Ageism is defined as stereotypes, prejudice, and discrimination related to old age, older people, or the aging process. It appears in various contexts, including institutions, communities, interpersonal relationships, and self-perception.
There are two forms of ageism:
Explicit ageism: Overt and conscious expressions of discrimination.
Implicit ageism: Unconscious biases that influence healthcare providers’ decisions.
According to the University of Michigan’s National Poll on Healthy Aging, 93% of older adults experience ageism regularly.
In healthcare settings, 1 in 5 people aged 50 and older report experiencing ageism.
The U.S. population aged 65 and older increased from approximately 39.6 million in 2009 to 54.1 million in 2019, and is projected to double again over the next 50 years.
The adult population with visual impairment and age-related eye diseases, including neuro-ophthalmic conditions, is projected to double over the next 30 years.
Visual impairment is more common in older adults and women. 86% of blindness and 80% of low vision occur in people aged 50 and older, and at all ages, it is more common in women than men. Longer life expectancy in women and limited access to healthcare in impoverished societies are cited as background factors. 90% of visually impaired people live in developing countries. Without improvements in treatment, it is projected that by 2050, the number of blind individuals will triple to 114.6 million, and those with low vision will increase 2.5 times to 550 million.
QWhat specific actions does "ageism" refer to?
A
Ageism is a general term for imposing stereotypes based on age (e.g., “treating older adults is futile”), prejudice (negative evaluations of aging), and discriminatory acts. In healthcare settings, a typical example is omitting appropriate tests or treatments solely because of old age.
Older adults who experience ageism tend to internalize negative stereotypes about aging and feel pressure to conform to restrictive expectations. This leads to the following adverse effects.
Decline in physical strength: Negative expectations about aging accelerate the decline in physical function.
Worsening health status: Negative self-perception impairs overall health.
Reduced openness to new learning experiences: Older adults become reluctant to change or treatment.
Avoidance of medical visits: They self-diagnose symptoms as “normal aging processes” and delay ophthalmology visits.
Ageism in healthcare negatively affects both the quality of care and physician-patient communication.
Among 149 studies examining healthcare access for older patients, 85% confirmed that older patients receive fewer procedures and treatments, even when they would benefit as much as younger patients.
When older adults perceive age discrimination, their psychological well-being declines.
Multiple studies have shown significant negative effects on physical, physiological, and cognitive performance.
Self-perception of aging is influenced by multiple factors including personality, health status, societal views on aging, and relationships with healthcare providers. Longitudinal studies have shown that this self-perception is an important predictor of overall health and longevity.
Participants with negative self-perceptions of aging at baseline had significantly worse functional health at follow-up.
Longitudinal studies have found that individuals with negative self-perceptions have a 7.5-year shorter lifespan compared to those with positive self-perceptions.
Older adults with visual impairment who depend on care are particularly vulnerable to ageism, as decisions about receiving care are often delegated to others. Caregivers with strong ageist attitudes are also less likely to provide emotional, instrumental, and nursing care.
QTo what extent does self-perception of aging affect health?
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Longitudinal studies have shown that negative self-perceptions of aging are associated with worse functional health outcomes, and individuals with negative self-perceptions live on average 7.5 years shorter than those with positive perceptions. This indicates that self-perception is not merely a subjective feeling but affects actual health outcomes.
The following are neuro-ophthalmic diseases that are common in older adults and particularly susceptible to the effects of ageism.
Presbyopia
Definition: Age-related loss of accommodative ability of the lens. Causes blurred near vision and eye strain.
Epidemiology: Prevalence in the US population aged 45 and older is 83–89.9%. As of 2020, approximately 123 million people are affected, with 16% not receiving proper correction.
Relationship with ageism: Symptoms are often considered a “normal part of aging,” leading to delays in seeking eye care.
Posterior Cortical Atrophy
Definition: A neurodegenerative disease causing higher-order visual and spatial impairments. A subtype of Alzheimer’s disease. Onset typically after mid-50s.
Diagnostic challenges: In early stages, ophthalmic and neurological exams may appear normal. Comprehensive neurological, neuropsychological, and imaging evaluations are required.
Relationship with ageism: Early symptoms (simultanagnosia, abnormal distance perception, etc.) are easily mistaken for age-related changes.
Giant Cell Arteritis
Definition: The most common idiopathic systemic vasculitis. It affects medium and large arteries.
Epidemiology: Mean age of onset is 72.5 years in women and 70.3 years in men. More common in Northern European Caucasians, with women affected 2–6 times more often than men.
Diagnosis and treatment: The gold standard is temporal artery biopsy. Treatment involves corticosteroids. Permanent vision loss occurs in 8–20% of cases.
Relationship with ageism: Early nonspecific symptoms (headache, muscle pain) may be overlooked, delaying referral to ophthalmology until irreversible vision loss occurs. Reports suggest that undertreatment contributes to increased aortic complications.
Sagging Eye Syndrome
Definition: A degenerative strabismus caused by degeneration of the orbital connective tissue and rectus pulley system. One of the main causes of diplopia in the elderly. More common in women.
