PROFESSIONAL AGEISM: The Impact of Ageism among Research and Healthcare Professionals on Older Patients: A Systematic Review The Impact of Ageism among Legal and Financial Professionals on Older People: Systematised Reviews Susan Markham A thesis in fulfilment of the requirements for the degree of Master of Science (Research) School of Psychiatry Faculty of Medicine September 2020 1 Thesis Title PROFESSIONAL AGEISM: The Impact of Ageism among Research and Healthcare Professionals on Older Patients: A Systematic Review The Impact of Ageism among Legal and Financial Professionals on Older People: Systematised Reviews ABSTRACT Ageism – stereotyping, prejudice and discrimination towards people on the basis of chronological age – is ubiquitous in society and has a significant impact on older people across many aspects of their lives, including the provision of critical services. However, the impact of ageist behaviours on the part of key frontline professionals who interact closely and regularly with older people – healthcare, legal and financial professionals – has never been synthesised. Aim: The aim of this project was to examine how ageism influences professional behaviour among these providers and subsequently affects outcomes for older people. The overall hypothesis was that ageist actions and decisions by healthcare, legal and financial professionals would adversely impact the care and management of older people, including the provision of clinical care, services and advice. Methods: The project involved three components: a systematic review of the medical literature (the major component) and two systematised reviews of the legal and financial literature. The systematic review of the medical literature was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidelines in order to identify, evaluate and synthesise research focusing on age-based actions by research and healthcare professionals and consequences for older patients. Multiple electronic databases were searched including PubMed, Embase, Web of Science core collection, Medline via EBSCO, PSYCHInfo, CINAHL, Scopus, Ageline and ProQuest Central. Additional data were gathered via hand searches of relevant reference lists and leading journals. No date or geographical restrictions were set. The systematised reviews of the financial and legal literature were conducted using key elements of systematicity (i.e. a priori specification of the research hypotheses, comprehensive search of multiple databases using defined search terms and determination and application of explicitly defined inclusion and exclusion criteria). While less comprehensive than a systematic review, this method enables a degree of consistency in methodological approach across the three research areas. Similarly, no date or geographical restrictions were set. Results: The systematic review in health care yielded 73 studies. The review found clear associations between age-based management among clinical researchers/healthcare professionals and adverse impacts on older patients. Compared with younger patients, older patients were under- represented or excluded from clinical trials and evidence-based treatments in the majority (68) of studies. The systematised review in law found eleven eligible studies, nine of which showed older people were treated more leniently that younger people in sentencing judgements, potentially due to positive ageism; two studies found negative consequences for older people in terms of unequal justice for older victims of crime and ageism in adult protection, guardianship and conservatorship. Two studies were identified in finance and showed that older people were directly or indirectly mistreated by financial institutions, through pressure to buy financial products and a failure to address future financial needs or investigate indicators of possible financial abuse. Conclusion: Collectively, the evidence found that older people either experienced ageism through arbitrary age barriers, were subject to differences in management compared with younger people, or received a lower standard of care than was warranted. While these findings were associated with largely negative outcomes for older people, there were some positive outcomes associated with age-based decision-making. For example, the majority of legal studies found that more leniency was shown to older defendants in sentencing decisions. Overall, decisions about the care and management of older people should be based on each person’s individual situation, tolerance and needs. INCLUSION OF PUBLICATIONS STATEMENT TABLE OF CONTENTS Acknowledgements 7 List of figures 8 List of tables 8 Abstract 9 PART 1: INTRODUCTION 11 1.1 Background 11 1.2 Ageing population 13 1.3 Prevalence of ageism 14 1.4 Rationale 14 1.5 Aims 15 1.6 Hypotheses 15 1.7 Thesis structure and approach 15 