Contemporary Perspectives On Ageism: Liat Ayalon Clemens Tesch-Römer Editors

International Perspectives on Aging 19
Series Editors: Jason L. Powell, Sheying Chen
Liat Ayalon · Clemens Tesch-Römer

Editors
Contemporary
Perspectives on
Ageism
International Perspectives on Aging
Volume 19
Series editors
Jason L. Powell
University of Lancashire, Preston, Lancashire, UK
Sheying Chen
Pace University, New York, New York, USA
The study of aging is continuing to increase rapidly across multiple disciplines. This
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is yet to be seen. The series bridges the gaps in the literature and provides cutting-
edge debate on new and traditional areas of comparative aging, all from an
international perspective. More specifically, this book series on International
Perspectives on Aging puts the spotlight on international and comparative studies of
aging.
More information about this series at http://www.springer.com/series/8818

Liat Ayalon • Clemens Tesch-Römer
Editors
Contemporary Perspectives
on Ageism
Editors
Liat Ayalon Clemens Tesch-Römer
Louis and Gabi Weisfeld German Centre of Gerontology
School of Social Work Berlin, Germany
Bar Ilan University
Ramat Gan, Israel
Funded by the Horizon 2020 Framework Programme

of the European Union
This publication is based upon work from COST Action IS1402, supported by COST
(European Cooperation in Science and Technology).
COST is a funding agency for research and innovation networks. Our Actions help connect
research initiatives across Europe and enable scientists to grow their ideas by sharing them
with their peers. This boosts their research, career and innovation. www.cost.eu
ISSN 2197-5841 ISSN 2197-585X (electronic)

International Perspectives on Aging
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Acknowledgements
Ageism is a social construct of old age that portrays ageing and older people in a
stereotypical, often negative, way. We are convinced that ageism is harmful both to
the individuals affected and to society as a whole. Hence, this book provides a thor-
ough overview of insights into the origins of ageism and descriptions of the mani-
festations and consequences of ageism in different domains and also presents
interventions which might curtail and reduce ageism.
This book is the collaborative result of a COST Action entitled “Ageism: A
Multinational, Interdisciplinary Perspective” (IS1402). COST is an EU-funded pro-
gramme that enables researchers like us to set up interdisciplinary research net-
works in Europe and beyond. We were lucky enough to secure funding for a 4-year
research network on the topic of ageism. Among the stated goals of our network was
the creation of a common language to allow researchers from various countries,
disciplines and sectors to work together in the field of ageism. We aimed for the
enhancement of knowledge, the integration of different disciplines and the develop-
ment of a new generation of researchers in the field of ageism.
The researchers in our network come from 35 countries and represent a highly
diverse group of established and early-stage researchers as well as policymakers. As
a result, this book is a multidisciplinary, cross-national product of researchers in the
fields of psychology, sociology, social work, health, nursing, law, policy, economy,
demography, pharmacy, occupational therapy, communication studies, gender stud-
ies and labour studies – all working on the topic of ageism.
We are grateful that COST has given us the opportunity to collaborate with
excellent colleagues from all over the world. We have learned a lot in this process,
and we hope readers will find this book both useful and inspiring.
Tel Aviv, Israel Liat Ayalon

Berlin, Germany Clemens Tesch-Römer
August 2017
v
Contents
1 Introduction to the Section: Ageism—Concept and Origins............... 1

Liat Ayalon and Clemens Tesch-Römer
2 Ageism: The Relationship between Age Stereotypes
and Age Discrimination........................................................................... 11
Peggy Voss, Ehud Bodner, and Klaus Rothermund
3 Multiple Marginalizations Based on Age: Gendered
Ageism and Beyond.................................................................................. 33
Clary Krekula, Pirjo Nikander, and Monika Wilińska
4 Origins of Ageism at the Individual Level............................................. 51
Sagit Lev, Susanne Wurm, and Liat Ayalon
5 Work Environment and the Origin of Ageism...................................... 73
Laura Naegele, Wouter De Tavernier, and Moritz Hess
6 Ageism and Age Discrimination in the Labour Market:
A Macrostructural Perspective............................................................... 91
Justyna Stypińska and Pirjo Nikander
7 Introduction to the Section: On the Manifestations
and Consequences of Ageism.................................................................. 109
8 Ageism in the Third Age.......................................................................... 115
Angela Kydd, Anne Fleming, Sue Gardner,
and Trish Hafford-Letchfield
9 Pathways from Ageism to Loneliness..................................................... 131
Sharon Shiovitz-Ezra, Jonathan Shemesh,
and Mary McDonnell/Naughton
vii
viii Contents
10 Ageism and Sexuality............................................................................... 149

Ateret Gewirtz-Meydan, Trish Hafford-Letchfield, Yael Benyamini,
Amanda Phelan, Jeanne Jackson, and Liat Ayalon
11 Visual Ageism in the Media..................................................................... 163
Eugène Loos and Loredana Ivan
12 Ageism and Older Immigrants............................................................... 177
Pnina Dolberg, Sigurveig H. Sigurðardóttir, and Ursula Trummer
13 Ageism in the Health Care System: Providers, Patients,
and Systems.............................................................................................. 193
Mary F. Wyman, Sharon Shiovitz-Ezra, and Jürgen Bengel
14 Ageism in Medication Use in Older Patients......................................... 213
Daniela Fialová, Ingrid Kummer, Margita Držaić,
and Marcel Leppée
15 Ageism in Mental Health Assessment and Treatment
of Older Adults......................................................................................... 241
Ehud Bodner, Yuval Palgi, and Mary F. Wyman
16 Ageism and Dementia.............................................................................. 263
Simon Chester Evans
17 Ageism and Neuropsychological Tests.................................................... 277
Boaz M. Ben-David, Gali Malkin, and Hadas Erel
18 Introduction to the Section: Against Ageism......................................... 299
19 Ageism and Anti-Ageism in the Legal System:
A Review of Key Themes......................................................................... 303
Israel (Issi) Doron, Ann Numhauser-Henning, Benny Spanier,
Nena Georgantzi, and Eugenio Mantovani
20 The Council of Europe’s Approach towards Ageism............................ 321
Barbara Mikołajczyk
21 The European Union’s Approach towards Ageism............................... 341
Nena Georgantzi
22 Ageism and the Rights of Older People................................................. 369
Annika Taghizadeh Larsson and Håkan Jönson
23 Educational Methods Using Intergenerational
Interaction to Fight Ageism..................................................................... 383
María del Carmen Requena, Hannah J. Swift, Laura Naegele,
Marc Zwamborn, Susan Metz, Wilco P. H. Bosems,
and Joost van Hoof
Contents ix
24 Introduction to the Section: Researching Ageism................................. 403

25 Normative, Empiricist, and Interpretive Considerations
in the Ageism Research Process.............................................................. 409
Fredrik Snellman
26 Ageism in a Cross-Cultural Perspective: Reflections
from the Research Field.......................................................................... 425
Monika Wilińska, Astrid de Hontheim, and Els-Marie Anbäcken
27 Agisem in the European Region: Finding from the European
Social Survey............................................................................................ 441
Hannah J. Swift, Dominic Abrams, Sibila Marques, Christin-
Melanie Vauclair, Christopher Bratt, and Maria-Luisa Lima
28 Measures of Ageism in the Labour Market in International
Social Studies............................................................................................ 461
Liili Abuladze and Jolanta Perek-Białas
29 Researching Ageism in Health-Care and Long Term Care.................. 493
Sandra C. Buttigieg, Stefania Ilinca, José M. S. de Sao Jose,
and Annika Taghizadeh Larsson
30 Children’s Attitudes toward Older People: Current
and Future Directions.............................................................................. 517
Joana Mendonça, Sibila Marques, and Dominic Abrams
31 Researching Ageism through Discourse................................................. 549
Amanda Phelan
Erratum............................................................................................................ E1
About the Authors
Dominic Abrams PhD, is professor of social psychology and director of the

Centre for the Study of Group Processes at the University of Kent. His research
focuses on the psychological dynamics of social exclusion and inclusion within and
between groups. He is codirector and founder of the European Research Group on
Attitudes to Age, which designed the European Social Survey Round 4 module on
experiences and expressions of ageism, (http://www.eurage.com). He is coeditor
with Michael A. Hogg of the journal Group Processes & Intergroup Relations and
(with Melanie Killen) of the Journal of Social Issues (2014) special issue on social
exclusion and children. He is a past president of SPSSI, fellow of the Academy of
Social Sciences and vice president of the British Academy.
Liili Abuladze MSc, is a PhD researcher in demography and a project manager at

the Estonian Institute for Population Studies, Tallinn University. Her PhD research
focuses on population ageing and its consequences in Estonia and other European
countries. She is a national representative at the Academic Network of Experts on
Disability (ANED). She has previously attended a research master programme in
population studies at the University of Groningen, the Netherlands, and the European
Doctoral School of Demography.
Els-Marie Anbäcken has been an associate professor in social work at Mälardalen

University (Sweden) since 2014. She was born and brought up in Japan, which
continuously influences her life and research. After the PhD thesis (1997), “an eth-
nography focusing on filial duty and eldercare in the Japanese society”, she has
continued with research on later life, in both explicitly and implicitly comparative
studies. From 2000 to 2008 and 2012 to 2014, she belonged to the Faculty of Social
and Welfare Studies at Linköping University. In 2006 (–2011), she became the coor-
dinator of the Swedish-Japanese research network on ageing and care. In 2008 she
moved to Japan for a full-time professorship at Kwansei Gakuin University, School
of Human Welfare Studies, where she did 4 years of teaching and researching in
gerontology, end-of-life care and international social work. She continued to deepen
these research profiles, focusing on existential needs in later life as well as
xi
xii About the Authors
transnational issues. In a globalising world, the ageing experience in many ways

transcends national borders, which is crucial to gerontological social work.
Liat Ayalon received her PhD in clinical psychology from the Illinois Institute of
Technology. She did her internship and postdoctoral training at the University of
California, San Francisco. She is currently a full professor in the School of Social
Work at Bar-Ilan University. She is currently focused on three major lines of
research: ageism, discrimination based on age; the intersection between formal and
informal care; and social networks of older adults. Her work has been funded by the
German Israel Foundation, the Israel Science Foundation, the National Insurance
Institute of Israel, the Israel National Institute for Health Policy Research and the
Israel Ministry of Health. She is currently the chair of a COST Action on ageism
(IS1402) and the chair of a Marie Curie Innovative Training Network on ageism
(EuroAgeism), both funded by the EU. She is also a member of the WHO core
group to combat ageism.
Boaz M. Ben-David PhD, is an assistant professor at the Baruch Ivcher School of

Psychology in the Interdisciplinary Center (IDC) Herzliya, where he heads the
Communication, Aging and Neuropsychology lab (CANlab). Dr. Ben-David com-
pleted his PhD in cognitive psychology at Tel Aviv University. He was a postdoc-
toral fellow at the University of Toronto and later a scientist at the Toronto
Rehabilitation Institute. He currently holds adjunct faculty positions at the University
of Toronto (Department of Speech-Language Pathology) and at the Toronto
Rehabilitation Institute (University Health Networks). His research interests include
the premise that reductions in the quality of the sensory input in older age will result
in less efficient cognitive functioning, specifically when communicating in adverse
environments (such as a noisy restaurant or a badly lit room); the complex interplay
that governs the perception of emotions in spoken language in unique populations;
speech perception in adverse conditions in ageing and for second language speak-
ers; and promoting better and more valid ways to test cognitive abilities in older age
and other special populations.
Jürgen Bengel is professor and chair of rehabilitation psychology and psycho-

therapy at the University of Freiburg, Germany. He received his doctoral degree in
psychology in 1986 and in medicine in 1987. Dr. Bengel’s research focuses on
psychological distress in patients with chronic somatic diseases, and he conducts
health services research in psychotherapy, psychiatric diagnosis, coping, rehabilita-
tion psychology and health psychology. He is head of the Rehabilitation
Multidisciplinary Research Network, head of the Center for Methodology Support
and head of the Psychotherapy Outpatient Treatment Center in the Department of
Psychology.
Yael Benyamini PhD, attained her bachelor’s degree in psychology and biology

and her master’s degree in social psychology at Hebrew University in Jerusalem and
her PhD in health and social psychology at Rutgers University. She is currently a
About the Authors xiii
professor at the Bob Shapell School of Social Work, Tel Aviv University. She is an
elected honorary fellow of the European Health Psychology Society. She has pub-
lished numerous articles and chapters and has recently coedited the book Assessment
in Health Psychology. Her research focuses on self-regulation in chronic diseases
and ageing, women’s health issues and health promotion. Her main focus is on sub-
jective perceptions of health, ageing and illness and their effects on coping with
health threats and ultimately on the psychological and physical outcomes. Her stud-
ies provided evidence for the intricate ways in which one’s subjective perceptions of
health, age and ageing are interrelated.
Ehud Bodner PhD, received his bachelor’s degree in psychology and criminology

as well as his PhD in psychology at Bar-Ilan University in Ramat Gan and his mas-
ter’s degree in clinical psychology at Tel Aviv University. He served as the head of
the research branch in the Mental Health Department of the Israel Defense Forces.
He is currently an associate professor at the Interdisciplinary Department of Social
Sciences and the Music Department at Bar-Ilan University and an active clinical and
medical psychologist. His research is currently focused on ageism and ageing and
dying perceptions and on emotional complexity and emotion recognition and regu-
lation through music in adulthood and in old age. His studies in the field of gerontol-
ogy provide evidence for the intricate connections between age, ageing and death
perceptions, emotion regulation and mental health aspects.
Wilco P. H. Bosems earned his MSc in psychology and bachelor in applied geron-

tology at Fontys University of Applied Sciences in Eindhoven. He works as a lec-
turer at the same university and coordinates the project “Seniors in Class” that
facilitates several departments in participation of older people in relevant bachelor
programmes and the minor “Healthcare and Technology”.
Christopher Bratt Ph.D., is Honorary Research Fellow at the School of

Psychology, University of Kent. His research focuses on various aspects of inter-
group relations, with a particular interest for predictors of social discrimination and
mental health in an intergroup context.
Sandra C. Buttigieg MD (University of Malta), PhD (Aston University,

Birmingham, UK), FFPH (UK), MSc (University of Malta), MBA (University of
Malta), is associate professor and head of the Department of Health Services
Management, Faculty of Health Sciences at the University of Malta. She is also a
consultant in public health medicine at Mater Dei Hospital, Malta. Prior to this post,
Prof. Buttigieg also held the position of medical superintendent of a 1000-bed geri-
atric hospital in Malta. She lectures in health services management, public health,
family medicine and management. Her research is mainly in health management in
the areas of performance management, organisational behaviour, operations man-
agement and research and public health. She is currently on the Editorial Boards of
Frontiers in Public Health, the International Journal of Human Resource
Management, Journal of Health Organization and Management and the Journal of
xiv About the Authors
Geriatrics and Gerontology Research. She is currently a national delegate for Malta
in a COST Action on ageism (IS1402).
José M. S. de Sao Jose has PhD in sociology. He is currently an assistant professor

in the Faculty of Economics at the University of Algarve (Portugal) and a researcher
in the Research Centre for Spatial and Organizational Dynamics (University of
Algarve). He has researched on social care for older people, exploring themes such
as reconciliation between work and care and experiences of providing family care
and preserving dignity in later life. His research has been funded by the Portuguese
Foundation for Science and Technology and by the European Commission. He is
currently interested in the following research topics: ageism, active and healthy age-
ing and sexuality in later life. He is currently a national delegate in a COST Action
on ageism (IS1402) and a member of the Iberoamerican Research Network on
Ageing and Society (Red Iberoamericana Interdisciplinar de Investigación en
Envejecimiento y Sociedad). He is also a member of the Observatory of Families
and Family Policies (Institute of Social Sciences, University of Lisbon).
Wouter De Tavernier PhD, is a postdoctoral researcher at the Centre for

Comparative Welfare Studies, Aalborg University. He works on issues of social
policy and social gerontology, particularly on issues of older workers, retirement,
pensions and eldercare. His PhD, awarded by Aalborg University, particularly
focused on the role of the family in social policy for older individuals. Before, he
was a research assistant at the Centre for Sociological Research, University of
Leuven, researching pension protection in Belgium. He also holds an MA in sociol-
ogy and an MSc in social policy analysis from the University of Leuven.
Pnina Dolberg PhD, is a researcher in the fields of immigration and older age. She
obtained her PhD in social work at Ben-Gurion University of the Negev and was a
postdoctoral fellow at Louis and Gabi Weisfeld School of Social Work at Bar-Ilan
University. Her published work concerns phenomenology of middle-aged and older
immigrants, mental health among immigrants, policy concerning older immigrants
and phenomenology of middle age.
Israel (Issi) Doron LLB (Hebrew University of Jerusalem, Israel), LLM

(Washington College of Law, Washington DC, USA), PhD (Osgoode Hall Law
School, Toronto, ON., Canada), is the head of the Center for Research and Study of
Aging at the University of Haifa and the past president of the Israeli Gerontological
Society. He specialises in the fields of law and ageing, social policy and ageing,
human rights and ageism. Professor Doron has written extensively on topics such as
law and ageing and human rights of older persons (e.g. Doron, I. & Apter, I. (2010):
The Debate Around the Need for an International Convention on the Rights of Older
Persons. The Gerontologist, 50(5), 586–593) and is the editor of key books in the
field such as Theories on Law and Ageing: The Jurisprudence of Elder Law
(Springer, 2009) and Beyond Elder Law: New Directions in Law and Aging
(Springer, 2012; with Ann Soden). Finally, Prof. Doron is also the founder of an
About the Authors xv
Israeli NGO, “The Law in the Service of the Elderly”, which was involved in key
strategic litigation regarding rights of older persons in Israel.
Margita Držaić MPharm, univ. mag. phar. of clinical pharmacy, attained her mas-
ter’s degree in pharmacy at the Faculty of Pharmacy and Biochemistry, University
of Zagreb, Croatia. In 2017 she has finished postgraduate specialist study in clinical
pharmacy at the same faculty. Currently, she is working as a community pharmacist
at Zagreb City Pharmacies, Zagreb, Croatia. She is a member of Croatian Chamber
of Pharmacists and an active member of Croatian Pharmaceutical Society (Executive
Committee member of Section for Community Pharmacy). Also, she is mentor for
trainees and students accredited by the Croatian Chamber of Pharmacists. She
cooperates with the Centre for Applied Pharmacy at the Faculty of Pharmacy and
Biochemistry, University of Zagreb, on the project “Development of Community
Pharmacists’ Competencies”. Her professional and scientific interests are in the
field of clinical pharmacy, development of pharmacists’ competencies and medica-
tion use safety, especially in the use of potentially inappropriate medication (PIM)
in older adults.
Hadas Erel PhD, is a research associate at the Communication, Aging and

Neuropsychology lab (CANlab) at the Baruch Ivcher School of Psychology in the
Interdisciplinary Center (IDC) Herzliya. Dr. Erel completed her PhD in cognitive
psychology at Ben-Gurion University. Her research interests include the influence
of the quality of sensory information on cognitive performance, fluid intelligence
training in ageing and visual attention and ageing.
Simon Chester Evans PhD, is a principal research fellow and head of research
with the Association for Dementia Studies at the University of Worcester, UK. Simon
has developed a substantial portfolio of research projects and publications that span
a wide range of topics including housing, health, social care, the arts, assistive tech-
nology, care homes and communities. His role includes applying for research fund-
ing, managing a team of researchers and ensuring that research findings are
disseminated to key audiences. Recent research projects include an international
evaluation of the Meeting Centres Support Programme for people with dementia
and family carers and an exploration of the ability of extra care housing to respond
to changing care needs. Simon is part of TanDEm, a Doctoral Training Centre run
in partnership with the Centre for Dementia, University of Nottingham, and funded
by the Alzheimer’s Society. He is a fellow of the National Institute for Health
Research School for Social Care Research and a member of the British Society of
Gerontology and the ESRC Peer Review College.
Daniela Fialová received her PharmD and PhD degrees from Charles University
in Prague, Faculty of Pharmacy (2006), and the Ward Certification in Clinical
Pharmacy at the Institute for Postgraduate Training in Healthcare, Prague, Czech
Republic (2001). She has been the head of the University Educational Centre in
Clinical Pharmacy, Charles University (since 2014), and researcher and
xvi About the Authors
academician at the Department of Geriatrics and Gerontology, First Faculty of

Medicine and Department of Social and Clinical Pharmacy, Faculty of Pharmacy,
Charles University (since 2003). As an expert in medication safety and inappropri-
ate prescribing in older patients, she participated in EU projects, ADHOC (AgeD in
Home Care, 5th FP, 2001–2005) and SHELTER (Services and Health in the Elderly
in Long-Term Care, 7th FP, 2009–2014), and now is involved in the EU project
EUROAGEISM (2017–2021, MCSF-INT, Horizon 2020). She is an invited fellow
of the interRAI research corporation; chair of the scientific subgroup “Aging and
Changes in the Therapeutic Value of Medications in the Aged” that develops
research works in inappropriate prescribing in older patients in Eastern and Central
Europe; chair of the WG1b subgroup “Healthy Clinical Strategies for Healthy
Ageing” of the EU COST Action IS1402; board member of the Section of Clinical
Pharmacy, Czech Pharmaceutical Society and Czech Medical Association
J.E. Purkyně; and board member of the European Society of Clinical Pharmacy
Research Committee. Her professional interests include clinical pharmacy in geri-
atrics, evaluation of the medication efficacy and safety in older patients, changes
(pharmacological, physiological) accompanying ageing, risk management in phar-
macotherapy and analyses of polypharmacy and inappropriate prescribing in the old
age. She received several awards for her professional work, e.g. French Award in
Pharmacy, Scientific Award of the Czech Medical Society J.E. Purkyně and
Scientific Award of Dr. Paul Janssen for Pharmacoeconomics and Drug Policy.
Anne Fleming has PhD in nursing and was qualified as an occupational therapist

in 1983 from Queen Margaret College, Edinburgh. While working in the NHS, she
completed her master’s degree in inclusive environments at the University of
Reading. Her doctoral dissertation explored stakeholder perceptions of homeliness
in care homes for older people at the University of the West of Scotland. She is
interested in two strands of research: project work in which the end user of services
or products is involved in the creation, evaluation or redesign of the service or prod-
uct and projects designed to improve practice and service delivery.
Sue Gardner has MPhil in clinical psychology and undertook a first degree in
psychology in London and completed her clinical training in Glasgow. She has
worked, taught and supervised in clinical services for 40 years as a practitioner
psychologist and as a service manager. She held various positions in the British
Psychological Society from 1985 to 2011 including chairing the Division of Clinical
Psychology, the Professional Practice Board and the Ethics Committee and was
president in 2009/2010. She worked as clinical manager for Specialist Psychological
Services for Adults and Older Adults in Oxfordshire prior to her retirement. Her
clinical specialisms as a consultant clinical psychologist were addictions, complex
needs, the impact of organisational change on service users and staff and the provi-
sion of care. She now works as an independent consultant and lecturer.
About the Authors xvii
Nena Georgantzi has MA in human rights and European social protection. She is

a trained lawyer specialising in human rights (Université de Strasbourg, France) and
social protection (KU Leuven, Belgium). Nena Georgantzi has been working since
2010 for AGE Platform Europe (AGE), the European network of organisations that
represent over 40 million older people in the continent. Since 2014, Nena has been
also doing a PhD on human rights of older persons at the National University of
Ireland in Galway. Her professional experience includes policy analysis, project
coordination and strategic implementation in the NGO sector. She is currently in
charge of the organisation’s policy and advocacy work in relation to non-discrimi-
nation and human rights of older persons. She has previously been involved in a
large number of EU research projects in the field of ageing and contributed with
legal expertise to various EU dossiers. She participated in the Council of Europe
drafting group, which finalised in 2013 a recommendation on older people’s rights.
She has spoken on various occasions on the rights of older people, including in the
frame of the UN Open-Ended Working Group on Ageing. She has represented AGE
in the Fundamental Rights Platform, the Global Alliance for the Rights of Older
People and various expert groups on the rights of older people.
Ateret Gewirtz-Meydan MSW, is a PhD candidate in the School of Social Work,

Bar-Ilan University, and was awarded a Full Presidential Scholarship for excellence
for her dissertation. Her dissertation focused on sexual and relationship satisfaction
among community couples. Currently, Ateret is a member of The Aging Research
Lab (headed by Prof. Liat Ayalon) where she is involved in research projects regard-
ing sexuality and romantic relationships in later life. In clinical practice, Ateret spe-
cialises as a sex therapist in the Sex and Couples Therapy Unit in Meir Medical
Center.
Trish Hafford-Letchfield EdD, MA, is professor of social care at the School of

Health and Education, Middlesex University, London, UK. Trish is a qualified nurse
and social worker and had a long career in social work (1985–2003) including 10
years of managing statutory social care and supported housing for older people. Her
research interests are very diverse. She has a long history of pedagogical research in
interprofessional learning where she has led many local and national initiatives
which co-produce learning with older people and students. Trish engages with the
arts and humanities to enrich her teaching, practice and research. Her main research
interests are in educational gerontology and the quality of social care, leadership
and management and organisational development and LGBTQI issues in ageing and
social work. Trish is co-chair and founder member of an international network of
professionals interested in sexuality and social work. Recent research includes a
national study on mental health hate crime, transgender students in higher educa-
tion, the experiences of care workers in relation to older people’s self-harm and
suicide and organisational responses to disabled employees in the National Health
Service.
xviii About the Authors
Moritz Hess has PhD in sociology. He is a researcher and project coordinator at

the Institute of Gerontology at the TU Dortmund University. He received his PhD at
Mannheim University and his MA in sociology from the Free University Berlin. He
furthermore holds an MSc in gerontology from the Free University Amsterdam. His
research foci are comparative welfare state analysis, the generational conflict and
pension policies. His work has been published in several journal articles and book
chapters. In addition, he edited a book on the policy shift towards active ageing. He
has won research awards from the German Society of Gerontology and Geriatrics,
the UN and the Intergenerational Foundation.
Astrid de Hontheim Ph.D. in Anthropology (2007), was at fieldworks in West

Papua, remote Oceania, SE Asia, and central Africa. She is currently lecturing in
Belgium, formerly in Canada (UOttawa). Her research is focused on traditional
healers (Papua, Uganda, Belgium), missionaries strategies among forest people,
invisible content of the Oceanic artifact, rituals related to disasters and misfortune,
and Western chamanism (drum, ayahuasca) with self-involvement. She is also a
yoga instructor focused on energy (prânâ) channeling.
Stefania Ilinca PhD, is researcher and policy analyst in the Health and Care Unit
of the European Centre for Social Welfare Policy and Research (UN affiliated)
where she is primarily working on projects related to chronic diseases, long-term
care and equity in access to care. She holds a PhD in health economics, with a spe-
cialisation in frailty and multimorbidity in older age and care integration in devel-
oped health systems. She has extensive experience working in large international
research projects with comparative and interdisciplinary focus as well as with both
quantitative and qualitative research methods. Her publications include numerous
peer-reviewed book sections and policy-oriented contributions on topics in the
fields of health economics, health and long-term care policy and public health.
Loredana Ivan has PhD in sociology. She is associate professor at the National

University of Political Studies and Public Administration (SNSPA), Communication
Department, Bucharest, Romania. She is teaching topics related to interpersonal
communication and interpersonal communication mediated by technologies. She is
part of the Ageing Communication Technologies project (http://actproject.ca/)
based in Canada and co-applicant of ACT project research grant. She is also part of
the COST Action IS1402 “Ageism: A Multinational, Interdisciplinary Perspective”.
Loredana Ivan was a Marie Curie scholar (2003–2004) at the University of
Groningen, Interuniversity Center for Methodology (ICS), and a visiting researcher
at Humboldt University from Berlin, Department of Social and Organizational
Psychology (2012–2013). She is the author of Cele mai importante 20 de secunde
(The Most Important 20 Seconds, 2009) and coeditor of two other books in nonver-
bal communication area.
About the Authors xix
Jeanne Jackson has PhD in occupational science. She is professor at University

College Cork where she holds the positions of head of the School of Clinical
Therapies and head of the Department of Occupational Science and Occupational
Therapy. Previously, she was an associate professor at the University of Southern
California where she co-authored the Well Elderly Lifestyle Redesign® Program
and was involved in various nationally funded research studies addressing health
and wellness among older adults. Her current research interests include understand-
ing how diverse groups of people or individuals who may not fit within the particu-
lar social, historical and political constraints of their communities create meaningful
lives. Specifically, she focuses on the challenges that heterosexism, disablism and
ageism play in people’s daily lives. She is a fellow of the American Occupational
Therapy Association and on the editorial board of Journal of Occupational Science.
Håkan Jönson PhD, is professor at the School of Social Work, Lund University,

where he is also the director of studies at the PhD programme. He heads the Lund-
based research group “Care for Older People: Conditions and Everyday Realities”
and the “The National Network for Social Science Research on Ageing and
Eldercare”. His research has focused on images of ageing and older people, pen-
sioners’ organisations, crime and abuse as social problems for older people and
nursing home scandals. He has published extensively on different aspects of ageism
and has during later years devoted his main interest to different aspects of eldercare.
He is currently responsible for the research project “Improving Everyday Conditions
by Reconceptualising Elder Care Through the Lens of Disability Policies” that is
funded by the Swedish Research Council for Health, Working Life and Welfare.
Clary Krekula has PhD in sociology. She is an associate professor in sociology at

Karlstad University. Krekula’s thesis from 2006 problematised embodied perspec-
tives on women’s ageing. In her subsequent research, she has looked at gendered
ageing, age and gender in work organisations, age discrimination and dance among
older adults, which has resulted in a number of books, chapters and articles. In sev-
eral nationally and internationally funded research projects, she has emphasised
issues of extended working life, and work and entrepreneurship in later life, and has
shed light upon temporal sociological perspectives on age and ageing. She runs
AgeS, the Swedish research network on age, where she focuses on developing criti-
cal age studies. She is a board member of COST Action 1409 on extended working
life.
Ingrid Kummer univ. mag. phar. of clinical pharmacy, works as a community

pharmacist at Zagreb City Pharmacies, Zagreb, Croatia. She received her degree in
2016. She is a member of Croatian Pharmaceutical Society, Executive Committee
of Section for Community Pharmacy. She cooperates with the Centre for Applied
Pharmacy at the Faculty of Pharmacy and Biochemistry, University of Zagreb, on
the project “Development of Pharmacist’ Competencies that Are Necessary in Daily
Work in Public and Hospital Pharmacy”, research in progress. Her interest focuses
on potentially inappropriate medication use in older adults, pharmacy competencies
and improving pharmacy services in community pharmacy.
xx About the Authors
Angela Kydd has PhD in nursing. She is an associate professor in gerontology.

