Ageism in Neuro-Ophthalmology

From EyeWiki
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 by Mary Labowsky, MD on August 11, 2023.


The United States population experienced a dramatic increase in the number of individuals aged 65 years and older over the last decade, from approximately 39.6 million in 2009 to 54.1 million in 2019.1 Over the next 50 years, this number is expected to double.[1] Consequently, the population of adults with vision impairment and age-related eye diseases, specifically neuro-ophthalmic pathologies, is also projected to double over the next three decades.[2][3][4] It is necessary that these diseases be diagnosed and treated in a timely manner to prevent blindness and improve the quality of life of those affected. Thus, ophthalmologists must adjust their models of care to ensure that the needs of the aging population are met and properly address any barriers to receiving ophthalmic care. One such obstacle to accessible care is ageism.

Ageism is defined as stereotypes, prejudice, and discrimination related to old age, older adults, or the aging process.[5] Ageism may manifest in various contexts, including institutions, communities, interpersonal connections, or as a result of self-perception.[5] Ageism can be explicit, or overt and conscious expressions of discrimination based on age, or implicit, which involves unconscious or subtle bias towards individuals based on their age.[5]  Negative attitudes towards older individuals are becoming increasingly prevalent.[6] The University of Michigan Poll on Healthy Aging found that 93 percent of older adults regularly experience ageism.[7] In healthcare settings specifically, one study reported that one in five individuals over the age of 50 have experienced ageism.[8] After experiencing ageism, elderly individuals often internalize negative stereotypes associated with aging and limit themselves to conforming to age-related expectations.[5] This can result in diminished physical strength, poor health, and reduced openness to new learning experiences.[5]

Ageism and Healthcare Outcomes

In healthcare, ageism impacts the quality of care and treatment as well as patient-provider communication. Multiple studies have supported these findings, reporting a significant relationship between ageism and negative healthcare outcomes.[9]Systematic reviews and meta-analyses of experimental studies found that negative age stereotypes adversely affect older people’s physical, physiological, and cognitive performance.[9] Additionally, when age discrimination is perceived by older adults, it tends to lead to more negative psychological well-being.[9] Another systematic review revealed that 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 benefits for both age groups.[9]

Additionally, several studies have found self-perception of aging 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.[10] 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.[10] Self-perceptions of aging are influenced by a variety of factors including personality, health condition, societal views of aging, and relationships, such as those with one’s healthcare provider.[10]

Neuro-Ophthalmic Conditions in the Elderly

There are a number of neuro-ophthalmic pathologies found predominantly in elderly patients, all of which are expected to rise in prevalence with the increase in the aging population. These include presbyopia, posterior cortical atrophy, giant cell arteritis, sagging eye syndrome, progressive supranuclear palsy, and non-arteritic anterior ischemic optic neuropathy.[4]  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.


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.[11] 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.[12] As of 2020, there were approximately 123 million individuals affected by presbyopia, and 16 percent of presbyopes lack adequate correction.[12] 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.[13]

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.[14] 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.[15]

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. Providers are known to speak to display implicit ageist attitudes towards affected patients through their use of “elderspeak,” or inappropriate simplified speech that is similar to baby talk.[16] Elderspeak is condescending and imposes further barriers to communication between patients and providers.

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.[17][18][19] 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.[20] 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.[20] Despite medical treatment, reports of permanent partial or complete vision loss are between 8 percent and 20 percent.[21]

Earlier symptoms of GCA such as head and muscle pain are often misinterpreted; this finding can be attributed to ageist attitudes amongst providers and patients.[22] GCA patients are not referred to an ophthalmologist until their visual symptoms become more severe. Additionally, ageist attitudes amongst providers can lead to undertreatment with immunosuppressants amongst elderly GCA patients; one study found that undertreatment contributed to increased aortic complications.[23]

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.[24] SES was found to occur more commonly in females than in males.[25] 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.[26]

Accurately diagnosing patients with chronic or acute diplopia with SES can avoid unnecessary neurologic evaluation and imaging. Ageist attitudes amongst providers can lead to dismissing even clear signs of disease.

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.[27] 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.[28] 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.[29][30] Treatment for PSP is mainly supportive and prognosis is poor, with the average survival time from diagnosis being 5 to 9 years.[28][31]

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.[29][30]  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.


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.[32] The prevalence of NAION in the United States is estimated to be between 2.3 to 10.2 per 100,000.[32] It most commonly affects Caucasians.[32] 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.[32] 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.[32][33][34] Treatment options for NAION are lacking, but several trials evaluating medical and surgical treatment options are ongoing.[35]

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.[36] 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.[37]  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.[37] 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.[38] Caretakers with more ageist attitudes were found to be less likely to provide emotional, instrumental, and nursing care.[39]

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.[5] More specifically, there is a significant association between depressive symptoms, stress, and anxiety, and experiences of ageism.[5]

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.[40] 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.[41]


Ageism remains relatively understudied compared to other types of discrimination (e.g., racism, sexism) Additional research is needed to examine how ageism amongst providers, patients, and patient caretakers impacts 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.


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