Ageism in Neuro-Ophthalmology

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Article initiated by:
Amna Ali
All contributors:
Andrew Go Lee, MD, Nagham Al-Zubidi, MD, Noor Laylani, M.D., Nagham Al-Zubidi, MD, Noor Laylani, M.D., Mary Labowsky, MD
Assigned editor:
Mary Labowsky, MD
Review:
Assigned status Up to Date
 by Mary Labowsky, MD on October 22, 2024.


Description/Overview

Ageism is defined as stereotypes, prejudice, and/or discrimination related to old age, older adults, or the aging process.[1] It manifests in various contexts, including institutions, communities, interpersonal connections, or as a result of self-perception.[1] Ageism can be explicit, or overt and conscious expressions of discrimination.[1]  Negative attitudes towards older individuals may be becoming more prevalent.[2] The University of Michigan Poll on Healthy Aging found that 93 percent of older adults regularly experience ageism.[3] In the healthcare settings, one study reported that one in five individuals over the age of 50 have experienced ageism.[4] After experiencing ageism, elderly individuals often internalize negative stereotypes associated with aging and feel pressure to conform to limiting, age-related expectations.[1] This can result in diminished physical strength, poor health, and reduced openness to new learning experiences.[1]

In the last decade, here has been a dramatic increase in the number of individuals aged 65 years and older in the United States: from approximately 39.6 million in 2009 to 54.1 million in 2019; over the next 50 years, this number is expected to double.[5] The population of adults with vision impairment and age-related eye diseases, including neuro-ophthalmic pathologies, is also projected to double over the next three decades.[6][7][8] Prompt recognition and management of these diseases prevents blindness and improves the quality of life of those affected. However, ageism may pose an obstacle to ensuring that the needs of the aging population are met.

Ageism and Healthcare Outcomes

In healthcare, ageism impacts not only patient-provider communication but also the quality of care and treatment. Multiple studies have reported a significant relationship between ageism and negative healthcare outcomes, with an adverse impact on older people’s physical, physiological, and cognitive performance. [9][10] When age-discrimination is detected by older adults, it tends to lead to more negative psychological well-being.[9] In 85% of 149 research papers focusing on healthcare access among older adults, medical professionals were inclined to provide fewer procedures and treatments to older patients compared to younger patients, despite equal potential benefit for both age groups.[9]

Self-perception of aging is influenced by a variety of factors including personality, health condition, societal views of aging, and relationships, such as those with one’s healthcare provider.[11][12] Self-perception of aging has been found to be a significant predictor of overall health and longevity. In one longitudinal study, participants who had a more negative self-perception of aging at baseline reported worse functional health in follow-up visits compared to those who had a more positive self-perception of aging at baseline.[11] Another longitudinal study reported that those with negative self-perceptions of aging at baseline lived 7.5 years fewer than those with a more specific self-perception.[11]

Neuro-Ophthalmic Conditions in the Elderly

There are a number of ophthalmic and neuro-ophthalmic pathologies found predominantly in elderly patients, all of which are expected to rise in prevalence with the increase in the aging population.[8]  Effectively diagnosing, managing and treating these conditions requires clear communication and understanding between patients and providers, and ageism is a critical barrier that must be overcome. It is important to raise awareness of these diseases among patients in order for them to recognize that their symptoms are not just a typical part of the aging process. Providers must also be cognizant that these diseases are common amongst the elderly and take steps to properly evaluate their older patients.

Some examples of conditions of increasing prevalence in the aging population are discussed below.

Presbyopia

Presbyopia is an age-related loss of lens accommodation, resulting in an inability to focus on objects at close distances. Patients experience near-distance blurred vision, asthenopia, heightened sensitivity to light, and the necessity to perform tasks from progressively greater distances.[13] These factors collectively have a significant impact on their quality of life. Presbyopia is the most common physiological change to occur in the aging eye; the estimated prevalence of presbyopia in the United States population over the age of 45 is between 83 percent and 89.9 percent.[14] As of 2020, there were approximately 123 million individuals affected by presbyopia, and 16 percent of presbyopes lack adequate correction.[14] Management of presbyopia typically involves corrective glasses such as bifocals or progressive lenses. Surgical treatment options for presbyopia include refractive lens exchange, modification of corneal optics, and scleral correction procedures.[15]

Presbyopia patients with ageist attitudes may delay seeking ophthalmic care even as they notice increased blurriness at close distances, attributing their symptoms to a normal part of the aging process instead of a condition that can be medically addressed.