Her clinical background involved nursing older people in acute care and working as
a care home manager. Her interest is the oldest old. Her PhD was focused on the
experiences of older people living in a care setting. She has written and taught on
gerontology and dementia courses from workshops to leading a nurse specialist
programme in gerontological nursing and a master’s course in later life. She also
teaches internationally and has led and partnered several Erasmus Intensive
Programmes. She has led several funded projects, one of which involved the cre-
ation of bespoke philosophies of care underpinning practice development with staff
in nursing homes, one on a seven-country project on attitudes to nurses who work
with older people and one on teaching student nurses to interview older people on
their experiences of health and social care. She has coedited a gerontology textbook
and has over 50 publications. She is co-founder of the Ageing Research Network at
Edinburgh Napier University.
Annika Taghizadeh Larsson PhD, is a senior lecturer at the Division Ageing and

Social Change at Linkoping University, Sweden. She received her doctorate in age-
ing and later life in 2009, with a dissertation on the meanings of “becoming old” for
people who have lived with physical disabilities for all or most of their lives. Since
then her research has mainly focused on questions and issues at the intersection of
disability studies and social gerontology. Theoretically, her main interest concerns
age norms and how such ideas about what is appropriate and normal at a certain age
are applied in different contexts and by different actors. Between 2011 and 2016,
she was linked to CDR (Center for Dementia Research), which was a large 6-year
programme, led by Prof. L-C Hydén, with the ambition to conduct social scientific
and humanistic research around persons living with dementia diseases. On 1 January
2015, she was part of the project “Improving Everyday Conditions by
Reconceptualising Elder Care Through the Lense of Disability Policies”, led by
Prof. Håkan Jönson. She is actively involved as a MC member in the COST Action
on ageism (IS1402).
Marcel Leppée PhD, was born on 30 September 1951 in Zagreb, where he attended

elementary school and high school. He graduated from the School of Medicine,
University of Zagreb, in 1975. He finished postgraduate study in public health and
epidemiology and also study in healthcare and information systems. In 1982 he
passed the specialistic exam from social medicine and healthcare organisation. He
completed his internship in Dom Zdravlja Željeznčara in Zagreb. He worked in a
primary health centre in Rovinj in 1978, in the Croatian Institute of Public Health
from 1979 to 1984 and in the Andrija Stampar Teaching Institute of Public Health
in Zagreb in 1984. In 2002 he acquired a master of science from the Zagreb
University Medical School and in 2003 became primarius. In 2009 he acquired a
doctorate academic degree from the Faculty of Medicine University of Osijek. He is
a member of Croatian Medical Chamber and Croatian Public Health Association.
He is author of about 300 professional and scientific papers.
About the Authors xxi
Sagit Lev PhD, is a researcher in the fields of old age, ethics and social work. Her
studies deal with the ethical dilemmas and conflicts experienced by social workers
that work in long-term care facilities for older adults, as well as the emotional rami-
fications of these experiences on the social workers. These studies have been con-
ducted both qualitatively, by examining the social workers’ conflicting obligations
between the residents and organisations, and quantitatively, by exploring moral dis-
tress among social workers in long-term care facilities. As a part of the quantitative
study, a unique questionnaire was developed and validated in order to assess moral
distress among this population. In addition, cluster analysis was conducted in order
to identify a typology of long-term care facility social workers, based on environ-
mental and personal features and the association of these clusters with moral dis-
tress. Her fields of research also include ageism, deinstitutionalisation processes in
services for older adults and the maltreatment of older adults in long-term care
facilities.
Eugène Loos received his PhD in social sciences from Utrecht University in the
Netherlands. He is a professor of “Old and New Media in an Ageing Society” in the
Department of Communication Science at the University of Amsterdam and an
associate professor of communication, policy and management studies at the
Utrecht University School of Governance in the Netherlands. He is a member of
ASCoR (Amsterdam School of Communication Research) [http://ascor.uva.nl/] and
the Netherlands Institute of Government (NIG) [https://www.utwente.nl/en/nig/].
As a linguist, he has conducted research and written several books, book chapters
and journal articles in the field of organisational (intercultural) communication and
the use of new media. Currently, his research focuses on the role of old and new
media related to accessible information for senior citizens, in order to guarantee
their inclusion in our society. He investigates the (ir)relevance of age for (1) senior
citizens’ digital information search behaviour; (2) the impact of textual and visual
signs in health information on their cognition, affection and behaviour; and (3) the
use of digital (sport) games for their physical and social well-being. He is currently
the co-chair of the WG Media of a COST Action on ageism (IS1402).
Maria Luisa Lima Ph.D., is Professor of social psychology at ISCTE University

Institute of Lisbon. Her research focuses on the application of social psychological
processes to health and environmental issues, in particular on the importance of
social bonds and identities. She was President of the Portuguese Association of
Psychology and is Honorary Professor at the University of Bath.
Gali Malkin PhD, is a postdoctoral fellow at the Baruch Ivcher School of

Psychology in the Interdisciplinary Center (IDC) Herzliya. She received her PhD in
social-organisational psychology from Bar-Ilan University. Prior to her PhD stud-
ies, she completed her BA degree at Ben-Gurion University and MA degree at Bar-
Ilan University. Her dissertation focused on the interactive role of social identity
and threat, in predicting gender harassment behaviours. She is currently the research
manager on the “SINAI” (Social Interaction in Aging Immigrants) research team,
xxii About the Authors
focusing on the study of ageing, health and well-being from a multidisciplinary

perspective. She is also investigating the social outcomes of the intersection of age
and migration.
Eugenio Mantovani LLM, works at the multidisciplinary Research Group on

Law, Science, Technology & Society (LSTS) at the Vrije Universiteit Brussel
(VUB), where he is active in pursuing a number of research interests, including in
areas such as data protection, privacy issues, and problems related to aging and
human rights law. On one hand, his research focuses on privacy and data protection
law, in particular in the area of health care delivery. In this area, Eugenio is inter-
ested in the use of patient data, in the applications of eHealth and mhealth technolo-
gies, and in the impact of technologies on vulnerable groups or groups with special
needs. In this connection, Eugenio has developed specific expertise in e-aging and
in other human body related questions raised by technology. On the other hand,
Eugenio has been active in research into issues associated with aging and in particu-
lar about the human rights status of older persons. His Ph.D. research brings together
these two research paths in an investigation of privacy and data protection law from
the point of view of older persons in the digital age.
Sibila Marques PhD, is an assistant professor in psychology at ISCTE – University

Institute of Lisbon, Portugal. She is a member of the EURAGE research group, an
international project investigating attitudes to age across Europe and in charge of
the design of the ageism module in the European Social Survey. She has partici-
pated in several projects related with ageing (e.g. “Aging of People with Mental
Disabilities”, “Technology Experience Cafés“, “imAGES: Intervention Program to
Fight Ageism in Children”) and supervised several master thesis related with this
field. She has published a number of papers related with ageing in high-impact sci-
entific journals since 2005. She is the author of the essay “Discrimination of older
people” and a regular presence in the media regarding issues of ageing and ageism.
She has participated in EQUAL initiative projects “FE-FORMEMPREGO” and
“RUMO À QUALIDADE”, and in 2011 she was a contributor to the FUTURAGE
road map. From 2012 to 2016, she was the scientific coordinator in ISCTE-IUL of
the FP7 European Project SIforAGE – Social Innovation for Active and Healthy
Ageing.
Mary McDonnell/Naughton is a registered nurse and midwife and lecturer in the

Department of Nursing and Health Care, Athlone Institute of Technology, Ireland.
She received her doctorate from the College of Medicine, University College,
Dublin, in 2007, with a thesis on the “Epidemiological Profile of Child Health in
Ireland”. Since 2010, she has been involved in research studies with the older per-
son in collaboration with different disciplines, such as dementia and nutritional sta-
tus, an examination of “social capital” and the older person in Ireland. Presently, she
is involved in a review of rural transport and its importance for the older person in
collaboration with a Local Link programme and the factors which have influenced
the health and well-being of centenarians living in Ireland. She is also actively
About the Authors xxiii
involved in developing educational programmes and supervises research in the area

of disability. She is also a member of two COST actions, namely, ageism (IS1402)
and “Reducing Old-Age Social Exclusion: Collaborations in Research and Policy,
ROSEnet” (CA15122). As part of her work in socioeconomic engagement and
external stakeholder partnership, she encourages a collaboration with the older per-
son both in a voluntary and educational capacity. She is also actively involved in
getting AIT recognised as an Age-Friendly University and is a member of
Roscommon County Council Age-Friendly Alliance developing a strategy to
enhance the quality of life for the older person in the region. Within AIT, she chairs
the Research Ethics Committee and is a member of the National Ethics Committee
on the National Forum for the Enhancement of Teaching and Learning in Higher
Education.
Joana Mendonça holds a master’s in social and organisational psychology from

ISCTE – Lisbon University Institute. She was a member of the ISCTE team as part-
ner of the European Project SIforAGE – Social Innovation for Active and Healthy
Ageing – and has developed reports about ageing programmes and intervention
programmes to fight ageism among children/adolescents and policies at national
level and across several European countries. She is presently doing her PhD in the
field of ageism aiming to further understand how ageism develops among children
and how we can assess it in a proper and effective way.
Susan Metz MSc, holds a master’s degree in health sciences. She works as a proj-
ect manager with Summa Health Care of Summa College, a school for vocational
education in Eindhoven, the Netherlands. She is the coordinator of the “Seniors in
Class” project that supports the participation of older people in relevant programmes
for vocational students of various departments.
Barbara Mikołajczyk is a professor at the Faculty of Law and Administration of

the University of Silesia in Katowice, Poland, and the head of the Department of
International Public Law and European Law. She has been involved in the COST
Action on ageism (IS1402) and in works of the Polish Commissioner for Human
Rights’ Group of Experts on Older Persons. She is a member of the Odysseus
Academic Network for Studies on Immigration Asylum in Europe. She was also
appointed as the ad hoc judge in the European Court of Human Rights (2012–2014).
She has authored books and articles dedicated to human rights of various categories
of vulnerable persons, as migrant workers, asylum seekers, children, ethnic minori-
ties, sexual minorities and older persons.
Laura Naegele MA, is a researcher, project manager and graduate student with the
Department of “Ageing and Work” at the Institute for Gerontology at the University
of Vechta, Germany. She holds a BA in media science and sociology from Ruhr-
Universität Bochum and an MA in sociology from the Free University of Berlin.
Since receiving her degree in 2012, she has worked in multiple research and project
management positions in Germany and Belgium. Her research focuses primarily on
xxiv About the Authors
ageing workforces, extending working lives, competence development in small-

and medium-sized enterprises and ageism at the workplace. Her work has been
accepted for various conferences, workshops and summer schools at national,
European and international levels and published in several scientific and applied
journals and books.
Pirjo Nikander has PhD in social science. She is a research director of the Doctoral
School and a member the Gerontology Research Centerin the University of Tampere,
Finland. After completing her master’s (in Finland) and her PhD in social science
(as a member of the Discourse and Rhetoric Group in Loughborough University,
UK), her academic experience and expertise comprise research in the areas of age-
ing, the workforce, interprofessional decision-making, meeting interaction and the
baby-boom generation. She has always had a keen interest in qualitative research
methodology, research ethics and evidence and research design. Nikander is the
author of numerous articles and handbook chapters on discourse analysis, social
constructionist epistemology and qualitative methodology, as well as the editor of
books on women and ageing and interview research. Currently, she is PI for a
research project engaged in utilising and developing qualitative longitudinal
research methodology.
Ann Numhauser-Henning is professor at the Faculty of Law at Lund University,

Sweden, and the former pro-vice-chancellor of the said university. She has been the
head of the Norma Research Programme since 1996 and initiated the Norma Elder
Law Research Environment in 2012. She has written widely on labour law, espe-
cially employment law and non-discrimination law. A more recent field of research
is social security law in a European integration perspective.
Yuval Palgi PhD, is a clinical psychologist, the head of the Department of

Gerontology and past head of the Center for Research and Study of Aging in the
University of Haifa, Israel. His research focuses on psychological aspects of ageing
(as manifested by well-being, optimism and subjective perceptions of age or dis-
tance to death). He examines how psychological aspects of ageing enhance favour-
able psychological environment that regulates the effect of life adversities,
posttraumatic reactions and ageing processes. He has published more than 100
papers and chapters in peer-reviewed journals and books.
Jolanta Perek-Białas has PhD in economics. Since 2016 she has been adjunct
professor at Jagiellonian University in Cracow (full time) and in the Warsaw School
of Economics, Poland, as well. She is currently focused in her research on ageism
and age discrimination in the labour market, reconciliation care and work and use of
indicators in ageing research like active ageing index. She received the Leslie Kish
Scholarship and participated in the Survey Sampling Programme at the University
of Ann Arbor, in Michigan, USA. She coordinated and participated in many national
and international projects funded by the Polish institutions, the European
Commission, the Norwegian Research Council, the OECD, the UNECE and the
About the Authors xxv
World Bank and as well has been author/co-author of many publications on ageing,
active ageing and ageism. She is the chair of Working Group on Ageism in the
Labour Market of a COST Action on ageism (IS1402) and a Polish representative in
the COST Action Reducing Old-Age Social Exclusion (CA15122). She is also a
member of the Expert Group on Active Ageing Index (UNECE/EC) and the
Evaluation Board on AAI Seminars (2015, 2018).
Amanda Phelan RGN, RM, RPHN, RNT, BNS, MSc, PhD, is an associate profes-
sor in the School of Nursing, Midwifery and Health Systems. She also holds the
position of associate dean for Global Engagement, codirector of the National Centre
for the Protection of Older People and subject head of Older People’s Nursing.
Amanda’s research and publications focus on elder abuse, abuse of vulnerable
adults, person-centred coordinated care, missed care in nursing, ageism and resil-
ience in caregivers of people with dementia. Amanda serves on the AIGNA
Committee, the Policy and Procedures and National Advisory Committees of Sage
Advocacy and Support for Older People, the Board of Directors of Third Age and
the Fitness to Practice Committee of the Nursing and Midwifery Board of Ireland.
Amanda was also appointed to the Expert Advisory Group for the Citizens’
Assembly on Ageing and is a visiting professor in Norwegian University of Science
and Technology (NUTU) and an international research project advisor in NUTU
and the University of Toronto (Canada).
María del Carmen Requena PhD, attained her bachelor’s degrees in psychology

and education and obtained her PhD in neuroscience at the Complutense University
in Madrid. She was postdoctoral research fellow at the Spanish
Magnetoencephalography Center and intern clinical psychologist (PIR). Currently,
she is assistant professor of psychology at the University of Leon. She has designed
and developed the “Memoria Mejor” (Better Memory) Program for older persons
and directs the “Aging at All Ages Scholarship” giving scientific support to public
and private projects and programmes related to ageing. She also directs the EEG
Laboratory for the Study of Human Development at the interuniversity E3 campus.
She has published several articles related to ageing, both in the field of neuroscience
and in the field of psychology and gerontology. Her main focus is on long-term
memory and embedding emotional-cognitive programmes in daily life. Her current
research grants include a project on adult reasoning. She develops joint research with
Prof. G. Rebok on paradigm change in psychostimulation programmes for older per-
sons at the Johns Hopkins Center of Aging and Health. She also works on intergen-
erational educative methodologies applied in the realm of higher education.
Klaus Rothermund has PhD in psychology (University of Trier, Germany, 1998)

and venia legendi in psychology (University of Trier, Germany, 2002). Since 2004,
he has been full professor and chair of psychology at the Friedrich-Schiller-
University of Jena, Germany. He is a member of the Scientific Advisory Board of
the German Ageing Survey (DEAS) and a member of the Board of Directors of the
Center for Ageing Research Jena (ZAJ, Zentrum für Alternsforschung Jena). His
xxvi About the Authors
current research interests include quality of life and well-being in old age, volun-
teering and civic engagement, health and health behaviour, social relations and
social integration of older persons and comparative ageing research. He has served
as a principal investigator of the COST Action IS1402 “Ageism” (since 2014, work
group chair) and Ageing as Future (VolkswagenStiftung, since 2009, speaker and
chair). He has published 10 monographs, edited books and special issues and has
more than 170 publications in scholarly journals and books. He is currently editor-
in-chief for Cognition & Emotion.
Jonathan Shemesh is a graduate student of cognitive science at Ben-Gurion

University of the Negev and a research assistant at the Israel Gerontological Data
Center. His interests focus on the intersection between cognition and society. At
present, he is conducting research on the links between personality, morality and
economic attitudes. At the Israel Gerontological Data Center, he is involved in
research on the psychological and biological determinants of healthy ageing.
Sharon Shiovitz-Ezra PhD, is a senior lecturer at the Paul Baerwald School of

Social Work and Social Welfare at Hebrew University, where she received her doc-
torate in 2005. In 2008 she served as a postdoctoral scholar in the Center on
Demography and Economics of Aging, at the University of Chicago. Her theoretical
and research agenda focuses on loneliness experienced in the second half of life.
Her studies on loneliness have pursued two main directions: identifying risk and
protective factors for loneliness and addressing the harmful consequences of loneli-
ness. In 2015 she initiated a large multidisciplinary research proposal that was
funded by the Israeli Ministry of Science, Technology and Space, entitled “Do
Interpersonal Relationships ‘Get Under Your Skin?’: Bio-physiological Mechanisms
by which the Quality of the Interpersonal Social Milieu Affects the Health of Older
Adults”. Another research topic of Dr. Shiovitz-Ezra is the phenomenon of
“Ageism”. Following her scientific work in this field, she served as a principal
investigator of a large research project on ageism in the healthcare system in Israel.
Since 2015, she has been actively involved in the COST Action on ageism (IS1402).
Since 2016 she has served as the head of the MSW programme at the Paul Baerwald
School of Social Work and Social Welfare at Hebrew University.
Sigurveig H. Sigurðardóttir PhD, MPH, SW, is an associate professor and the
head of the Faculty of Social Work, University of Iceland. Her PhD awarded from
the School of Health and Welfare, Jönköping University, Sweden, focused on the
situation of community-living older people, 65 years of age and older, in Iceland.
Her research focuses mainly on formal and informal care of older people, social
networks of older adults and social policy. She was a social worker at the Geriatric
Department of the University Hospital in Iceland for several years and the adminis-
trative officer of the Red Cross Reykjavik Division and participated in implement-
ing different resources for older people such as group living facilities, day-care
centres and a nursing home. She is a national delegate in the Cost Action on ageism
(IS1402) and in the Cost Action on reducing old-age social exclusion (CA15122).
About the Authors xxvii
She has participated in different Nordic research projects such as REASSESS (The
Nordic Centre of Excellence: Reassessing the Nordic Welfare Model) and SIA
(Social Inequalities in Ageing; the challenge for the Nordic Welfare Model).
Sigurveig is responsible for the Icelandic part of the Nordic Master’s Degree
Programme in Gerontology (NordMaG), a multidisciplinary and jointly imple-
mented degree programme taught in collaboration of four Nordic universities. She
is a board member of the Icelandic Gerontological Research Center.
Fredrik Snellman has PhD in social work and licentiate’s degree in social policy.
He is a university lecturer and researcher at the Department of Social Work at Umeå
University in Sweden. Some of his recent work has appeared in the Journal of
Interpersonal Violence (2017), Nordic Psychology (2016) and the International
Journal of Sociology and Social Policy (2014). He is currently involved in the inter-
disciplinary GERDA (Gerontological Regional Database) research initiative, aim-
ing to investigate a wide range of topics affecting people in older (65+) ages. He is
actively involved in the COST Action IS1402 on ageism and is a committed spokes-
person for raising societal awareness of ageism (e.g. management education for
leaders in geriatric nursing in Sweden, pensioner organisation’s annual meetings).
Benny Spanier has BA in history and Jewish studies (Hebrew University,

Jerusalem), MA in religious studies (Tel Aviv University), LLB (Interdisciplinary
Center, Herzliya), LLM (University of Haifa) and PhD (University of Haifa). His
research focuses on ageism and the rights of older persons in the international arena.
Currently, he is an associate researcher in the Center for Research and Study of
Aging at the Department of Gerontology, University of Haifa. He published a num-
ber of articles regarding the rights of older persons (e.g. Spanier Benny, Doron
Israel (Issi), “From wellbeing to rights: Creating an international older persons’
rights index (IOPRI)”, 24(2) The Elder Law Journal 245 (2016); Spanier Benny,
Doron Israel (Issi), Milman-Sivan Faina, “In course of change? Soft law, elder
rights, and the European court of human rights”, 34(1) JLI 55 (2016). He has also
been involved in the establishment of IOPHRI, the International Older Persons’
Human Rights Index, and has studied key European institutions such as the European
Court of Human Rights and the European Social Commission.
Justyna Stypińska PhD, is a researcher at the Freie Universität Berlin in Germany.

She studied sociology and law at the Jagiellonian University in Kraków, Poland,
where she defended her thesis (in sociology) on the topic of age discrimination in
labour market in Poland. Her major research focus includes the issues of work in
later life and the life course analysis. Currently, she coordinates an international
research project on older entrepreneurs in Poland and Germany (in cooperation with
researchers in Sweden) financed by the German. In previous research project, she
studied topics related to reconciliation of work and elderly care, age discrimination
in work, healthcare and education, the transformations of life courses in post-com-
munist countries and wage inequalities in German labour market from the perspec-
tive of age, gender and migration. She is a board member of the European
xxviii About the Authors
Sociological Association Research Network on Ageing. She held fellowships from

the University of Washington in Seattle, USA, and the German Centre for
Gerontology in Berlin.
Hannah J. Swift PhD, is a research fellow at the School of Psychology, University

of Kent, from where she also completed her PhD (2012) as an ESRC-CASE grant
holder in conjunction with Age UK. Her research focuses on ageism, attitudes to
age, active ageing and the consequences of age stereotypes. Aside from contributing
to several reports for the UK Government, the European Social Survey, Age UK and
the Gerontological Society of America’s policy briefings, her research has been
published in journals including Journal of Gerontology: Psychological and Social
Sciences, Psychology and Aging, Journal of Social Issues, BMJ Open, Journal of
Applied Social Psychology and Social Issues and Policy Review. Her research thus
far has been supported by funding from research councils, the government and
NGOs from UK, EU and the USA. She is a core member of EURAGE, which con-
tributed to the design and analysis of the “Ageism” module in European Social
Survey and the UK’s Age Action Alliance’s working group on attitudes to age.
Clemens Tesch-Römer has PhD in psychology. He has been a director of the

German Centre of Gerontology in Berlin since 1998 and an adjunct professor at the
Free University of Berlin since 2003. He has been a member of the Expert
Committees for the German Government Reports on Older People in Germany
since 1998. His current research interests include quality of life and well-being in
old age, volunteering and civic engagement, health and health behaviour, social
relations and social integration of older persons and comparative ageing research.
He has served as a principal investigator of COST Action IS1402 “Ageism” (since
2014), German Ageing Survey (DEAS, since 2001), German Volunteering Survey
(FWS, since 2012) and Old Age and Autonomy: The Role of Service Systems and
Intergenerational Family Solidarity (OASIS, 2000–2003). He has published 20
monographs and edited books and has more than 100 publications in scholarly jour-
nals and book chapters. From 2008 to 2010, he was president of the German Society
for Gerontology and Geriatrics. And since 2015, he has been president of the
International Association of Gerontology and Geriatrics, European Region
(IAGG-ER).
Ursula Trummer PhD, MSc, MA, obtained her PhD in sociology and master’s
degree in socioeconomic sciences at the University of Vienna, Austria, and an MSc
in organisational development and counselling at the Sigmund Freud University
Vienna. She is co-founder and head of the Center for Health and Migration (www.c-
hm.com). Her main research interests are social determinants of health, access to
healthcare for vulnerable groups, diversity management and methodological chal-
lenges of trans- and interdisciplinary research. A recent focus of her work is on
ageing in immigrant populations and intergenerational family solidarity among
migrant families. She is national delegate to the COST Actions on ageism (IS1402)
and on Intergenerational Family Solidarity (IS1311). Ursula Trummer acts as
About the Authors xxix
project director of European and international projects and lectures at various uni-
versities, e.g. the Medical University of Vienna (Diversity and Medicine, Gender
Medicine) and the Medical University of Graz (Public Health). She is an indepen-
dent expert to the European Commission, the European Union Agency for
Fundamental Rights and the Norwegian Research Council.
Joost van Hoof PhD, MSc, Eur Ing, works as a research leader and associate pro-
fessor in the field of design for healthcare with the School of Allied Health
Professions of Fontys University of Applied Sciences in the Netherlands. Van Hoof
attained his doctoral degree in 2010 from Eindhoven University of Technology with
a dissertation on ageing in place for people with dementia (awarded the certificate
for best dissertation of the Department of Architecture, Building and Planning) and
an MSc degree in building physics and services in 2004. He also studied environ-
mental engineering (mechanical engineering) at the Czech Technical University in
Prague. He attained his Eur Ing qualification from the European Federation of
National Engineering Associations (FEANI) in 2007. Key to his work are inclusive
and participatory design for older people, designing technologies and housing that
stress the needs and abilities of people, not their limitations. For his work, Dr. van
Hoof won various (inter)national awards, including the best education innovation
award by the Netherlands Association for Medical Education, the REHVA Young
Scientist Award 2011 by the Federation of European Heating and Air-Conditioning
Associations and the 2010 BJ Max Prize. He is a board member of various ISI jour-
nals on building, technology and healthcare. Moreover, he is board member of the
Herman Bouma Fund for Gerontechnology Foundation and holds two membership
positions of the board of directors within the domain of healthcare real estate.
Christin-Melanie Vauclair is a Researcher at the university ISCTE-IUL, Centre

for Psychological Research and Social Intervention in Lisbon, Portugal. She holds
a Ph.D. in Cross-Cultural Psychology and her research focuses on identifying simi-
larities and differences across different countries and cultures in regard to attitudes
to age and the experience of ageism. She is a member of the European Research
Group on Attitudes to Age (www.eurage.com; www.melanie-vauclair.com).
Peggy Voss has MSc in psychology. She is a doctoral student at the Department of

Psychology of the Friedrich-Schiller-University Jena in Germany. She is part of the
international and interdisciplinary research project “Ageing as Future” (funded by
the VolkswagenStiftung). Her research interests are images of ageing and their
developmental outcomes as well as age stereotypes and (perceived) age
discrimination.
Monika Wilińska PhD, works as a senior lecturer at the School of Health and
Welfare, Jönköping University, Sweden. Her research focuses on the practices and
processes of inequality (re)production across the life course and in various sociocul-
tural contexts. She has extensive research experiences from countries, such as Japan,
Poland, Sweden and the UK. Monika’s specific research interest is in the ways in
xxx About the Authors
which age and gender orders are being established, sustained and revised in every-
day interactions, including encounters between clients and institutional health and
welfare actors. She is a qualitative researcher, with a strong background in discourse
and narrative studies.
Susanne Wurm PhD, received her PhD in psychology at the Freie Universität
Berlin and is currently a professor of psychogerontology at the Friedrich-Alexander-
University (FAU) in Nuremberg, Germany. Her research areas are health and health
changes in later life and the role of psychosocial resources therein. In particular, her
research focuses on the impact of different views on ageing for health and health
behaviour, adaptation processes after health events and the promotion of effective
health behaviour via interventions. She is editorial board member of the European
Journal of Ageing and Journal of Gerontopsychology and Geriatric Psychiatry. She
is deputy president of the “Health Reporting and Health Monitoring” Committee of
the Robert Koch Institute, member of a research network on images of ageing
funded by the German Research Foundation (DFG), member of the European
Cooperation in Science and Technology (COST) Network and co-chair of COST
Workgroup 5 on “internalised age stereotypes”.
Mary F. Wyman PhD, received her doctorate in clinical psychology and neurosci-
ence from Indiana University, Bloomington, USA, and received further training at
the University of California-San Francisco. In 2015–2016, she was a visiting scien-
tist at the University of Freiburg, Germany. Dr. Wyman’s research seeks to achieve
a better understanding of the relationship between psychological and physical
health in older adults, with a focus on depression and dementia, and to address older
adult-specific challenges within the healthcare system. She is a geriatric researcher
with the US Department of Veterans’ Affairs and an adjunct associate professor at
the University of Wisconsin School of Medicine and Public Health.
Marc Zwamborn MSc, holds an engineering degree in molecular sciences. He

works as a project manager with Summa Health Care of Summa College, a school
for vocational education in Eindhoven, the Netherlands. He is the coordinator of
various projects related to transitions in healthcare and the consequences to
vocational education.
The original version of this book was revised.

An erratum to this book can be found at DOI https://doi.org/10.1007/978-3-319-73820-8_32
Chapter 1
Introduction to the Section: Ageism—
Concept and Origins
Human ageing is not solely the biological process of senescence—the gradual dete-
rioration of bodily functions that increases the risk for morbidity and mortality after
maturation. Human ageing is embedded in social contexts and is shaped by social
factors. We grow old within a social network of partners, family members, and
friends. In many countries, we count on old age pensions as well as health and social
care services. And we have explicit and implicit assumptions about older people (as
a social group), growing old (as a developmental process), and being old (as part of
the life course). These assumptions, expectations, and beliefs shape human ageing,
as well. We often speak about older people in general (and not about different indi-
viduals), about “the” process of ageing (and not about the multiple, unique courses
which exist), and about old age as a uniform stage at the end of life (and not about
the diverse and heterogeneous living situations of older people). As soon as we
neglect the differences between individuals, we over-generalise and treat older peo-
ple, ageing, and old age in a stereotypical manner. This stereotypical construction of
older people, ageing, and old age is called “ageism.”
Ageism is ubiquitous: It is in our perception of older people and in our actions
towards older people. We even look at ourselves as ageing persons through the lens
of ageism. Most often, we are not aware of our ageist perceptions and behaviours.
Ageism is prevalent in different domains of life: at work, in public spaces, in shops,
and in doctors’ offices. Elements of ageism can be found in individuals’ behaviour,
in organizational regulations, and in cultural values. Ageism is often negative and it
L. Ayalon (*)
Louis and Gabi Weisfeld School of Social Work, Bar Ilan University,
Ramat Gan 52900, Israel
e-mail: [email protected]
C. Tesch-Römer
German Centre of Gerontology, Berlin, Germany
© The Author(s) 2018 1

L. Ayalon, C. Tesch-Römer (eds.), Contemporary Perspectives on Ageism,
International Perspectives on Aging 19,
https://doi.org/10.1007/978-3-319-73820-8_1
2 L. Ayalon and C. Tesch-Römer
can harm older people because stereotyping ageist beliefs may lead the older person
to act as she or he is expected to behave: as a stereotypical older person. Hence,
ageism may become a self-fulfilling prophecy.
As scientists, we want to look into the origins of ageism (e.g., how does ageism
come about?) and we want to describe the manifestations and consequences of age-
ism (e.g., what does ageism look like and what follows from ageism?). We are also
in need of practical tools with which to study ageism and to adequately monitor its
occurrence. This is not enough, however. As scientists, we are also interested in
interventions against ageism (e.g., what works best?). Consequently, this book is
composed of different sections. The first section contains five chapters on the con-
cept and aetiology of ageism. These chapters provide a review of potential ways to
conceptualise and explain the occurrence of ageism. The second section is focused
on the manifestations and consequences of ageism. This section is the largest in the
book and contains ten chapters, which range in scope from the micro- to the macro-
level, including different settings and groups exposed to ageism. The third section
includes five chapters dedicated to interventions to fight ageism. Four of the chap-
ters discuss legal and policy interventions, whereas the latter chapter is on interven-
tions in the field of education. Finally, a section on researching ageism is devoted to
knowledge gained by quantitative and qualitative researchers with regard to research
in the field of ageism. This section contains seven chapters which address philo-
sophical, methodological, and cultural issues concerning research in the field of
ageism.
In this introductory chapter, we discuss definitions of the concept of ageism and
give an overview of the most important theories used to explain ageism on different
levels. We also introduce the chapters of the first section of this book.
1.1 Ageism: Concept
Definitions and concepts of ageism have changed over the years. The term was first
defined by Robert Butler, one of the pioneers in ageing research. Butler used the
word ageism to describe “prejudice by one age group against another age group”
(Butler 1969, p. 243). Butler argued that ageism represents discrimination by the
middle-aged group against the younger and older groups in society, because the
middle-aged group is responsible for the welfare of the younger and older age
groups, which are seen as dependent. He compared the effects of ageism to the
negative effects of racism or discrimination based on social class and discussed the
intersections between ageism and other forms of discrimination and disempower-
ment (Butler 1969). In subsequent work, Butler (1980) continued to compare age-
ism to sexism and racism (the other two well-known “isms”), arguing that ageism is
manifested as attitudes, behaviours, and institutional practices and policies directed
towards older adults. Ageism can be either positive or negative, yet it tends to carry
negative consequences by creating self-fulfilling prophecies (Butler 1980).
1 Introduction to the Section: Ageism—Concept and Origins 3
Erdman Palmore, another eminent ageing researcher, has argued that older adults
should be seen as a minority group in society (Palmore 1978). Palmore (2000) has
argued that normal ageing is seen as a loss of functioning and abilities. Hence, it
carries a negative connotation. Accordingly, terms such as “old” or “elderly” have
negative connotations and thus should be avoided (Palmore 2000). This corresponds
with the notion of language as shaping reality and constructing the meaning of old
age (Nuessel 1982).
A clear acknowledgement of the presence of ageism not only in the way one
group treats another but also as the “enemy within” was introduced in a paper by
Levy (2001). According to Levy, ageism is often directed at one’s self and can be
implicit. It occurs with very little awareness or intention and literally impacts the
social interactions and life of each and every one of us. This definition considers
ageism as having behavioural, attitudinal, and emotional components based on
chronological age. It can be positive or negative and is thought to shape most inter-
actions with older adults. It has been argued that older adults have internalised nega-
tive ageist messages throughout their lives. This, in turn, impacts their view of
themselves as well as their view of others in their surroundings (Levy 2001; Levy
and Banaji 2002). Every person who grows old is likely to be the target of ageism at
some point in life. This is very different from other types of discrimination, which
are not likely to impact all people in society (Palmore 2001). Hence, the scope and
breadth of ageism are massive (Ayalon 2014).
A more general definition of ageism equates it with discrimination based on age.
Because age-related stereotypes are embedded in our lives, we disregard them and
hardly notice their effects. It has been suggested that ageism is broadly defined as
prejudice or discrimination against or in favour of any age group. While both young
and old are affected by ageism, as both age groups are commonly defined as being
dependent, rather than as productive members of society (Angus and Reeve 2006),
also individuals in middle adulthood may suffer from ageism. Additional attempts
at a comprehensive definition of ageism address its emotional, behavioural, and
cognitive aspects; its implicit and explicit nature; its positive and negative impacts;
and its possible manifestations at the micro-, meso-, and macro-levels (Iversen et al.
2009).
Although both stereotypes and discrimination are discussed with regard to age-
ism, it is largely accepted that age stereotypes precede age discrimination. Chapter 2
by Voss, Bodner, and Rothermund (2018) in this section suggests that a reverse
direction should also be considered. The authors argue that expectations and behav-
iours reinforce each other. This occurs both at the actor and the perceiver levels and
has a domain-specific nature. Hence, this chapter provides a fresh look at the concept
and its occurrence.
In this book, we define ageism as the complex, often negative construction of old
age, which takes place at the individual and the societal levels. Despite the fact that
ageism is regarded as affecting the lives of people of all ages, the entire book is
primarily devoted to ageism towards older adults.
1.2 Ageism: Aetiology
Over the past few decades, multiple theories have attempted to explain the occur-
rence of ageism. We look at three levels of ageism: the micro-level, which is con-
cerned with the individual (thoughts, emotions, actions); the meso-level, which is
concerned with groups, organizations, and other social entities (e.g., in the domain
of work or health care services); and the macro-level, which relates to cultural or
societal values as a whole (e.g., political regulations). A division of theories accord-
ing to micro-, meso-, or macro-level explanations for the occurrence of ageism is
somewhat arbitrary as theories can relate to several levels at the same time.
Obviously, other categorizations are also possible.
1.2.1 Micro-level Theories to Explain the Origins of Ageism
Theoretical approaches to ageism on the micro-level of the individual come from