Diagnosis and Management: Orbital MRI confirms displacement of connective tissue between the lateral rectus and superior rectus muscles. Managed with prism glasses or strabismus surgery.
Relationship with Ageism: Accurate diagnosis can avoid unnecessary neurological workup and improve function for activities requiring distance vision, including driving.
Characteristic findings: Progressive supranuclear vertical gaze palsy and postural instability. As the disease progresses, vertical saccade impairment and loss of the vestibulo-ocular reflex occur.
Neuroimaging: MRI midsagittal view shows atrophy of the rostral midbrain, known as the “hummingbird sign.”
Prognosis: Average survival from diagnosis is 5–9 years. Treatment is mainly supportive.
Diagnostic difficulty: Symptoms overlap with Parkinson’s disease, leading to misdiagnosis, but PSP progresses much faster.
Relationship with ageism: Ageist assumptions may result in fewer rehabilitation opportunities (physical therapy, occupational therapy, orthoptic therapy) for elderly PSP patients.
Nonarteritic anterior ischemic optic neuropathy (NAION) is a major cause of optic disc edema and optic neuropathy in adults over 50 years old, and is the most common acute optic neuropathy in middle-aged and elderly individuals1).
Prevalence: 2.3–10.2 per 100,000 people in the United States1). Most common in Caucasians (approximately 95% of US patients), with increasing reports in males and Asian populations1).
Symptoms: Sudden onset of vision loss. Approximately 10–15% of patients have periocular pain (not associated with eye movement).
Findings: Relative afferent pupillary defect (RAPD) and optic disc edema at onset. Peripapillary OCT shows thickening of the retinal nerve fiber layer, and the contralateral eye often has a cup-to-disc ratio (C/D) of 0.2 or less.
Treatment: No established treatment; multiple trials evaluating medical and surgical options are ongoing.
Relationship with ageism: It is easily misdiagnosed as optic neuritis or papillitis, leading to diagnostic delay. There is a tendency to underestimate the benefits of clinical trial participation and aggressive treatment for elderly patients.
QWhat happens when visual symptoms in the elderly are dismissed as "due to aging"?
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In giant cell arteritis, neglect of early symptoms can lead to irreversible vision loss due to ophthalmic artery occlusion. In nonarteritic anterior ischemic optic neuropathy, diagnosis is delayed, resulting in loss of opportunity to participate in ongoing trials. In PCA, diagnosis is postponed, and opportunities for early intervention with rehabilitation and supportive therapy are compromised.
Addressing ageism begins with clinicians recognizing their own biases.
Awareness of bias: Healthcare professionals should consciously examine whether implicit or explicit ageist attitudes are influencing diagnosis and treatment decisions.
Direct inquiry about symptoms from patients: Especially in diseases with diverse symptoms like giant cell arteritis, it is essential for healthcare providers to directly ask patients about disease-specific symptoms.
Disease awareness: Provide thorough explanations about each disease so that patients do not mistakenly attribute their symptoms to “normal aging processes.”
Appropriate evaluation measures: Even for elderly patients, do not omit examinations or referrals solely based on age; perform the same evaluation as for younger patients.
Ensuring rehabilitation opportunities: For neurodegenerative diseases including PSP, actively provide rehabilitation (physical therapy, occupational therapy, vision therapy) that has been shown to be effective, even for elderly patients.
Engagement with caregivers: Keep in mind that caregivers’ ageist attitudes can affect older patients’ healthcare-seeking behavior, and provide education that includes caregivers.
6. Vicious Cycle of Ageism, Mental Health, and Visual Impairment
Ageism is also closely related to mental health. Older adults with lower psychological well-being are more strongly affected by ageist attitudes. Significant associations have been shown between depressive symptoms, stress, anxiety, and experiences of ageism.
Relationship Between Visual Impairment and Mental Health
People with visual impairment are more likely to have mental health problems and tend to internalize ageist attitudes directed at them from others.
According to a study by the Centers for Disease Control and Prevention (CDC), 1 in 4 adults with visual impairment report anxiety or depression.
Visual impairment has been shown to be a risk factor for suicidal ideation in older adults.
A longitudinal study of adults aged 65 and older experiencing visual impairment confirmed that attitudes toward aging, depressive tendencies before the onset of visual impairment, and the severity of visual impairment all contribute to increased depressive symptoms.
Although older adults aged 65 and older have the highest prevalence of visual impairment, they are the least likely to seek ophthalmic care for preventable blindness. This indicates a vicious cycle in which ageism-related avoidance of medical visits, worsening mental health, and progression of visual impairment reinforce each other.
QWhat is the relationship between visual impairment and mental health?
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According to CDC research, one in four adults with visual impairment reports anxiety or depression, and visual impairment is also a risk factor for suicidal ideation in older adults. Longitudinal studies have shown that negative attitudes toward aging, pre-onset depressive tendencies, and severity of disability all contribute to worsening depressive symptoms, indicating a mutually exacerbating relationship between visual impairment and mental health.