Posterior Cortical Atrophy

Posterior cortical atrophy (PCA) is a neurodegenerative disease that leads to higher-order visual and spatial impairments. While thought of as a variant of Alzheimer’s disease, PCA differs in that it does not necessarily impact cognition and memory in its early stages. PCA typically presents in patients who are in their mid-50s and older; initially, patients have no reported abnormalities on ophthalmic and neurological examinations. As the disease progresses, symptoms include difficulty reading and writing, spatial disorientation, blurred or double vision, difficulty in recognizing objects, and problems with depth perception and visual coordination, eventually leading to a homonymous hemianopsia or cortical visual loss. PCA is a rare disease and can be challenging to diagnose, and requires comprehensive neurological examinations, neuropsychological assessments, brain imaging (such as MRI or PET scans), and ruling out other potential causes of the symptoms.[16] The primary approach to managing the disease revolves around providing support, with a focus on enhancing the patient's quality of life through occupational therapy and visual rehabilitation. Current efforts aim to increase awareness and earlier detection of PCA to improve outcomes for patients.[17]

The rarity of PCA produces additional challenges to timely diagnosis, even more so when ageist attitudes are prevalent among healthcare providers, patients, and their family members. Oftentimes, patients with PCA will have a history of repeated visits to optometrists and ophthalmologists, as well as multiple unsuccessful changes in their eyeglasses prescription and surgeries attempting to improve visual acuity. Due to ageist attitudes, earlier PCA symptoms such as nonspecific anxiety, difficulties in judging distance, problems reading analog clocks and pixelated images, issues with reading text, and simultanagnosia, are attributed to age-related changes. As the disease continues to progress, its presentation becomes nearly identical to advanced Alzheimer’s disease. Even the vernacular used to address patients with dementia can be inappropriately simplified (“elderspeak", similar to "baby-talk") which is condescending and imposes further barriers to communication between patients and providers .[18]

Giant Cell Arteritis

Giant cell arteritis (GCA) is the most common idiopathic, systemic vasculitis. It involves middle and large-sized vessels, including the external carotid arteries, internal carotid arteries, and vertebral arteries.[19][20][21] Patients present to ophthalmology with acute unilateral or bilateral vision loss due to involvement of the ophthalmic artery and posterior ciliary arteries. Other symptoms include jaw claudication, new onset headache, and scalp tenderness; patients may also display systemic symptoms such as fatigue, weight loss, and fever. Given the wide range of symptoms that GCA patients can present with, it is critical that providers question patients directly about GCA symptoms. The average age of presentation is 72.5 years for women and 70.3 years for men. GCA most commonly affects white patients of Northern European descent, and women are 2 to 6 times more likely to develop GCA.[22] The gold standard for GCA diagnosis is a temporal artery biopsy. Lab tests used for GCA diagnosis include erythrocyte sedimentation rate and c-reactive protein. Treatment for GCA typically involves corticosteroids.[22] Despite medical treatment, reports of permanent partial or complete vision loss are between 8 percent and 20 percent.[23]

Early symptoms of GCA such as headache and muscle pain are non-specific and can easily be discounted by a provider.[24] GCA patients are often not referred to an ophthalmologist until they have developed irreversible vision loss. Ageist attitudes amongst providers can lead to undertreatment with immunosuppressants and glucocorticoids amongst elderly GCA patients; one study found that undertreatment contributed to increased aortic complications.[25]

Sagging Eye Syndrome

Sagging eye syndrome (SES) is a degenerative strabismus disorder caused by orbital connective tissue degeneration and rectus pulley system degeneration. It is one of the leading causes of strabismus in the elderly population.[26] SES was found to occur more commonly in females than in males.[27] Patients typically present with a gradual or acute onset of binocular diplopia. Orbital MRI can be used to confirm a diagnosis of SES; patients may have a significant displacement of the LR-superior rectus. Management of SES involves observation, prisms for diplopia, and strabismus surgery for patients who do not respond to prism.[28]

Accurately diagnosing patients with chronic or acute diplopia with SES can avoid unnecessary neurologic evaluation and imaging; symptoms can also be easily managed as above, which can markedly improve patient's functioning and ability to enjoy activities which require distance vision, including driving.