two traditions of psychological research: social psychology (terror management
theory, social identity theory, and the stereotype content model, among others) and
developmental psychology (theories based on the social-developmental perspective,
stereotype embodiment theory, and others).
Terror Management Theory provides a prominent explanation for the occurrence
of ageism. According to terror management theory, older adults serve as a constant
reminder of one’s mortality and vulnerability. In order to manage the anxiety that
their presence produces, individuals unconsciously sustain faith in cultural world-
views that offer literal or symbolic immortality. By adhering to these cultural world-
views, individuals attempt to increase their self-esteem which in turn provides for
the person a buffer against death-related anxiety. These efforts, allow the person to
maintain relative equanimity despite awareness of one’s vulnerability and mortality
(Greenberg et al. 1986, 1997).
Social Identity Theory proposes that individuals do not act just on the basis of their
personal characteristics or interpersonal relationships, but as members of their ref-
erence groups. Group memberships are the basis for the individual identity of group
members and, moreover, determine an individual’s relationships with members of
other groups (Tajfel and Turner 1979). Social identity theory posits that people want
to have a positive self-identity. They achieve this goal by demonstrating biases
which create positive distinctions between their group (in-group) and other groups
(out-groups), and by elevating their in-group status above that of other groups (Kite
et al. 2002; Tajfel and Turner 1979). Because age can be one criterion for group
identification, the theory can be used to explain ageism, as proposed in the Chap. 4
by Lev, Wurm, & Ayalon in this section.
The Stereotype Content Model suggests that groups of people are commonly clas-
sified by varying levels of warmth and competence. Older adults, for example, are
commonly perceived as being warm but incompetent. These perceptions lead to
feelings of pity and sympathy and less so to feelings of envy (Cuddy and Fiske
2002; Fiske et al. 2002).
Theoretical approaches from the perspective of human development emphasise
changes over time. According to this group of theories, ageism has origins in child-
hood and its focus and outcomes may change over the life course. A social develop-
ment perspective suggests that ageism develops throughout the life course.
Perceptual, affective, and sociocultural mechanisms are responsible for the develop-
ment of ageism. Age-based categories are thought to be universal. For instance,
children might perceive older adults negatively with regard to dimensions of activity
and potency and positively with regard to social goodness. Negative attitudes
towards ageing might also be universal, but seem to vary with children’s age, social
class, and older adults’ gender (Montepare and Zebrowitz 2002).
Stereotype Embodiment Theory proposes that lifetime exposure to negative stereo-
types of older adults leads to the internalization of ageism. Over the course of their
lives, older adults have internalised negative attitudes towards their own age group,
often implicitly. In support of these claims, longitudinal studies have shown that
negative age stereotypes and self-perceptions of ageing among older adults have an
adverse influence on health, longevity, and cognitive performance (e.g., Levy et al.
2002a, b, 2012; Wurm and Benyamini 2014; Wurm et al. 2007).
Efforts to separate the ageing body from the “young spirit” are seen as attempts
to accept old age and mortality. These attempts are equated with the concepts of
successful ageing or active ageing, which aim to differentiate between pathological
processes that occur in old age, normal aspects of ageing (like decline in cognitive
and motor speed), and “exceptional” (successful) aging (aging with low illness bur-
den, good functioning, and high social engagement). These concepts can be seen as
combatting certain negative stereotypes of ageing; however, they can also be seen as
ageist, because they place the responsibility for failure to “age successfully,” which
includes a large portion of the population of older adults, on the individual (Liang
and Luo 2012).
Chapter 4 by Lev et al. (2018) in the first section of the book attempts to explain
the origins of ageism at the individual level. According to the proposed model, terror
management theory offers reasonable explanations for the origins of ageism among
younger age groups, but not among the oldest-old, who are less concerned with
impending death. Stereotype embodiment theory, on the other hand, argues that age-
ism and its manifestation as discrimination against one’s own age group in old age is
internalised over the life course. The authors conclude that whereas successful age-
ing, healthy ageing, and active ageing models can be effective for some older adults,
the acknowledgement of decline and losses should be a viable option as well.
1.2.2 Meso-level Theories to Explain the Origins of Ageism
Ageism does not always start at the individual level. Groups, organizations, and
other social entities might be the precipitators of ageism, as well. An important
example concerns the rules governing entry to and exit from an organization. In the
labour market, age can be decisive for entry into a company (“too old to be hired”)
or for exit from a company (“pension age”).
Evolutionary Theories on Group Membership have argued that people are pro-
grammed to be part of a group and that they learn that their own wellbeing is inter-
dependent on that of other members of the group. A living arrangement that consists
of small groups results in social transactions, cooperation, and reciprocity among
members, and the criteria for determining the exchange of assistance are usually
implicit, rather than explicit. In this theory, a person’s age, wealth, reputation, and
health play a role in determining whether or not assistance will be provided, because
individuals who are perceived to have greater reproductive potential are more likely
to be helped. The degree of threat posed by a situation is also an important factor in
determining people’s willingness to help. When life is in danger, people are more
likely to assist relatives and those who are younger, healthy, and wealthy.
Nevertheless, when there is no risk to one’s life, people are more likely to assist the
very young or old, the sick, and the poor (Burnstein et al. 1994).
Age Segregation is a prominent explanation at the meso-level. In most modern
Western societies, there is a clear segregation between the young and the old, based
on pre-planned life scripts, which include: (a) education, (b) family creation and
work, and (c) retirement (Riley and Riley 1994). When the younger and older gen-
erations do not socially engage, ageism is likely to flourish (Hagestad and Uhlenberg
2005).
Intergroup Threat Theory suggests that individuals react in hostile ways towards
outgroups, particularly when outgroups are perceived as potentially harmful. The
theory identifies two major threats—realistic threats and symbolic threats—which
serve to enhance intergroup hostility and conflict. Realistic threats refer to threats to
the group’s power, resources, and welfare; symbolic threats are threats to one’s
world view, belief system, and values (Stephan and Mealy 2011). Although the
theory was not developed specifically to explain ageism, it can be used to account
for age divisions in society.
Intergenerational Conflict Theory proposes three bases for intergenerational con-
flict, which are exacerbated by the expectations that younger generations have of
older generations. These include expectations for the succession of resources from
the older to the younger generations; minimal consumption of shared resources by
older generations; and age-appropriate symbolic identity maintenance, which
means that the older generation should not attempt to “cross the line” and become
indistinguishable from the younger generation (North and Fiske 2013). When these
expectations are not met, ageism might flourish.
Chapter 5 by Naegele, De Tavernier, and Hess (2018) in this section addresses
ageism at the meso-level as it manifests in the workplace. The authors identify
organizational and contextual factors at the meso-level, which contribute to the
occurrence of ageism in the organization. This adds to a broader understanding of
ageism in the workplace as well as to a theoretical understanding of meso-level
explanations that account for ageism.
1.2.3 Macro-level Theories to Explain the Origins of Ageism
Ageism can also be located at the macro-level, in cultural values that depreciate
older people, and in societal institutions, such as age-related retirement
regulations.
Modernization Theory postulates that through the process of societal moderniza-
tion, which includes advancements in technology and medicine, older adults have
lost their social status in modern times (as compared to pre-modern eras). For one,
advancements in technology and medicine have resulted in a larger number of older
adults. As a result, old age is no longer the exception, representing a “survival of the
fittest,” but rather a common occurrence generally associated with frailty, morbidity,
and disability. In more modern societies, the accumulated knowledge of older adults
is often considered obsolete as a result of advancements in technology. The fact that
younger generations tend to have higher levels of education than older generations
is yet another contributor to the low status of older adults in modern society. In addi-
tion, with increasing urbanization, younger people tend to move to the city, leaving
their older parents behind, so that the degree of contact between the generations
declines (Cowgill and Holmes 1972). Finally, increased secularization has a role to
play in reduced levels of familism and the embracement of individualism (Burgess
1960). In essence, even though this theory is primarily concerned with the declining
status of older people, it also predicts an increase in power and status of the younger
generations, who are seen as holding the knowledge and skills valued by modern
society (Cowgill and Holmes 1972).
Chapter 6 by Stypińska and Nikander (2018) in this section uses the moderniza-
tion theory to account for ageism in the workforce. The authors also discuss the
roles of anti-discrimination policies and macro-level structural, political processes
with regard to ageism. This chapter provides context-specific examples for the
occurrence of ageism due to macro-level processes.
Ageism may be considered to be one mechanism creating societal inequality,
similar to inequalities stemming from gender, race, poverty, and sexual orientation.
A more nuanced picture of ageism can be achieved by looking at several mecha-
nisms together, rather than only looking at one mechanism and neglecting the
o thers. Hence, it is important to look at ageism from an intersectionality perspec-

tive. Intersectionality theory suggests that it is not age per se, but the intersection of
age and gender, race, socioeconomic level, sexual orientation, and/or other factors
which results in discrimination (Boggs et al. 2014; Krekula 2007; Marcus and
Fritzsche 2015; McMullin and Berger 2006?/2013?). Chapter 3 by Krekula,
Nikander, and Wilińska (2018) in this section views ageism within a wider context
of multiple marignalizations. It is argued that discrimination is never solely based
on age alone, but rather, on a multiplicity of characteristics, such as gender, appear-
ance, financial status, and socioeconomic status.
1.3 Conclusions
Clearly, there is no consensus regarding the concept of ageism or its causes. Ageism
as a concept has gone through various changes, and although it is currently acknowl-
edged that ageism can be directed towards any age group, ageism against older
adults has thus far received the most attention. In addition, although positive ageism
is well-defined, it has hardly been examined in the literature. Hence, ageism directed
at younger age groups and the positive aspects of ageism are potential subjects for
future research.
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Chapter 2
Ageism: The Relationship between Age
Stereotypes and Age Discrimination
Peggy Voss, Ehud Bodner, and Klaus Rothermund
2.1 Introduction
[…] everything matched with my occupational profile. But nevertheless I received a rejec-
tion because of my age. Born 1943, not stout and fat, not lazy and sluggish but instead still
energetic and fit. […] On the one hand people talk about skilled worker shortage and on the
other hand being 65+ years old one has no chance. (K. H. 2014)
Several explanations can be suggested for this rejection experience: From the
person’s perspective, which of course might reflect the truth, there is no doubt that
he was discriminated against based on his age because it is generally assumed that
people of his age are not fit anymore as workers. However, independently of whether
or not the recruiter held negative stereotypes about older adults, it is also possible
that there was simply someone who was better qualified for the job among the other
applicants. In yet another version, the event that led to the rejection could be
explained by his interview results that might have been worse compared to those of
other applicants, which then again might have been for example caused by what is
referred to as “stereotype threat” in the literature (Hess et al. 2003). This was defined
as a situation-based fear that one’s behaviour is going to be judged based on stereo-
types or that one might act in way that confirms a stereotype (Steele et al. 2002) and
it might especially occur during an interview with a younger interviewer. This
example demonstrates at least two important things: On the one hand, it shows how
P. Voss · K. Rothermund (*)

Fakultät für Sozial- und Verhaltenswissenschaften, Allgemeine Psychologie II, Friedrich-
Schiller-University Jena, Jena, Germany
e-mail: [email protected]; [email protected]
E. Bodner
Interdisciplinary Department of Social Sciences and Department of Music, Bar Ilan
University, Ramat Gan, Israel

https://doi.org/10.1007/978-3-319-73820-8_2
12 P. Voss et al.
difficult it can be to determine whether a negative outcome or behaviour constitutes

a case of age discrimination and if so whether it was caused by age stereotypes at
all. Furthermore, even if this is taken for granted, it is important to know whose
stereotypes were activated and led to a case of (perceived) discrimination. Taking on
different perspectives on a seemingly age discriminatory event can lead to very dif-
ferent conclusions regarding the role that discrimination and age stereotypes played
in the event. Age discrimination and the perception of age discrimination are com-
plex phenomena which, at least on a micro-level, most likely emerge from social
interactions (see Sect. 2.5). Accordingly, in order to make informed decisions about
new research on age stereotypes and age discrimination, to conduct interventions
targeting age discrimination, or to initiate policies directed at reducing age discrimi-
nation based on age stereotypes, it is of upmost importance to understand the com-
plex relationship between age stereotypes and age discrimination.
Following the introductory quote, and in order to start the inquiry of the relations
between age stereotypes and age discrimination, we first have to discuss one of the
most widespread and persistent beliefs about the occurrence of age discrimination,
that is the idea that age stereotypes and age discrimination are closely intertwined.
This idea is already reflected in an early definition of ageism. According to Butler
(1980) who first introduced the term, “ageism” is a complex phenomenon subsum-
ing three different aspects: (1). Prejudice against older adults, old age and ageing
(i.e., attitudes towards older adults), (2). Discrimination against older adults (i.e.,
behavioural acts targeting older adults), and (3). Institutional norms and strategies
supporting stereotypes and reducing the opportunities of older adults. Thus, from
the very beginning it was assumed that age discrimination and age stereotypes as
well as prejudice against older adults represent related constructs that are “mutually
reinforcing to one another” (Butler 1980, p. 1).
Although empirical evidence for the existence of age stereotypes and age dis-
crimination related to various life domains is abundant (e.g., Brockmann 2002;
Hummert et al. 1994; for more examples and reviews on age stereotypes and age
discrimination, e.g., in the domains health care, mental health, and work, see Wyman
and Shiovitz-Ezra; Bodner, Palgi and Wyman; De Tavernier, Naegele and Hess in
this book), their assumed causal relations are difficult to prove and might be more
complex than expected (Dovidio et al. 1996; Voss and Rothermund in press). In this
chapter, we draw a differentiated picture of this relationship by (a) disentangling
conceptual and empirical relations between age stereotypes and age discrimination
and (b) focusing not only on the role of age stereotypes held by those who show
ageist behaviours, but additionally considering the perspective of older adults them-
selves as they also hold stereotypes about (their own) age and ageing that are related
to perceived age discrimination (Voss et al. 2017). Figure 2.1 gives an overview of
the complex mutual relations between age stereotypes and age discrimination,
simultaneously taking into account both the perspective of actor and perceiver
whereby actor refers to people interacting with older adults (potentially behaving
towards them in a discriminatory way) and perceiver refers to older adults (poten-
tially perceiving age discrimination).
2 Ageism: The Relationship between Age Stereotypes and Age Discrimination 13
2.2 A
geist Behaviour and Perceived Age Discrimination:
Different Sides of the Same Coin?
Over the last decades, laws that aim at protecting people from age discrimination
have been established in legal systems of countries all over the world (e.g. Age
Discrimination in Employment Act in the USA 1967; Allgemeines
Gleichbehandlungsgesetz in Germany 2006; for a review of EU law and ageism see
Doron, Numhauser-Henning, Spanier, Georgantzi, and Mantovani in this book). The
incorporated definitions of age discrimination attempt to provide a clear and objec-
tive reference standard of what constitutes age discrimination in different areas of
life (e.g., age-dependent selection and recruitment of employees). However, how
people interpret behaviour and what they perceive as age discrimination does not
necessarily meet these criteria (Rothermund and Mayer 2009). In everyday life,
behaviour is often ambiguous and inconclusive with regard to its intentions and
underlying causes (Major and Sawyer 2009), and the very same behaviour can have
multiple meanings. Therefore, actual age discrimination might remain unnoticed
(e.g., if it is widely accepted; Australian Human Rights Commission 2010), but
older adults might also feel discriminated against although the way they were treated
constitutes no instance of ageist behaviour (e.g., the behaviour was unrelated to their
age or did not conflict with any rightful claims or prescriptions). In Fig. 2.1, this is
captured by the dotted shape linking perceived age discrimination by the perceiver
with non-discriminatory and with discriminatory behaviour produced by the actor as
both can be interpreted as age discrimination. Accordingly, to acknowledge the sub-
jective nature of an individual’s perception of age discrimination, it is important to
differentiate between perceived age discrimination and actual “objective” age
Fig. 2.1 Illustration of the relations between age stereotypes and (perceived) discriminatory
behaviour considering the actor’s and the perceiver’s perspective as well as situational, macro-, and
meso-level influences
14 P. Voss et al.
discrimination. Considering the subjective nature of perceived age discrimination,

we neither intend to deny that “objective” age discrimination exists nor do we con-
sider (falsely) perceiving age discrimination to be less harmful than noticing actual
age discrimination. This perspective can, however, help to identify individuals or
situations for whom or which the probability of perceiving discrimination is particu-
larly high (Voss et al. 2017), and it also elucidates possible relations between (per-
ceived) age discrimination and an actor’s (as well as a perceiver’s) behaviour.
Although perceived and “objective” age discrimination are conceptually differ-
ent, they are somehow empirically linked. For example, in the work domain, the
prevalence pattern of perceived age discrimination across adulthood matches with
known age preferences for workers (Gee et al. 2007). This points to the possibility
that perceived age discrimination is a valid indicator or symptom of actual “objec-
tive” age discrimination, at least in some cases. Nevertheless, although perceived
age discrimination shows a relation to objective indicators, age discrimination often
remains under-reported, potentially due to the strong internalization of age stereo-
types (European Commission 2011).
2.3 A
ge Stereotypes and Age Discrimination
from the Actor’s and the Perceiver’s Perspective:
Distinguishing Between Conceptual and Empirical
Relations
Focusing on the mere definition of age discrimination, a conceptual dependency

among age stereotypes and age discrimination becomes apparent. Discrimination can
be defined as “inappropriate and potentially unfair treatment” (Dovidio et al. 2010,
p. 8) that is based on people’s group membership (e.g., belonging to a certain age
group), with age being one of the three basic dimensions of automatic social catego-
rization (besides ethnicity, social class, and sex; Fiske and Neuberg 1990). This pro-
cess of categorization is assumed to be accompanied by the automatic activation of
associated stereotypes (Allport 1958; Devine 1989), which in turn shapes the behav-
iour towards the target person. A closer look reveals that a reference to age alone is not
sufficient for behaviours to be classified as age discrimination. What is needed for a
categorization as ageist behaviour is a description of the behaviour in terms of a char-
acteristic associated with age (e.g., based on age stereotypes or prejudice). Without
such a reference to age stereotypes and age-related prejudice, the age categorization
and the resulting behaviour would still be unconnected. Age stereotypes are thus
inherent in the mere concept of age discrimination: Age-related stereotypes and preju-
dice represent a necessary condition for describing a behaviour as discriminatory,
thereby providing a possible link between categorization and age discrimination.
Similarly, feeling discriminated against due to one’s age also implies that behav-
iour in a situation that highlights the group membership as old is perceived or
interpreted in a certain way (Major et al. 2002). Essentially, perceiving age discrimi-
nation requires that people have an idea of what it means to be treated in a discrimi-
natory way that is “based on age”. Such an idea is inherent in a prototype of a
situation where discrimination is likely to occur (Baron et al. 1991; Major and
Sawyer 2009; Rodin et al. 1990). This prototype is assumed to work like a template:
It can be compared against actual situations and the closer they match the more
likely it is that discrimination is perceived (Major and Sawyer 2009). Among other
factors, this prototype is informed by the negativity of stereotypes ascribed to older
people compared to younger people (i.e. stereotype-asymmetry which could for
example be the case in situations that test cognitive abilities, as negative stereotypes
about older adults are very prominent in that domain; Major and Sawyer 2009;
O’Brien et al. 2008). Accordingly, individually held age stereotypes and perceived
age discrimination are conceptually related, although stereotypes are assumed to be
only one aspect of many possible contextual and individual characteristics influenc-
ing the attribution of behaviour to discrimination (for an overview see, Major et al.
2002; Major and Sawyer 2009).
In sum, age stereotypes are involved in actual as well as in perceived age dis-
crimination for purely conceptual reasons. A reference to age-stereotypical attri-
butes provides the specific link between the age of the target person and the
respective discriminating behaviour by explaining or describing it in terms of age
stereotypes or age-related prejudice. Importantly, however, reference to age is only
a necessary, not a sufficient condition for the emergence (or interpretation) of age-
discriminating behaviour. This leaves ample room for empirical analyses of the
causal role of age stereotypes and of the sufficient conditions for their activation in
explaining and predicting (perceived) age discrimination.
Processes of Age Stereotype Activation Early empirical research regarding pro-
cesses and conditions of stereotype activation seemed to suggest that mere catego-
rization is associated with the activation of stereotypes, even if these stereotypes
were only known and not personally endorsed (Devine 1989). Although this study
was later criticized for a number of methodological shortcomings (e.g., stereotype-
related primes were used instead of mere category primes), it still makes an impor-
tant point in showing that subtly increasing the accessibility of stereotype-related
content has a marked influence on subsequent processes of perceiving, evaluating,
and behaving towards others. Later research addressing this issue revealed that indi-
vidual levels of prejudice of the actor had an impact on subsequent impression for-
mation (Lepore and Brown 1997), which attests to the importance of considering
individual differences in prejudice when explaining actual and perceived age
discrimination.
Other variables affecting whether or not stereotypes are activated are, for exam-
ple, the availability of cognitive resources (with a lack of resources preventing ste-
reotype activation; Gilbert and Hixon 1991), mind set (priming creativity reduces
stereotypic thinking; Sassenberg and Moskowitz 2005), and goals (chronic egalitar-
ian goals are associated with stereotype inhibition; Moskowitz et al. 1999). Similarly,
Rahhal et al. (2001) showed that the framing of a cognitive task as being unrelated
to memory (e.g., by framing it as a learning task) can prevent the detrimental effect
16 P. Voss et al.
on memory performance, which according to the authors might be explained by the

lack of activation of corresponding negative age stereotypes. These results demon-
strate that the mere categorization of someone as old does not automatically imply
the activation of (negative) age stereotypes, indicating that the relation between
categorization and an activation of old age stereotypes is more complex and indirect
than is often assumed, and does not hold for everyone or in every situation.
Activation of Different Sub-Stereotypes of Aging Images of older people are
heterogeneous and encompass a broad mixture of negative and positive stereotypes
(e.g. Hummert et al. 1994) differing in their content and in the contexts to which
they refer (e.g., Casper et al. 2011; Kornadt and Rothermund 2011). The valence
and content of activated stereotypes should not be neglected in discussing their
effects, especially as effects of (self- and other-) stereotypes on behaviour were
shown to be mostly assimilation effects (i.e., behaviour and stereotypes are consis-
tent, Wheeler and Petty 2001). Which of the multiple stereotypes is predominant in
a situation depends for example on contextual information (Casper et al. 2011;
Kornadt and Rothermund 2011) and the age of the target person (young-old vs. old-
old; Hummert et al. 1997). Not every stereotype possibly activated in a certain situ-
ation would be associated with discrimination.
Furthermore, domain-specificity as well as the differential effects of positive and
negative stereotypes were also shown with regard to the effects of age stereotype
activation among older adults. Specific activated stereotypes unfold their impact
most strongly in those domains to which they apply (Levy and Leifheit-Limson
2009). In particular, individually held views on ageing in a specific domain (e.g.,
physical losses) were only predictive of perceived age discrimination in a matching
domain (e.g., medical care; Voss et al. 2017; inner black frame in Fig. 2.1). In line
with the importance of stereotype valence it was shown that besides detrimental
effects of negative stereotypes, the implicit activation of positive age stereotypes in
older adults has positive effects (e.g., Levy 1996). Accordingly, stereotype activa-
tion depends on multiple influences and contextual information and is not necessar-
ily detrimental for older adults.
Translation of Stereotypes into Behaviour Most importantly, although several
studies show an association between stereotypes and judgements, perceptions, as
well as stereotype-consistent behaviour towards older adults (e.g., Hummert et al.
1998; Krings et al. 2011) the mere stereotype activation does not imply that people
inevitably act according to them (e.g. Gilbert and Hixon 1991; for a theoretical
framework see Kunda and Spencer 2003), also not in an age discriminatory way.
Whether or not stereotypes are applied depends for example on cognitive busyness
(Gilbert and Hixon 1991) and time pressure (Gordon and Anderson 1995). Similarly,
two meta-analyses on the effects of age stereotypes on different performance mea-
sures and behaviours in older adults revealed that their association depends on sev-
eral variables (i.e. moderators; Lamont et al. 2015; Meisner 2012). Investigating
stereotype threat Lamont and colleagues found that under certain conditions, for
example, when performance in a cognitive domain was measured, the effects were
more pronounced. Meisner showed that stereotype priming effects were more pro-
nounced when negative stereotypes are primed.
In sum, we have argued that age stereotypes and age discrimination are concep-
tually related, whereby age-related stereotypes and prejudice provide a possible link
between categorization and age discrimination. Such a categorization may be par-
ticularly likely in situations where a conflict of interest between groups is salient
(e.g., young and old persons competing for jobs, and when older adults are per-
ceived as consuming shared resources; North and Fiske 2012). Going beyond these
general conceptual connections, empirical research has contributed important
insights regarding the processes underlying the activation of stereotypes and their
translation into age discriminating behaviour, and has identified important modera-
tors of this association (see “cognitive aspects” on the actor’s side in Fig. 2.1; see
above and Sect. 2.3.2). Age stereotypes are not inevitably negative, but differ
strongly in content and valence between contexts and individuals (e.g., Kornadt and
Rothermund 2011). Even holding negative stereotypes about older adults does not
necessarily imply that these negative stereotypes are activated (see above “Processes
of age stereotype activation”). Most importantly, however, it does not imply that
they are applied and cause discriminatory behaviour (see above and Sect. 2.3). We
will address these complexities in more detail in the subsequent paragraphs.
2.4 A
geism from the Actor’s Perspective: Age Stereotypes
as Predictors of Age Discrimination
The fact that age stereotypes are a reason for age discrimination is firmly estab-
lished in research and in law. However, Allport pointed out as early as 1958 (p.14)
that how people actually behave towards members of a group does not necessarily
match what they think about these group members.
2.4.1 R
eview of Existing Evidence for Age Stereotypes
as Predictors of Age Discriminatory Behaviours
A large body of research demonstrates that negative stereotypes about older adults
are widespread in different areas of life whereby their content and valence depend
on the specific life domain (e.g., lower performance in the domain work, Bal et al.
2011; perfect grandparent in the domain family, Hummert et al. 1994). Similarly,
age discrimination takes on different forms depending on the life domain in which
it occurs (e.g., fewer chances for job interviews, Bendick et al. 1999; less expensive
treatments in the health care sector, Brockmann 2002). Nevertheless, most of the
research conducted so far regarding age stereotypes as predictors of age discrimina-
tion focused on the work domain. Although it is assumed that age stereotypes
18 P. Voss et al.
predict discriminatory behaviour, this is rarely tested. Often proxies of age discrimi-
nation are investigated as dependent variables like stereotype-consistent behaviour
or intentions to act in a discriminatory way.
Age Stereotypes and Intentions for Age Discriminatory Behaviours A variety
of studies demonstrated that negative age stereotypes predict intentions for discrim-
inatory behaviour using experimental and correlative designs (e.g., Chiu et al. 2001;
Krings et al. 2011; Rupp et al. 2006). In a vignette study with students, Rupp et al.
(2006) showed that participants made more severe suggestions regarding conse-
quences (e.g., demotion, transfer) in case that an older employee makes a mistake
which was especially the case for participants with more negative age stereotypes.
Additionally, the association between employee age and consequences was found to
be based on the assumption that the cause of errors among older employees as com-
pared to younger employees is more likely to be stable. Similarly, Krings et al.
(2011) showed that competence- and warmth-related stereotypes mediate the asso-
ciation between the job applicant’s age and interview intentions in a sample of busi-
ness students. Most importantly, besides testing their mediation model using data
from students, the authors also presented the same materials to people working in
human resources departments of organizations and again found the same effect. In
a study comparing age stereotypes and discriminatory attitudes across Hong Kong
and the UK in a sample of part-time students some of which worked in personnel
management, Chiu et al. (2001) found that negative stereotypes are related to ageist
intentions regarding outcomes like training, promotion, and retention. To further
test the role of stereotypes about older adults beyond information about the actual
age Abrams et al. (2016) omitted age from their vignettes and instead presented two
applicants which either were described using typical old skills (e.g. settling argu-
ments, using a library) or typical young skills (e.g. learning new skills, using social
media). The authors found that the participants would rather hire the candidate with
the young profile. However, other studies failed to demonstrate an effect of stereo-
types on discrimination within the domain of work (Leisink and Knies 2011).
Besides the inconsistency of the results within this area of research, the informa-
tive value of many studies regarding the question how age stereotypes are related to
discriminatory behaviour is limited due to their design and participants relying
mostly on student samples and artificial employment contexts. Regarding partici-
pants, it was shown that students and actual managers differ in their performance
evaluations and hiring decision (Singer and Sewell 1989). In a meta-analytic review
it was found that supervisors as compared to students evaluate older workers more
positively (Gordon and Arvey 2004). Regarding the study design, Morgeson et al.
(2008) found in their literature review on age discrimination in the work domain
that there are fewer discrimination effects in field studies as compared to laboratory
studies.
To complicate matters further, studies using a correlative design face an addi-
tional problem: The opposite direction of the causal relation between stereotypes
and discrimination was proposed as well, whereby stereotypes are considered as an
outcome of discrimination (Dovidio et al. 1996; Talaska et al. 2008). This hypoth-
esis is related to the justification function of stereotypes (Allport 1958) suggesting