References 17 PART 2: THE IMPACT OF AGEISM AMONG RESEARCH AND HEALTHCARE PROFESSIONALS ON OLDER PATIENTS: A SYSTEMATIC REVIEW 20 Chapter 1: Introduction 20 1.1 Background 20 1.2 Rationale 21 1.3 Aims 22 1.4 Hypotheses 22 Chapter 2: Literature review 23 1.1 Definitions of ageism 23 1.2 Labels and definitions of ‘older’ 24 1.3 Theoretical framework of ageism 27 1.4 Ageism in health care: Research approaches and settings 30 1.5 Impact of ageism in clinical research and health care 31 1.6 Ageing, ageism and human rights 34 1.7 Conclusion 35 2 Chapter 3: Methods 36 3.1 Search process 36 3.2 Data sources and search strategy 36 3.2.1 Search terms 38 3.2.2 Database search string example 39 3.2.3 Automatic search updates 39 3.3 Inclusion and exclusion criteria 39 3.3.1 Inclusion criteria 40 3.3.2 Exclusion criteria 40 3.4 Data extraction 40 3.5 Data analysis and synthesis 41 3.6 Assessment of quality and risk of bias 42 3.7 Ethics approval 42 Chapter 4: Results 43 4.1 Search results 43 4.2 Study characteristics 45 4.2.1 Methods 45 4.2.1.1 Statistical methods 45 4.2.2 Focus 45 4.2.3 Year of publication 46 4.2.4 Geographical location 46 4.2.5 Study sites 47 4.2.6 Disease focus 47 4.3 Synthesis of findings 48 4.2.1 Terminology of ageism 48 4.2.2 Definitions of ‘older’ or ‘elderly’ 48 4.3.3 Exclusions from clinical research 50 4.3.4 Differential healthcare receipt 54 4.3.5 Increasing disparity with increasing age 55 4.3.6 Inappropriate medication management 55 4.3.7 Under-representation of older patients 55 4.3.8 Changes over time 56 4.3.9 Clinical outcomes in different settings and locations 57 4.3.10 Management of older patients and human rights 57 4.3.11 Differences in guidelines-based care 57 3 4.4 Lack of ageism 58 4.5 Assessment of additional variables 58 4.6 Quality and risk of bias assessment 59 Chapter 5: Discussion 62 Limitations 70 Future directions 71 Conclusion 73 References 74 PART 3: THE IMPACT OF AGEISM AMONG LEGAL PROFESSIONALS ON OLDER PEOPLE: A SYSTEMATISED REVIEW 87 Chapter 1: Introduction 87 1.1 Background 87 1.2 Rationale 89 1.3 Aims 90 1.4 Hypothesis 90 Chapter 2: Methods 91 2.1 Approach 91 2.2 Methodology 91 2.3 Inclusion and exclusion criteria 92 2.3.1 Inclusion criteria 92 2.3.2 Exclusion criteria 92 Chapter 3: Results 93 3.1 Search results 93 3.2 Synthesis of eligible studies 94 3.2.1 Age-based sentencing of older offenders 94 3.2.2 Age-based inequity of access to justice 95 3.2.3 Older age and adult protection, guardianship and conservatorship 96 3.3 Conclusion 97 Chapter 4: Discussion 103 Limitations 106 Conclusion 107 References 108 4 PART 4: THE IMPACT OF AGEISM AMONG FINANCIAL PROFESSIONALS ON OLDER PEOPLE: A SYSTEMATISED REVIEW 111 Chapter 1: Introduction 111 1.1 Background 111 1.2 Rationale 112 1.3 Aims 112 1.4 Hypothesis 113 Chapter 2: Methods 114 2.1 Approach 114 2.2 Methodology 114 2.3 Inclusion and exclusion criteria 115 2.3.1 Inclusion criteria 115 2.3.2 Exclusion criteria 116 Chapter 3: Results 117 3.1 Search results 117 3.2 Findings 117 3.2.1 Mistreatment by financial institutions 117 3.2.2 Lack of safeguards in lending 118 3.2.3 Response to financial abuse 119 Chapter 4: Discussion 122 Limitations 124 Conclusion 125 References 126 PART 5: FINAL DISCUSSION 129 5.1 Individual review findings 130 5.1.1 Healthcare professionals 130 5.1.2 Legal professionals 131 5.1.3 Financial professionals 131 5.2 Synthesis of results 132 5.2.1 Similarities and differences 132 5.3 Future directions 135 5.4 Conclusion 136 References 137 5 Appendices 138 Appendix 1. Systematic review studies: Tabulated data 138 Appendix 2. Risk of bias assessment tool used to assess observational studies 178 Appendix 3. Systematic review: Included studies 181 6 ACKNOWLEDGEMENTS Writing this thesis during the COVID-19 pandemic has highlighted how serious the consequences of ageism can become, and has reinforced my desire to investigate ways of identifying and overcoming ageism in our society. Many thanks to my supervisors, Professor Carmelle Peisah and Professor Prue Vines, for their support and expertise. Thanks to Dr Nicola Gates for her time and advice about the systematic review process, to Professor Philip Ward for his timely guidance, and to my brother, Paul Markham, for his ongoing support and IT assistance. To my three favourite people in the world – Joss, Christian and Luke Hawthorn – for their amazing encouragement, unconditional love and support, and for cheering me on at every step. In particular, thanks to Joss for his inspiration, expertise, valuable insights and constant encouragement; to Christian for his calm and steadfast presence, kindness and gentleness, and willingness to discuss all things medical; and to Luke for the fabulous food, fun and laughter, fashion discussions, and reminder that we are nothing without a song or a dance. You are all simply the best.