Julie Kiefer: When someone walks into a room, one of the first things we notice about them is their age. In that split second, we make assumptions about what that person can or can't do. And these assumptions can lead to stereotypes, prejudice and discrimination that can lead to real harm.

I'm Julie Kiefer, associate director of science communications at University of Utah Health, and our guest today on U Rising is Linda Edelman. She's co-director of the Utah Geriatric Education Consortium and the Hartford Center, and she thinks a lot about our perceptions of age and of aging.

Welcome to U Rising, Linda.

Linda Edelman: Thank you.

Julie Kiefer: Linda, do you feel like you've ever been a subject of ageism? What's an example of something that's happened to you?

Linda Edelman: So, I'm honestly not sure that I have been subject to ageism. I'm a professor and it's not one of those careers where aging has a lot of negative connotations like it might in other areas, especially if you're working in a physically labor-intensive position.

But I also think it's natural for us to think about intergenerational biases and wondering if different generations look at us differently at the age level that we're in now. I think that perhaps the ageism I'm experiencing right now is more internal. I'm in my early sixties and I find that I'm engaging in this internal dialogue. I'm comparing my appearance and my health and my activity levels to others my age. I'm wondering if I move as easily as I did 10 years ago. And I think that thinking more about the future and how aging is going to impact it is more present in my mind.

For example, when I retire in a few years, my husband and I are moving to a small farm in Oregon and we're going to build a new house there. And so, I'm thinking a lot about universal design. What is that house going to look like? How can we age well and live independently for as long as possible? And what does that design look like?

I think that I'm probably thinking about this more than others do and I wonder how that impacts me in the future in regards to how I feel others are viewing me. And does this set me up for feeling like people are being ageist against me? I don't know! Time will tell, I guess.

Julie Kiefer: So, how would you describe what ageism is?

Linda Edelman: The World Health Organization defines ageism as a stereotype, or how we think, the prejudice, how we feel, and discrimination, how we act toward others or oneself as we age. It is the one “ism” that we're all going to experience if we're lucky enough.

Another way to explain ageism that I just came across last month was that it's a prejudice against one's future self and there are a lot of different types of ageism. I talked about internal ageism, the kind of internal dialogue that I have going on now as I age, but there's also institutional ageism. How do institutions treat people who are older and how do they adapt the environment so that it's inclusive of older adults? And then there's also interpersonal ageism, the ageism that we think about when we talk about elder speak, et cetera. So, the data from a 2020 study actually shows over 80% of older adults perceive that they have had ageist attitudes toward them, which I find fascinating. So, it's very prevalent in our culture.

Julie Kiefer: Yeah, absolutely. And we'll get to that in a little bit. I mean, there's actually a movement to reframe how we talk about age, and one of the reasons is that ageism can cause harm. So, what kind of impacts can ageism have?

Linda Edelman: It can impact us in a number of ways. It can lead to social isolation. So, if we have institutional ageism and people can't access resources, they can become more isolated. If we live in a community that's not very walkable or it's not easy for older adults to get around, people can be stuck at home more, especially, for example, here in Salt Lake in the winter.

It can also lead to negative health outcomes. When ageism is internalized and perceived as negative, it can actually decrease lifespan. Some research has shown that people who have positive attitudes toward aging live seven and a half years longer. I find that fascinating.

Julie Kiefer: Wow.

Linda Edelman: So, that internal dialogue is really important in being able to keep a positive attitude as we age. And then, of course, there's institutional ageism when it comes to health care. So older adults may not have the access to health care that they need, one because they can't get to it, or two because their health care providers are not looking at them in terms of what is their function and how can we keep that function and keep people aging healthy and in a way that matters most to them.

Julie Kiefer: Yeah, it's really fascinating to think about how that really plays through all aspects of life, like how you think about yourself, how others feel about you and the environment that you live in. We saw some real examples of ageism early in the Covid-19 pandemic. Hospitals were short on staff and supplies and had to make decisions on who to treat and age became one of those main criteria. So, explain to us exactly what is the problem with something like that?

Linda Edelman: Well, to go back to talk a little bit about Covid, there's no doubt that age that Covid disproportionately affected older adults, particularly older adults who were in poor health and lived in long-term care. Covid also disproportionately impacted those who were vulnerable because of social determinants of health, low education, poverty, and then Covid also disproportionately impacted people of color.

And so that was kind of a perfect storm and why Covid was such a devastating pandemic for older adults, especially those who were living in long-term care. So, initially, as hospitals and systems were starting to think about how are we going to provide care and how are we going to allocate resources to the people who would benefit the most? There was a lot of talk about including age as one of the criteria. But I'm really proud of the work that Dr. Timothy Farrell, who is a geriatrician here at the University of Utah and also the division chief of our Age Friendly Health System initiatives.

