It is unknown whether implicitly age based referrals, investigations, and treatment policies in primary care and secondary care reflect rationing criteria or prejudices against older people. The consequences of both rationing and prejudices are that younger people take priority over older people.5
In relation to rationing, shortages of resources might lead to discrimination against older patients on the basis of the belief that they are more expensive to treat (for example, they may need longer to recover after surgery) or that they have a shorter life expectancy and therefore resources should be diverted to younger people who would be expected to live longer. Age is frequently discussed as a criteria for rationing. It is defended on the grounds that older people have had their “fair innings.”21
It is rejected on the grounds that decision making on the basis of sociodemographic characteristics, without reference to relevant comorbidity and ability to benefit, is unethical.22,23
Age biases are likely to be a consequence of different values being attributed to different social groups and to age stereotyping. Any ageism in medicine is simply a reflection of ageist attitudes that exist in the wider society, where youth is given priority over age.24,25
Older people are frequently portrayed as frail and haggard, contrasting strongly with images of children (fig ). However, advertisers increasingly look to the futureand are adept at shaking up society's common stereotypes of age (fig ).
New Born by Jacob Epstein (from the former BMA building, the Strand). Reproduced with the permission of Kitty Godley, copyright estate of the artist
Some advertisers have recently used images like this one to sell energy drinks
Ageism in medicine may be partly a consequence of a lack of awareness of the evidence based literature on the treatment of older people. Variations in clinical decisions made on the basis of the age of the patient might also be caused by the differing thresholds for intervention that exist when a healthcare professional is faced with clinical uncertainty; these variations might also reflect preferences for selecting low risk, rather than high risk, patients to undergo interventions. That variations in treatment exist is unsurprising given that people aged 65 and older, and certainly those who are 75 and older (most of whom are women), have been largely excluded from major clinical trials. They are therefore significantly underrepresented in the evidence base used to determine clinical effectiveness.19,26,27
Investigators have traditionally used age limits as cut off points when recruiting patients into clinical trials to minimise analytical problems caused by factors such as comorbidity and an increased risk of loss to long term follow up caused by death. Most of the evidence on the clinical effectiveness of treatments for older people is based on a few smaller trials and cohort studies. This research bias may have led clinicians to be cautious in treating very old people, especially older women.
The collective consequences of these biases, whatever their causes, is that older people may not be treated equitably when it comes to allocating healthcare resources.Moreover, current practice is not necessarily the most efficient for health or social services. Clinical delay or denying older people the benefit of certain interventions may lead to greater spending on “maintenance” services such as those provided by district nurses, home helps, and “meals on wheels” programmes. The provision of more invasive treatments could be cost effective if they enabled people to function independently.