that if members of a group are rejected, cognitions are formed to justify this behav-
iour. A consensus might be reached in the idea that the interrelation among stereo-
types and discrimination is reciprocal (Dovidio et al. 2010).
Age Stereotypes and Stereotype-Consistent Behaviour As proposed within the
behaviours from intergroup affect and stereotypes framework (Cuddy et al. 2007)
different behaviours towards members of groups (e.g, older adults) are based on
different stereotypes about them, as well as corresponding emotions. As an example
for stereotype-consistent behaviour, it was assumed that older adults are confronted
with the communication predicament of ageing (e.g., Ryan et al. 1986) “as a conse-
quence of lower expectations for performance”. It was shown that people would
adjust their communication with older adults for example by reducing their speak-
ing rate depending on the context and characteristics of the older person (Hummert
et al. 1998). In this study participants assumed that they would speak to an older
adult described as “despondent” in a way that might reflect their age stereotypes like
a lower memory performance. However, stereotype consistent or age-differentiated
behaviours and judgements do not necessarily equal age discrimination.
In sum, evidence for a simple relation between explicit age stereotypes and age
discrimination is sparse, especially considering how wide-spread the idea is. There
are two main problems in this regard: The definitions of age discrimination are het-
erogeneous and in most cases indicators of actual discrimination are used as depen-
dent variables. Accordingly, the relation of age stereotypes and age discrimination
was hardly ever investigated. Additionally, studies in this field face a variety of
methodological challenges which complicate the interpretation of the results.
However, even without those limitations, a small association between age stereo-
types and overt discriminatory behaviour against older adults would not be surpris-
ing, looking at research from a related area. As was already shown for
attitude-behaviour relations in general, correlations between (stereotypical) general
beliefs or attitudes and actual specific behaviour in a certain context are relatively
small (Ajzen and Fishbein 2005; Schütz and Six 1996). Similarly, studies investi-
gating age stereotypes as predictors of age discrimination show mixed results.
2.4.2 M
oderators of the Relation Between Age Stereotypes
and Ageist Behaviour
There is a variety of potential reasons for the mixed results with regard to the
stereotype-discrimination relation. A wide-spread critique that was proposed com-
paratively early within this line of research is the neglect of situational and contextual
influences on the relation between stereotypes and discrimination (e.g., Dovidio
et al. 1996; inner black frame of Fig. 2.1). In a review on age stereotypes and their
outcomes in the work domain, Posthuma and Campion (2009) identified the match
20 P. Voss et al.
between perceived appropriate age in a job and actual age as a moderator of the effect
of age stereotypes on age discrimination. It is assumed that besides information that
can be derived from a person himself/herself (e.g., by making inferences based on
someone’s age) there is also information that can be inferred from the specific situa-
tion. In a selection context these different sources of information can be compared
and the outcome (e.g., a hiring decision, promotion) depends on a match between
target age and job age prototype (e.g., Perry et al. 1996). The authors found that
young applicants are more positively evaluated for a prototypical “young-typed job”
than older applicants. However, there is no difference for the typical “old-typed job”.
Similar propositions were made by role congruity theory that assumes that discrimi-
nation emerges from the interplay of contextual information and stereotypes about
the target (Eagly and Diekman 2005). In line with role congruity theory it was shown
that in contrast to younger applicants where no difference was found, the hireability
of older applicants is higher for a stable company than for a dynamic company
(Diekman and Hirnisey 2007). Most importantly the authors also found that this rela-
tion was further mediated by perceived adaptability.
In a meta-framework proposed by Posthuma et al. (2012) the authors acknowl-
edge that moderators can exist on different levels whereby some of them are related
to an individual level affecting mostly the association between age and stereotypes
whereas others are related to the meso-level, and are more likely to affect the
stereotype-discrimination association. As discussed in more detail by De Tavernier
and colleagues in this book on a meso-level structural as well as softer characteris-
tics of organizations are among the factors associated with age discrimination in the
work context. Organizational climate as well as organizational structure like the
average or typical age of job holders are related to targeting older applicants whereby
the latter indicates that in an organization with an older workforce older applicants
appear less non-traditional and less likely to violate expectations regarding typical
job holders (Goldberg et al. 2013).
Although discrimination at an institutional level can be associated with stereo-
types that are held by individuals and individual actions, it is part of its specific
characteristics that it does not depend on them (Dovidio et al. 2010). However, an
institution can reinforce the use of age stereotypes in decision making thereby
strengthening the link between stereotypes and age discrimination. In the context of
medical care, aspects of curricula used during the medical education can entail case
studies with “typical “medical conditions of older adults (Higashi et al. 2012). In
combination with institutional requirements (e.g. time pressure; Hinton et al. 2007)
these circumstances create an environment that could reinforce stereotype-based
decisions potentially to the disadvantage of older patients (outer black frame in
Fig. 2.1). Going beyond organizational moderators, on a macro-level social norms
and laws that prohibit ageist behaviour (Rothermund and Mayer 2009, p. 80) and
the cultural background (Chiu et al. 2001) are also assumed to affect the stereotype-
behaviour relation (outer black frame in Fig. 2.1). Accordingly, several factors on
different levels have been proposed to modulate the relation between explicit age
stereotypes and overt age discrimination, indicating that the relation is more com-
plex than was initially presumed (Voss and Rothermund, in press).
2.5 A
geism from the Perceiver’s Perspective: Individually
Held Age Stereotypes as Predictors of Perceived Age
Discrimination
A very interesting aspect of stereotypes about older adults which sets them apart
from stereotypes based on other characteristics like gender and race is that eventu-
ally everyone gets older. At the same time, age stereotypes become internalized into
perceptions older adults have about themselves and their own ageing (Kornadt et al.
2015a; Levy 2009; Rothermund and Brandtstädter 2003), so-called (future) self-
views or self-perceptions of ageing. Accordingly, age stereotypes do not only affect
people’s behaviour towards other people (i.e., older adults) but also older adults
themselves.
2.5.1 R
eview of Existing Evidence for Age Stereotypes
as Predictors of Perceived Age Discrimination
A major factor that explains who interprets others’ behaviour in terms of discrimi-
nation are inter-individual differences (e.g., stigma consciousness, Pinel 1999; sen-
sitivity to befallen injustice, Schmitt et al. 1995). Some of these concepts also relate
stereotypes to perceived age discrimination. Within the framework of stigma, which
manifests itself in stereotypes and prejudice (for a review see, Chasteen and Cary
2015), the so-called stigma consciousness describes the extent to which people
expect that their behaviour is interpreted based on group membership and that they
are stereotyped or discriminated against (Pinel 1999). Stigma consciousness was
shown to be associated with perceived discrimination (Pinel 1999). Similarly, age-
based rejection sensitivity describes older adults’ expectation or perceptions of age-
based rejection which was also shown to be related to awareness of ageism (Kang
and Chasteen 2009; see “cognitive aspects” on the perceiver’s side in Fig. 2.1).
Both concepts, stigma consciousness and age-based rejection sensitivity imply
that older adults have an idea of which stereotypes members of an out-group hold
about them (i.e. they hold meta-stereotypes, Vorauer et al. 1998) based on which they
assume to be rejected or discriminated against just as in the introductory example.
These meta-stereotypes were demonstrated to be related to perceived discrimination
(Owuamalam and Zagefka 2013). Additionally, their own negative self-perceptions
of ageing might provide a basis for the expectation of being stereotyped and dis-
criminated as indicated by the fact that perceived stigma (e.g., being rejected, social
isolation) is negatively related to different dimensions of self-perception (Fife and
Wright 2000; see “cognitive aspects” on the perceiver’s side in Fig. 2.1). However,
the causal direction remains unclear. A process of mutual influence is conceivable
whereby negative self-perceptions of ageing are related to more perceived age dis-
crimination, which in turn reinforces negative self-perceptions of ageing. Therefore
Voss et al. (2017) examined the association among self-perceptions of ageing and
22 P. Voss et al.
perceived age discrimination across two measurement occasions that were separated
by a three-year interval. Their results point to a stronger effect of self-perceptions of
ageing on subsequent changes in perceived age discrimination.
Contrary to what was discussed so far, it was also shown that positive expec-
tations can be related to perceived discrimination (Inman 2001) and can have
negative effects on social interactions (Son and Shelton 2011). Inman con-
cluded that people who were surprised by a negative evaluation because they
had a more positive self-perception were more likely to perceive discrimina-
tion. This would indicate that those who have negative as well as those with
positive views on ageing should both report higher levels of perceived age dis-
crimination. These seemingly contradictory results might be reconciled by
identifying moderators that highlight either positive or negative views on aging
as a risk factor for perceiving age discrimination. A likely candidate is the ref-
erence object of views on aging, with positive self-views of aging and negative
views on aging purportedly held by others pose risk factors for feeling under-
valued due to one’s age, rendering experiences of exclusion or rejection as
examples of age discrimination.
Generally, it is assumed that whether discrimination is perceived or not does not
only depend on characteristics of the individual but also on features of the situation
and specific event (Major and Sawyer 2009; inner black frame in Fig. 2.1). According
to stereotype-asymmetry assumption, people are more likely to perceive discrimina-
tion in a situation that is characterized by negative stereotypes about the perceiver
than by positive stereotypes (O’Brien et al. 2008). Furthermore, macro-level aspects
like societal norms and regulations are assumed to affect age stereotypes and self-
perceptions of ageing (e.g., Kornadt and Rothermund 2015; outer black frame in
Fig. 2.1). Processes like the internalization of stereotypes (e.g., Kornadt et al. 2015a;
Levy 2009) point to the role of the macro- and meso-level influences that have an
indirect impact on perceived age discrimination.
2.5.2 M
ediators of the Relations Between Age Stereotypes
and Perceived Age Discrimination
The studies and concepts discussed so far reveal that perceived age discrimination
is related to age stereotypes and self-perceptions of ageing. In the current section,
we address the question of how these relations can be explained, that is, we focus on
the underlying mechanisms that link views on aging with perceived age discrimina-
tion. In a model from research on stigma it was assumed that stereotypes not only
affect the behaviour of others, but also the way people with a stigma (e.g., old age)
interpret the behaviour of others (Rüsch et al. 2005; lower dashed arrow in Fig. 2.1).
In an ambiguous situation, members of stigmatized groups are more likely to
attribute negative feedback to prejudice, compared to those without a stigma

(Crocker et al. 1991). Accordingly, the relations between self-perceptions of ageing
as well as meta-stereotypes and perceived age discrimination could be based on an
attributional bias. However, considering that perceived discrimination and “objec-
tive” discrimination are not always independent (see Sect. 2.1) it seems likely that
other (additional) processes are at work.
Research on the developmental implications of views on aging has produced
ample evidence that age stereotypes held by older adults are related to their own
behaviour (e.g., Levy and Myers 2004; Kornadt et al. 2015b). This relation provides
another potential pathway through which age stereotypes and perceived age dis-
crimination may be linked (Voss et al. 2017). The basic idea behind this explanation
is that by behaving in a stereotype-consistent manner themselves, older adults invite
others to behave towards them in a stereotype-consistent fashion, which then gives
rise to perceptions of age discrimination. Processes that potentially mediate the
relations between age stereotypes and stereotype-consistent behaviour of older
adults are internalization of age stereotypes, self-stereotyping, and stereotype threat,
all of which were shown to have performance-related behavioural consequences for
older adults (e.g., Hess et al. 2003; Levy 1996, 2009; Lamont et al. 2015; for more
information on stereotype threat and internalization of age stereotypes see Swift,
Abrams, Marques, Vauclair and Bratt in this book). A meta-analysis on the effects
of priming with age stereotypes on behaviour of older adults showed the detrimental
effects of the activation of negative age stereotypes on different behavioural and
performance related outcomes (Meisner 2012). In a related vein, in their study on
stereotype threat Hess et al. (2003) reported that older adults’ memory performance
decreased depending on the degree to which negative stereotypes of ageing were
activated. The authors concluded that those mechanisms could also be at work in
many situations in everyday life, because subtle characteristic of the environment
can trigger the activation of negative age stereotypes, and thereby affect the every-
day functioning and behaviour of older adults.
Interestingly, it is furthermore assumed that rejection sensitivity might act as a
self-fulfilling prophecy creating a situation that confirms the expectation (Levy
et al. 2001). In ambiguous situations expectations of rejection or discrimination
(e.g., triggered by the assumed attitude someone has about in-group members) were
shown to evoke maladaptive behaviours in terms of a reduced performance
(Mendoza-Denton et al. 2009). This might increase the likelihood of a (perceived)
rejection. Similarly, the effects of stereotypes on interpretation and behaviour might
not represent two different mediating mechanisms but could also reinforce each
other (e.g., if the interpretation of behaviour as discriminatory leads to reactance, or
if an older adult’s behaviour elicits behaviour in an interaction partner that is easily
perceived as discriminatory).
24 P. Voss et al.
2.6 I nterrelations Between the Perceiver’s and the Actor’s

Perspectives
Although so far we discussed the perspective of an older person feeling discrimi-

nated against separately from the perspective of another person behaving in a dis-
criminatory way, it is important to note that they are most likely interrelated, as in
everyday life situations behaviours and expectations of actors and perceivers rein-
force each other (Snyder 2001). Consider for example that stereotypes held by older
adults also affect their behaviour (see Sect. 2.4.2). The detrimental effects of stereo-
type threat (e.g., Hess et al. 2003) or self-stereotyping (Levy 1996) on performance
could reinforce negative age stereotypes about older adults held by someone else
and thus potentially evoke a corresponding reaction. These mutual effects are the
central elements of Fig. 2.1: On the backdrop of social and situational constraints
and cues the expectations and corresponding behaviours of interaction partners
mutually reinforce each other. From studies regarding racial and gender discrimina-
tion we know that stereotypes and expectations about a target person can elicit
anticipatory behaviour in the interaction partner, which again causes the target per-
son to behave in a way that confirms the stereotype (for review see Snyder 2001;
Word et al. 1974). Chen and Bargh (1997) labelled this the expectancy-driven model
of behavioural confirmation effects. They demonstrated that this effect even applies
to situations where stereotypes are activated unconsciously.
Based on findings demonstrating that stereotypes can elicit stereotype-confirming
behaviour in the target person, one might assume that those processes can result in
perceived discrimination. If for example, an older applicant in a job interview con-
firms negative stereotypes about older adults (e.g. because of stereotype threat or
stereotype-consistent behaviour of the interviewer) this might entail a rejection. A
similar effect was shown in the context of interracial bias. White interviewers cre-
ated a more negative interview environment for black as compared to white partici-
pants which was, as shown in a second experiment, associated with a worse
performance (Word et al. 1974). Within the context of employment, Maurer (2001)
proposed a model of worker age and self-efficacy for development of career-relevant
skills. According to the model, worker’s age is related to the confrontation with
negative age stereotypes, which results in a decrease in self-efficacy for develop-
ment and career-relevant learning and eventually in a lesser degree of voluntary
training activities. These behavioural outcomes would in turn confirm stereotypes
about older workers being resistant to change (Weiss and Maurer 2004) and less
interested in training (Ng and Feldman 2012), which then again might result in
fewer training opportunities offered to older employees.
As proposed by Rüsch et al. (2005), stereotypes affect both the behaviour of
actors as well as the behaviour and interpretation of stigmatized people. In interac-
tions, this can result in a self-sustaining chain reaction whereby stereotypes not only
shape expectations and interpretations but also elicit corresponding behaviours.
Accordingly, in order to fully understand the interrelations among age stereotypes
and discrimination from both, the perspective of older adults and potential actors,
they should be investigated in interactive situations, allowing to disentangle the

mutually reinforcing contributions of both pathways.
2.7 Conclusion and Implications
A reference to age stereotypes and/or age-related prejudice is a constitutive element

of both actual and perceived age discrimination. Importantly, this connection is nec-
essary but not sufficient, allowing for situations in which age stereotypes are acti-
vated but do not result in age discrimination. Despite this close conceptual linkage,
empirical evidence for a simple empirical association of age stereotypes and overt
discriminatory behaviour is scarce. Partly, this can be traced back to the lack of
studies actually examining stereotypes as predictors of overt discrimination, but
also to difficulties in assessing overt “objective” discrimination and, relatedly, to the
large variation of what is considered an instance of age discrimination. Considering
the relatively small predictive value of stereotypes for discrimination some authors
completely dismiss the idea of stereotypes as predictors of age discrimination and
propose prejudice or emotions as a more promising predictor of intergroup behav-
iour and discrimination (e.g., Cuddy et al. 2007; Talaska et al. 2008). It was pro-
posed that “stereotypes, beliefs, and emotional prejudices all closely relate to what
people say they did or will do toward outgroup members, but emotional prejudices
are more closely related to what people actually do” (Talaska et al. 2008, p. 284).
Amodio and Devine (2006) showed that implicit stereotypes and prejudice distinc-
tively predict different types of inter-group behaviours like judgements and social
distance respectively. Accordingly, age stereotypes might be better predictors of
perceived age discrimination than they are for “objective” discrimination. The cur-
rent review of the scarce and limited literature on this important topic clearly sug-
gests, however, that it is much too early for sweeping conclusions regarding the
influence of age stereotypes on age discrimination. Additional evidence is needed,
in particular, along the lines that have been suggested by recent promising studies
that have extended the boundaries of the stereotype-discrimination relations by
using, for example, implicit stereotype measures (Sekaquaptewa et al. 2003), by
considering additional variables (e.g., Cuddy et al. 2007), or by focussing on mod-
erators (see Sect. 2.3.2). Implicit attitude measures were shown to predict behav-
iours that could not be predicted by explicit measures or had predictive value above
those (Dovidio et al. 2002; Vargas et al. 2004).
Future research on the relations between age stereotypes and age discrimination
is urgently needed that (a) is based on an adequate definition and assessment of age
discrimination, (b) combines field studies (typically using a correlative design) with
more controlled experiments in the lab, and (c) takes into consideration moderating
variables in order to investigate for whom and in which situations the relation holds
or does not hold.
A second upshot of our review is that taking into account not only the actor, but
also the perceiver’s perspective provides us with a much broader and more
26 P. Voss et al.
c omprehensive understanding of the stereotype-discrimination relations, and also

implies a new starting point for interventions targeting age discrimination. Both
perspectives can inform each other, and considering influences of age stereotypes
on the behaviours and perceptions of both sides in interactive situations seems to be
a promising avenue for further research. This conclusion is much in line with a sug-
gestion that was put forward by King and Hebl (2013) who claimed that stereotyp-
ing is best investigated in real life contexts and interactions. This would also
counteract the concerns regarding ecological validity (e.g., a meta-analysis on age
bias in laboratory and field settings identified negative relations between generaliz-
ability and effect size, Gordon and Arvey 2004).
In sum, although conceptually an involvement of age stereotypes in age discrimi-
nation is inevitable, the mere activation of age stereotypes is by no means a suffi-
cient condition for the occurrence of age discrimination. A full understanding of the
complexities of these relations requires frameworks that incorporate additional per-
sonal and contextual constraints and also consider the domain-specificity of age
stereotypes and age discrimination.
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Chapter 3
Multiple Marginalizations Based on Age:
Gendered Ageism and Beyond
Clary Krekula, Pirjo Nikander, and Monika Wilińska
3.1 Introduction
When Butler introduced the concept of ageism in 1969, it primarily aimed to high-
light forms of marginalization and discrimination that older people are exposed to.
This was in line with the wider scientific discourse of the time that focused on
revealing categorical inequalities as experienced by different social groups based on
age, gender, race/ethnicity, and so on. Rooted in social movements, the debate
revolved around identity politics with an ambition to expose unique forms of dis-
crimination faced by diverse social groups that were, however, approached from the
perspective of a homogeneous collective (Addelson and Potter 1991; Mirza 1997).
As presented in the Chap. 25 by Snellman in this volume (2018), ageism has
made a conceptual journey since its inception in the 1960s. One of the hallmarks of
that journey was a gradual move from understanding ageism in terms of attitudes
only to conceptualizing it as a form of oppression deeply embedded in social struc-
tures. In parallel, age is increasingly seen as a socially constructed category that is
by no means equivalent to a personal characteristic (Calasanti 2003; Laz 1998;
Krekula 2009; Nikander 2009). Age has steadily become recognized as a producer
of social division, with a role as a social and identity marker, but also underlining its
power in defining social relations, giving rise to institutions and creating i nequalities
C. Krekula (*)
Karlstad University, Karlstad, Sweden
P. Nikander
University of Tampere, Tampere, Finland
M. Wilińska
Jönköping University, Jönköping, Sweden

https://doi.org/10.1007/978-3-319-73820-8_3
34 C. Krekula et al.
(Gullette 2004; Hockey and James 1993; Krekula 2007; Krekula and Johansson
2016; Nikander 2009). Essentially, this posits age as one of many dimensions of
social differentiation processes that cannot be understood in isolation. The under-
standing of age is therefore becoming further enriched as it is recognized as socially
constructed in interaction with other categorizations, such as gender, class, race, and
ethnicity (Hockey and James 1993; Krekula 2007; Nikander 2002).
One of the first categories used to complicate the understanding of ageism was
gender. The term “gendered ageism” was introduced by Itzin and Phillipson (1993,
1995) in their study of age barriers at work where they focused particularly on gen-
der in both the private and public sector. Since then, gendered ageism has been
defined in a range of ways. One recurrent definition describes it as a double jeop-
ardy, where two interacting power systems lead to an increased vulnerability (cf.
Barrett and Naiman-Sessions 2016; Handy and Davy 2007; Walker 1998). In gen-
dered ageism, the perspective of double jeopardy emphasizes the dominance of
patriarchal norms combined with a preoccupation with youth that results in a faster
deterioration of older women’s status compared to that of men (Barrett and Naiman-
Sessions 2016).
Any definition of gendered ageism as a phenomenon directed solely against
older women is built on delimited categorizations that ascribe them with a presup-
posed subordinated position. The same is true for definitions of ageism that see it as
directed against older people only (see for example Butler 1980; Kalish 1979;
Palmore 2001). Both perspectives differ from later research that has shown ageism
also as targeting younger people (Duncan and Loretto 2004), and from theoretical
work which emphasizes gender as a relational process, and as something which can-
not be reduced to women only. Further theoretical problematization of the concept
is therefore needed to understand the processes of multiple marginalizations based
on age and to see how these affect both men and women of various ages.
In this chapter, we discuss multiple marginalizations based on age by focusing
specifically on age and gender as an intersection of power relations. We centre our
attention on the concept of gendered ageism that was introduced to spotlight the
context-specific dynamics of ageism that women and men alike can be exposed to.
The concept is thus placed in a wider context to further problematize the processes
which create multiple marginalizations. In this, we draw attention to underlying
theoretical assumptions of age-based marginalization and the concept of gendered
ageism; we problematize how ageism relates to the current debate on age as socially
construed, as a power relation and as marginalization; and we argue that gendered
ageism can be understood as a form of doing age. We offer an outline of a research
approach that develops the understanding of the processes that can create multiple
marginalizations based on age and encourage innovative routes that yield further
insight into the complexity of social and gendered inequalities in later life.
3 Multiple Marginalizations Based on Age: Gendered Ageism and Beyond 35
3.2 F
rom Ageism to Gendered Ageism and Multiple
Marginalizations
In their seminar studies of age barriers at work in the public and private sectors,
Itzin and Phillipson (1993, 1995) managed to show that ageism does not operate in
isolation from other categories, and, alongside others, claimed that the sexualization
of women’s value in youth was a clear proof of this. They concluded that “gender
on its own is an insufficient explanation of the discrimination experienced by
women in organisations” (Itzin and Phillipson 1995, p. 91) and claimed that “gen-
dered ageism” formed a central part of organizational cultures. They discovered
discrimination in relation to recruitment, career, and pension, and noted that women
were defined as ageing at an earlier chronological age, reaching their peak at age 35,
while men were considered to reach their peak much later. Their argument indicated
that gendered ageism also meant age- and gender-based glass ceilings for women
regarding both employment and promotion.
The definition of gendered ageism as a double jeopardy has, with some modifica-
tion, been applied by other researchers, not least some feminist researchers (e.g.,
Arber and Ginn 1991; Duncan and Loretto 2004). Researchers have shown that
women of all ages, more so than men, experience ageism based on appearance and
sexuality in the labour market, among other contexts (Clarke and Griffin 2008;
Duncan and Loretto 2004; Granleese and Sayer 2006). Research has also shown, for
example, that doctors ask fewer questions and prescribe less medication for coro-
nary heart disease to middle-aged women, which in turn can contribute to inequality
in relation to health (Arber et al. 2006), and that female older workers were made
invisible in a public inquiry into the older unemployed, due to a discursive struggle
for recognition of older male workers as a disadvantaged group in the labour market
(Ainsworth 2002).
The concept of gendered ageism as a double jeopardy is also used when pointing
to the dynamics of gendered ageism and other categorizations and dimensions, like
physical beauty and looks. Here, a so-called triple jeopardy occurs, as appearance
has been posited as a further interactive dimension of ageism against women (cf.
Granleese and Sayer 2006; Handy and Davy 2007; Jyrkinen 2013; Jyrkinen and
McKie 2012). However, in societies that favour health, vitality, and appearance,
such requirements might affect older men as well (Hearn 1995). The combined
normative forces of healthism (Crawford 1980), lookism, and fitnessism, further
supported by ideals of consumerism, means that our future understanding and the
scope of gendered ageism continues to unfold.
Despite numerous definitions and continuous discussions on the combined effect
of age and gender, the terms double/triple jeopardy remain theoretically underdevel-
oped and somewhat poorly explored (for a criticism of the concept, see Krekula
2007). For instance, while the dual effect of gender and age is often evidenced by
examples concerning women, no substantial data or ambitious theorizing to date
exists on whether and how such combined jeopardies affect men, and, if they do,
how the dynamics, contexts, and experiences of such ageism might change. Duncan
and Loretto’s (2004) study on ageism in working life showed that a larger number
of men than women experienced age discrimination, particularly among the age
group 25–44. Consequently, they argued that it would actually be more appropriate
to apply the slogan “Never the right age” to men rather than to women. In a similar
vein, Thompson (1994) argued that later-life masculinities have been subordinated
to the effort to understand middle-aged and younger men’s lives, which contribute
to gerontophobic masculinity ideals. More recently, work on gendered ageism has
mapped the contextual variations and the gender-specific dynamics of people’s
daily lives to see how interactional contexts shape men’s perceptions of ageism in
ways that work to provide them with immunity from it (Ojala et al. 2016).
Based on an analysis of an employment tribunal court’s final judgment of an
accusation of discrimination on the basis of both age and gender, Spedale et al.
(2014) argued that ageism has a base in the social construction of an ideology of
youthfulness. This ideology is described as having been reproduced through dis-
courses on “brand refreshment and rejuvenation” (p. 1586) and, in that way, obscur-
ing the agency of the more powerful organizational actors while at the same time
marginalizing the weaker ones (cf. Clarke and Griffin 2008 and Handy and Davy
2007 on ageism and youthfulness). However, the ideology of youthfulness as a
starting point does not suffice to explain marginalization based on age, as it affects
younger age groups as well. An increasing number of studies demonstrate that age-
ism is also directed against children and youth, often discussed through the concepts
of adultism (Bell 1995; Ceaser 2014; Flasher 1978; Kennedy 2006) and childism
(Pierce and Allen 1975; Young-Bruehl 2012). For instance, entry as well as exit
from the labour market can be affected by ageism, the former to a large extent espe-
cially targeting youth.
Later shifts in the problematization of both age and ageism resulted not only
from changing social realities but also from theoretical developments in understand-
ing inequalities more broadly. Where a focus on homogeneous categories used to
exist, contemporary research emphasizes differences within categorizations like
age, revealing also their relational nature. For instance, a growing number of studies
explore the interaction between age, gender, and class (see McMullin and Cairney
2004; Zajicek et al. 2007), age, gender, and race (Mair 2010), age, gender, and sexu-
ality (Ambjörnsson and Jönsson 2010), and age and masculinity (Bartholomaeus
and Tarrant 2016). Reviewing dominant ways of approaching intersectionality and
reflecting upon their shortcomings, Walby et al. (2012) proposed that an intersec-
tional perspective encourages a language of inequalities and systems of inequalities.
From this perspective, intersectionality stresses the need to understand the powerful
alongside the powerless and opens a discourse of mutual shaping while recognizing
the flexibility and the unfinished projects of creating differences.
Transferred to debates on ageism, these developments demonstrate that the main
problem with the concept, or any other social inequality for that matter, is not
oppression organized along the lines of age. Rather, analytic and theoretical work
increasingly zoom in on the coexistence of various intersecting forms of oppression
that are recreated to produce differencing outcomes and conditions for various
groups of people. These challenges are yet to be taken up in the discussions regarding
ageism. First, as Gullette (2004) vehemently advocated, there needs to be a greater

understanding of the prominence of age in the lives and institutions that relate not
only to older people but to people of all ages. Second, the relations between people
and institutions need to be seen as an interactive whole rather than as flows between
static entities (Hancock 2007). Third, instead of presuming a priori defined catego-
ries, any intersectional perspective on ageism needs to employ a more empirically
driven approach to discover rather than just to test assumptions that are taken for
granted (Hancock 2007).
3.3 The Perspective of Age as Doing
The perspective of age as doing is grounded in an understanding of age as a socially

and culturally constructed category. As such, age does not constitute a role, an iden-
tity, or an individual attribute, but is rather an expression of the social context.
Researchers have used different concepts to discuss the active and interactional
dynamics of age, for example, age-as-accomplishment (Laz 1998), generationing
(Alanen 1992), as doing age (Nikander 2002, 2009; Utrata 2011), age relations
(Calasanti 2003), and age coding (Krekula 2009). Such interactional perspectives of
age offer a move beyond simple understandings of marginalization or ageism as
things that are done to one group by members of another. What we begin to see
instead is a collaborative social process that involves everyone. This means that age-
ism, similar to other inequalities, is situationally and interactionally accomplished
rather than a natural category (Schwalbe 2008).
Furthermore, to conceive of ageism as actively created in social encounters and
processes is to recognize that no one has a predefined role of a victim or an offender.
This immediately challenges the widely spread discourse on old age and ageism in
which older people are mere victims of ageism. To date, the literature on ageing and
inequality typically focusses on things that are perpetrated against old people, while
less attention is given to ageist actions by older people themselves. Minichiello
et al. (2000) discussed, for example, the concept of interactive ageism to emphasize
the diverse ways in which people of different ages respond to and reproduce ageism.
Likewise, older people with different life experiences and histories respond to simi-
lar oppressive structures differently. What is more, on many occasions, older people
themselves are found to convey and maintain ageist attitudes, and to partake in self-
inflicted ageism (e.g., Andrews 1999; Hurd 1999; Lund and Engelsrud 2008; Öberg
and Tornstam 2001; Wilińska 2012).
Age as formed in and through interaction, negotiation, and on-going discursive
processes involves everyone at different levels. Fineman (2011) described this with
the metaphor “the social game we play with age” and argued that age as an organiz-
ing principle is powerful because it is seen as a neutral affiliation and because the
organization thus receives an objective character. In a similar vein, Nikander (2002)
claimed that “the theoretical and analytic myopia of much lifespan and ageing
research has, in practice, meant overlooking the interactional processes whereby
age and its meanings are accomplished” (p. 29). The study of age from an interac-
tional perspective thus means examining the nuances and situationally or institu-
tionally processual dynamics of age rather than the category itself. How does age
become relevant? How is it done, by whom, and to what ends? When analysing the
persistence of the hierarchical gender system, Ridgeway and Correll (2004) pro-
posed that in addition to considering gender norms and beliefs, it is crucial to con-
sider social relational contexts, which they define as “the arenas where these beliefs
or rules are in play” (p. 511). This framework can be applied to age to disentangle
the variety of ways in which age enters or is actively brought into people’s everyday
thinking and discourse and institutional contexts, and the ways it produces age
orders that organize societies (Twigg 2004).
Observing the encounters between art gallery workers and visitors at the ticket
office, Llewellyn (2015) demonstrated the creative ways in which the parties col-
laboratively do age while engaging in the process of purchasing and selling age-
grouped and age-priced entry tickets. Here, the organizational encounter was
structured according to the age of the visitors. Some visitors voluntarily announced
membership in an age category to receive an age concession. At other times, gallery
workers stepped in and actively offered the concession based on their professional
ability to interpret visual age cues. An opposite relation was observed in a study of
a non-governmental organization working with social programmess addressing
older people (Wilińska and Henning 2011). The organization first used socially
available images of age to construct an intervention program, and then looked for
people who would fit into a very precise definition of an older person. The organi-
zational objectives were therefore reliant on the process of fitting real people into
age categories; age was used as resource enabling the organization to govern the
participants.
Age as a cultural and social construct comes with an easily accessible and ready-
to-use arsenal of culture-specific beliefs and norms (see also Tilly 1998, 2003).
These are construed around opposing poles: “young,” the desired age characterized
by beauty, vitality, and strength; and “old,” the feared age associated with decline,
disease, and weakness. In this construct, age is a cultural resource that, like any
other category, helps us make sense of reality, but also limits our way of thinking
(Juhila 2004; Ojala et al. 2016). For example, when 55+ members of the University
of the Third Age (U3A) reject the idea of old age, they reject the socio-cultural con-
struct that has also very strong moral underpinnings (Wilińska 2012). The rejection
becomes an act of protecting one’s sense of self-esteem and self-identity.
The same goals of protecting one’s sense of self-esteem and self-identity can also
be achieved via bodily practices. For instance, a study by Ward and Holland (2011)
following older women and their hairdressing practices demonstrated that older
women who dyed their hair were not interested in just any type of beauty. Instead,
they were interested in non-old standards of beauty. Similarly, when Twigg (2012)
discussed the dressing practices of older women, she demonstrated the negotiations
and struggles that go into deciding not only what to wear but also where to purchase
the clothes. As Krekula (2009) pointed out, different outfits and shopping spots are
age coded to indicate those that are more or less appropriate for certain groups of
women. Regardless of the outcome of such negations, age stands out as a cultural
and actively (re)produced resource that facilitates the process of even mundane
decision making.
As a chronologically ordered category, age, in other words, clearly allows us to
situationally mark and index cultural lifespan norms, preferences, and activities
(Nikander 2002). Krekula and Johansson (2016) have noted that there are different
aspects of the meaning-creating contexts where age is done. They argue that, even
though these are not separate from each other, it can be fruitful to distinguish
between, for example, age as a norm, age as a (discursive) resource, and age as
marginalization. These different types of doing relate to ageism in different ways,
and the doing of age is intimately connected with age as a power relation.
Regardless of the concepts applied, age is thus understood as a kind of political
and discursive location. Thus, the perspective of age as doing is only one of several
steps that need to be taken in order to have a broader and more dynamic understand-
ing of ageism. Each act of doing, negotiating, and interacting is deeply situated in
power structures that are constantly recreated. Age must therefore be understood as
an important power structure that has a key role in organizing society, informing
groups’ identities and their access to power, and intersecting with other power rela-
tions (Calasanti and Slevin 2006; Calasanti et al. 2006; Fineman 2011; Krekula
2009). It is only via such conceptualization of age that we come closer to under-
standing the diversity and complexity of ageing, and by extension, ageism (McMullin
2000).
3.4 The Perspective of Age as a Power Relation
Power is not something that one has while others do not; power is a productive
capacity emerging in and producing social relations (Foucault 1997). Taking into
account the diverse theoretical definitions of power, we take it to refer to the “capac-
ity to make things happen, but exactly what can be made to happen always depends
on the context in which resources we possess are or are not usable” (Schwalbe 2008,
p. 201). To re-emphasize, it is the situational context that makes some resources
more usable than others, and that determines the ways in which those resources can
be used.
Three dimensions of power are particularly relevant when seeking to understand
ageism: categorical inequality, the normality which appears in (un)marked age, and
the structuring via temporality which exists for example in institutionalized life
courses and various temporal codes (Krekula and Johansson 2016).
Using the concept “categorical inequality,” Tilly (1998, 2003) discusses how
“durable inequalities” arise in categorical pairs that are transferred across interac-
tions and contexts, thus (re)producing the system of inequalities organized along the
lines of age, gender, race, religion, sexuality, and (dis)ability. In this, the meaning of
age to the system of inequality cannot be fully comprehended without understand-
ing the dynamic existing between “old” and “young” age. These two opposing
c ategories not only delineate the discursive possibilities, but also indicate the sys-
tem of values, activities, and norms. To be young is to be active and full of life; to
be old is to be passive and void of life. The categorization is, thus, held as the fun-
damental cause behind inequality and marginalization (see also Bodily 1994), or as
expressed with the concept of age coding: these are practices of distinction that are
based on and preserve representations of actions, phenomena, and characteristics as
associated with and applicable to demarcated ages (Krekula 2009).
The strength in these processes is that they facilitate the transfer of joint notions,
practices, and interpersonal relations between different contexts and, by doing so,
enable the reproduction of old routines in new contexts. All in all, this perspective
points to the fact that inequality is not something done by some people to others, but
rather it is a process involving various actors, who do not necessarily reproduce
inequality in order to perpetuate harm, but rather to accomplish different goals and
objectives. Marginalization based on age is, thus, created in the practices where age
is done; it is a form of age doing. In the words of Tilly (1998, 2003), inequality is
created when people try to solve other organizational problems by applying categor-
ical inequality to divide valued resources. The availability of existing categorization
scripts makes the whole process very easy and accessible to everyone who shares
the same socio-cultural context. This is also what makes the process very durable
and dangerous.
Through categorization, we do perpetuate marginalization. As Schwalbe (2008)
contends, the power of small things contributing to the process of inequality is
underestimated. This is particularly the case when those small things we do are
conceived of as natural or when categorical notions are discussed in terms of nor-
mality. Krekula and Johansson (2016) use the the concept pair marked/unmarked
age to problematize this type of normality based on age. They argue that marginal-
ization of demarcating age groups is created in the processes where some ages are
construed as an unproblematized—“unmarked”—norm, by means of, for example,
prefixes and derogatory names which construct one side of a binary categorization
as epistemologically unproblematic. When age is done as an age hierarchy, discur-
sively and materially, the unmarked age is both the basis for the doing and the main
beneficiary of it. The unmarked age makes up the norm to which other ages relate
(Brekhus 1998).
The way normality is shaped and which age groups appear as an unproblema-
tized norm and which are seen as divergent varies in different contexts and situa-
tions. For example, Krekula’s studies on discrimination and age relations in work
organizations show how age normality varies among different work organizations.
While employees just under the age of 40 are considered to be too old by the tele-
marketing industry, they can also be seen as too young to gain status and prestigious
assignments within parts of the academic world (Krekula 2011) or regarded as
being of the best age to be a firefighter (Krekula 2012). It is therefore essential to
precisely focus on the unspoken norm organizing a given context. Importantly, the
unspoken/the norm is context-bound, meaning that, once revealed, the same
unmarked category cannot be simply applied to different contexts. For example,
while being 50 is often considered to be “far too old” to become a parent, the same
age is regarded as “far too young” to retire (Wilińska and Cedersund 2010).
A third relevant power approach puts emphasis on normativity in relation to tem-
porality: the complex and dynamic relations between the past, the present, and the
future (West-Pavlov 2013). This type of power—norma-/temporality (Krekula and
Johansson 2016)—is practised through notions of how life ought to be lived and
through norms of what is considered a natural consequence and time for different
phases in life such as education, long-term relationships, having a family, and retire-
ment. Even though this power perspective has been lifted within several different
disciplines in recent years, for example in social and cultural studies (see Ahmed
2007) and queer studies (see Freeman 2010; Halberstam 2005; Riach et al. 2014),
the life course perspective has been the most prominent perspective so far.
In his seminal definition of the life course, Elder (1994) describes it as “pathways
through the age-differentiated life span, to social patterns in the timing, duration,
spacing and order of events” (p. 21). Life course as socially constructed is seen as a
dynamic process in which structured pathways interrelate with individual life tra-
jectories. Those structural pathways are bounded by institutions that create a frame
for our lives.
One of the most influential theories concerning the patterning of the life course
as movement through a sequence of positions is a model of the institutionalization
of the life course (Kohli 1986, 1988). This widely used and accepted theory empha-
sizes life-time temporalization as one of the core structural features of the life
course. It sees chronological age as having become the basic criterion for a stan-
dardized “normative life course,” and focusses on the institutional patterns that
shape life course movement through a temporal tripartite order of periods of prepa-
ration, activity, and retirement (Kohli 1986, p. 272). The institutionalized life course
model provides a general macrosociological frame for understanding how specific
patterns of rules constituting the life course operate and process people through
social structure, and how collective institutional transitions and expectations shape
individual actions and people’s biographical perspectives. It can therefore be seen as
a power structure—a temporal regime—both in terms of division of resources and
opportunities, and as a type of disciplinary element to enforce norm compliance.
The degree to which a unified model of the historical institutionalization of the
life course still captures the increasing complexity, heterogeneity, and social dif-
ferentiation across life can easily be thrown into question. Indeed, both class and
gender (Formosa and Higgs 2013; O’Rand and Henretta 1999) as major potential
sources of social inequality and marginalization clearly challenge life course pat-
terns and typical (male) trajectories. Bringing gender and gender specific economic
life course dynamics and pluralities into the picture clearly complicates any for-
merly clear-cut view on life course inequality and ageism.
3.5 Gendered Ageism as Doing
Understanding age as doing, and thus also as a power relation, sheds new light on
the concept of ageism. Not only does it illustrate the complexity of ageism, but also
emphasizes the need to approach marginalization based on age from the perspective
of multiplicity. This brings us back to the discussion on gendered ageism and the
need to further problematize it theoretically.
We argue that gendered ageism can be understood as a dynamic social position-
ing practice. This is in contrast to the common approach to gendered ageism that
conceives it in terms of stereotypes, prejudices, and discrimination. We draw on
contemporary research on age and other social positions that put emphasis on cate-
gorizations and the relations between them as created through practices, processes,
and everyday interactional doings where one applies notions of difference between
age groups. Jyrkinen (2013) gives an example of the elements of such an approach
to gendered ageism. Starting from a position that ageism is a question of discrimi-
nating practices (for an overview of this perspective, see, e.g., Heikkinen and
Krekula 2008; Wilkinson and Ferraro 2002), Jyrkinen argued that gendered ageism
refers to discriminatory actions, whether intentional or non-intentional, that are
based on the intersection of gender and age. She also contends that gendered ageism
is not limited to relations between men and women, but also manifests among
women as well as among men.
In a similar vein, we propose that gendered ageism is not only based on notions
that age and gender groups are different, but also on notions that phenomena, situa-
tions, and spaces are gendered and age coded (Krekula 2009). Importantly, such
coding takes place within the context of other structures (e.g., class, ethnicity) that
actively delineate the possible repertoire of resources and practices used to define
certain situations and their actors. For example, the idea of Marks and Spencer (a
company that sells clothing among other things) as a store for older women (Twigg
2012) is also intertwined with structures of social class and ethnicity.
We understand gendered ageism as consisting of differentiating practices which
put demarcated age and gender groups in a marginalized position, or, expressed dif-
ferently, practices which give age-based meaning to bodies. In other words, specific
age and gender codings result in the subordination of and in unequal division of
resources for the demarcated group. Implied in this is the fact that the perspective of
power has not so far been explicitly applied in work on the concept of gendered
ageism. However, the presence of power relations in assumptions about gendered
ageism appears in studies which emphasize counter-power, or strategies against
ageism. One example is Barrett and Naiman-Sessions’ (2016) focus on how the
simulation of girlhood by the so-called Red Hat Society, in the forms of adopting
children’s social roles, dressing up, and playing, constitutes a performative act that
resists gendered ageism by increasing ageing women’s visibility and asserting their
right to leisure. At the same time, they argue, it can be seen as resonance with a
dominant cultural metaphor for old age as a “second childhood” and therefore not
only provides opportunities for resistance to gendered ageism but also contributes
to its entrenchment.
Similar strategies and counter-power can be seen in Clarke and Griffin’s (2008)
study on how women up to the age of 70 used beauty work to respond to gendered
ageism. The practices they discussed—dressing and beauty—can be seen as an
attempt to broaden the room for manoeuvring by challenging perceived age coding
(Krekula 2009; Nikander 2008), and therefore can be interpreted as strategies
against categorical inequality. This is further exemplified by a study of active,
female members of the University of the Third Age. At the outset of ageist structures
that exclude older people from social and public life, older women actively turn to
different images of womanhood to create a more positive environment for them-
selves. Effectively, they repress oppressive age identities to fully embrace their vari-
ous gender identities, such as wife, mother, or girlfriend (Wilińska 2016). Turning
to the feminine appears to be an enabling strategy among older women that reduces
the impact of ageism that is innately gendered.
Gendered ageism as a practice of inequality is deeply embedded in institutions.
Age as a category that defines social relations gives rise to various age-based institu-
tions. One of these is retirement and the pension system. The extant literature exam-
ining these two major age-based institutions provides a wealth of examples of how
the institutionalized life course contributes to the marginalization and discrimina-
tion that, engaging with age, engages also with gender. For example, recent devel-
opments within the pension system schemes that promote individualization and
privatization of pensions are found to exacerbate gender inequality (Leitner 2001),
where the diverse life courses and work histories of men and women have their
immediate result in a considerable gender pension gap (Foster and Smetherham
2013; Frericks et al. 2007, 2009; Price 2006). Therefore, not without a reason,
Hartmann and English (2009) stated that financial security while on pension is of
particular importance to women. The institution of retirement as we know it is a
men’s concept (Calasanti 1993, 2002) and within that context it is not surprising
that unquestioned heteropatriarchal norms (Grady 2015) are overlooked in social
policies as a gender-neutral approach.
We also emphasize the relational character of gendered ageism, meaning that its
constitutive practices and outcomes vary from situation to situation. This may refer
to a range of language and bodily practices that only when put in context gain their
ageist meaning. For example, the perception of hair dying as a potentially ageist
practice changes its meaning not only depending on how old the person doing it is
(compare a 20-year-old woman with a 60-year-old woman), but also what the pur-
pose of doing it is (e.g., covering grey hair versus dressing up for a Halloween
party). Similarly, it is within the limits of certain situations that we observe the ways
in which gendered ageism affects various groups. This interactive approach to gen-
dered ageism means that we need to remain open to the empirical results revealing
concrete forms of marginalization as directed towards different groups of men and
women (Ojala et al. 2016).
Further, approaching gendered ageism through the perspective of ongoing

