating stereotypes: individuals (ie, the self-afr fi mation technique). These different counter-stereotypes, as we saw earlier; and stereotype sup- clinical approaches have not yet been validated in the specic fi pression. Stereotype suppression is based on a very simple context of oncogeriatry. Additional studies have to be done principle: subjects must try to control their stereotypes about in order to determine the extent of the positive effects of each a group to prevent their judgment from being influenced. technique, but also to identify the most adequate patient prol fi e This procedure is illustrated in the following experiment: for each approach. In a more global way, we could question students were shown a photograph of a male skinhead and the terminology used during caring of the elderly – being sent asked to describe a typical day for him. One group was told to the “geriatric department”, being addressed to a “geriatri- that our impressions are often biased by our stereotypes and cian”, receiving a “senior menu”, etc; all of these terms refer they had to try to avoid preconceptions. The control group to old age and consequently activate associated stereotypes. did not receive any specific instructions. The authors found All of this daily vocabulary can be considered as pointless that subjects produced fewer stereotyped descriptions when detail, but the impact of stereotypes should lead us to further they were asked to suppress their stereotypes. However, this questioning. In order to measure the effect of such terminol- methodology can provoke a “rebound effect”: when subjects ogy, additional studies have to be done. are told to suppress their stereotypes, they may reappear later with greater intensity. This was observed in the second Conclusion part of the experiment; another male skinhead’s photograph Ageism is constantly present in daily life (in the media, in our was shown and subjects were asked to perform the same attitudes, etc), and it can be subconscious. It influences interac - task, but this time without any instructions for either group. tions with elderly people and can have negative consequences submit your manuscript | www.dovepress.com Clinical Interventions in Aging 2015:10 Dovepress Schroyen et al Dovepress 43,48 5. Sheikh RB, Mathew E, Rafique AM, Suraweera RSC, Khan H, for them. Moreover, as we age, our conceptions of aging Sreedharan J. 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