He was the lead of an American Geriatrics Association guideline that looked at how do we address age and resource allocation? And they came out with a policy statement that very strongly stated that age as a number should not be included in resource allocation criteria, but instead it was important to look at the overall health of that individual, what the short-term outcomes would be.

And I think that they were really successful of making that a dialogue that systems are thinking about even today, that, okay, we should not be including age as a number in our resource allocation, but instead looking at the health of that individual, what types of other conditions do they have and how will that impact the outcomes of treatment?

Another thing that they really discussed in these criteria was to look at social determinants of health and to acknowledge the intersection of social determinants of health and race and ethnicity in how people age. And to recognize that people of color, people who have grown up in poverty, have had less access to healthcare over their lifespans, and so they come into the hospital looking different and that we need to think about equity and providing care to all people.

The other thing that they really talked about is having systematic criteria that are used uniformly and with justice across settings. So, in that way, I think Covid has really been a benefit in looking at how we care for older adults and how we consider the treatment that they will receive.

Julie Kiefer: Yeah, it's really interesting how Covid became this forcing function for so much change. Do you feel like some of those policies are being enacted today?

Linda Edelman: I think that they are. It's a lot more in the public discourse. There has been a lot of talk about this in health systems. Equity, diversity and inclusion is something that we care deeply about and here at the University of Utah it has been a big discussion with our age-friendly initiatives. And Dr. José Rodríguez, who's the vice president of EDI for the U Health, has really committed to bringing this to the forefront and we include it not only in how we care for patients, but also in our education of health professional students.

Julie Kiefer: We think of aging as a catastrophe to avoid, but what we don't often appreciate is that getting older has benefits, too. Can you tell us about some of those?

Linda Edelman: Yeah. I think there are many benefits to aging. I think that our culture doesn't focus on them and we just don't consider them. But older persons have wisdom, they are more resilient and they also have a lot of time to help others. And it is reported that older adults are happier. I don't know if you've heard of the U curve of happiness, but this is research that was done measuring happiness across the lifespan. And they found that younger adults in their twenties were very happy, and then their happiness decreased into their forties. And about age 50, happiness started to increase. And in one curve I saw they actually showed that people in their eighties and nineties were happier than the 20-year-olds. So, we tend to think so negatively about aging because we think about the impact on health and our mobility and our independence, but there are so many other factors that go into happiness and wellbeing, including the way that we look at the world and how resilient we are, that I think is a real positive as we age.

Julie Kiefer: Yeah, I mean, it's so interesting because even considering that, ageism is still very prevalent in our society, what are some examples of common words and phrases that promote age bias? I've certainly heard some.

Linda Edelman: Yeah. There's an initiative by the Gerontological Society of America called Reframing Aging, and I think it's reframingaging.org is the website for it. And they have a great communication manuals and they talk about some of this. And I think one of the things that they talk about is stopping the use of catastrophic words when we talk about aging. In health care over the last 20 years, we've been talking about this tsunami that's occurring of the aging tsunami, all of these older adults that are going to need care and services and how that is going to be a drain on society. The reality is that's not necessarily true. There's a lot of benefits to an aging population and there's a lot that older adults can give back to.

So, a second thing that the Reframing Aging Initiative talks about, and this goes actually for any “ism,” is to avoid using othering terminology. Using words like “seniors” or “elders” are good examples. In health care, we often, we say, “Oh, well, we don't say elderly,” but we often talk about older adults. And the Reframing Aging Initiative they take it one step further and so they say, let's talk about “older persons,” not even “older adults.” So, language that is more inclusive is really important. And then finally, I think is to talk about aging as a dynamic process. It's not all doom and gloom, but it's a dynamic process that can affect both individuals and the societies that they live in positively.

Julie Kiefer: Yeah, I think that dynamic part can be really hard for some people. I think 15 years ago we were told to say seniors or senior citizens, and now we're being told not . . .

Linda Edelman: We still have senior centers.

Julie Kiefer: Yeah, exactly. So that change is really difficult. And for some people, I don't know, what's a way that we can think about that so that we can embrace it? I mean, how is there another, can we put ourselves in their shoes and maybe understand a little bit better how those types of words and catch all phrases can impact a person?

Linda Edelman: I think one way is to think about not putting ourselves in their shoes, but put ourselves in our shoes because we're all aging. And when you're 30, you're different than you were when you were 18. When you're 60, you're different than when you were 50. But I think that if we can acknowledge that there is aging across the lifespan and that we change at different times in our lives and to take that perspective into place, and that, yes, at every time in life we have strengths and then we have areas that we're not so successful at. And so, I think considering how older adults respond to their environment and how they can bring strength, resilience and wisdom into a relationship, into a community is important. And to recognize that a lot of times older adults who say, if you ask them, they'll say, “My health is good.” And we might look at them and say, “Oh my goodness, they're in a wheelchair. They're needing an assistant. How can they say that their health is good?” But I think that as we move into older adulthood, we become more accepting of some of the things that we can't do any more and more aware of the strengths that we are gaining.