dynamics and processes means recognizing that the construction and reproduction
of various age and gender categories takes place in a range of contexts serving dif-
ferent purposes and involving discursive and bodily practices. The doing of age as a
power relation is an embodied practice in a sense that age and ageist practices
always refer to concrete bodies that are assessed via the perspective of age (Laws
1995). Laz (2003) adds to that, emphasizing the mutually constitutive relation
between age and embodiment that cannot be separated. In this, bodies are often the
key markers of age at large. Gendered ageism as a concept cannot therefore be
reserved for certain groups of people, and the understanding of embodied age opens
new ways for examining this phenomenon. For example, a reflection upon media
representations of successful ageing images (Calasanti and King 2005) reveals the
ways in which bodies of older men are highly sexualized and described based on
gendered age norms. Thus, men are not immune to ageism (Duncan and Loretto
2004; Ojala et al. 2016), but the outcomes of gendered ageism on the lives of older
men and women are different, as Sandberg’s (2013) study on intimate relationships
demonstrates.
3.6 Conclusions
Starting out from a discussion about the concept of gendered ageism, this chapter
problematizes and further develops the phenomenon of multiple marginalizations
based on age. Our discussion is inspired by critical age research, a field which
emphasizes age as organizing, doing, and as a power relation, and which argues for
analyses based on wide age spans, that is, those that do not simply focus on demar-
cating age categorizations (Krekula and Johansson 2016). This proposition echoes
an understanding of different social divisions as having varying organizing logics
(e.g., Phoenix and Pattenama 2006; Yuval-Davis 2006).
In this chapter, we placed gendered ageism in a wider context and subsequently
examined two interconnected practices: age as doing and age as a power relation.
We introduced the concept as a socially constructed relational and differentiating
practice, which places specific age groups in marginalized positions with unequal
division of resources. From the social constructionist perspective, meanings of age
are upheld and/or challenged in everyday interactions, and gender, like other inter-
sectional categorizations, becomes enmeshed with age in everyday encounters.
From this perspective, gender as an interactionally constructed facet of ageism can
be understood as something which sheds light on age, and, in a similar vein, on
practices that construe age as a position of marginalization. This understanding can
also, as we have discussed here, be generally applied to multiple marginalization
based on age. Below we outline the key starting points for further research on gen-
dered ageism and multiple marginalization.
One of the most important insights following from our definition of gendered
ageism is that research into this phenomenon (and other marginalizations based on
age) cannot easily be related to chronological age only. For example, studies high-
lighting appearance as central to the discrimination of older women (Clarke and
Griffin 2008; Handy and Davy 2007) indicate that problematizations of gendered
ageism cannot only be based on chronological age, but also need to include how
these markers are used and how they create ageism. This brings us to the importance
of ideas such as lifetime chronological order and temporal schemes, norms, and
imperatives as key conditions affecting the organizational lives of both men and
women. The concept of gendered ageism clearly calls for studies that take to heart
the temporal processual aspects that may help to further dismantle typical life
course patterns. These temporal aspects and dynamics, taken together and explored
as mutually intertwined, may open up new venues for the theorizing of multiple,
intersectional marginalizations. Viewed in this manner, age, gender, sexuality, and
class as temporal practices (see Ahmed 2007) may be approached in ways that go
beyond simple understandings built on additive or mutually reinforcing relation-
ships characterized by former notions of double or triple jeopardy.
Methodologically, this draws us towards everyday life and interactional
approaches to the study of social life, or as Sztompka (2008) calls it, the sociology
of existence that aims to capture social life as it unfolds. By aiming to grasp “the
happening of the social world” (Lury and Wakeford 2012, p. 2; see also Pink 2012),
we propose to focus on the processes and practices that in turn are contingent upon
the engagement with the concepts of time and place.
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Chapter 4
Origins of Ageism at the Individual Level
Sagit Lev, Susanne Wurm, and Liat Ayalon
4.1 Introduction
The term ageism was first coined by Butler in 1969. According to his early definition,
ageism is an age discrimination which is reflected in the prejudice of one age group
toward other age groups (Butler 1969). Although ageism can be aimed at younger
age groups (Snape and Redman 2003), most of the theoretical and empirical research
on ageism has focused on the old age group (Iversen et al. 2009). Butler himself
refined his definition of ageism in 1975 as “a process of systematic stereotyping and
discrimination against people because they are old” (Butler 1975). Following Butler’s
later definition, the current chapter focuses on ageism toward the old age group.
Although Butler focused on negative stereotypes, current perceptions of age-
ism include both positive and negative stereotypes towards older adults (Iversen
et al. 2009; Palmore 1999). According to the stereotype content model, older
adults are perceived as incompetent but warm. These perceptions lead to emo-
tions of pity and sympathy and less so to emotions of envy (Cuddy and Fiske
2002; Fiske et al. 2002). Consistent with this claim, a large body of research has
indicated that ageism is manifested in both negative and positive age stereotypes
S. Lev (*)
Department of Social Work, Ariel University, Ariel, Israel
S. Wurm
Friedrich-Alexander-Universität Erlangen-Nürnberg, Nürnberg, Deutschland
L. Ayalon

https://doi.org/10.1007/978-3-319-73820-8_4
52 S. Lev et al.
and affective attitudes (e.g., Kite et al. 2005; Meisner 2012). In addition to cogni-
tive and emotional aspects of ageism, studies have also identified behavioural
implications of ageism, reflected in avoidance (Bodner et al. 2012) and patron-
izing language towards older adults (Nelson 2005).
Negative stereotypes as well as discriminatory behaviours toward older adults
are spread over diverse areas of society, such as in the labour market (e.g., Posthuma
and Campion 2009) and the healthcare system (e.g., Bowling 2007) (for further
details see section introduction of this book: “On the Manifestation and Consequences
of Ageism;” Ayalon & Tesch-Römer 2018). Diverse social and psychological theo-
ries, operating at a variety of levels (individual, interpersonal, evolutionary, and
socio-cultural), shed light on the roots and dynamics of ageism, and by doing so,
provide a robust understanding of the topic (North and Fiske 2012).
In this chapter, we present three theories to provide a comprehensive understand-
ing of the psychological and sociological processes that constitute the basis of age-
ism at the individual level: terror management theory (Greenberg et al. 1986);
stereotype embodiment theory (Levy 2009); and social identity theory (Tajfel and
Turner 1979). These three theories were chosen because they provide a wide and
comprehensive theoretical understanding concerning the causes as well as the
expressions of ageism. Additionally, these theories have served as the basis for
numerous studies that examine various aspects of ageism and provide evidence for
the relevance of these theories to explain ageism at the individual level.
It is important to note that other theories, such as social affordances theory (Montepare
and Zebrowitz 2002), which provides an explanation of the roots and dynamics of age-
ism at the interpersonal level, or social role perspective theory (Kite et al. 2002), which
provides an explanation at the socio-cultural level, could also have served as potential
explanatory models for the development of ageism (North and Fiske 2012).
Each of the theories sheds light on different roots of and reasons for ageism, and
on different reflections of ageism among various age groups. Capitalizing on these
three theories, we present a model that suggests possible interactions and relation-
ships between ageism as it is manifested in various age groups across the life span.
We suggest that terror management theory provides an explanation for the roots
and motives of ageism towards old age groups among young and middle aged
groups as well as among the young-old age group, and that stereotype embodiment
theory provides an explanation for ageism among the young-old and old-old age
group. Social identity theory, in contrast, provides an overview of the manifestation
of ageism among different age groups (see Fig. 4.1).
The definition of ageism is fraught with an assumption that society tends to view
the old age group as a distinct and separate group with unique features. Although in
the definition lies a criticism of this separation and of the attribution of specific fea-
tures to the old age group, this separation forms the basis for the theoretical under-
standing of the dynamic nature of ageism, as well as a methodological basis for the
empirical examination of ageism. Hence, the three theories that are presented are
based on the assumption that age groups can be captured and defined as social groups
with unique features that separate and distinguish them from other age groups.
The following section first provides an overview of the theoretical and empirical
basis of the division of individuals into age groups. The subsequent three sections
4 Origins of Ageism at the Individual Level 53
Chronological Age
Terror Management theory
Older adults= Death anxiety
Stereotype Embodiment theory
Embodiment of internalized ageist attitudes
Social Identity Theory
Older adults= Low status
Ageism Self-Ageism
Temporary adaptive
strategies (Subjective age;
successful ageing; active
Inevitable physical
deterioration
Long term adaptive strategies
-Acceptance of the inevitable deterioration

-Strengthening of alternative resources for
self-esteem and meaningful life
Fig. 4.1 An integrated model of ageism in younger and older adult
present the three theories and their possible contribution to the understanding of the
roots and maintenance of ageism at the individual level. Finally, we present a com-
prehensive model, based on the three theories, to better conceptualize the roots and
maintenance of ageism across the life span. The model we present expands on
Bodner’s (2009) etiological model for ageism among younger and older adults.
4.1.1 A
Rationale for Examining the Etiology of Ageism
in Different Age Groups
Various studies have shown that chronological age is an important marker of objec-
tive and subjective transformations that unfold during one’s lifespan. According to
these studies, older age is associated with deterioration of physical abilities such as
sensory and motor performance and gait speed (Chodzko-Zajko and Ringel 1987;
54 S. Lev et al.
Reinders et al. 2015) or cognitive ability (e.g., Craik and McDowd 1987; Old and
Naveh-Benjamin 2008; Rönnlund et al. 2015). Recent studies that have examined
psychological and sociological features, such as wellbeing, emotional experience,
and social power, have indicated that these features tend to increase during the first
period of life. However, from midlife on, these features tend to decline (Blanchflower
and Oswald 2004; Carstensen et al. 2000; Eaton et al. 2008).
The attribution of unique features to different age groups is also reflected in fun-
damental theories concerning the life course, when different periods are character-
ized by certain types of psychological crises (Erikson 1950) or by various
psychological tasks (Havighurst 1956). Others, however, have noted that there is a
wide heterogeneity within age groups. This heterogeneity tends to be particularly
pronounced in old age, as older adults are highly affected by their diverse life expe-
riences (Baltes and Baltes 1990).
Although changes during the lifespan are gradual and continuous, in the theoreti-
cal and empirical literature it is common to divide the adult population into three
main age groups: young adults (from 18 to 34–39 years), middle-aged adults (from
35–40 to 59–65 years), and older adults (aged 60–68+) (e.g., Bodner et al. 2012;
Cherry and Palmore 2008; Laditka et al. 2004).
In recent years, due to longevity and improvements in the quality of life, there is
a tendency to divide the old age group into two distinct groups: the young-old,
which is called the third age (65 to 80–85) and the old-old, which is called the fourth
age (80 or 85+) (e.g., Alterovitz and Mendelsohn 2013; Baltes and Smith 2003).
Due to increasing longevity, some authors have suggested an even more detailed
division into three distinct groups in the fourth age: old (75–84), old-old (85–95),
and oldest-old (95+) (Cohen-Mansfield et al. 2013).
Unlike other social characteristics, such as gender or nationality, where member-
ship tends to be permanent during the lifespan, the boundaries between different age
groups are permeable and temporary. Thus, although middle-aged adults may per-
ceive themselves as an in-group, and older adults as an out-group, these distinctions
are temporary. The instability of the boundaries between age groups is reflected by
the fact that the old age group used to be part of the younger groups, and the younger
age groups are expected to become part of the old age group, if they survive
(Greenberg et al. 2002).
This somewhat arbitrary division into different age groups, and especially the
primary division that perceives old age as a distinct category, forms the basis of the
theories presented in this chapter. Despite its limitations, this division has been used
in studies that examine ageism, and can be a useful tool in understanding of the
roots and dynamics of ageism during the life span among different age groups.
4.2 Terror Management Theory
Terror management theory claims that humans possess cognitive abilities that allow
them to be self-conscious, and that this self-consciousness is reflected in humans’
awareness of their vulnerability and mortality, which creates the potential for a para-
lysing terror. According to terror management theory, in order to manage the anxi-
ety brought about by the awareness of mortality, humans unconsciously sustain
faith in cultural worldviews, which enable them to portray human life as meaning-
ful, important, and enduring. The adoption of social and cultural rules allows
humans to believe that they are valuable and deserving within their culture. Perceived
social approval leads humans to feel self-esteem, which is reflected in the belief that
they are significant human beings in a meaningful world. These perceptions allow
humans to buffer anxiety and to maintain relative equanimity despite their aware-
ness of their vulnerability and mortality (Greenberg et al. 1997; Greenberg et al.
1986). Unlike proximal and conscious defences, such as active suppression and
cognitive distortion of death-related thoughts, self-esteem and worldview are not
based on a logical or rational approach to death, but provide symbolic and ongoing
defences which allow humans to construe themselves as valuable participants in a
meaningful universe (Greenberg et al. 1994, 1997; Pyszczynski et al. 1999).
There is a large body of research on terror management theory. These studies
follow the assumption that self-esteem and faith in one’s cultural worldview are two
important psychological structures that provide protection against death anxiety.
Based on this main assumption, studies have generated two hypotheses. The anxiety
buffer hypothesis states that strengthening either self-esteem or faith in one’s cul-
tural view reduces anxiety. The mortality salience hypothesis states that reminding
people of their mortality activates the need for validating their self-esteem and their
faith in their cultural view (Greenberg et al. 1997). Studies that have tested these
hypotheses for over 30 years, relying on more than 500 experiments in over 30 dif-
ferent countries, have yielded support for the theory and its core propositions
(Darrell and Pyszczynski 2016).
4.2.1 S
ocial Groups and Stereotypes in Light of Terror
Management Theory
Social relations and group identification constitute significant elements in terror

management theory. According to the theory, being part of a social group and hav-
ing significant social relations with others allows people to feel as though they are
integral parts of the cultural world and forms the basis for attaining self-esteem. Yet
the wish to be part of a group varies; people may wish to belong to certain groups
or to avoid others, according to their pertinent worldviews and their perceived
56 S. Lev et al.
self-worth (Solomon et al. 2004). Thus, out-group members who subscribe to dif-
ferent worldviews might threaten explicitly or implicitly the validation of the in-
group’s worldview. This psychological threat is one of the main causes of prejudice
and discrimination (Greenberg et al. 2002).
To conclude, according to terror management theory, identification with the in-
group is derived from the need to approve one’s worldview, to attain self-esteem,
and thus to buffer death anxiety. Conversely, discrimination towards out-groups is
derived from the anxiety that is evoked as a result of different worldviews that can
seem to threaten the worldview of in-group members (Greenberg et al. 2002;
Solomon et al. 2004).
These assumptions have formed the basis of various experimental studies that
have examined in-group bias as a reaction to mortality salience. Studies have indi-
cated that mortality salience leads to a more positive evaluation of in-group mem-
bers and a more negative evaluation of out-group members (e.g., Greenberg et al.
1990; Harmon-Jones et al. 1996). Studies have also shed light on the mechanisms
that lead from mortality salience to in-group bias, indicating the mediating role of
in-group identification and perceived collective continuity (Castano et al. 2002;
Herrera and Sani 2013) as well as control motivation (Agroskin and Jonas 2013). In
addition, studies have found that mortality salience increased the use of stereotypes
based on nationality, race, gender, sexual orientation, and age (e.g., Castano 2004;
Martens et al. 2004; Schimel et al. 1999). The use of negative stereotypes further
increased when a competitive or threatening out-group member was present
(Renkema et al. 2008).
4.2.2 A
geism Among Young and Middle-Aged Adults in Light
of Terror Management Theory
Following Greenberg et al. (2002), Martens et al. (2005) have suggested that terror
management theory could be used as a theoretical and empirical framework for
understanding the psychological and sociological processes that underlie ageism.
They have identified three psychological threats, derived from terror management
theory, to explain negative reactions toward older adults. These three threats include:
the threat of death, the threat of animality, and the threat of insignificance (Martens
et al. 2005). In the following sections, we discuss these threats and review some
studies that have examined ageism in relation to these threats.
4.2.2.1 The Threat of Death
Older adults serve as a direct reminder of our inevitable mortality. A sense of threat
is embedded in the human awareness that ageing leads to death. The encounter with
ageing, especially in its final stages, reminds us that even if we are able to avoid
accidents, diseases, and disasters, we will eventually die (Greenberg et al. 2002;
Martens et al. 2005). In an experimental study that examined this hypothesis,
Martens et al. (2004) found that mortal salience caused participants from the young
age group to rate the attributes of older adults as considerably different from their
own, thus increasing their distance from older adults. Furthermore, participants who
were exposed to mortality salience viewed older adults less positively than in the
control group. Another study demonstrated that distancing from and derogating
older adults in response to mortal salience occurs primarily among participants who
rated their personalities as similar to those of older adults. However, mortal salience
did not affect the level of distance from teenagers (Martens et al. 2004). This implies
that when participants perceive similarities between themselves and older adults,
they might feel more threatened by the prospect of their ageing and inevitable death
(Martens et al. 2004).
Additional support for this hypothesis is provided by a study that found a posi-
tive correlation between ageism and fear of death among young age groups (Bodner
and Cohen-Fridel 2014). A similar pattern has also been found among middle- and
old age groups, where death anxiety was correlated with ageism (Bodner et al.
2015) as well as with negative stereotypes of old age (Depaola et al. 2003).
These findings stress the uniqueness of the relationship between social versus
age groups and discrimination in different age groups. Whereas among social
groups discrimination towards out-groups emerges from holding a different world-
view, which can be perceived as a threat to the worldview of in-group members
(Greenberg et al. 2002; Solomon et al. 2004), among age groups the threat emerges
from the possible similarity between members of the groups. This distinction
emphasizes the unique nature of ageism, which is different from other forms of
prejudice and discrimination and points to the necessity for generating unique
hypotheses concerning its roots (Martens et al. 2004).
4.2.2.2 The Threat of Animality
A less direct association of older adults and death is embedded in the deterioration
of the physical body that is reflected in older adults’ physical appearance (e.g., wrin-
kles), as well as in the physical and cognitive decline that is often seen in older age,
and in the diminishing control over bodily functions that older adults often experi-
ence. These characteristics of old age remind us that, like all animals, we are flesh
and blood creatures who are vulnerable to death (Martens et al. 2005). According to
Isaksen (2002) the fear of encountering the deteriorating bodies of older adults
might be particularly high in Western society. This fear might be explained by the
prevailing perception in Western society, influenced by Judeo-Christian beliefs, that
view human beings as composed of body, mind, and soul. According to this belief,
as regards bodies, all humans are alike. In contrast, soul and mind are perceived as
unique features that define us on a social and cultural level and make us different and
separate from one another. Thus, physical decline and diminishment of physical
control among older adults creates an emphasis on the physical self over the spiritual
self and can symbolize the inability to impose mind over matter (Isaksen 2002).
58 S. Lev et al.
This hypothesis can be included as part of a wider hypothesis that suggests that
physical aspects of the body remind us of our mortal nature. According to this
hypothesis, the efforts of human beings to buffer their death anxiety by adopting
cultural beliefs and standards are threatened by their awareness of the physical
aspects of the human body. Humans might feel uneasiness and even disgust toward
physical aspects of their body, because they remind them of their animal nature,
their vulnerability, and their inevitable death (Goldenberg 2005).
This hypothesis is supported by studies that found that when mortality was salient,
participants expressed negative reactions and disgust towards different aspects of the
physical body, such as body products (Goldenberg et al. 2001) and breast feeding (Cox
et al. 2007a, b). In addition, the presence of stressing stimuli related to physical aspects
of the body were found to lead to higher death-thought accessibility compared with
neutral pictures (Cox et al. 2007a, b). However, other studies found that the effect of
mortality salience on physical aspects of the body, such as exercise and sexual activity,
was limited for participants high in neuroticism ( Goldenberg et al. 1999, 2008).
4.2.2.3 The Threat of Insignificance
Finally, ageism might evoke perceptions concerning the difficulty of preserving

positive self-esteem in old age (Martens et al. 2005). According to terror manage-
ment theory, self-esteem is a vital resource in human life, because it buffers the
potential for death-related anxiety (Greenberg et al. 1986). Social perceptions and
stereotypes often associate old age with ongoing loss of abilities and resources
(Bowd 2003; Cuddy and Fiske 2002; Ellis and Morrison 2005). It is these abilities
and resources that are perceived as crucial to acquiring and preserving self-esteem
in youth and middle-aged individuals. As a result, these age groups might perceive
the older adults as a threat, since they serve as potent reminders of the transitory
nature of these attributes. Thus, the threat of loss of these attributes might trigger
death anxiety (Martens et al. 2005).
One study that examined this hypothesis found that participants viewed teenag-
ers more favourably than older adults when they were primed with the importance
of engaging in physical activity, an attribute that usually declines with age. However,
when participants were primed with the importance of wisdom, an attribute that is
predicted to increase with age, there was no significant preference of teenagers
(Martens et al. 2005).
4.2.3 A
geism Among Older Adults in Light of Terror
Management Theory
Terror management theory is based on the assumption that death anxiety is a main
motive in human life, and that cultural worldview and self-esteem serve as uncon-
scious mechanisms to buffer the threat of death (Greenberg et al. 1997). According
to Martens et al. (2005), the encounter with older adults might evoke anxiety
because they represent inevitable mortality, physical deterioration, and loss of

resources perceived as essential to our self-esteem. This anxiety might be manifest
in ageism (Martens et al. 2005). However, this theory is focused on the perceptions
of young and middle-aged groups towards the old age group and does not describe
the way older adults perceive their own ageing process.
McCoy et al. (2000) claim that the protection of one’s cultural worldview and
self-esteem against the threat of mortality becomes less effective in old age. The
ongoing loss of abilities and resources might threaten older adults’ self-esteem. In
addition, the constantly changing values and rapid technological advancements that
characterize the Western world might threaten both the self-esteem and the world-
view of older adults. As a result of feeling “left behind” by these advancements,
older adults might perceive their abilities and roles as less relevant even before they
experience a loss of physical abilities. Moreover, they might perceive their world-
view as being threatened by newly emerging worldviews in society. Not only are the
mechanisms of self-esteem and the worldview less effective among older adults, but
the salience of death is also heightened in this age group through their physical
deterioration and the loss of their loved ones (McCoy et al. 2000).
According to McCoy et al. (2000), the increase in mortality salience and the
decrease in the effectiveness of protective mechanisms might provide an impetus
for psychological reorganization that ultimately functions to help older adults cope
with their nearness to death, which is an inherent and inevitable part of late-life.
This psychological reorganization, which can be derived from the accumulated wis-
dom of older adults, may assist older adults in shielding themselves from the terror
of death (McCoy et al. 2000).
Support for this hypothesis can be found in studies that have shown that fear of
death is diminished in old age (e.g.,(Gesser et al. 1988; Fortner and Neimeyer 1999).
Furthermore, experimental studies have found that under a mortality salience condi-
tion, old-old adults and young-old adults low in neuroticism perceived their subjec-
tive age as significantly lower than young-old adults high in neuroticism (McCoy
et al. 2000). Furthermore, unlike other age groups, mortality reminders did not sig-
nificantly affect the life expectancy of old-old adults (Maxfield et al. 2010). These
studies indicate that older adults, especially in the last stage of life, tend to achieve
greater acceptance of the inevitability of their own death. The different reactions of
older and younger adults to mortality salience is also reflected in studies that have
found that young adults respond to mortality salience induction as predicted accord-
ing to terror management theory, that is, by holding a harsher judgment of moral
transgressions and by engaging in health-promoting behaviours, whereas older
adults do not (Bozo et al. 2009; Maxfield et al. 2007).
Thus, empirical evidence suggests that death anxiety diminishes in old age, and
that older adults respond unlike other age groups to mortality salience. These find-
ings notwithstanding, two studies that examined the relationship between ageist
attitudes and death anxiety among older adults showed a positive correlation
between them (Bodner et al. 2015; Depaola et al. 2003). However, a careful exami-
nation of the age of the participants in these two studies might imply that most of
them belonged to the young-old age group, as the mean age ranged between 58.15
and 69.4 (Bodner et al. 2015; Depaola et al. 2003).
60 S. Lev et al.
To summarize, the hypothesis of McCoy et al. (2000) that death anxiety dimin-
ishes in old age and that, therefore, terror management theory might be less relevant
to this age group, is partially supported by empirical studies. According to these
studies, terror management theory might be relevant to some extent in the young-
old age group and might explain self-ageism in this age group. However, in the last
stages of life, the decrease in death anxiety makes terror management theory less
relevant as a source of self-ageism.
4.3 Stereotype Embodiment Theory
The internalization of negative attitudes towards the self among older adults could be
explained by the unique features of different age groups. Unlike other social groups,
which tend to be a part of the individual identity for a prolonged period, individuals
pass through different age groups during their life course. Thus, negative attitudes
and stereotypes of older adults, which the individual has internalized during the
lifespan, are often unconsciously embodied in old age (Kite et al. 2002; Levy 2009).
Studies examining explicit attitudes of older adults toward their age group found
a positive self-identity (Cherry and Palmore 2008; Laditka et al. 2004). Studies
exploring implicit attitudes, however, found a tendency towards internalization and
embodiment of negative attitudes among older adults (e.g., Levy and Schlesinger
2005; Meisner 2012).
The embodiment of negative attitudes among older adults towards their own age
group is reflected in a study that found that older participants were more likely than
younger participants to oppose increased funding to programs that benefitted their age
group. This opposition was predicted by age stereotypes (Levy and Schlesinger 2005).
The embodiment of negative stereotypes among older adults has also been shown
in experimental studies. These studies found that underperformance in cognitive
and physical tasks among older adults was influenced by age group identification
(Haslam et al. 2012; Kang and Chasteen 2009) as well as by priming with age ste-
reotypes (Lamont et al. 2015). Additionally, negative age stereotyping had a stron-
ger effect on important behavioural outcomes compared with positive age
stereotyping (Meisner 2012). Similarly, longitudinal studies have shown that nega-
tive age stereotypes and self-perceptions of ageing among older adults have an
adverse influence on health, longevity, and cognitive performance (e.g., Levy et al.
2002a, b, 2012; ; Wurm and Benyamini 2014; Wurm et al. 2007).
4.4 Social Identity Theory
According to social identity theory, social behaviour is characterized by two typical