Progressive Supranuclear Palsy

Progressive supranuclear palsy (PSP) is a neurodegenerative tauopathy that presents in adults older than 40 years of age. Studies estimate the prevalence of PSP to be 5.8 to 6.5 cases per 100,000.[29] The classic hallmark of PSP is extraocular movement abnormalities, specifically a progressive supranuclear vertical ophthalmoplegia that is more apparent in the downgaze, and postural instability. As the disease progresses, patients have impaired vertical saccades and an absent vestibulo-ocular reflex.[30] Neuroimaging by MRI of PSP can be used to rule out other diseases, and MRI of PSP typically shows a “hummingbird sign,” which is the hummingbird shape of the rostral midbrain atrophy on mid-sagittal images.[31][32] Treatment for PSP is mainly supportive and prognosis is poor, with the average survival time from diagnosis being 5 to 9 years.[30][33]

Due to overlapping symptoms, PSP is often misdiagnosed as Parkinson’s disease; however, PSP progresses much faster, highlighting the need for providers to pay careful attention to their patients as they describe their symptoms.[31][32]  Ageist assumptions may result in older PSP patients being offered fewer opportunities for physical, occupational, and vision therapy, despite the proven benefits of rehabilitation in managing the disease.

NAION

Non-arteritic anterior ischemic optic neuropathy (NAION) stands as the prevailing cause of optic nerve swelling and optic neuropathy in adults over the age of 50.[34] The prevalence of NAION in the United States is estimated to be between 2.3 to 10.2 per 100,000.[34] It most commonly affects Caucasians.[34] Patients present with sudden onset vision loss and, in about 10 to 15 percent of patients, there is pain in and around the eye, but not with eye movements.[34] Patients also have a relative afferent pupillary defect and optic nerve edema at the time of presentation. Peripapillary optical coherence tomography typically shows thickening of the retinal nerve fiber layer and patients have a cup-to-disc ratio of 0.2 or less in the fellow eye.[34][35][36] Treatment options for NAION are lacking, but several trials evaluating medical and surgical treatment options are ongoing.[37]

NAION is often misdiagnosed as optic neuritis or papillitis, leading to incorrect workup and a delay in appropriate management; this can occur due to ageist beliefs amongst healthcare providers.[38] Additionally, providers may underestimate the potential benefits of trials or more aggressive therapies in older patients compared to younger ones.

Ageism and Neuro-Ophthalmic Care Outcomes

There is limited research examining how age discrimination in neuro-ophthalmic care settings impacts visual health outcomes. Nevertheless, ageism can manifest in various ways in the context of neuro-ophthalmic care, especially given the number of pathologies that affect primarily elderly patients. Healthcare providers may underestimate the severity of visual symptoms and attribute them solely to age-related changes without conducting a thorough evaluation. Additionally, healthcare providers may stereotype older patients as being less likely to respond to treatment or rehabilitation, leading to lower expectations for their visual outcomes. Providers may also be less inclined to recommend certain treatment options to older patients based on their age alone. Ageism can also contribute to fewer referrals to neuro-ophthalmologic specialists, leading to delayed diagnosis and suboptimal care. Ageist attitudes among healthcare providers can impede open and effective communication with patients, decreasing the likelihood that elderly individuals will continue to seek care.

While elderly patients, defined as those over the age of 65, have the highest prevalence of vision impairment, they are the least likely to seek ophthalmic care for preventable causes of blindness.[39]  Proposed explanations for this correlation include an increased number of comorbidities amongst older patients, socioeconomic barriers, geographic disparities in public transport, number of providers, and payment structures and insurance coverage.[39] Another consideration is the dependence of elderly patients on external support. One study exploring barriers to eye care among the elderly found that older individuals with vision loss who were care-dependent were particularly vulnerable to ageism as the decision to receive care is in the hands of another individual.[40] Caretakers with more ageist attitudes were found to be less likely to provide emotional, instrumental, and nursing care.[41]

One well-studied relationship is between ageism and poor psychological well-being; older adults with worse overall psychological well-being were found to be more affected by ageist attitudes.[1] More specifically, there is a significant association between depressive symptoms, stress, and anxiety, and experiences of ageism.[1]