Julie Kiefer: I imagine that some of these very principles are integrated into this age-friendly health system that you've talked about, and this is a designation that University of Utah Health has received. So, talk about that. What is an age-friendly health system and what is it trying to do or what is it doing?

Linda Edelman: Yeah, so the age-friendly health system movement is really something amazing. It's taking over how we think about caring for older adults. It's taken it over by a storm. It was first proposed in 2016, so it's a relatively new movement. And health systems can apply to receive age-friendly health system designation. And the University of Utah is at the forefront of this. We actually have level two designation. We're the only institution in the state that has that. And level two designation indicates that or shows that we are committed to care excellence for older adults. That means that the care that we are providing adheres to the age-friendly health system framework, which is the “4Ms” framework, where we consider for every patient these four MS. And the four MS are medication, so what kind of medications are people on and how can we handle those medications to allow them to be as productive and active as possible?

Mentation, so that can include mental illness, but also dementia and Alzheimer's disease. Mobility, so how are people getting around? And then the most important one is, what matters?

And by using this framework, taking these building blocks to provide the care that is very holistic to older adults has been shown to decrease hospitalizations and to improve patient experience. And I think that's what's really important, is that patient experience not only with health care, but how they're living their life.

So here at the University of Utah, especially in the Madsen Geriatrics Clinic providers are really working with a program called Patient's Priorities Care. And that means that they are working with patients to identify what are the priorities for these individuals' lives and what is most important for them? And then using the patient as a full member of the healthcare team to help determine what is the care that this individual should receive based on those priorities. So maybe they're not controlling their blood pressure completely because the medications have side effects that impact how they want to live their life, but it's coming to an agreement and team-based decision on how that care plan should look for each individual that allows them to really achieve their goals.

Julie Kiefer: I imagine staff and health care professionals have to go through a lot of intensive training to get there. I mean, you can't just say, okay, we're going to do this change now. Can you talk a little bit about what's been entailed in getting this designation?

Linda Edelman: Yeah, so the designation, the first part of the designation is just looking at overall numbers. How are the metrics regarding how older adults are cared for. The second designation that we have, the committed to care excellence, means that we are actively working to improve the care that we provide for older adults. So that means educating providers and staff about the 4Ms framework, ensuring that older adults are members of their health care team, that their voice is heard, that providers and staff are working with the older adults and their caregivers to provide that care. And it also means that we are doing measurements in regards to are we providing good care for older adults? Do they have the outcomes that are important to them? And then also we want to show that there's value added to the system. As I said, the age-friendly health system just started in 2016, so there isn't a lot of outcome measures looking at the whole system.

The 4Ms framework uses evidence-based methods to ensure that medications are discussed to, looking at what are our fall risk assessments, et cetera. But now we're starting to work with other universities to look at larger outcomes of this age-friendly health system 4Ms framework as a whole. So, it's going to be exciting in the next couple of years to see what the impact of 4Ms-based care looks like. But how it's changing for a patient is that we're talking to them differently and we're ensuring that we're listening and that we're really looking at what their priorities are when we address how to provide care for them.

Julie Kiefer: So even though you don't know these larger impacts, are there some anecdotal benefits that you've seen now that this has been put into action?

Linda Edelman: Well, I wish I were Dr. Farrell because I'm not actually in the clinic, but I know that the clinic members that I work with are really enthusiastic about this model. For example, the what matters most? That is something that can be a little bit hard for a provider to ask, especially when you're talking about advanced care planning. And it's what matters most to you now, what matters most to you at the end of your life? Those can be difficult conversations to have, but what I've heard is that they find it so rewarding when they learn and become comfortable with asking those questions, that the patients really respond, the patients are thinking about, just as I'm thinking, it's in my early sixties, what's my house going to look like so that I can live longest independently? People toward the end of life are really thinking about what they would like their end of life to look like. And so, when those questions are asked in a non-threatening way and they have trust in their provider and feel that people are really listening to them, they're able to provide them with really good details about this is what I would like it to look like. And then you can work together as a team to do as much as you can to make that happen.

Julie Kiefer: So outside of the health system and health care, what are some things that we can do in our everyday lives to reframe aging?

Linda Edelman: Well, we talked a lot about the language. We can talk differently about language, about aging. We can not think of it as a catastrophe, both for ourselves as individuals, but also as part of the society. As individuals, I think staying positive is one thing, recognizing that we age, but that aging doesn't mean that we're going to not be able to live independently. Aging doesn't mean that we're going to have dementia. Aging means that we're getting older. Age is just a number. We live as healthy and actively as we possibly can. And I think what's really important is that we stay socially engaged.