behaviours: interpersonal and intergroup behaviours. Interpersonal behaviour is
determined by individual characteristics and interpersonal relationships whereas
intergroup behaviour is determined by respective membership in various social

groups or categories. The social behaviour of individuals combines these two
aspects. Accordingly, individuals do not act just on the basis of their personal char-
acteristics or their interpersonal relationships, but as members of their reference
groups. These memberships reflect on the identities of the individuals as well as on
their relationships with members of other groups (Tajfel and Turner 1979).
According to social identity theory, the identification of an individual with a
certain group is relational and comparative and can be based on minimal criteria.
This determination was based on several studies that indicated that the mere percep-
tion of belonging to two distinct groups is sufficient to provoke intergroup competi-
tive or discriminatory responses on the part of the in-group (e.g., Billig and Tajfel
1973; Turner 1975).
Social identity theory posits that people want to have a positive self-identity.
They achieve this goal by demonstrating biases which create a positive distinction
between their group (in-group) and other groups (out-groups), and by elevating
their in-group status above that of other groups (Kite et al. 2002; Tajfel and Turner
1979). However, Tajfel and Turner (1979) claimed that, contrary to the tendency to
prefer the in-group over the out-group, subordinate groups often internalize a nega-
tive evaluation of themselves and are positively oriented towards out-groups (Tajfel
and Turner 1979).
4.4.1 A
geism Among Young and Middle-Aged Adults in Light
of Social Identity Theory
By examining different age groups in relation to social identity theory, we can infer
that young and middle-aged adults might create a positive unique identity, which
consists of their age group, by differentiating themselves from and elevating them-
selves above the old age group. This tendency might increase due to society’s nega-
tive view of older adults (Kite et al. 2002). An empirical support for this phenomenon
can be found in various studies documenting negative attitudes of young adults
toward older adults (e.g., Bergman and Bodner 2015; Rupp et al. 2005).
Among middle-aged adults, the need for a positive distinctiveness of their age
group might increase due to the recognition that they are closer to becoming mem-
bers of a devalued group (Kite et al. 2002). This assumption is supported by studies
that found that participants in middle-aged groups were more ageist than younger
and older groups (Bodner et al. 2012; Laditka et al. 2004). However, other studies
did not find significant differences between young and middle-aged groups (Cherry
and Palmore 2008) or found conversely that the young group was more ageist than
the middle-aged group (Rupp et al. 2005).
According to social identity theory, positive self-identity of the young group
could be achieved not only by derogating the old age group, but also by relative
positive distinctiveness of both age groups based on personally relevant traits
62 S. Lev et al.
(Harwood et al. 1995). The positive distinctiveness of the young age group from the
old age group is supported by studies that stressed the mixed nature of older adults’
stereotypes, with young adults attributing positive stereotypes to older adults (e.g.,
warmth and experience) alongside negative ones (e.g., inflexibility and incompe-
tence) (e.g., Chasteen et al. 2002; Cuddy et al. 2005).
4.4.2 A
geism Among Older Adults in Light of Social Identity
Theory
According to social identity theory, subordinate and minority groups in society

often internalize a social evaluation of themselves as “inferior” or “second class”
(Tajfel and Turner 1979). Thus, the low status of older adults in society could affect
their self-perceptions as members of this age group by internalizing the negative
representations of old age that are prevalent in society (Kite et al. 2002). This can be
reflected in self-ageism (Bodner et al. 2015).
Along with the assumption of social identity theory that subordinate groups tend
to internalize the socially prevalent view of themselves as inferior, an additional and
contrary assumption of this theory claims that social groups have a motivation to
have a positive self-identity (Tajfel and Turner 1979). This complexity, in the case
of older adults, is reflected in studies that examined perceptions and attitudes of
older adults towards their own age group (e.g., Levy and Schlesinger 2005; Meisner
2012).
A few studies have explored explicitly ageist attitudes and behaviours of older
adults toward their own age group. Research has indicated that older adults have
more positive views about older adults than young and middle-aged groups do
(Laditka et al. 2004). A different study that examined positive and negative ageist
behaviours did not find significant differences between the older and the younger
age groups (Cherry and Palmore 2008). However, studies that examined these atti-
tudes as they are implicitly manifested, found a tendency towards internalization
and embodiment of ageist attitudes among older adults (e.g., Levy and Schlesinger
2005; Meisner 2012).
4.4.3 S
trategies to Maintain Positive Self-Identity According
to Social Identity Theory
In order to maintain a positive self-identity among minority and subordinate groups

(e.g., older adults), Tajfel and Turner (1979) indicated three strategies that members
of these groups could adopt. First, older adults can use social mobility by avoiding
identification with the old age group. They can achieve this goal by maintaining a
youthful appearance and by avoiding behaviours associated with the old age group.
Second, older adults can use social creativity by focusing on the positive attributes
of ageing or by comparing themselves with other less well-off older adults (e.g., a
social downward comparison). Finally, older adults can act towards social change
by stimulating social action in favour of changing the status of older people in soci-
ety (Harwood et al. 1995; Kite et al. 2002; Tajfel and Turner 1979).
Evidence for the use of social mobility strategy among older adults can be found
in experimental studies that have shown that older adults who were exposed to nega-
tive age stereotypes displayed a lower group identification and a stronger subjective
age bias, while they tended to feel younger than their actual age (Weiss and Freund
2012; Weiss and Lang 2012). Similarly, the impact of negative age-related informa-
tion on older adults’ explicit and implicit self-esteem was moderated by self-
differentiation from their age group (Weiss et al. 2013). Furthermore, the tendency
of individuals in middle and later adulthood to report younger age identities
(Montepare and Lachman 1989) can be interpreted as a desire of these individuals
to relate themselves to the young age group and to differentiate themselves from the
old age group.
Other studies have found, however, that perceived age discrimination among
older adults was positively associated with age group identification (Garstka et al.
2004) and older subjective age (Stephan et al. 2015). Finally, an experimental study
found a complex view concerning the activation of negative age stereotypes on three
measures of subjective age: felt age (“How old do you feel?”), desired age (“If you
could choose your age, how old would you want to be?”), and perceived age (“How
old would you say you look?”). Whereas, older adults in good health felt older than
their chronological age, older adults in bad health reported older perceived age and
younger desired age (Kotter-Grühn and Hess 2012).
Support for the use of social creativity strategies can be found in theories on
“successful ageing” (Rowe and Kahn 1997) and “active ageing” (WHO 2002),
which stress the positive attributes of ageing. Additional support for these strategies
can be found in arguments that call for the separation of the “third age” from the
“fourth age.” This separation allows young older adults to preserve their status by
comparing themselves to the “fourth age,” which represents “real old age” and is
characterized by frailty, abjection and the “othering” of the self. This results in the
defining of older adults by their alienation and vulnerability as well as their exclu-
sion from society (Gilleard and Higgs 2011; Higgs and Gilleard 2014).
4.5 S
ynthesis of the Three Theories from a Life Span
Perspective
Although these theories can be seen to provide three different explanations for the
origins of ageism at the individual level, a careful examination indicates that they
provide a complementary and coherent overview of the origins and processes of
ageism over the life course. A sociological and psychological explanation of the
64 S. Lev et al.
roots of ageism can be found in terror management theory. According to this theory,
the unconscious threats that are embodied in old age undermine our confidence in
our cultural worldview and self-esteem (Martens et al. 2005). Ageism is seen as an
unconscious defense against death anxiety, which might arise as a result of the
encounter with the old age group (Martens et al. 2005). However, studies indicate
that this mechanism is relevant mostly among young and middle-aged groups
(Bodner and Cohen-Fridel 2014; Martens et al. 2004) and to some extent among
old-young adults (Maxfield et al. 2010; McCoy et al. 2000). It becomes less relevant
among the old-old age group (Maxfield et al. 2010; McCoy et al. 2000), suggesting
a gradual reduction of death anxiety in this age group (e.g., Fortner and Neimeyer
1999) and a greater acceptance of the inevitability of death.
Whereas terror management theory provides an explanation for the roots of age-
ism among the young, middle- and young-old age groups, stereotype embodiment
theory provides a complementary explanation for self-ageism among the young-old
and old-old age groups. According to this theory, processes of assimilation of the
negative representation of old age from the surrounding culture and the internaliza-
tion of these representations over one’s life span might lead to an embodiment of
stereotypes in old age (Levy 2009). Thus, older adults might perceive their status as
low, not as a direct response to death anxiety, but due to the internalization of these
negative attitudes.
Finally, social identity theory focuses on the diverse expressions of ageism
among different age groups. According to this theory, ageism is derived from the
desire of the young and middle-aged groups to distinguish themselves from and
elevate themselves above the old age group in order to create a positive unique iden-
tity based on their own age group. The low status of the old age group, which is
reflected in negative attitudes and stereotypes toward older adults in society (and can
be explained by the two previous theories) might increase this tendency among dif-
ferent age groups, including older adults themselves (Kite et al. 2002) (see Fig. 4.1).
4.5.1 S
hort-Term and Long-Term Strategies for Coping
with Self-Ageism
A unique feature of ageism that emerges from the three presented theories is the
inherent threat embedded in it. Unlike other kinds of prejudice and discrimination,
which are directed toward distinct out-groups and pose an external threat, ageism is
directed toward our future selves by symbolizing our fear of death and the accom-
panying deterioration of the self (Martens et al. 2005).
Although studies have shown that stereotypes toward older adults in society con-
sist of both negative and positive aspects (e.g., Fiske et al. 2002), the thoughts of
inevitable deterioration and death that are associated with old age pose a significant
threat to the wellbeing and confidence of the older adults, as they overshadow the
positive representations of old age. Moreover, even when old age representations
are positive, they tend to be devalued in society, relative to the stereotypes of youth.
Thus, although people might have a nuanced view of old age as having both positive
and negative attributes, they act consciously and unconsciously to differentiate
themselves from this age group due to the threats embedded in it.
The conscious and unconscious desire of different age groups to differentiate
themselves from the old age group is reflected in their relating themselves to
younger age groups or by reporting younger age identities (Montepare and Lachman
1989; Weiss and Freund 2012; Weiss and Lang 2012). Although it may be claimed
that this tendency can emerge from the internalization of negative age stereotypes,
a growing body of research indicates that a younger subjective age is positively
associated with diverse subjective and objective outcomes such as improved physi-
cal and cognitive functioning, health, psychological wellbeing, and longevity (e.g.,
Gana et al. 2004; Kotter-Grühn et al. 2009; Stephan et al. 2014; Stephan et al. 2013).
Hence, this strategy has positive outcomes and is highly desirable.
The desire of the middle-age and the young-old age groups to differentiate them-
selves from the old age group is also reflected in theories such as successful ageing
(Rowe and Kahn 1997) and active ageing (WHO 2002), that focus on positive
aspects of ageing. These theories undermine the prevailing assumptions that ageing
is necessarily characterized by physical and cognitive deterioration, disease, and
social isolation and emphasize the potential for maintaining physical, social, and
mental wellbeing throughout the life course. According to these theories, successful
or active ageing can be achieved by reducing risks for disease and disabilities, maxi-
mizing cognitive and physical function, maintaining interpersonal relations, con-
tinuing one’s engagement in productive activities, and participating in social,
economic, cultural, spiritual, and civic affairs (Rowe and Kahn 1997; WHO 2002).
Despite the dominance of these theories, there have been calls over the years that
have questioned their legitimacy. These calls have argued that the distinction
between successful and unsuccessful agers follows an ageist worldview, as “suc-
cessful” old age is seen as a continuation of middle age and avoidance of all illness
and deterioration (Calasanti 2015; Dillaway and Byrnes 2009; Liang and Luo 2012).
Furthermore, the paradigm in these theories reflects Western values of i ndependence
and productivity and fails to address values of intergenerational solidarity or harmo-
nization that may be of greater relevance for defining desirable old age for some
groups of older adults (Lamb 2014; Liang and Luo 2012). A similar criticism is
directed toward the distinction between the third (e.g., successful ageing) and the
fourth age (e.g., failed old age), as the fourth age is perceived as the “real old age”
and includes all negative attitudes of society toward this age group (Higgs and
Gilleard 2014). We suggest that due to the significant threats of death and deteriora-
tion that are embedded in old age, the perception of a subjective young age identity
ingrained in theories such as successful ageing and active ageing, which emphasize
the importance of maintaining physical, social, and mental wellbeing in old age, are
essential and have positive outcomes (Montepare and Lachman 1989; Rowe and
Kahn 1997; WHO 2002).
66 S. Lev et al.
However, these strategies are temporary. Even if an older adult uses all of his or
her efforts to maintain good health and good physical and cognitive functioning, he
or she would not be able to ignore the deterioration which is almost inevitable in the
later stages of life. Therefore, we suggest that a young subjective age identity and
theories like successful ageing and active ageing can serve as short-term strategies
that are mostly relevant to the middle-age and young-old age groups, but that they
gradually become less relevant in the later stages of life, especially in the old-old
age group. The encounter with the gradual reduction of physical, cognitive, and
social resources in the later stages of life requires the adoption of long-term strate-
gies that do not ignore and repress the inevitable deterioration and death that are
embedded in the life course.
These strategies include first a recognition of meaningful decline as a valid
dimension of ageing and personhood (Lamb 2014). Second, they pose an alternative
to values that emphasize functionality by emphasizing such resources as tradition,
wisdom, memory, narrative, change, generation, and leadership (Katz and Marshall
2003). These long-term strategies are reflected in several theories which pose alter-
natives to the successful ageing and active ageing theories. According to the “con-
scious ageing” theory, old age is characterized by processes of decrement and
compensation. These processes promote a creative response to disability whereby
losses are balanced by gains and the decline is compensated for by spiritual insight.
According to this theory, old age can be an opportunity for spiritual growth (Moody
2005). Similarly, the “harmonious ageing” theory, which is inspired by Eastern phi-
losophy, possesses a dialectic and holistic ageing approach that allows for cross-
cultural, liberal, inclusive, and open discourses that emphasize the complementary
coexistence of body and mind. The theory defines “harmonious ageing” as a bal-
anced outlook towards the ageing process, which follows the natural laws of the
human body and promotes cultivating a sense of harmony with oneself and one’s
surroundings. This balanced and harmonious outlook promotes handling challenges
and thus making adaptations accordingly (Liang and Luo 2012).
4.6 Conclusions
To summarize, ageism among young, middle-, and young-old age groups derives
from the unconscious threats of death and deterioration that are embedded in old
age (Greenberg et al. 1986). Self-ageism among older adults can also derive from
the internalization of ageist stereotypes during the life span (Levy 2009). Even
when the threat of death declines, especially in the last stages of life (McCoy et al.
2000), self-ageism is often preserved due to these internalization processes (Levy
2009).
In order to protect themselves from the negative consequences of the threat of
death and deterioration that are embedded in old age, members of the young-old
group might use various strategies. They might perceive their subjective age as
younger (Montepare and Lachman 1989), identify old age with the “fourth age”
(Higgs and Gilleard 2014), or adopt theories such as successful or active ageing,
which focus on the positive aspects of old age (Rowe and Kahn 1997; WHO 2002).
However, the positive effects of these strategies are limited, especially among the
old-old group, when deterioration and death can no longer be ignored. In order to
preserve self-esteem, the old-old might better adopt worldviews that emphasize
alternative resources for self-esteem and meaning in old age, alongside the accep-
tance of the inevitable deterioration in old age (Cosco et al. 2013; Kahana et al.
2012) (see Fig. 4.1).
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Chapter 5
Work Environment and the Origin
of Ageism
Laura Naegele, Wouter De Tavernier, and Moritz Hess
5.1 Setting the Scene: Ageism at the Workplace
The ageing of the population and the approaching retirement of the baby boom gen-
eration are changing the structure of the workforce all over the industrialised world.
The shrinking population of working age and the increased share of older workers
within it challenge companies and organizations and call the financial sustainability
of welfare states into question (Hedge 2012). While the practice of early retirement
of older workers—in order to ‘free up’ employment opportunities for younger work-
ers—was quite popular in the 1970s and 1980s, governments now recognize the
fallacy and the unsustainability of this policy (‘lump of labour fallacy’). Older and
younger workers are not simply interchangeable e.g. due to their differentiating skill
sets, positions within and their contributions to the labour market. Empirical evi-
dence suggests that an increase in employment of older workers is even associated
with increasing employment rates of younger cohorts (Kalwij et al. 2010).
Another widely and controversial discussed aspect in this regard is the pre-
sumed lower productivity of ageing workforces. Even though the performance or
productivity of a worker in itself is rarely viewed as a coherent, analytically easily
determinable factor, a negative relationship with age is often almost automatically
assumed (Ng and Feldman 2012). Instead of acknowledging that workers age
L. Naegele (*)
Institute of Gerontology (IfG), University of Vechta, Vechta, Germany
W. De Tavernier
Centre for Comparative Welfare Studies (CCWS), Aalborg University, Aalborg, Denmark
M. Hess
Institute for Gerontology at TU Dortmund, Dortmund, Germany

https://doi.org/10.1007/978-3-319-73820-8_5
74 L. Naegele et al.
individually and that their productivity is affected by their abilities (physical and
cognitive limitations due to age) (Cardoso et al. 2010), education and work experi-
ence (outdated or obsolete skills) as well as by work environment related factors
such as age-appropriate workplaces and/or career development opportunities
(Frerichs et al. 2012), older workers are often seen as less productive than their
younger counterparts (Ng and Feldman 2008). A closer look at the scientific litera-
ture reveals that existing studies do not support this one sided view as they appear
to be inconclusive in this regard: Some researchers conclude that ageing popula-
tions have a negative effect on labour market productivity, whereas others suggest
that at the company level, a higher share of older workers is associated with higher
productivity (Van Dalen et al. 2010).
However, the lingering prevalence of prejudices and stereotypes as well as
the discrimination of older workers based on age may compromise govern-
ments’ efforts to extend working lives, which has become a key priority in most
of the Western world as well as parts of Asia (Bal et al. 2011). Ageism, defined
as discriminatory practices, attitudes and perceptions regarding older workers
(Butler 1969), is still pervasive in many companies and organizations in the
developed world (Rothenberg and Gardner 2011). In addition previous research
has shown that experiencing stereotypes and discrimination at the workplace
can influence older employees’ productivity (Thorsen et al. 2012), retirement
intensions (Schermuly et al. 2014), organizational commitment (Snape and
Redman 2006), and work satisfaction (Orpen 1995). The individual perceptions
of age discrimination may furthermore be amplified through the interaction with
co-workers and supervisors and foster the prevalence of ageism at the organiza-
tional level.
Despite efforts to constrain discriminatory behaviour via law-making and
employment policies in Europe and elsewhere, ageism is still prevalent in organiza-
tions and companies1 and affects the careers of older workers in terms of job oppor-
tunities, promotions and performance evaluations. As a result—in combination with
a shortage of skilled junior personnel—companies might run into difficulties when
trying to fill their vacancies, affecting their overall performance and ultimately the
growth of the economy (Kunze et al. 2011; Rothenberg and Gardner 2011).
Therefore, it is crucial to identify which factors foster or mitigate ageism in the
workplace, as it impacts not just older workers’ lives, but also organizational perfor-
mance and the economy and society as a whole.
Understanding the sources of age discrimination at the workplace is the first step
in repelling it. Studies explaining ageism and its origins generally fit into three cat-
egories. First, there are studies looking at individuals (the micro level), linking age-
ist attitudes to individual characteristics such as education, gender or income. A
1
For improved readability we use the terms ‘company’ and ‘organizations’ synonymously in order
to describe the ‘places of work’ throughout the chapter. We acknowledge that even though all
companies can be described as organizations, in a narrow interpretation not all organizations can
be described as companies (e.g. in the public sector). The processes discussed in the chapter are
relevant for both public and private organizations, as well as non-profit and for-profit ones.
5 Work Environment and the Origin of Ageism 75
second perspective focuses on the macro level. In this perspective, ageism is

attributed to cultural norms and attitudes prevalent in societies (Ayalon 2013).
Shared values and norms have been shown to manifest themselves through preju-
dice and discrimination while shaping individual and organizational behaviour
regarding ageism (Shiu et al. 2015). The third perspective relates to the social sphere
of work organizations/companies (meso level) which play a key role in age dis-
crimination. They provide the ‘places of work’ and therefore set the scene for the
prevalence of discriminating behaviour towards older workers.
By focusing on the organizational level, this chapter aims to outline how ageism
manifests itself in the important arena of work. While acknowledging the impor-
tance of other (younger) cohorts within the labour market, as well as the increasing
amount of volunteer work done by older people, this chapter aims to primarily focus
on ageism at the workplace faced by older workers in paid employment. We present
a conclusive overview of theories and findings in the scientific literature regarding
the role of organizations or companies in cultivating, preserving or reducing ageism
within them. Focusing on studies from the developed world, we first look at the
company level where we identify organizational characteristics that affect ageism,
namely organizational structure and hierarchy, age structure of the workforce, com-
pany size, shared values and aspects of age-friendly human resource management.
As organizations and companies never exist within an institutional vacuum, we sub-
sequently identify contextual factors that shape and affect companies and organiza-
tional behaviour, and hence ageism within the organization. Here, we consider
sectorial affiliation and legal frameworks on the company level. Overall we will
discuss seven main determinants of age discrimination at the work place, without
any claim for completeness at this point. Rather, these determinants are not set in
stone, nor do they exist independently of each other or affect all organizations/com-
panies the same way. In addition, as labour markets, organizations and companies
are constantly evolving, it can be expected that in the future new determinants of
ageism at the company level might arise.
5.2 O
rganizational Characteristics as Sources of Ageism
at the Workplace
5.2.1 Organizational Structure and Hierarchy
Even though several studies stipulate the importance of organizational structures for
age discrimination within the workforce (e.g. Branine and Glover 1997; Brooke
2010; McGoldrick and Arrowsmith 2001; Riach and Kelly 2015), the structure typi-
cally is not the focus of ageism research, but only present as a contextual factor—if
at all. McGoldrick and Arrowsmith (2001), for instance, link the organizational
structure to stereotypes about and discrimination of older workers, to what it means
to be old and to possible solutions to ageism in their conceptual scheme, but this is
completely overlooked in their analyses. This lack of attention for organizational

structures in ageism literature is in stark contrast with the attention it has in other
areas of research concerning discrimination. For instance, there is a vast body of
research regarding the discrimination of women in the workforce (Gelfand et al.
2007). Other findings suggest that sexual and racial inequalities in an organizational
hierarchy tend to reproduce themselves (Gelfand et al. 2005). Bird and Rhoton
(2011) develop this idea further in their research on gender and ‘professional
bureaucracies’. They identify four components elementary to the professional work
organization that are vulnerable to discrimination and as such effectively work as a
filter guaranteeing that only individuals complying with the logic of the organiza-
tion reach higher positions in the organizational hierarchy: the organization of work
itself (e.g. work hours), decision-making processes (e.g. who makes the decisions),
performance evaluation practices (e.g. which criteria are used in the evaluation) and
information networks (e.g. largely informal networks through which individuals
gather important information for job performance and career advancement).
Regarding the latter, Gelfand et al. (2005) also point to the fact that, in line with the
similarity-attraction theory (see further below), individuals tend to form informal
networks in an organization with other individuals who are similar to them. In a
white male dominated organization, for instance, women and ethnic minorities will
have less informal access to those higher in the hierarchy than do white men. In the
context of ageism, this would mean that workers may benefit from informal net-
works if individuals higher up in the hierarchy are of the same generation or, as the
flip side of the coin, that they receive less opportunities if that is not the case.
Interestingly, in their study in the information technology sector in the Anglo-Saxon
world, McMullin et al. (2011) find that hierarchy can be beneficial for older work-
ers. Due to the fast evolution in the information technology sector, programming
skills can become outdated rather quickly—hence the finding of McMullin and
Dryburgh (2011) that programmers are considered ‘old’ already in their early 40s
(note that this implicitly involves the ageist assumption that workers above age 40
are not able to adapt to changes). By climbing higher in the hierarchy into a mana-
gerial position, however, different skills become relevant—skills that are more often
attributed to older workers.
That brings us to the role of skills: organizational and company structures, like
sectors, demand specific skills. In the words of Miles and Snow (1995, p. 5): “Every
organizational form—pyramid or pancake, centralized or decentralized—places
unique demands on people.” These skills can be the subject of ageist ideas, if for
example some skills are being mainly attributed to certain age groups and hence
they can be a mediator between the organization of work and discrimination based
on age. There is a large agreement in the literature that organizational structures
have a ‘skill bias’ (Caroli and Van Reenen 2001).
Much has been written about the knowledge, skills and creativity of workers
being important in processes of organizational change and new forms of organiza-
tion. Whitley (1989) wrote that managerial work is characterized by its unstandard-
ized nature, orientation towards problem-solving and balancing between
reproduction and innovation. In a strongly hierarchical system, these skills would
traditionally be seen as traits of experienced workers in management positions. In

new types of organizations with flat hierarchies, where individual workers get more
and more tasks and responsibilities (Caroli and Van Reenen 2001), these character-
istics are not limited to the management anymore. Such lean organizations redefine
and break down established hierarchical models of organizational behaviour and
with them the inherent expectations of how age and skill is dispensed within orga-
nizations (Ashton 2004; Worley and Doolen 2015). Ashton (2004) argues that such
organizations in addition strengthen workers’ skills for two reasons: first, to distrib-
ute knowledge more widely within the organization, and second, to give workers
more opportunities to practice new skills and techniques. Andriopoulos (2001)
notes that organizations and companies show an increased focus on creativity and
problem-solving, and that flat structures stimulate creativity among their employ-
ees. Network organizations, which are flat, flexible and market-oriented, and work
with relatively autonomous self-managing teams, require workers who have strong
skills (‘capabilities’) and who are trustworthy (Miles and Snow 1995). Even though
none of these studies makes the link with ageism, it is a common finding in studies
on ageism that older workers are considered to be less creative though more trust-
worthy (e.g. Gringart et al. 2005; Taylor and Walker 1998).2 Hence, the relationship
between these new organizational structures and ageism could be a dual one: on the
one hand, the value placed on knowledge and trust may benefit older workers,
though the perception of older workers as less creative may be a serious disadvan-
tage for employment of older workers in organizations with flat hierarchies.
5.2.2 Age Structure
‘Relative age’, referring to an individual’s age as compared to the average or mean

age in a sector, company or profession (McMullin and Duerden Comeau 2011), is a
basis for age discrimination in the labour market—the general idea being that the
bigger the difference between the individual’s age and what is considered ‘normal’
for a certain function, the higher the risk for discrimination. Individuals working as
programmers in the information technology sector, for instance, could be consid-
ered ‘old’ in their early 40s, while a judge may only reach that point 20 years later
(McMullin and Dryburgh 2011). Data from the German Institute for Employment
Research Establishment Panel show that older workers (50+ years) are perceived
more positively regarding their capabilities and performance by management per-
sonnel in companies with a higher share of older workers (Bellmann et al. 2003).
However, due to the cross-sectional nature of the analysis, it is not possible to make
a statement on the causal direction of the relation.
2
According to Binnewies et al. (2008), earlier “[s]tudies reporting relationships between age and
creativity most of the times found no relationship (…) or a slightly negative relationship” (p. 442).
Their own study suggests that the relation between age and creativity is dependent on the level of
job control of the worker.
Kunze et al. (2011) note two general strands in earlier research, linking increased
age diversity in an organization to decreasing age discrimination. The first one
refers to the contact hypothesis, suggesting that age diversity leads to more contact
and familiarity between individuals of different age groups, leading to lower age
discrimination. A second strand suggests that increasing age diversity causes work-
ers to believe the organization values diversity, thereby shaping a ‘positive diversity
climate’ (see further below).
However, there are also four prominent hypotheses in the literature expecting the
opposite: that ageism will be higher as age diversity in the organization increases.
First, the similarity-attraction paradigm suggests people like others they feel are
similar to themselves (Kunze et al. 2011, 2013; Shore and Goldberg 2012). Second,
according to social identity and self-categorization theory, “individuals tend to clas-
sify themselves and others into certain groups on the basis of dimensions that are
personally relevant for them” (Kunze et al. 2011, p. 268), and prefer individuals that
fall in the same category as themselves (Kunze et al. 2011, 2013; Shore and Goldberg
2012). Growing age diversity might then make age as a trait more salient, and hence
an element in this categorization process.
The concept of ‘career timetables’ is a third hypothesis (Kunze et al. 2011, 2013;
Shore and Goldberg 2012). It involves expectations of how individuals move up in
the organizational hierarchy as they become older and more experienced, and that
employees who ‘lag behind’ on this schedule—and who are hence surrounded by
younger individuals in their work unit—are more likely to face discrimination. A
fourth theory is related to ‘prototype matching’, the idea being that certain jobs are
considered to be for a specific group of people, for instance because of the skills or
knowledge they require (Kunze et al. 2011; Shore and Goldberg 2012). An older
person performing a job that would typically be seen as a job for young people has
a higher risk of facing discrimination, just like a younger person who has a job
higher up in the hierarchy, while workers think the position requires much knowl-
edge and experience—and should hence be executed by an older person.
While Nishii and Mayer (2009) do not find a relation between age structure in the
working unit and experiences of age discrimination among older workers in the
United States, Kunze et al. (2011, 2013) do find that higher age diversity leads to
more perceived age discrimination among employees in German companies.
Interestingly, Kunze et al. (2013) find that this relation is exacerbated when case
managers have ageist attitudes, while the presence of diversity-oriented human
resource policies has the opposite effect.
5.2.3 A
ge-Diverse Climate, Age-Friendly Corporate Identity
and Leadership
Not only structural characteristics like the size or sector of a company determine the
level of ageism at the workplace. ‘Soft’ factors like company climate, inclusion and
diversity policies, and corporate identity are important as well. Four selected factors
in this context—organizational culture, company climate, corporate identity, and

leadership—will be the topic of this section. As human resources measurements
that can help fight ageism are also immensely important in this regard, they will be
discussed separately in the following section.
When researching discriminative behaviour at the workplace Ciampa and
Chernesky (2013) distinguish the important concepts of organizational culture and
climate. “Organizational culture refers to the deep structure of organizations, rooted
in the values, beliefs, and assumptions of organizational members. It is established
through socialization to a variety of identity groups that converge in the workplace
[…]. The standards against which behavior is evaluated are that of the majority
culture, and reflect the attitude and values of those who hold positions of authority
and power” (Ciampa and Chernesky 2013, p. 96). Managers should strive for a cul-
ture that does not allow discriminative behavior. Organizational or company cli-
mate is the sum of all the members’ individual psychological climates. Boehm et al.
(2013, p. 671) define a climate that hinders the emergence of ageism “[…] as orga-
nizational members’ shared perceptions of the fair and non-discriminatory treat-
ment of employees of all age groups with regard to all relevant organizational
practices, policies, procedures, and rewards.” Hence, an age-friendly or age-diversity
climate is based on the workers in the organization agreeing that no one should be
discriminated because of age.
Closely linked to these rather abstract conceptions of a positive organizational
culture and age-diversity climate is the concept of an age-friendly corporate identity
(Kunze et al. 2011, 2013). Companies should free their internal and external com-
munication of ageist language (Fowler et al. 2015) and avoid discriminative behav-
iour in the hiring and promotion process. They should seek to design and create
products that are not ageist, and not be ageist towards their customers (Stroud and
Walker 2013). An age-friendly corporate identity will help to form an age-diverse
climate. As already mentioned with the concept of organizational culture, one cru-
cial mediator here is the leadership behaviour of managers and supervisors (Liden
et al. 2006). They should internalize the idea of an organization or company without
ageism, act accordingly, and serve as role models for the other employees (Nishii
and Mayer 2009). By doing so, they can positively influence organizational culture
and climate.
5.2.4 Human Resource Measures
In addition to having an age-friendly corporate identity and trying to create an atmo-

sphere in which older workers feel welcome and that their work is appreciated,
companies also have or rather should have a human resources management strategy
that aims to fight ageism. Several tools can be identified that human resources man-
gers can use to create an age-friendly climate at the workplace. In the literature
(Boehm et al. 2013; Kooij et al. 2010; Lepak et al. 2006), most scholars agree that
human resources measures should be age-inclusive, meaning that no workers should
be excluded from human resources programs or ignored in the promotion and