Since those affected by vision loss are likely to develop mental health issues, it makes sense that these populations would be prone to internalizing ageist attitudes perpetuated by those around them. In a recent study conducted by the Center for Disease Control and Prevention, 1 in 4 adults with vision loss reported anxiety or depression.[42] Visual impairment has also been found to be a risk factor for suicidal ideations in the elderly.[43] Another longitudinal study of adults 65 years of age and older experiencing vision loss found that attitudes and expectations about aging, pre-vision loss tendencies towards depression, and severity of vision loss are all factors that contribute to increased depressive symptoms.[44]

Conclusions

Ageism remains relatively understudied compared to other types of discrimination (e.g., racism, sexism). Additional research is needed to examine how ageism impacts the relationship amongst providers, patients, and patient caretakers, and the impact on health outcomes for patients receiving ophthalmic care. Further research must also be conducted to examine and support the relationship between vision loss, incidence of psychiatric disease, and ageism.

Clinicians should be aware of the possibility of ageism in neuro-ophthalmology and other areas of ophthalmology. Recognition of ageism is an important first step in mitigating the effects of both implicit and explicit bias towards older adults.

References

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 1.6 Kang H, Kim H. Ageism and Psychological Well-Being Among Older Adults: A Systematic Review. Gerontol Geriatr Med. 2022;8:23337214221087023. Published 2022 Apr 11. doi:10.1177/23337214221087023
  2. ↑ Rogers SE, Thrasher AD, Miao Y, Boscardin WJ, Smith AK. Discrimination in Healthcare Settings is Associated with Disability in Older Adults: Health and Retirement Study, 2008-2012. J Gen Intern Med. 2015;30(10):1413-1420. doi:10.1007/s11606-015-3233-6
  3. ↑ Allen JO, Solway E, Kirch M, et al. Experiences of Everyday Ageism and the Health of Older US Adults. JAMA Netw Open. 2022;5(6):e2217240. doi:10.1001/jamanetworkopen.2022.17240
  4. ↑ Levy BR. The Role of Structural Ageism in Age Beliefs and Health of Older Persons. JAMA Netw Open. 2022;5(2):e2147802. doi:10.1001/jamanetworkopen.2021.47802
  5. ↑ 2020 Profile of Older Americans. Adm Community Living.
  6. ↑ Varma R, Vajaranant TS, Burkemper B, et al. Visual Impairment and Blindness in Adults in the United States: Demographic and Geographic Variations From 2015 to 2050. JAMA Ophthalmol. 2016;134(7):802-809. doi:10.1001/jamaophthalmol.2016.1284
  7. ↑ Congdon N, O'Colmain B, Klaver CC, et al. Causes and prevalence of visual impairment among adults in the United States. Arch Ophthalmol. 2004;122(4):477-485. doi:10.1001/archopht.122.4.477
  8. ↑ 8.0 8.1 Tabba S, Yeh YH, Kini A, et al. Neuro-ophthalmology in the Geriatric Eye. US Ophthalmic Rev. 2020;13(1):30. doi:10.17925/USOR.2020.13.1.30
  9. ↑ 9.0 9.1 9.2 Chang ES, Kannoth S, Levy S, Wang SY, Lee JE, Levy BR. Global reach of ageism on older persons' health: A systematic review. PLoS One. 2020;15(1):e0220857. Published 2020 Jan 15. doi:10.1371/journal.pone.0220857
  10. ↑ Jeyasingam N, McLean L, Mitchell L, Wand APF. Attitudes to ageing amongst health care professionals: a qualitative systematic review. Eur Geriatr Med. 2023 Oct;14(5):889-908. doi: 10.1007/s41999-023-00841-7. Epub 2023 Aug 8. PMID: 37553540; PMCID: PMC10587319.