And so, as we age ourselves, I think is important that we continue to reach out, be engaged, make friends and relationships with people of other generations and try new things. One, that's important and healthy, that's one thing that we can do to help prevent Alzheimer's disease is to learn new activities. So, I think that sometimes as we age, we think, okay, well, things are only going to be taken away from us, there's not things that are going to be added, but that's absolutely not true. Look at every change in our life as an opportunity for new things to come into our life.

Julie Kiefer: What about our communities and in particular rural communities where people might actually go to retire? Do these places have the resources that we'll need as we age?

Linda Edelman: So, there's no doubt that there are fewer geriatricians in rural communities. There are fewer people that have specific training to work with older adults. There are often more nursing homes in rural areas, but less of the community resources that could maybe keep people who need care independently in their home. So, obviously there are great workforce needs and there are great access to care needs. So geography plays a role, the size of a community plays a role, but I don't think that that means that people shouldn't live or age in rural communities. As a matter of fact, rural communities on a whole are older than urban communities because of the out-migration of younger people moving to more urban areas as well as people moving into certain communities because they're seen as retirement communities. But there are a lot of good things that are happening right now that can help combat that.

Telehealth, for example, during Covid telehealth became something that people became much more comfortable with. And so as long as people have access to broadband, they can have care through telehealth. There's also a lot of technology for people where they can actually have robots or equipment in their homes that can measure blood pressure, can measure their weight, can do a lot of physiologic monitors that then can be sent back to a provider or a health care person in a more urban center who can then adjust medications or adjust the person's care plan. So, while it would be wonderful if we had more people trained to work with older adults in rural communities, we also are seeing a lot of the good aspects of technology that allows people to be more healthy and engaged in those communities than in the past.

Julie Kiefer: Well, and it seems like part of the solution might be the people who are aging themselves, and for people who are older, what are things that they can do to combat ageism in their community?

Linda Edelman: I think age is such a mindset. Age is a number, but it's how we look at ourselves and how we're aging that I think is so important. So, combating that internal ageism that people, not looking just at how we're aging and how maybe we're not able to do things quite as easily as we had in the past, but to look at the other things that we're able to do just as well or even better. So, combating that internal ageism, having a positive attitude, we know is really important.

But then I think it's also important for older adults to engage in their communities, to have intergenerational relationships so that one, they're showing young people and children that being an older adult is not a horrible thing and making people more comfortable with aging. I think also being an advocate for communities is important. So older adults often have time and a lot of times have more resources where they can actually contribute back to that community.

And so the more they're engaged in the community, the more they're visible in the community, that alone can combat ageism, especially for younger generations, and it also allows them to advocate both for themselves. So, what are policies that are important to them, such as being able to access buildings. The University of Utah just became an age-friendly university thanks to my colleagues, Katarina Felsted and Jackie Eaton. So that means that the University of Utah is a welcoming place for older adults. So how can older adults engage in university activities and be visible in the university setting? How can older adults advocate for policy that is good for themselves, that ensures that they continue to be protected in regards to health care, et cetera? Some of the things that we know are going to be issues in the future, having a voice.

Julie Kiefer: So traditionally, our definition of what an older adult is is age 65. That's the border. But is that changing?

Linda Edelman: Well, I guess it's within which context you're thinking about it. So, age 65 is the time when people become eligible for Medicare. That age was an arbitrary number that was set when Medicare was developed. And at that point, people weren't living 20 years after the age of 65, so it really was to provide care for people toward the end of their life. Well, now we know that the lifespan has extended and the fastest growing population are those 80 and over. And so there are a lot individuals who at 65 who are still very, very, very healthy. And so, in that context, if you think about age being an older adult as age 65 or older, it is changing because people are living considerably longer than that.

But I'd just like to go back to the fact that in my mind, I think age is not a number. Age is a mindset. And as people age, they need to keep in mind that as people age, they need to consider how they can remain active in both their community and in relationships, and how they can continue to move forward in their lives, taking advantage of new opportunities instead of thinking, okay, I'm at this age, I shouldn't be doing this anymore. Everybody has different capabilities across their lifespan, and so to be able to engage as fully as you can with the physical and mental capabilities that you have for as long as you can is what's really important.

Julie Kiefer: Well, Linda, this has been incredibly informative and I'm feeling better about my age and my future already. So, thank you very much for being my guest on U Rising.

Linda Edelman: Thank you so much for having me.

Julie Kiefer: Listeners, that's it for today's episode of U Rising. Our executive producer is Brooke Adams, and our technical producer is Robert Nelson.

And happy holidays from all of us at U Rising. We're going to take a break for the holidays and we'll be back on January 9th with a new episode. I'm Julie Kiefer. Thank you for listening.