recruitment process. In addition, the human resources measures should also follow
a certain organizational strategy and not consist of single, isolated tools that are not
interrelated (Kunze et al. 2013). Instead the human resources tools should be bun-
dled into one consistent and coherent policy. Three examples of tools that help to
decrease ageism at the workplace are inclusion of older workers into training
courses, age-blind promotion and hiring processes, and special training courses for
older workers. Suspending older workers from training measures and programs
because of their age is an ageist action and leaves them with outdated and/or obso-
lete skills. In addition including workers from different age groups into training
courses could actively help to decrease ageism (Brownell and Kelly 2013; Chiu
et al. 2001). Drawing on classical contact theory (Aronson et al. 2004) which claims
that if individuals from different groups get into contact, this will decrease the ste-
reotypes they hold of each other, one could argue that these age-inclusive training
programs lead to fewer age stereotypes, and consequently to less ageism at the
workplace. A second important human resource tool in the fight against ageism is
age-blind promotion (Machado and Portela 2013) and recruitment procedures
(Ahmed et al. 2012). They help to ensure that older workers are not discriminated
against when applying at a company or for a new job in the same company. Deleting
the applicant’s age from the curriculum vitae and, thus, having age-blind applica-
tions is one practical measure to ensure age-blind promotion and recruiting proce-
dures (Rocco et al. 2014). Besides the age-inclusive general human resources
approach and the age-blind promotion and recruiting procedures, companies can
also offer specific human resource programs for older workers (Göbel and Zwick
2013). Such specific programs might include part time retirement, support for car-
ing obligations, retirement consultation, and life work-time accounts—the latter
allowing older workers to ‘save’ over-time working hours over several years and use
them to work less later on (Burke and Ng 2006). These help older workers to live up
to their potential and be productive employees (Picchio and Van Ours 2013; Göbel
and Zwick 2013). This in turn will decrease the occurrence of ageism at the work-
place. However, one has to acknowledge that human resources measures aimed at
fighting ageism might actually increase it. One unintended consequence of age-
blinded promotion and recruitment and special training programs for older workers
might be that they are seen as groups that receive undeserved benefits and this might
result in ageism (Dipboye and Colella 2013; Lyon et al. 1998).
5.2.5 Company Size
Closely linked to the question of the prevalence of age-friendly human resource

measurements is the question of company size. Since small and medium sized com-
panies (<250 employees) are rather the rule than the exception in a majority of
countries, taking a closer look at their relation to ageism might be worthwhile.
When taking human resource measurements into account, a rather easy assumption
would be: Small companies have less means to implement age management mea-
sures, which have shown to tackle negative stereotyping of older workers (Kunze
et al. 2013; Fuertes et al. 2013), while larger sized companies already widely
adapted these measures (Leber et al. 2013). Furthermore, small companies are more
likely to not feel the need to change their policies due to changing legislation con-
cerning ageism (Metcalf and Meadows 2010), they do not see older workers as the
solution for labour market shortages (Van Dalen et al. 2009) and offer fewer training
possibilities for older workers (Taylor 2011), although research in this regard is
inconclusive. When for instance asked for less institutionalized, work-integrated
measures for older workers, smaller companies have shown to offer these on the
same level as companies with more employees (Naegele and Frerichs 2015).
Regarding the perception of older workers, various studies affirm that in smaller
companies, older workers are viewed more positively than in companies with larger
workforces (Bellmann et al. 2003; Boockmann and Zwick 2004). Similar results
have been found when asked about self-perceived stereotyping: Older workers
employed by small companies report to be more frequently confronted with positive
stereotyping than older employees working in larger companies (Hess 2013). Flat
hierarchies and close social embeddedness within the respective workforce, the
monopoly held by older workers on company-specific knowledge (Hilzenbecher
2006), or the fact that older workers often hold key positions within small compa-
nies, which are unlikely to be filled easily by others such as younger workers (Beck
2013), could be explanatory factors for the relatively positive view on older workers
within small and medium sized enterprises. Additionally—even though often not
sufficiently recognized—the prevalence of less formal, work-integrated measures
focused on older workers in small and medium sized companies could also be a
preventive factor for ageist behaviour.
5.3 C
ontextual Factors as Sources of Ageism
at the Workplace
5.3.1 Industrial and Sectorial Affiliation
Not only the size of a company or the age structure of its labour force influence the
perception of older workers in their work environment, the same goes for the sector
or industry in which older workers are employed. According to ‘age-typed theory’
by Oswick and Rosenthal (2001) workers are judged by the fit between the require-
ment of a particular job and the assumed competences they bring to the table.
Negative stereotyping and ageist behaviour towards older workers may result from
a perceived ‘lack of fit’ between a job’s requirement and the abilities of a worker.
Within certain sectors job requirements ‘match up’ better with competences
generally attributed to older workers (such as stability, loyalty or experience) and

therefore these sectors may supply more ‘fitting places’ of work for older employ-
ees (Richardson et al. 2013; Turek and Perek-Bialas 2013). An easy example can
be drawn by looking at the German craft sector—a work environment which highly
depends on knowledge as well as experience of workers, both attributes generally
ascribed to older workers (Hilzenbecher 2006). Whereas in small craft businesses,
older workers are often highly valued and their retirement day considered a dreaded
event, research has shown that in other industries, where the question of productiv-
ity of workers is high on the agenda, older workers are more often confronted with
negative stereotyping (Van Dalen et al. 2010; Malmberg et al. 2008). Hess (2013)
estimated differences between sectors and/or industries in Germany by focusing on
the prevalence of stereotyping experienced by workers (49+ years). A more posi-
tive stereotyping—‘older workers being more reliable than their younger col-
leagues’—was often found in the retail and health care sectors, whereas negative
stereotypes—‘older workers being less adaptable’ and/or ‘less productive’—
occurred more often in the educational sector, public administration as well as
manufacturing. Henkens (2005) finds that amongst Dutch mangers in the public
sector, negative stereotypes towards older workers are much stronger than in the
private sector. He suggests this might be due to the seniority-based salary system
and high job-protection.
The sectorial variations in employment rates of older workers are also found to
be influential of a negative age-discrimination climate in industries and ultimately
companies (Kunze et al. 2013; Stettes 2012). The cultural and political contexts or
more generally speaking the ‘institutional surroundings’ in which employers oper-
ate (e.g. when hiring an older worker) are linked not only to the major changes in
national level policies but also to experiences with and normative assumptions about
older workers within their respective sectors/industries (Shiu et al. 2015). Employers
with a high share of older workers (50+ years) in their respective companies are
more likely to report that older workers are less often sick than their younger coun-
terparts, whereas management personnel from ‘younger’ companies do not share
this perception (Stettes 2009). Whereas sectors such as agriculture and fishing are
known for employing the oldest workforces (Macinol 2010), in sectors with a pre-
dominantly younger workforce such as advertising (Carrigan and Szmigin 2003),
older job seekers are often more liable to age discrimination (Richardson et al.
2013). Nevertheless, this behaviour is reported to go both ways. Metcalf and
Meadows (2010) concluded from a British survey that close to one fifth of employ-
ers viewed certain jobs as more suitable for particular age groups, with a tendency
to favour the middle age group (30–50 years old) over not only older but also younger
workers (Taylor 2011).
5.3.2 L
egal Framework for Prohibiting Discrimination Based
on Age
Discriminating behaviour based on age in the field of employment and occupation

has been subject to legal controls for several decades (Doron et al. 2013). While
acknowledging the wide range of legislations worldwide, due to the level of sophis-
tication, the existing European legal framework presents an especially interesting
case in this regard and will be discussed in the following section.3
Since the broadening of the scope of anti-discrimination measures beyond sex
and nationality with the Amsterdam Treaty (1997), the European Union limits the
circumstances under which member states may permit employers a different treat-
ment of workers on the ground of age. Imposed under the European Council direc-
tive 2000/78/EC, member states are to be encouraged to combat early resigning as
well as to facilitate the hiring, employment, career development and retirement of
older workers (Numhauser-Henning 2013; O’Cinneide 2005). By 2006, almost all
of the member states had implemented the directive in their national discrimination,
employment and labour laws (Spencer 2013).
While prohibiting age discrimination is an important legal mechanism in order to
promote the equal treatment of older workers in employment, training and the work-
place, it is questionable how successful these non-discrimination laws are in prac-
tice. Taking the example of compulsory retirement practices, some authors have
argued that legal retirement ages are one of the leading forms of age discrimination,
since they exclude people en masse from the workforce, solely due to their age
(Walker 1990). Other authors concluded that driven by economic and political inter-
est’s mandatory retirement can be interpreted as an institutionalized form of ageism
(McDonald 2013; Woolever 2013).
A steady stream of law cases was brought to the Court of Justice of the European
Union and while one would expect compulsory retirement age to be contrary to
the ban on discriminatory behaviour based on age, so far the Court of Justice of
the European Union has accepted age limits if proportionate means of achieving a
legitimate aim arise. The court has argued that ‘age’ is to be set apart from other
protected characteristics under the Discrimination Directive because it is shared
by everyone and can be seen as a continuum which changes over time: Over the
span of a lifetime, almost every worker will benefit from provisions targeting
older workers (Vickers and Manfredi 2013). Secondly, according to the Directive
a different treatment of workers does not constitute age discrimination if one does
not distinguish based on individual factors but based on “legitimate employment
policy, labour market and vocational training objectives” (Numhauser-Henning
2013, p. 401).
3
For a more detailed overview on this topic please see Doron et al. (2018; Chap. 19); Mikołajczyk
(2018; Chap. 20) and Georgantzi (2018; Chap. 21) as well as Abuladze and Perek-Białas (2018;
Chap. 28) in this volume.
Even if such discrimination lawsuits make it to court the ‘learning effect’ on the
employer’s side seems to be rather questionable as the review of recent literature
addressing age-related cases from the United States of America reveals: It seems
that a number of legal firms have established themselves in the lucrative market of
assisting human resource managers to avoid lawsuits by terminated older workers.
Instead of advising management to adapt more ethical practices towards their older
workers, these legal firms specialize in preventing companies to become the target
of age-related lawsuits in the first place (Woolever 2013). Furthermore, research has
shown that even though legal frameworks are in place individuals are reluctant to
acknowledge ageist behaviour (and go to court for it), possibly due to the fact that
they do not view themselves as being ‘old’ and therefore attribute perceived harass-
ment at the workplace as not being related to their age (Blackstone 2013). In addi-
tion, in contrast to their younger counterparts, older workers tend to not report
harassment at the workplace, while at the same time employers, lawyers as well as
other actors within the legal system, tend to treat age discrimination cases as less
serious than race or gender based offences (Spencer 2013).
Taking a look at the hiring practice, the existing limitation of laws become obvi-
ous: Oblivious to existing legal regulations, ageism can occur in hiring practices
when human resource personnel “consciously or subconsciously applies age limits
to older applicants” (Spencer 2013, p. 147). Existing stereotypes regarding the pro-
ductivity or performance of older workers on the employer or human resource side
furthermore might lead to older workers taking longer to find new employment or
when being reemployed tend to receive a lower salary than in their former employ-
ment (Woolever 2013). Although their importance is non-negotiable, laws are often
insufficient to guide the personnel actions of human resource managers as a wide
range of policies and actions fall outside the domain of the law. Therefore, ethics in
general as well as a company’s attitude towards their ageing workforce become
increasingly important in the daily work of human resource managers.
5.4 Conclusion: Fighting Ageism at the Workplace
Against the background of ageing societies in general and an ageing workforce in

particular, the subject of old age discrimination at the workplace has moved into the
spotlight. Age discrimination or ageism has among others a negative impact on
older workers’ productivity, quality of work and organizational commitment and,
thus, also harms the companies and organizations they are working in. Therefore,
fighting ageism must be a priority of policy makers, employers and trade unions. To
mitigate the effects of age discrimination, we must know its origins. In this chapter,
we focused on the meso-level and the origin of ageism at the workplace. Seven main
determinants of ageism were detected: organizational structure and hierarchy; age
structure; age-diverse climate; human resources measures; company size; industrial
and sectoral affiliation; and the legal framework.
Regarding a company’s organizational structure, four components were identi-

fied at which age discrimination is possible: the organization of work itself; decision
making process; performance evaluations; and information networks. Moreover, the
formal and informal structure of the organization determines the need for certain
skills over others, and these skills can be the subject of ageism. Hence, there can be
an indirect effect of the organizational structure on ageism through skills. Our litera-
ture review reveals a striking lack of research on the relation between age and orga-
nizational structure, especially when compared to research on gender and
organizations. This could be an interesting path to develop in future research.
A company’s age structure can influence the occurrence of ageism in two ways:
on the one hand growing age diversity can lead to more contact between workers of
different ages and, thus, reduce ageism. On the other hand, it could make age as a
category more salient and increase its importance as an element of categorization
and potentially lead to discrimination because of age.
Company size is linked with ageism in two ways: Larger companies have institu-
tionalized human resources departments offering age management measures that
help to tackle ageism. At the same time, the informal organizational structure of
smaller companies might help to create contacts between different generations of
workers and, thus, decrease ageism. In addition, less formal work-integrated mea-
sures might likewise contribute to a more positive reception of older workers in
small and medium sized companies. Further research in this regard could add valu-
able input to the debate.
A coherent human resources strategy—e.g. age inclusive training programs and
an age blind recruitment and promotion procedure—will help to reduce ageism.
Closely linked to the human resource strategy, the concept of age friendly climate
and corporate identity can play an important role. Creating an atmosphere of ageist-
free language, procedures and products is an important step to fight ageism.
Whereas the first five determinants are closely linked to the company level, the
last two determinants of ageism at the workplace—industrial and sectorial affilia-
tion and the legal framework—are located between the meso and macro level and
therefore policy makers and stakeholders have to put the topic of ageism actively on
the political agendas in order to prevent ageist behaviour in the workforce.
What implications can be drawn from this analysis of ageism’s sources at the
workplace? First, it is important to recognize that older and younger workers are
both valuable members of the workforce, and policies should refrain from playing
out different labour market groups against each other. Second, employers and trade
unions should try to create an ageist-free environment at the workplace. One main
tool to do so is the implementation of human resource measures as described above.
Third, when trying to fight ageism, companies must seek for tailor fit solutions
according to their sizes, sector and the age compositions of their employees. A ‘one
size fits all’ approach will not be sufficient in order to prevent discrimination based
on age in the labour market. Fourth, the state should set a legal framework that in
alliance with companies’ anti-discrimination measures grants workers protection
from discrimination based on age. Last, all efforts to combat discrimination because
of age at the workplace should be synchronized with each other and be embedded
into a general strategy of fighting ageism not only at the workplace but also in soci-
ety in general.
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Chapter 6
Ageism and Age Discrimination
in the Labour Market: A Macrostructural
Perspective
Justyna Stypińska and Pirjo Nikander
6.1 Introduction
Ageism and age discrimination in the labour market have been topics of scholarly
interest since the early twentieth century. Today, in markedly different economic
conditions, with increasingly globalised labour markets, the victories and failures of
workers’ movements, and the changing conditions of the European welfare state,
the problem of unequal and negative treatment of older workers still prevails. This
chapter looks at the phenomenon of age discrimination and ageism in the labour
market from a socio-political perspective and draws attention to deciding factors in
its emergence. We add to the individualistic and micro accounts adopted by psycho-
logical research (see Lev et al. 2018; Chap. 4, in this volume) and the meso level
studies of organisation and work environment conditions (see Naegele et al. 2018;
Chap. 5, in this volume) by examining the role of macrostructural processes and
transformations to identify their link to the persistence of ageism and age discrimi-
nation in contemporary labour markets. First, we provide an overview of the most
common conceptual understandings of ageism and age discrimination in employ-
ment. Second, we investigate the dynamics between the phenomena of ageism and
age discrimination and a range of socio-political contexts, cultural settings, and
legal and economic conditions. We then discuss the costs and consequences of age
discrimination in employment, and examine various policy responses to these costs
and consequences.
J. Stypińska (*)
Free University Berlin, Berlin, Germany
P. Nikander
University of Tampere, Tampere, Finland

https://doi.org/10.1007/978-3-319-73820-8_6
92 J. Stypińska and P. Nikander
6.2 A
geism and Age Discrimination in the Labour Market:
Key Theoretical Distinctions
The concepts of age discrimination and ageism in the labour market have been vari-
ously defined and conceptualized in the literature. According to Palmore (1999),
“Age discrimination may take the form of refusal to hire or promote older workers,
or forcing retirement at a fixed age regardless of the worker’s ability to keep work-
ing” (p. 119). Macnicol (2006) defined age discrimination as “the use of crude ‘age
proxies’ in personnel decisions” (p. 6), and Carmichael et al. (2011) proposed a
definition based on actual experiences of older workers who themselves define
workplace age discrimination as “not being allowed to do something you are capa-
ble of or willing to do just because of your chronological age” (p. 122). The defini-
tion based on subjective perception of age discrimination allows for improved
understanding of phenomenological aspects of how ageism operates, casting more
light on the individual experiences of older workers.
Another significant distinction was introduced with the tripartite definition of
ageism that is in frequent use especially among psychologists (Cuddy and Fiske
2000; Levy and Banaji 2004). This model assumes ageist attitudes as constituted of
three mechanisms: prejudice (affective), discrimination (behavioural), and stereo-
typing (cognitive). Here age discrimination is differentiated from the general con-
cept of ageism as it represents only those elements that have a behavioural and
externally manifested character. This partition helped enhance the understanding of
ageism and age discrimination and was adopted by McMullin and Marshall (2001),
who suggested two further distinct dimensions of ageism: “ageist ideology” and
“ageist behaviours.” Ageist ideology includes negative stereotypes, beliefs, and atti-
tudes; and ageist behaviours refer to behaviours that exclude certain people and
place them in a disadvantaged situation relative to others on the basis of their chron-
ological age (McMullin and Marshall 2001). This distinction is especially useful
when referring to the legal prohibition of age discrimination in employment
(Macnicol 2010). A key distinction based on empirical research that follows is that
biased ageist attitudes may, but do not necessarily, lead to discrimination (Furunes
and Mykletun 2010). Thus, ageism can exist without age discrimination.
To better comprehend the behavioural component of ageism (age discrimina-
tion), its specific manifestations in the labour market need to be discussed. Studies
point to several different types of age discrimination. The first type could be defined
as those behaviours which occur in strict relation to the employment status of the
worker, i.e. the hiring and firing decisions of employers. Refusing to hire an older
person or firing someone because of his or her age form the bluntest type of age
discrimination. A plethora of research shows a preference among employers to hire
younger workers while placing older ones in a disadvantaged position already in the
recruitment process (Malinen and Johnston 2013). The second area where ageism
6 Ageism and Age Discrimination in the Labour Market: A Macrostructural Perspective 93
manifests is in practices occurring within the workplace. Furunes and Mykletun

(2010) identified several such practices: being paid less than younger workers,
being left out of promotions, not being accepted to training programmes, and being
left out of companies’ modernisation processes. Stypińska and Turek (2017) distin-
guished between two types of age discrimination in the labour market: soft and
hard. Hard discrimination refers to the types of discrimination mentioned above,
whereas soft discrimination consists of practices that occur in the interpersonal
sphere and in the general atmosphere of the workplace; it is also not directly prohib-
ited by law. Examples of these include hearing ageist jokes or remarks; being treated
disrespectfully by employers, co-workers or clients; receiving lower evaluation of
work outcomes; hearing that “you are too old for something”; or being humiliated
or intimidated because of your age (Stypińska and Turek 2017). This is by no means
an exhaustive list, but rather examples of possible manifestations of age discrimina-
tion on the level of personal experiences.
An important concept in ageism studies is institutional ageism, which refers to a
bias against or in favour of (see positive ageism below) actions inherent in the oper-
ation of any of society’s institutions, including schools, hospitals, police, and the
workplace (Wilkinson and Ferraro 2004). Institutional ageism has been explained
by Palmore (1999) as a “policy of institutions or organizations, which is discrimina-
tory in a positive or negative way towards older persons” (p. 44). One standard
example of institutional ageism in the area of employment is the statutory retire-
ment age that serves as an obligatory condition for leaving the labour market.
Institutionalisation of retirement at fixed chronological age boundaries, such as 60
or 65, has, in many industrialised countries, led to an increase of institutional age-
ism (Breda and Schoenmaekers 2006). Rigid chronological age boundaries support
the social conviction that once past a certain age, the economic and social value of
an individual suddenly drops, regardless of actual skills and qualifications. Shifting
the responsibility for institutional ageism from the individual onto an institution or
organisation may lead to its further institutionalisation which, if not contested,
might further decrease control over possible consequences (Bytheway 1995).
To introduce the flipside of the predominantly negative term, positive ageism is
understood as those stereotypes, attitudes, and practices of individuals and institu-
tions which influence the situation of older adults positively (Palmore 1999).
Palmore (1999) recognized eight major positive stereotypes about older adults:
kindness, wisdom, dependability, affluence, political power, freedom, eternal youth,
and happiness. A number of favourable stereotypes specifically about older employ-
ees also exist (Loretto et al. 2007), which can work to their advantage in the labour
market, including maturity, experience, responsibility, reliability, stability, loyalty,
customer service skills, and patience (Loretto et al. 2000; Malinen and Johnston
2013; Posthuma and Campion 2009). However, studies also show that even when
employers display positive attitudes towards older workers, these do not directly
translate into positive practices (Loretto and White 2006).
6.2.1 S
pecific Features of Age Discrimination in the Labour
Market
To better understand the dynamics of labour market age discrimination, we need to

separate it from ageism in other areas of social life (health care, law, media, access
to services, etc.). This distinction boils down to two primary features. First, ageism
and age discrimination in the labour market use different chronological ages as
benchmarks to define old age than other spheres of life. There is ample evidence of
ageist practices being applied to workers and job seekers already in their 30s or 40s
(Ghosheh 2008; Stypińska 2015). The contextual character of age that stems from
its clearly socially constructed meanings (Aronsson 1997; Hazan 1994; Maier 2009;
Nikander 2000) further contributes to the complexity and specificity of the phenom-
enon of labour force age discrimination. The definition of who is an older worker
varies between branches of economy and types of entrepreneurship, as well as
among various cultural and local organizational contexts. Certain types of occupa-
tions (e.g., programmers, customer service workers, online marketers) and eco-
nomic branches (e.g., hospitality, new technologies, entertainment, social media,
and tech start-ups) are permeated with ageist attitudes, and the “middle age” in
these types of companies can be as early as 27 years old (Gaster et al. 2002;
Stypińska 2015). To reflect the phenomenon of extreme ageism in modern high tech
and start-up working environments, the term Silicon Valley ageism has been coined,
which describes the dominant ageist attitudes of most enterprises in this sector
(Wickre 2017). It is best manifested in the infamous words of Mark Zuckerberg,
CEO and co-founder of Facebook, who stated that “young people are just smarter”.
The second important distinction is that age discrimination in the labour market
is the only area of social life where legal protection against unequal treatment is
deeply institutionalised due to binding regulations, and thus provides a specific con-
text for country-specific analyses. The protection of older workers inscribed in
European Union law since the early 2000s, and in the USA since 1967, allows for
efficient counteraction to inequalities due to age, be it at the individual or organiza-
tional level.
6.2.2 Intersectional (Multiple) Discrimination
A further framework for enhancing the understanding of age discrimination in

employment, and beyond, is the academic and legal perspective of intersectionality.
Crenshaw (1991), who launched the concept within academic research, claimed that
the experiences of individuals who hold several disadvantaged statuses are utterly
unique, and thus any comparison to single-status disparity is not justified in legal or
political terms. Intersectional (or multiple) discrimination is seen to operate between
various socio-demographic categories, such as sex, race, age, ethnicity, class, and
sexual orientation, and to be structurally carved into societal institutions, creating a
tangle of multiple oppressions (Baer et al. 2010). The intersectionality framework

has also been widely adopted in gerontological research. So far, the most commonly
studied aspect of intersectionality in ageing studies has been the combination of age
and gender (Calasanti and King 2005; Krekula 2007; Ojala et al. 2016). The litera-
ture on the intersection of these two statuses goes back to the work of Simone de
Beauvoir’s seminal book, The Coming of Age (1970). In this classic work, the com-
mon situation of older women was first described as a “double jeopardy” that com-
bines both age and gender, whereas older men were seen to hold only one marginal
status (de Beauvoir 1970). The categories of age and gender have also been coupled
with minority statuses such as ethnic origin and race when analysing the experi-
ences of older women with different types of discrimination in employment (Moore
2009; van den Heuvel and van Santvoort 2011). In such cases one can talk about
“triple jeopardy”, where the person suffers from discrimination based on three
grounds (Macnicol 2005). These intersecting statuses are also the source of differ-
ence in the experiences of various social groups within the labour market. The
effects are visible in lower labour force participation rates, lower earnings, and,
consequently, lower pension benefits among female populations across Europe.
Ample evidence exists of the fact that older women experience barriers to re-
entering the labour market and that these experiences also vary substantially accord-
ing to the women’s ethnic origin or race. In the area of self-employment, older
minority women are similarly precluded from embarking on an entrepreneurial
path, as they are constantly confronted with the normative white male ideal type for
the entrepreneur (Ainsworth and Hardy 2008).
Intersectional experiences of discrimination often prove challenging for empiri-
cal researchers and legal practitioners. Despite the wide theoretical agreement on
the fact that intersectional discrimination occurs and that it has detrimental effects
on the individual, a lack of agreement prevails as to how to measure this type of
discrimination, and moreover, how to address it at the policy level. It is crucial to
note, however, that minority statuses as grounds for discrimination and inequality in
the labour market are not static functions which operate with the same force through-
out the lives of individuals. Work force dynamics and the interplay of socio-
demographic characteristics should therefore be analysed from a broader, life-course
perspective. The differences between different age groups (cohort effect) as well as
the differences between different stages of life (age effect) are certainly valuable
and should be incorporated into the intersectional analysis of relatively more static
statuses, such as gender, ethnicity, and migration background.
6.2.3 Ageism and Discrimination Across the Life Course
Loretto et al. (2000) observed a loosening of the tight association of the term ageism
solely with older employees. Instead, ageism is increasingly being recognised as
potentially affecting all age categories. Negative stereotypes and discrimination of
older people are matched by similar stereotypes and discrimination of children or

young adults, which is called adultism. Studies of ageism in Europe revealed that
across the European Social Survey (ESS) countries, respondents felt more posi-
tively towards people aged over 70 than people in their 20s (Abrams et al. 2011). A
study of age-related prejudice in the UK showed that younger age groups (below
25 years of age) were more likely to report age discrimination as more serious than
older groups (over 64). Moreover, it showed that younger respondents are at least
twice as likely to have experienced age prejudice than all other age groups (Swiery
and Willitts 2012). Studies also confirm that these attitudes can have a negative
effect on the employment opportunities of young adults (Abrams et al. 2011).
Similar to challenges faced by older workers, younger employees often come across
discriminatory practices, such as lower wages, disadvantaged working conditions,
mistrust for their skills and competencies, as well as for their loyalty to the employer
(Loretto et al. 2000; Sargeant 2010). What sets experiences of ageism in these age
groups apart, however, is their potential outcome. Research shows that younger
workers suffer less because of discriminatory practices and have greater opportuni-
ties to find alternative employment and to develop new career paths, simply due to
the longer span of time available to work ahead of them. Older workers, on the other
hand, resort to voluntary resignation much more frequently than younger workers.
For older workers this entails a risk, as their options of finding a new job are more
limited due to widespread age discrimination in recruitment practices (Sargeant
2010).
The situation of younger workers has also significantly deteriorated in recent
years, with the global economic crisis of 2008 bringing an unprecedented rise in
unemployment rates among the youngest age cohorts (under the age of 25)
(European Commission 2014). The most recent data show a 19.7% unemployment
rate on average in the European Union, with the highest rates found in Greece
(48%), Spain (46%), Croatia (44%), and Italy (38%), and the lowest in Germany
(7%), Denmark (10%) and the Czech Republic (11%) (Eurostat 2016). Even though
no direct link between the levels of unemployment and age discrimination can be
established with certainty, there is evidence that in dire economic situations, younger
people tend to be confined to more precarious and insecure jobs with lower levels of
workers’ protection, including protection from discrimination (Blackham 2015).
The harsh effects of the crisis have concentrated on one particular generation,
namely those born in the 1980s (Hills et al. 2013). According to Hills et al. (2013),
“Despite being better qualified than previous generations, people in their twenties
were worst hit by the crisis in terms of unemployment, pay and incomes…The legal
cases of age discrimination of younger workers suggest that the phenomenon is
relatively widespread and goes underreported when compared with cases from
older workers” (p. 6). However, despite its significance, more in-depth study into
the experiences of age discrimination in the labour market by younger persons is
still largely lacking (Furunes and Mykletun 2010).
6.3 M
acrostructural Processes and Age Discrimination
in the Labour Market
Three levels of analysis should be used to explain the origins of age discrimination
in the workplace: the micro level, where psychological structures of deep-rooted
prejudices, stereotypes, and biases are discussed; the meso level, where structures
of the enterprise and of the management and interpersonal relations between
employees can be studied, and the macro level, where the importance of macro-
structural processes and factors on a global scale can be linked to the experiences of
older workers with age discrimination. Since the literature on age discrimination
pays less attention to the latter, this section digs deeper and discusses the role of
macrostructural factors. These will be discussed in three subsections reflecting dif-
ferent macrostructural processes: social and cultural change (in the section on
“Modernisation”); mechanisms of capitalist development (in the section on
“Globalisation and Economic Crises”); and retirement regulations and anti-
discrimination laws (in the section on “The Political Economy of Old Age”).
6.3.1 Modernisation
Modernisation processes of the last two centuries in industrialised countries have

impacted the status of older workers and dramatically changed the structure of the
labour market (Hofaecker 2010; Kohli 1985; Palmore and Manton 1974). This
change is based on the shift within the economy and society to higher levels of pro-
ductivity, efficiency, and competitiveness—all core values inscribed in capitalism.
Such emphasis has often worked to the disadvantage of older workers, who stereo-
typically have difficulties keeping up with the strength of younger workers, and
with the increasing levels of technological advances and new forms of employment
(Macnicol 2006; Palmore 1999).
One of the key theories explaining the decreasing status of older people in societ-
ies and the labour market is the modernization theory of Cowgill and Holmes
described in 1972 in the book Aging and Modernization. The modernization theory
shows that the reduced status of older people occurred because of the transforma-
tion from traditional, agrarian societies to modern, urbanised, and industrialised
societies. Four major shifts occurred in the social structure throughout the mod-
ernising process: (1) improvement of health care resulting in the extension of the
lifespan and hence institutionalisation of retirement schemes, but also more compe-
tition for jobs; (2) technological advances making older persons’ skills obsolete and
leading to the emerging pattern of preference for younger workers; (3) urbanisation
and the rapid movement of younger people out of traditional housing and family
settings which led to the collapse of close ties in extended families and to the loss of
status of “wise elders”; (4) the expansion of the public education system and the
disruption of traditional ways of intergenerational knowledge transfers (Cuddy and