  11. ↑ 11.0 11.1 11.2 Levy BR, Slade MD, Kasl SV. Longitudinal Benefit of Positive Self-Perceptions of Aging on Functional Health. J Gerontol B Psychol Sci Soc Sci. 2002;57(5):P409-P417. doi:10.1093/geronb/57.5.P409
  12. ↑ Sun N, Xu Z, Hua CL, Qiu X, Pittman A, Abdou B, Brown JS. Self-perception of aging and perceived medical discrimination. J Am Geriatr Soc. 2023 Oct;71(10):3049-3058. doi: 10.1111/jgs.18517. Epub 2023 Aug 18. PMID: 37596097.
  13. ↑ Patel I, West SK. Presbyopia: prevalence, impact, and interventions. Community Eye Health. 2007;20(63):40-41.
  14. ↑ 14.0 14.1 Zebardast N, Friedman DS, Vitale S. The Prevalence and Demographic Associations of Presenting Near-Vision Impairment Among Adults Living in the United States. Am J Ophthalmol. 2017;174:134-144. doi:10.1016/j.ajo.2016.11.004
  15. ↑ Katz JA, Karpecki PM, Dorca A, et al. Presbyopia - A Review of Current Treatment Options and Emerging Therapies. Clin Ophthalmol. 2021;15:2167-2178. Published 2021 May 24. doi:10.2147/OPTH.S259011
  16. ↑ Schott JM, Crutch SJ. Posterior Cortical Atrophy. Continuum (Minneap Minn). 2019;25(1):52-75. doi:10.1212/CON.0000000000000696
  17. ↑ Rajaram Manoharan SVR, Munakomi S. Posterior Cortical Atrophy. In: StatPearls. StatPearls Publishing; 2023. Accessed July 17, 2023. http://www.ncbi.nlm.nih.gov/books/NBK580553/
  18. ↑ Shaw CA, Gordon JK. Understanding Elderspeak: An Evolutionary Concept Analysis. Lee MA, ed. Innov Aging. 2021;5(3):igab023. doi:10.1093/geroni/igab023
  19. ↑ Chew SS, Kerr NM, Danesh-Meyer HV. Giant cell arteritis. J Clin Neurosci. 2009;16(10):1263-1268. doi:10.1016/j.jocn.2009.05.002
  20. ↑ Bengtsson BA, Malmvall BE. The epidemiology of giant cell arteritis including temporal arteritis and polymyalgia rheumatica. Incidences of different clinical presentations and eye complications. Arthritis Rheum. 1981;24(7):899-904. doi:10.1002/art.1780240706
  21. ↑ Li KJ, Semenov D, Turk M, Pope J. A meta-analysis of the epidemiology of giant cell arteritis across time and space. Arthritis Res Ther. 2021;23(1):82. doi:10.1186/s13075-021-02450-w
  22. ↑ 22.0 22.1 Baig IF, Pascoe AR, Kini A, Lee AG. Giant cell arteritis: early diagnosis is key. Eye Brain. 2019;11:1-12. Published 2019 Jan 17. doi:10.2147/EB.S170388
  23. ↑ Vodopivec I, Rizzo JF. Ophthalmic manifestations of giant cell arteritis. Rheumatology. 2018;57(suppl_2):ii63-ii72. doi:10.1093/rheumatology/kex428
  24. ↑ Ness T, Bley TA, Schmidt WA, Lamprecht P. The diagnosis and treatment of giant cell arteritis. Dtsch Arztebl Int. 2013;110(21):376-386. doi:10.3238/arztebl.2013.0376
  25. ↑ Monti S, Milanesi A, Klersy C, et al. Age at diagnosis influences the clinical phenotype, treatment strategies and outcomes in patients with giant cell arteritis: results from the observational GCAGE study on a large cohort of 1004 patients. Ann Rheum Dis. 2023;82(8):1098-1106. doi:10.1136/ard-2023-223895
  26. ↑ Chaudhuri Z, Demer JL. Long-term Surgical Outcomes in the Sagging Eye Syndrome. Strabismus. 2018;26(1):6-10. doi:10.1080/09273972.2017.1421676
  27. ↑ Goseki T, Suh SY, Robbins L, Pineles SL, Velez FG, Demer JL. Prevalence of Sagging Eye Syndrome in Adults with Binocular Diplopia. Am J Ophthalmol. 2020;209:55-61. doi:10.1016/j.ajo.2019.09.006
  28. ↑ Chaudhuri Z, Demer JL. Long-term Surgical Outcomes in the Sagging Eye Syndrome. Strabismus. 2018;26(1):6-10. doi:10.1080/09273972.2017.1421676
