Cognitive Aging, Geriatrics Textbooks, and Unintentional Ageism

Although aging means growth and loss at all ages, even into advanced age, an important contributor to ageism is an overemphasis on the losses of later life with a corresponding failure to recognize the gains of maturity, such as wisdom, strategic thinking, stoicism, and altruism.1 Although understanding and combating ageism is a core part of the training and practice of gerontologists and geriatricians, a persistent concern is that their discourse and dialogue may unconsciously exacerbate ageism by a focus on the “failure model” of aging,1 disproportionately dwelling on the deficits of old age and age-related diseases, albeit while emphasizing the efficacy of interventions.2 Some geriatricians have recently recognized the need to promote a discourse that places more emphasis on what has been gained with population aging: the longevity or demographic dividend.3 It was hypothesized that the failure model of aging continues to be predominant in the educational processes of geriatrics. The content of a series of textbooks was analyzed to determine whether academic geriatricians recognize the longevity dividend, in particularly with cognitive aging, because the literature in areas such as driving seems agnostic regarding the wider cognitive gains whereby older people make effective use of strategic and compensatory techniques to maintain a safe driving record.4 Trinity College Dublin is one of the three universities entitled to a copy of every textbook published in the British Isles; it also has an extensive stock of international textbooks. Their catalog was searched for textbooks listed under “geriatric,” “geriatrics,” and “geriatric medicine” over a 15-year time span to allow for modern gerontological insights. The search was restricted to titles targeted at physicians and geriatricians, excluding texts for other professionals such as gerontological nursing and veterinary medicine. For serial editions, the most recent was selected. The portion of text related to cognitive changes in normal aging was identified. Using a methodology already tested for biases in textual analysis,5 two registrars (fellows) (SR, RB) in geriatrics independently read and analyzed the section(s) of text. Each text was classified into one of five categories using the principle of Goffmann's stigmatization:6 overall negative, relatively negative, balanced, relatively positive, and overall positive. Where the assessors did not reach consensus, recourse was made to third-party senior review (DON). Each assessor recorded important phrases that contributed to their overall impression. The initial search yielded 313 textbooks; 54 met the criteria, and 40 of these had an applicable section of text (Appendix 1). The two assessing registrars reached a consistent matching agreement in 29 texts; the other 11 were referred to the third assessor. Of the 40 textbooks, 22 (55%) created an overall negative impression of cognition and aging, 13 (32.5%) gave a relatively negative impression, and five (12.5%) portrayed a balanced view of cognition and ageing. No textbook gained a rating of overall or relatively positive portrayal. It has been more than one-quarter of a century since Salthouse showed the power of strategic and compensatory measures (not routinely measured) in the maintenance of output of older typists, despite decrements in areas easily measured, such as reaction time.7 The findings of the current study support the contention that the focus of training and teaching emphasizes the decline and deficits in aging but neglects to reflect on the cognitive gains that allow many older adults to continue to retain high levels of function. It sustains Kalish's concerns that geriatricians unwittingly contribute to ageism and points to the need for academic geriatricians to develop a more-salutogenic format for expressing the mission, goals, and parameters for teaching geriatrics, reflecting more thoroughly on what messages their discourse transmits to students, patients, and society. Do we each truly believe that population aging has been overall a success for individuals and society? Do we really consider that aging brings gains as well as losses at all ages? Is our specialism truly the guardian of the longevity dividend, or are we performing a worthy (if highly effective) form of practice for a group for whom we consider the future to be represented largely in terms of decline? We have confidence that the accumulated wit and ingenuity of our discipline can find solutions to wider acceptance of the concept of simultaneous growth and loss at all ages. Complex ideas are often best expressed through metaphors. The achievements of great artists in later life, often faced with the vicissitudes of age-related disease and disability, may be a helpful educational support in illuminating, explaining, and promoting a balanced view of aging to clinicians and students. We acknowledge the Librarian Staff at Trinity College Dublin. Conflict of Interest: The editor in chief has reviewed the conflict of interest checklist provided by the authors and has determined that the authors have no financial or any other kind of personal conflicts with this paper. Author Contributions: Study concept and design: Robinson, O'Neill. Acquisition of subjects and data: Robinson. Analysis and interpretation of data: Robinson, Briggs. Preparation of manuscript: Robinson, O'Neill. Sponsor's Role: No sponsor had a role in the preparation of this project or manuscript. Morewitz SJ, Goldstein ML. Aging and Chronic Disorders. New York, NY: Springer, 2007, pp. 44–51. Carstensen LL, Edelstein BA, Dornbrand L. 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Oxford: Radcliffe, 2010, pp. 20–21. Jamison JR. Healthcare for an Aging Population: Meeting the Challenge. Edinburgh, UK: Churchill Livingstone Elsevier, 2007, pp. 50–51. Cassel CK. Geriatric Medicine: An Evidence-Based Approach, 4th Ed. New York, NY: Springer, 2003, pp. 205–211. Spar JE, La Rue A. Clinical Manual of Geriatric Psychiatry. Washington, DC: American Psychiatric Publishing, 2006, pp. 23–33. Blazer DG, Steffens DC. Textbook of Geriatric Psychiatry, 4th Ed. Washington, DC: American Psychiatric Publishing, 2009, p. 80. Lewis CB, Bottomley JM. Geriatric Rehabilitation: A Clinical Approach, 3rd Ed. Upper Saddle River, NJ: Pearson/Prentice Hall, 2008, pp. 51–53. Guccione AA. Geriatric Physical Therapy, 2nd Ed. St. Louis, MO: Mosby, 2000, pp. 150–159.

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