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Ageism and Behavioral Healthcare Disparities

Dr. Erin Emery-Tiburcio on Ageism and Behavioral Healthcare Disparities

Stephanie Hepburn is a writer in New Orleans. She is the editor in chief of #CrisisTalk. You can reach her at .​

“As a society, we’ve decided aging is bad,” says Dr. Erin Emery-Tiburcio, co-director at the Rush Center for Excellence in Aging. 

She herself hadn’t initially been interested in geriatrics psychology. However, that changed with her first clinical placement. “Most of the folks were older adults recovering from surgeries and strokes,” she says, “and I just found myself learning so much more from them than they were learning from me.”

Among them was an older woman who lived on a farm and talked to her about rural life and farming. “She shared what she had to do to keep her family afloat and the lessons she learned along the way.” 

Emery-Tiburcio was struck by the stories and the wisdom her patients shared. So much so that she pursued a graduate certificate in gerontology and advanced training in neuropsychology. “My interest was in the intersection of physical and mental health — and there’s nowhere where that’s more intense than in geriatrics.” 

The majority of older adults have multiple chronic health conditions. According to the National Council on Aging, nearly 80% of adults 60 and older have two or more chronic conditions. 

She believes the root of behavioral health disparities for aging Americans is ageism, which is woven throughout United States culture, from the greeting card aisle to anti-aging clinics. “It’s in every fiber of our society — even research at the National Institute of Health focuses on how we can stave off aging.” She believes society should flip the script and work to tap into the knowledge of older people and nurture intergenerational programs like AmeriCorpsSeniorCorps and the AARP’s Experience Corp.

Even how society perceives the utility of retired people in the economy turns on stigma, with the misconception of dependency and that older people no longer contribute. “It’s inaccurate — most people over 65 are contributing in some capacity.” This calculus works to devalue older adults.

In behavioral health, ageism reveals itself through assumptions and lack of treatment. For example, Emery-Tiburcio says providers often believe depression is normal in old age, so they don’t even bother screening for it. “Or they might assume an older person wouldn’t do drugs, so they don’t screen them for that either,” she says.

These assumptions are problematic for many reasons. As people age, their bodies are less able to metabolize alcohol or drugs. “So it stays in your body and has a greater detrimental effect.” This is especially problematic if the person has any mobility or cognitive difficulties. “Substance use can exacerbate those problems and become riskier.”

The metabolic changes in older bodies also affect how they process medication, so providers need to pay special attention to how medication, alone and combined, might affect the person. “Most older adults are taking at least a couple, if not several medications,” says Emery-Tiburcio. For example, one of her patients began acting confused in their sessions. He’d begun taking medication for incontinence. However, the medication can also cause confusion and dizziness, increasing the risk of falling. These are considerations providers need to be aware of when prescribing. 

She says ageism is deeply rooted in the medical model, with language that emphasizes that health is the absence of disease and disability. “If you have either, and many older adults do, you’re deemed unhealthy.” These beliefs similarly work to devalue older people. 

Nothing in recent years has illustrated this point more than Covid. As deaths of older Americans skyrocketed in 2020, Olga Khazan, a writer for The Atlantic, said the nation had an empathy problem. “Part of the reason this majority-white, majority-non-elderly country has been so blasé about COVID-19 deaths is that mostly Black people and old people are dying,” she wrote

In 2020, the age-adjusted death rate for people 65 and over was 533.5 per 100,000, with rates highest among Hispanic, Black and American Indian or Alaska Native men. Also disproportionately affected were American Indian or Alaska Native, Black and Hispanic women.

Along with the devaluation of older adults, comes poorer care. In May 2020, a group of physicians wrote an article published in the New England Journal of Medicine, discussing how to allocate scarce resources during a global pandemic. “Maximizing benefits requires consideration of prognosis — how long the patient is likely to live if treated — which may mean giving priority to younger patients and those with fewer coexisting conditions,” they wrote

Being and feeling valued is protective for older people. According to a commentary and review published in the International Journal of Mental Health and Addiction, mattering — “the feeling of being important to others in ways that give people the sense that they are valued and other people care about them” — became an important theme during the pandemic. In The Atlantic, Khazan highlighted the indifference of many Americans to the lives of those most affected by the virus, sending the message that they don’t matter. However, the authors of the International Journal of Mental Health and Addiction article wrote that political leaders recommending older adults physically distance themselves sent a message that they did. 

That said, the authors also pointed out that physical distancing disproportionately affects older adults. In the U.S., 27% of people 60 and older live alone, meaning many have experienced not just physical distancing but isolation. While the U.S. government has declared the pandemic over, Emery-Tiburcio says that’s not true for older adults. “Many older adults and people with multiple chronic conditions are still at risk and are terrified of having home health or direct care workers come into their homes, visiting family or flying in airplanes,” she says. “The fear and risks aren’t over for them.”

Most providers aren’t sufficiently trained in geriatrics. Emery-Tiburcio says the number of geriatric specialists, already small, has lessened. “We now have fewer than we did in 2012.” However, recent state legislation has given her hope that change may be imminent. “Illinois just added a licensing requirement for all healthcare providers to have a one-hour training on dementia diagnosis.” The law went into effect January 1, 2023. All healthcare professionals with continuing education requirements must complete the training each licensing renewal period. 

She finds the lack of similar legislation baffling because nearly all adult care providers will have older patients. “If you work in a hospital, you will treat older adults; if you work in a healthcare setting, you will treat older adults.” 

Using E4 Center of Excellence for Behavioral Health Disparities in Aging funding from SAMHSA, she and her colleagues have developed online modules to train 988 call centers in working with older adults. The modules are available on the E4 website. The modules are free and publicly available to anyone who wants to take them, including providers and the public. “That means legislators and policymakers can also do the trainings to learn more about older adult health.”

Emery-Tiburcio has also found warm lines critical to mitigating mental health crises for older people. For example, Friendship Line, an Institute on Aging’s Center for Elderly Suicide Prevention and Grief-Related Services program, gives older adults someone to talk to; the warm line responds to 11,000 inbound and outbound calls per month. “If the person is in crisis, they’ll transfer them, but if you just need someone to talk to, that’s what they’re there for — and that can go an incredibly long way to preventing people from getting to crisis space.”