  29. ↑ Ling H. Clinical Approach to Progressive Supranuclear Palsy. J Mov Disord. 2016;9(1):3-13. doi:10.14802/jmd.15060
  30. ↑ 30.0 30.1 Agarwal S, Gilbert R. Progressive Supranuclear Palsy. In: StatPearls. StatPearls Publishing; 2023. Accessed July 31, 2023. http://www.ncbi.nlm.nih.gov/books/NBK526098/
  31. ↑ 31.0 31.1 Litvan I, Mangone CA, McKee A, et al. Natural history of progressive supranuclear palsy (Steele-Richardson-Olszewski syndrome) and clinical predictors of survival: a clinicopathological study. J Neurol Neurosurg Psychiatry. 1996;60:615–20.
  32. ↑ 32.0 32.1 Owolabi L. Progressive supranuclear palsy misdiagnosed as Parkinson's disease: a case report and review of literature. Ann Med Health Sci Res. 2013;3(Suppl 1):S44-S47. doi:10.4103/2141-9248.121221
  33. ↑ Barer Y, Chodick G, Cohen R, et al. Epidemiology of Progressive Supranuclear Palsy: Real World Data from the Second Largest Health Plan in Israel. Brain Sci. 2022;12(9):1126. doi:10.3390/brainsci12091126
  34. ↑ 34.0 34.1 34.2 34.3 34.4 Raizada K, Margolin E. Non-Arteritic Anterior Ischemic Optic Neuropathy. In: StatPearls. Treasure Island (FL): StatPearls Publishing; October 31, 2022.
  35. ↑ Peeler C, Cestari DM. Non-Arteritic Anterior Ischemic Optic Neuropathy (NAION): A Review and Update on Animal Models. Semin Ophthalmol. 2016;31(1-2):99-106. doi:10.3109/08820538.2015.1115248
  36. ↑ Arnold AC, Costa RM, Dumitrascu OM. The spectrum of optic disc ischemia in patients younger than 50 years (an Amercian Ophthalmological Society thesis). Trans Am Ophthalmol Soc. 2013;111:93-118.
  37. ↑ Atkins EJ. Nonarteritic anterior ischemic optic neuropathy. Curr Treat Options Neurol. 2011;13(1):92-100. doi:10.1007/s11940-010-0099-0
  38. ↑ Behbehani R, Ali A, Al-Moosa A. Risk factors and visual outcome of Non-Arteritic Ischemic Optic Neuropathy (NAION): Experience of a tertiary center in Kuwait. Taniyama Y, ed. PLOS ONE. 2021;16(2):e0247126. doi:10.1371/journal.pone.0247126
  39. ↑ 39.0 39.1 Umfress AC, Brantley MA Jr. Eye Care Disparities and Health-Related Consequences in Elderly Patients with Age-Related Eye Disease. Semin Ophthalmol. 2016;31(4):432-438. doi:10.3109/08820538.2016.1154171
  40. ↑ Marmamula S, Kumbham TR, Modepalli SB, Chakrabarti S, Keeffe JE. Barriers to uptake of referral eye care services among the elderly in residential care: the Hyderabad Ocular Morbidity in Elderly Study (HOMES). Br J Ophthalmol. Published online April 1, 2022:bjophthalmol-2021-320534. doi:10.1136/bjophthalmol-2021-320534
  41. ↑ Sutter M, Perrin PB, Tabaac AR, Parsa L, Mickens M. Do ableism and ageism predict college students’ willingness to provide care for a family member with a chronic health condition? Stigma Health. 2017;2(2):110-120. doi:10.1037/sah0000045
  42. ↑ Lundeen EA, Saydah S, Ehrlich JR, Saaddine J. Self-Reported Vision Impairment and Psychological Distress in U.S. Adults. Ophthalmic Epidemiol. 2022;29(2):171-181. doi:10.1080/09286586.2021.1918177
  43. ↑ Park J, Lee OE. Association between vision impairment and suicidal ideation among older adults: Results from National Survey on Drug Use and Health. Disabil Health J. 2020 Oct;13(4):100939. doi: 10.1016/j.dhjo.2020.100939. Epub 2020 May 6. PMID: 32417146.
  44. ↑ Demmin DL, Silverstein SM. Visual Impairment and Mental Health: Unmet Needs and Treatment Options. Clin Ophthalmol. 2020;14:4229-4251. Published 2020 Dec 3. doi:10.2147/OPTH.S258783
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