Fiske 2000). Although appealing, the modernisation theory has also faced criticism
for employing imprecise definitions of social status, overgeneralising the processes
of modernisation, and disregarding intervening variables such as ideology and value
systems (Morgan and Kunkel 2007). In the process of testing the theory of modern-
ization, Palmore and Manton (1974) concluded that indeed “employment status
does decline steadily with the shift from agriculture, but that occupation and educa-
tion status have a J-shaped1 relationship to modernization…It is suggested that as
societies move beyond a transitional stage of rapid modernisation, discrepancies
between the aged and non-aged decrease, and the relative status of the aged may
rise” (p. 205).
6.3.2 Globalisation and Economic Crises
Globalisation involved similar processes to those that occurred in modernization

period. For this reason, the impact of globalisation on older workers needs careful
consideration. Research suggests that globalisation processes have greatly deterio-
rated the situation of older workers. The loss of status of older workers in globalised
economies is seen as a consequence of the demands of a global labour market in
which cost-efficiency, flexibility, adaptability, and transferable skills are required
(Baars et al. 2006; Hofaecker 2010). Hofaecker (2010) approached the worsening of
the situation of older workers with an explanation of profound structural changes
that the global economy imposed on labour markets. One such change is the deep
restructuring of the traditional industrial sectors of the economy, where older work-
ers were overrepresented. The aftermath of these processes meant increasing unem-
ployment rates for older workers and difficulty in re-entering the labour force,
which in turn prompted an intensification of age discrimination. Moreover, replac-
ing older workers with younger ones has sometimes been seen by employers as a
cost-saving technique (Roscigno et al. 2007). Age started to turn into a stigma also
outside traditional industries, as the competitiveness of new working environments
worked to the advantage of younger workers.
Since 2008, the global labour market has been affected by financial crises, the
age-specific effects of which are only recently becoming evident (Eurostat/European
Commission 2012). The evidence from European social surveys carried out in the
first year after the economic crisis of 2008 (European Commission 2009) showed a
strong conviction that the economic crisis would negatively influence the position of
older workers in job markets through the increase in age discrimination. Analysis
from the point of view of employers and companies also revealed that in a situation
of economic slowdown and deterioration of market opportunities, the burden shifted
towards older employees by cutting their salaries (which are sometimes higher due
1
J-shaped relationship refers to a variety of J-shaped diagrams where a curve initially falls, then
steeply rises above the starting point.
to seniority schemes) or by making them redundant (Cheung et al. 2010). The
research evidence from recent years, however, shows that while younger people in
many EU countries have faced severe difficulties in finding jobs since the crisis of
2008, employment rates of prime-age and older workers have remained remarkably
stable (Eichhorst et al. 2013).
6.3.3 The Political Economy of Old Age
Despite the key role of modernisation and globalisation processes discussed above,
the crucial role of state policies can shed light on the way older workers started to
be perceived as unattractive and a burden rather than as capital to the economy and
welfare systems. The political economy of old age describes the complex and
dynamic relationship between the situation of older people and the social and politi-
cal organisation of labour, retirement, and social assistance. The role of the state is
central to the understanding of how the political economy of old age operates and
thus the implications of certain state policies need to be analysed separately.
According to Alan Walker (1981), the state regulated boundaries of productive eco-
nomic activity (in the form of fixed retirement age) lead to high levels of depen-
dency of older people in capitalist societies. The evidence for this process comes
from theoretical deliberations on structured dependency - a term used to describe
how the dependency of older people came to be artificially structured or deepened
as an effect of various state policies (Townsend 2006). Among the most significant
are policies dating back to the 1960s and 1970s, such as a fixed age for retirement;
the minimal subsistence afforded on the state pension; substitution of retirement
status for unemployment; near-compulsory admission to residential care of people
whose abilities were fairly intact; the dependence of many residents in homes and
of patients in hospitals and nursing homes; and the conversion of domiciliary ser-
vices into commodity services (Townsend 2006). When it concerns age discrimina-
tion, however, the early retirement schemes introduced in many industrialised
countries impacted the status of older workers the most (Breda and Schoenmaekers
2006; Neumark and Button 2014), and thus will be discussed below in more detail.
Early retirement represents a long-term process, the first attempts of which can
be traced back to the 1950s for some industrialised countries. In the economically
prosperous period of the 1950s and early 1960s, most societies still practiced a full
labour force participation of older workers. It was only in the 1970s that early retire-
ment started to significantly increase in most Western societies (Hofaecker 2010).
The reason for early retirement schemes was attributed to the expansion of welfare
systems that provided financial security for old age and worked to pull older work-
ers out of active labour participation. Second, higher unemployment rates for older
workers in the late twentieth century represented a push factor for early retirement.
High unemployment rates were also grounds for the introduction of early retirement
policies in Eastern European countries in the 1990s,2 and also eased the effects of
the end of guaranteed employment after the collapse of Communism (Zimmer and
McDaniel 2016). The effects of early retirement policies triggered changes in retire-
ment behaviours of older workers, but also influenced the image of older workers in
general, as well as employers’ attitudes towards them. Employers increasingly
started to perceive workers aged 50 and over as redundant and unemployable, and
accordingly tended to disadvantage them in recruitment, training, and retirement
practices. Moreover, companies became used to early-exit policies as an “easy solu-
tion” for personnel management, especially in times of radical change in the global
economy (Baars et al. 2006; Bytheway 2007). Workers even in their 40s are often
seen as a risky investment and are therefore subjected to age discrimination in the
workplace.
The reversal of early retirement options has proven a difficult path for many
governments. In recent years, policy makers are increasingly developing strategic
goals for raising employment rates among older workers. The most prominent
examples of this have been the so-called “Stockholm” and “Barcelona” targets
introduced by the European Union, which aim to reach an average employment
level of 50% among older workers aged 55 to 64 years, as well as a 5-year postpone-
ment in the typical age of retirement (Hofaecker 2010). From 2002 onwards, the
employment rate of people aged 55–64 in the EU has grown steadily to reach 55.3%
in 2016, compared with 38.4% in 2002 (Eurostat 2017). Any increase in the number
of employed older persons does not on its own necessarily indicate that the levels of
age discrimination have decreased, but certainly points to a steady direction of
greater inclusion of older workers into productive labour.
6.4 The Consequences and Costs of Ageism in Employment
The negative consequences and costs of ageism and age discrimination in the labour
market can be divided into individual, institutional, economic (pecuniary), and soci-
etal (Minichiello et al. 2000; Palmore 2005; Taylor et al. 2012). Each category is
discussed below.
6.4.1 Individual and Institutional Costs and Consequences
The negative consequences of age discrimination for older workers themselves

include barriers to recruitment and hiring, diminished conditions of work and
employment, limited career development and, in the absence of legislation,
diminished employment protection and rights. Negative effects can be observed not
Although some aspects of these policies had been introduced before the 1990s.
2
only in career paths and occupational opportunities, but also increasingly in family
life, wellbeing, health outcomes, with increased stress levels, lower self-esteem, and
loss of a sense of control (North and Fiske 2012). These negative consequences can
in turn lead to self-inflicted discrimination, as victims of prejudice and discrimina-
tion sometimes adopt the dominant group’s negative image of the subordinate
group, start to behave accordingly, and thus further reduce their chances in the
labour market (Palmore 2005). Research also shows that age discrimination report-
edly leads older persons to consider changing their occupation or retraining, to give
up looking for work altogether, or to consider early retirement (Australian Human
Rights Commission 2015).
The institutional cost of age discrimination for employers is also on the rise.
Demographic analyses show unequivocally that older workers are the fastest grow-
ing labour pool. One in four workers will be over 55 in 2020, versus one in six in
2007 (Hofaecker 2010). Employer- and manager-level prejudice and bias against
older workers results in company loss of experienced workers and decreased effi-
ciency in the workplace (Ghosheh 2008; Stypińska 2014). Employers that do not
hire on merit, in other words, risk their own survival as they compete among them-
selves for a shrinking pool of younger workers.
6.4.2 Social and Economic Costs and Consequences
The social costs of ageism and age discrimination can be understood as the effects
of long-term exclusion from the labour market that result in social, economic, and
cultural segregation, which are detrimental for individuals and societies at large
(Simms 2004). Social isolation which might result from economic inactivity among
older workers can impact the integrity of families and local communities, pose a
great threat to their wellbeing, and impose an additional burden on the welfare state.
The costs of an ageist environment can be detrimental to the financial situation
of any company. Workplaces that embrace age diversity, and that are perceived as
doing so, tend to have higher levels of employee engagement, and motivated
employees are more productive, profitable, safe, create better customer relation-
ships, and are more loyal to the company (Parry and Tyson 2011). In contrast, less
engaged or motivated workers cost businesses in lost productivity, workers’ com-
pensation claims, and wasted time. Assessing the costs of age discrimination to a
single company’s economic performance is not easy. Some estimates are available,
however. According to a Gallup study, in a 10,000-person company, disengagement
of the workers due to unequal treatment represents 5000 unexcused days of absence,
and about $600,000 in lost salary per annum (Wilson 2006). Calculations concern-
ing the Australian labour market suggest that an increase of 5% in paid employment
of Australians over the age of 55 would result in a $48 billion impact on the national
economy every year (Australian Human Rights Commission 2015).
6.5 Policy Responses to Ageism
The remaining space of this chapter is dedicated to specific policies targeting age-
ism in employment. Anti-discrimination legislation and active ageing policies are
discussed in particular.
6.5.1 Legal Solutions and Responses
One policy tool that is receiving growing attention concerns age discrimination leg-
islation. Its main function is to safeguard access of older workers to employment
and hiring opportunities under conditions of equality with other age groups. Second,
it protects the employment status and training/career development opportunities of
those already employed (Ghosheh 2008). In the European context, until only
recently, age discrimination did not receive recognition and attention to the same
extent as other forms of discrimination based on gender or nationality (Mikołajczyk
2013). This lack of acknowledgement is due to two facts: first, age discrimination
has different characteristics from other types of inequality, because it applies to a
social group with less clearly identifiable features than women or ethnic minorities,
for instance. Age distinctions are more fluid as there is no fixed upper or lower
boundary at which the worker can be defined as old. Second, not all age distinctions
in employment necessarily constitute age discrimination, which makes recognising
them particularly challenging.
Whereas recognition of age discrimination by the European Union is quite a
recent fact, the United States started acknowledging, identifying, and tackling the
problem much earlier. American anti-discrimination legislation came into force in
1967 with the adoption of the Age Discrimination in Employment Act (ADEA). It
was part of an unprecedented turn in the 1960s, when public policy started advanc-
ing toward economic and social justice by defending the rights of vulnerable social
groups (Rothenberg and Gardner 2011). In the first instance, the law covered work-
ers between 40 and 65 years old. With the abolition of the mandatory retirement age
in 1986, the regulatory means gained a new momentum and older workers were also
covered (Friedman 2003; Macnicol 2006). The actions prohibited by the law per-
tained only to the employment field and covered discriminatory job advertisements,
discrimination in pay, and discrimination in the use of company facilities (Friedman
2003).
Several authors have suggested that the European legislation was modelled on
the American law, but with additional distinctive features (Friedman 2003; Lahey
2010). The approach adopted to combat age discrimination in the European Union
labour market is important due to two factors. First, the legal provisions existing in
the European law are binding for all member states and must be implemented in
national legal systems. This means that employers in all member states can be held
accountable for them. The proof that the legislation is not a dead letter law can be
seen in the systematically growing number of age discrimination cases in national
courts, as well as in the European Court of Justice (Rothermund and Temming

2010; Umhauser-Enning 2013). Second, these regulations are crucial, because
although ageism and age discrimination may occur in a range of fields, including
health care, financial services, housing, and education, it is the labour market which
has been given priority in the legal system of the EU (Mikołajczyk 2015).
Discrimination in the labour market can take many forms. EU legislation makes
a distinction between direct and indirect discrimination, harassment, and instruc-
tion to discriminate (Ghosheh 2008). Direct age discrimination occurs when a per-
son is treated less favourably than another person in an analogous situation due to
his or her age. Indirect age discrimination happens when an “apparently neutral
provision, criterion or practice would disadvantage people on the grounds of age
unless the practice can be objectively justified by a legitimate aim” (Furunes and
Mykletun 2010, p. 125). Harassment is defined as “unwanted conduct related to …
age with the purpose or effect of violating the dignity of a person and of creating an
intimidating, hostile, degrading, humiliating or offensive environment” (European
Commission 2009, p. 29). Instruction to discriminate occurs when, using existing
power dependencies, such as employer–employee, a person is told to discriminate
against another person (Ghosheh 2008).
The effects of anti-discrimination legislation are difficult to measure (Loretto
et al. 2000; Mikołajczyk 2015; Neumark 2009). Existing studies show that legisla-
tion could increase employment levels of older workers, but that there is no positive
impact on the hiring practices of protected workers as their contracts are more dif-
ficult to terminate (Neumark 2009). Other studies have found that a minor number
of reported cases of age discrimination go to trial and an even smaller number ter-
minate in compensation. This is due to the difficulties of proving age discrimination
in court (Rothenberg and Gardner 2011). Moreover, severe labour market distrac-
tions, such as the economic crisis, make it difficult to recognise discrimination and
can weaken the effects of stronger state age discrimination legislation (Neumark
and Button 2014). It has also been found that anti-discrimination legislation can
raise awareness of the problem among older workers and employers (Amiraux and
Guiraudon 2010). However, as noted by Amiraux and Guiraudon (2010), the social
fluidity of discrimination contrasts with the boundaries of its legal existence, which
calls for more interaction between the two spheres to enhance the efficiency of the
legislation and to increase its social impact.
6.5.2 A
ctive and Productive Ageing Policies of the European
Union
The second leg of European policies aiming at reducing age discrimination in the
labour market consists of policies in the realm of active ageing, or, as it used to be
called, “productive ageing.” The history of active ageing policies can be traced back
to the 1960s in the United States, where it was argued that the key to successful age-
ing was the maintenance of the activity patterns and values typical of the middle
age. This approach came to be known later as activity theory (Walker 2002). In
relation to the area of employment, active ageing measures might include age man-
agement; lifelong education and continuous training; reconsideration of policies
that stimulate early exit; abolishing mandatory retirement age; and introducing flex-
ible options for pre-retirement employment (e.g., half-time contracts). A more
recent approach consists of policies targeted at combating age discrimination, age
boundaries in the labour market, and motivating employers to recruit and retain
older workers. Walker (2002) noted that “age discrimination is the antithesis of
active ageing,” and thus concerted efforts should be made at work in order to com-
bat it. He claimed that raising pension ages without fighting ageism in the work-
place would only result in more social isolation and poverty in old age. On the other
hand, policies targeting activity in older age have been systematically criticised
since their implementation. Moulaert and Biggs (2012) called such policies “a new
orthodoxy of ageing subjectivity” (p. 3), which restricts the social contribution of
older adults to work and work-like activities and propagates a one-size-fits-all
model for a very heterogeneous population of older adults.
In the EU, the most recent focus of Active Ageing as part of the Europe 2020
strategy is to enable older people to contribute fully both within and outside the
labour market. These policies envision older people as empowered to remain active
as workers, consumers, carers, volunteers, and citizens (European Commission
2012a). A special policy programme titled “A European Year for Active Ageing and
Solidarity Between Generations” was introduced in 2012. It presented tools for
improving the situation of older persons and preventing their exclusion, including a
new index, the Active Ageing Index, that monitors the situation of older people in
society. The index measures the extent to which older individuals can realise their
full potential with regard to employment, participation in social and cultural life,
and independent living. It also measures the degree to which the environment they
live in enables seniors to lead an active life. Attempting to evaluate the impact of the
reforms within the Active Ageing programmes is limited because they were intro-
duced relatively recently. As a result, only a few evaluations of their actual impact
have been carried out to date. Nevertheless, some countries have observed increased
participation of older workers in the period since the reform was introduced
(European Commission 2012b).
6.6 Conclusions
The aim of this chapter was to give an overview of conceptual distinctions between
ageism and age discrimination in the labour market, and to examine the impact of
macro-structural processes on the status of older workers in modern economies.
Age discrimination in employment is not only an effect of the individual prejudices
and stereotypes of the employers, but rather, has a longer history in industrial rela-
tions, and is firmly embedded in the structural components of global labour markets.
The strong relation between the status of older workers and economic situations and
state policies propagated in the past explain the structured nature of ageism and age
discrimination in the labour market. The critical question remains, however: can
ageism and age discrimination decrease let alone disappear from the workplace over
time? The overview of policies introduced in the EU during the last decade suggests
that a certain improvement in the situation of older workers can be observed, espe-
cially with regard to their increasing employment rates. A further chance for
improvement comes from the fact that an ever-growing older population will inevi-
tably change the social structure of age. This means that as older people become
increasingly difficult to ignore, perceptions of older employees will need to adjust
to the same measure and the relationship between work and retirement will need to
be reconsidered.
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Chapter 7
Introduction to the Section:
On the Manifestations and Consequences
of Ageism
The chapters in this section describe in detail the manifestations and consequences
of ageism. The diversity of settings and situations described in this section clearly
indicates the pervasiveness of the phenomenon. Ageism occurs at the individual
level as well as at the societal/structural level, and the interaction between these two
levels further perpetuates its occurrence. The negative impact of ageism on the lives
of older adults is clearly discussed and demonstrated in the ten chapters presented
in this section.
The first chapter in this section, by Kydd, Fleming, Gardner, and Hafford-
Letchfield (2018; Chap. 8) critically examines ageism in the third age that is directed
towards individuals in their fourth age. This chapter follows the definition of ageism
as the “enemy within” (Levy 2001) by discussing ways in which older adults attempt
to disassociate themselves from old age and decline. This division between the third
and the fourth age is clearly articulated by the author John Burroughs (1837–1921):
“To me, old age is always ten years older than I am”. In the successful or active age-
ing models, the third age is associated with good health and a high degree of societal
participation, whereas the fourth age represents the failure to maintain the function-
ing of middle age and the surrender into decline and decay. Hence, the fourth age is
classified as “old,” whereas the third age makes attempts to stay “forever young.”
The second chapter in this section, by Shiovitz-Ezra, Shemesh, and McDonnell-
Naughton (2018; Chap. 9) corresponds to the chapter by Kydd et al. (2018;
Chap. 8) by articulating the negative consequences of ageism on older adults’ satis-
L. Ayalon (*)
C. Tesch-Römer (*)

https://doi.org/10.1007/978-3-319-73820-8_7
faction with social life, manifested in high levels of loneliness. In the case of older
adults, ageism likely plays a role as an intra-psychic experience that inhibits older
adults from developing relationships with other older adults (similar to the case
described by Kydd et al. 2018) as well as with people of different age groups.
Ageism also serves as a structural barrier in societies that divide young and old,
allowing for very little contact between people of different generations. Finally,
although loneliness is in part a subjective experience associated with dissatisfaction
with one’s relationships, it is important to acknowledge that many objective losses
in old age also make older adults particularly vulnerable to loneliness. These vul-
nerabilities are further intensified by the experience of ageism.
Another area where ageism plays a role is sexuality. At the micro-level, the per-
ceptions and beliefs of older adults impact their expectations as well as behaviours
regarding sexuality. However, older adults do not operate in isolation. Instead, their
experiences, expectations, and behaviours are largely influenced by messages por-
trayed in the media, and by health care professionals, long-term care providers, and
family members, among others. The chapter by Gewirtz-Meydan, Hafford-
Letchfield, Benyamini, Phelan, Jackson, and Ayalon (2018; Chap. 10) points to the
role of ageism in shaping the discourse about sexuality in old age. The view of sexu-
ality as non-existent and invisible in old age, or as a purely bio-medical “problem,”
serves to deprive older adults of their sexuality and does not allow for the actual
diversity of experiences, desires, and beliefs about sexuality among older adults.
The media as a way to portray and also influence reality is discussed in the chap-
ter by Loos and Ivan in this section (2018; Chap. 11). The chapter demonstrates how
the visual presentation of older adults has changed over the years. Whereas early
representations of older adults were minimal and tended to focus on the negative,
current representations of older adults follow the spirit of successful and active age-
ing. Although the latter perspectives represent an attempt to move away from the
pathology of old age and ageing, they clearly place on older adults the responsibility
for their own decline and eventual mortality and, thus, they can be seen as promot-
ing another form of ageism (Liang and Luo 2012). The unreasonable expectations
disseminated by the media likely reinforce ageism and may increase social isolation
and loneliness among older adults who “fail” to age successfully (e.g., the fourth
age in Kydd’s chapter (2018; Chap. 8)).
In this section, Dolberg, Sigurðardóttir, and Trummer (2018; Chap. 12) discuss
an unexplored yet highly topical issue that has made the headlines recently, namely,
immigrants and immigration policies. Although ageism is not the first topic that
comes to mind when considering immigration, there is no doubt, after reading this
chapter, that ageism plays a substantial role in the life of older immigrants. As illus-
trated in the chapter, older immigrants are exposed to double or even triple jeopardy
by policies that privilege younger immigrants and by cumulative stresses and disad-
vantages associated with the deleterious effects of immigration status and old age
combined.
The chapter by Wyman, Shiovitz-Ezra, and Bengel (2018; Chap. 13) on ageism
in the health care system and the chapter by Fialová, Leppee, Kummer, and Držaić
(2018; Chap. 14) on ageism and medication in older adults are highly important
7 Introduction to the Section: On the Manifestations and Consequences of Ageism 111
given the fact that older adults have to rely on adequate health care services and are
at a high risk for taking a large number of medications. This reliance on medical
services in later life has even led some philosophers to ask whether older adults have
a duty to die (Hardwig 1997). The chapter by Wyman, Shiovitz-Ezra, and Bengel
(2018) provides a comprehensive overview of the role of ageism in the health care
system by demonstrating how ageism operates at the individual level, at the meso-
level, and at the macro-level to impact the quality of health care provided to older
adults. This chapter is complemented by the chapter on ageism and medication use,
which outlines the negative consequences of ageism on the prescription of medica-
tion for older adults. This chapter also contains recommendations for strategies to
reduce inappropriate prescribing, risky polypharmacy, and medication non-adher-
ence in older patients.
Bodner, Palgi, and Wyman (2018; Chap. 15) offer a fresh perspective on ageism
in mental health care. They vividly illustrate how both the assessment and the treat-
ment of mental illness are impacted by ageism. The role of countertransference has
received substantial attention in the mental health literature, but, in this chapter, it is
viewed in the context of ageism, as the psychologist’s feelings and attitudes about
age. Given the stigma of old age, many symptoms of mental illness are seen as signs
of ageing and vice versa. This often hampers the quality of treatment provided to
older adults with mental illness.
Like mental illness, dementia is a highly stigmatized condition. Hence, the chapter
by Evans in this section (2018; Chap. 16) explores the role of double stigma in the life
of older adults who suffer from dementia, and describes how this double stigma
impacts the care provided to them. Evans illustrates how older adults and having
dementia become synonymous at times. In addition to other chapters in this section
(Wyman, Shiovitz-Ezra, and Bengel 2018; Fialová et al. 2018; Bodner et al. 2018; and
Ben-David, Malkin, and Erel 2018), this chapter stresses the pervasive and debilitat-
ing presence of ageism in the health care system. Clearly, ageism impacts older adults’
access to health care services, as well as the quality and availability of services.
The concluding chapter in this section is by Ben-David et al. (2018; Chap. 17)
This chapter provides a brave attempt to dispute a priori assumptions about the
relationship between old age and cognitive decline and deterioration. The authors
argue for a sensory decline, rather than “the usual suspect” of cognitive decline, as
a barrier to adequate performance on neuropsychological tests. Moreover, another
major obstacle faced by older adults who encounter neuropsychological assess-
ments is the threatening and unfamiliar testing situation, which often puts them at a
disadvantage compared with younger adults. Self-fulfilling prophecies and the
internalization of negative stigma regarding the relationship between old age and
cognitive impairments are also substantial obstacles to adequate performance of
older adults on neuropsychological tests.
These highly diverse chapters have several aspects in common. First, they address
multiple levels of manifestations of ageism. All of the chapters in this section show
that ageism is manifested in social interactions involving older adults (see, for exam-
ple, Kydd et al. 2018). Moreover, ageism is well-internalized and impacts older
adults through their belief systems and expectations, influencing social integration
and their relations to other people (Shiovitz-Ezra et al. 2018; Gewirtz-Meydan et al.
2018). Ageism is also present at the meso-level, and manifests in interactions with
professionals (Wyman, Shiovitz-Ezra, and Bengel 2018; Bodner et al. 2018; Ben-
David et al. 2018). These may include a variety of health or mental health care pro-
fessionals (Wyman, Shiovitz-Ezra, and Bengel 2018; Fialová et al. 2018; Bodner
et al. 2018; Evans, Ben-David et al. 2018) or long-term care workers (Gewirtz-
Meydan et al. 2018). Finally, ageism also occurs at the macro-level, as clearly illus-
trated in policies which discriminate against older immigrants (Dolberg,
Sigurðardóttir, and Trummer 2018), older adults with dementia (Evans), or older
adults with other health conditions (Wyman, Shiovitz-Ezra, and Bengel 2018).
Another common feature of these chapters is the emphasis on multiple jeopar-
dies that older adults experience. The chapters demonstrate that ageism increases
vulnerability in old age, which is often further amplified by impaired health status
(Gewirtz-Meydan et al. 2018; Wyman, Shiovitz-Ezra, and Bengel 2018; Fialová
et al. 2018), immigration status (Dolberg, Sigurðardóttir, and Trummer 2018), men-
tal illness (Bodner et al. 2018), dementia status (Evans), or a sensory decline (Ben-
David et al. 2018). These multiple vulnerabilities correspond with the chapter by
Krekula et al. (2018; Chap. 3) in the previous section, and support the need to view
ageism in context, as part of other potential sources of discrimination. Healthism,
disablism, lookism, and sexism represent discrimination based on qualities other
than age. The ten chapters presented in this section clearly demonstrate the interac-
tion of ageism with these other bases for discrimination. Hence, it is often not age
per se, but age in combination with other qualities that promotes discrimination.
One question raised by this section is “What would be considered a non-ageist
approach?” The chapter on ageism in the visual media by Loos and Ivan (2018;
Chap. 11) attempts to answer this question by arguing for the importance of diver-
sity in older adults’ representations and experiences. They support a transition from
the portrayal of older adults in the visual media as invisible, weak, or frail to other,
more nuanced portrayals of ageing and old age. However, they argue that the current
successful ageing and active ageing models do not fit the ageing process of all older
adults, and, thus, they must be diversified. This is similar to the arguments made by
Gewirtz-Meydan et al. (2018) in this section regarding sexuality in the age of Viagra.
Providing older adults with diverse models of ageing is a necessary next step in
creating a non-ageist society. This claim is also supported in the previous section by
Lev et al., who see a long continuum that includes impairment, failure, and disabil-
ity as well as successful or active ageing, which should be acknowledged and
respected. The chapters by Wyman, Shiovitz-Ezra, and Bengel (2018) and Fialová
et al. (2018) in this section, on the other hand, argue that a non-ageist approach must
be individually tailored. Although age can be one characteristic to take into account
in medical diagnosis or treatment, it is by no means the only criterion. An individu-
alized approach to care takes into account a variety of factors, not just chronological
age. Such an approach is non-ageist and highly appropriate for both young and old.
Other chapters, such as the chapter by Bodner et al. (2018; Chap. 15) on ageism
in the mental health system, the chapter by Evans (2018; Chap. 16) on ageism and
dementia, and the chapter by Ben-David et al. (2018; Chap. 17) on ageism and neu-
ropsychological assessment, argue for increased knowledge and awareness as a
7 Introduction to the Section: On the Manifestations and Consequences of Ageism 113
means to address ageism. These authors, as well as others in this section, demon-
strate the role of the beliefs and attitudes of health and mental health professionals
in shaping reality. Greater awareness of ageist attitudes can help overcome some of
the ageist practices currently in use.
This section on the manifestations and consequences of ageism is important
because it demonstrates the pervasiveness of ageism and its negative contribution to
the life and care of older adults. Ageism can be subtle and hardly noticed or explicit
and well-acknowledged. Regardless of its form, it shapes the views of older adults
about their abilities and needs as well as the views of the people surrounding them.
Although the chapters do not aim to provide solutions to combat ageism, they do
point to future directions which could improve the wellbeing and quality of life of
older adults. These can be at the policy level (detailed in the next section), as well
as at the individual level, for example in the form of educational interventions to
promote individualized approaches and increase awareness of ageist attitudes.
References
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Dolberg, P. H., Sigurðardóttir, S., & Trummer, U. (2018). Ageism and older immigrants.
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perspectives on ageism: Vol. 19. International perspectives on aging (pp. 263–275). Berlin:
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(2018). Ageism and sexuality. In L. Ayalon & C. Tesch-Römer (Eds.), Contemporary perspec-
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Kydd, A., Fleming, A., Gardner, S., & Hafford-Letchfield, P. (2018). Ageism in the third age.
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Shiovitz-Ezra, S., Shemesh, J., Gardner, S., & McDonnell- Naughton, M. (2018). Pathways from
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Chapter 8
Ageism in the Third Age
Angela Kydd, Anne Fleming, Sue Gardner, and Trish Hafford-Letchfield
8.1 Introduction
Older people are the largest group accessing and using care services within Europe
(Eurostat 2015) and are often referred to as a “burden” (Beard and Bloom 2015).
Improvements in public health, medical screening, timely treatments, and improved
health and social care services in industrialized countries have all contributed to
people living longer and healthier lives (Carr and Komp 2011). Average life expec-
tancy is now estimated to be 78 years in developed countries and 68 years in less
developed countries, with the gap continually narrowing every year. By 2045–2050,
life expectancy is projected to reach 83 years in more developed countries and
75 years in less developed countries (Department of Economic and Social Affairs
Population Division 2013).
Whilst a defining characteristic of the ageing process may involve increased
vulnerability to a decline in health and wellbeing (Kirkwood 2014), novel approaches
to wellbeing alongside complex biological, medical, psychosocial, political, and
economic factors can influence both individual and group trajectories in later life.
Ageing remains an extremely complex field in terms of understanding the relation-
ships between these contributory factors and the transitions that connect them.
A. Kydd (*)
Edinburgh Napier University, Edinburgh, Scotland, UK
A. Fleming
Independent Researcher, Edinburgh, Scotland, UK
S. Gardner
Independent Researcher, Thame, UK
T. Hafford-Letchfield
Social Care, Middlesex University, London, UK

https://doi.org/10.1007/978-3-319-73820-8_8
116 A. Kydd et al.
Simultaneously, there has been a reorganization of health and social care services,
caused in part by the universal adoption of economic rationalism, managerialism,
and fiscal restraint (Hafford-Letchfield 2014). Not least, there has been a notable
change in the retreat of government from its traditional role as a provider of institu-
tional care, which has led to greater promotion of individualization while at the
same time reducing eligibility for services (Scourfield 2010). These expectations
and developments pose enormous challenges, tensions, and ambiguities for how the
ageing trajectory and the multiple factors affecting it over the life course are
understood.
The increasingly older population is accompanied by a new discourse about
“active and successful ageing” (Foster and Walker 2014). However, the “good” and
“successful” versus “bad” and “burdensome” dichotomy that is set up by this dis-
course may especially impact active older people who are averse to viewing their
future older selves as a burden (Nelson 2005). Both “good” and “bad” ageing dis-
courses differentiate between those who are “successfully” ageing and those people
for whom successful ageing is not possible. This may contribute to tensions between
third and fourth agers.
Discourses associated with ageing, and interactions between these two cohorts,
may indeed contribute to intergenerational ageism. Although there are few empiri-
cal studies of these tensions, this chapter capitalizes on the timeliness of exploring
such discourses by synthesizing some of the relevant literature and the possible
themes to increase our understanding. We address previous classifications of age-
ing; demography; key concepts of the third and fourth ages; evidence of distancing
between these two cohorts; and implications for health and wellbeing. We conclude
with recommendations for further research.
8.2 Classifications of Ageing
Gerontology has always engaged with critical theory to question normative theories
about ageing, wellbeing and the significance of deconstructing these theories to
promote self-determination and human rights (Cocker and Hafford-Letchfield
2014). Age-related prejudice and discrimination is commonly seen as a social con-
struction based on classification systems. Yet the classification of old age is ill
defined. Morrow-Howell (2012, p. 379), writing her paper at the age of 60, asked,
“Will we continue to use 60 or 65 years old to define the older population, even
when the majority of people in that category will be there for 20 or 30 more years?”
To classify people from the age of 55 to over 100 as “old” implies that there have
to be overwhelming commonalities in this period of life. Serra et al. (2011) believed
that age classifications would serve to dispel the image of the “burdensome old” and
suggested chronological age categories, such as octogenarians (80–89); nonagenari-
ans (90–99); centenarians (100–104); semi-supercentenarians (105–109), and super-
centenarians (110+). However, from the studies reviewed in this chapter, there are no
references to sexagenarians (age 60–69) or septuagenarians (age 70–79), and there is
8 Ageism in the Third Age 117
no apparent consistency in defining age groups. Using such categories would remove
the words “young” and “old” from common parlance and would serve to describe
cohorts over the life course. Further life-course categorizations would include denar-
ian (age 10–19); vicenarian (20–29); tricenarian (30–39); quadragenarian (40–49);
and quinquagenarian (50–59). These conventions, however, consider each category
as homogeneous and based solely on chronology, and such theorizing denies the
complex intersectionality of ageing and the importance of recognizing and respond-
ing to extremely divergent life experiences (Hafford-Letchfield 2013).
Older people’s experiences are not shaped by only one aspect of their identity,
but by a combination of factors, such as gender, age, religion, disability, health,
location, sexual identity, migration history, socioeconomic status, and ethnicity.
Key processes that shape outcomes for older people may include the texture of day-
to-day life, the decisions and assumptions that people make as individuals, and the
interactions between people (Hafford-Letchfield 2013). One example is the impact
of economic vulnerability on insecurity and sensitivity in the wellbeing of older
individual households and communities (Victor 2013). External factors may also be
mediated by internal factors such as an older person’s responsiveness and resilience
to risks they face in later life. These critiques draw attention to the inadequate nature
of normative life-course theories.
8.3 Perceptions of One’s Own Old Age
Heikkinnen (2000) searched for a narrative of ageing in a study of Finns (n = 20)

aged 80 in 1990, with a follow-up 5 years later (n = 17). The participants were all
born in the same year and all lived in the same city in Finland. In her group, she
found that experiences of ageing were expressed according to the positive and nega-
tive meanings that individuals attached to these experiences. In other words, she
found that their experiences of ageing were heterogeneous, together with the social,
physical, and cultural environments in which they occurred. At the baseline, her par-
ticipants did not consider themselves to be old, as they were not experiencing prob-
lems with everyday life, thus placing her 80-year-old participants firmly in the third
age. At follow-up, when they were 85 years old, most of her participants felt that they
were now old, due to deterioration in health, loss of human relationships, and an
increase in frailty and/or pain. The participants had to change the way they perceived
themselves and the way they organized their days to match with their abilities.
Nicholson et al. (2012) interviewed 17 older people, aged 86–102 years and liv-
ing at home, to gain an understanding of the experience of living and dying with
frailty in old age. Their data analysis revealed three main themes: the dynamics of
physical and psychosocial frailty, sustaining connections within the home, and con-
necting with death and dying. The first theme was concerned with increasing uncer-
tainty and loss as a result of physical and psychosocial deterioration, which changed
how the individual perceived themselves and how they were perceived by others.
The second theme was concerned with the work and adaptations participants made
118 A. Kydd et al.
to compensate for increasing frailty in order to maintain satisfactory routines and

sustain a feeling of being at home. The third theme focused on the participants’
recognition that they were approaching the end of life, which the authors describe
as “inhabiting the space between living and dying”.
In exploring self-perceptions of ageing with those who had outlived the average
age of their birth cohorts, both Nicholson et al. (2012) and Heikkinnen (2000)
highlighted resilience and capacity for change in contrast to traditional negative
stereotyping. They showed the ability of much older people to change their percep-
tions of self and the rate at which they felt becoming old happened to them and the
strategies they used to achieve this. According to Johnson and Barer (1997), older
adults’ re-conceptualization of their self-perception is thought to occur in the
following four domains. In the first, one accepts the temporality of life and places
oneself towards the end of it. In the second, the self-concept belies the reality of the
situation; for example, although physically and/or mentally less competent than
they used to be, they describe themselves as being in good health. In the third, they
detached voluntarily from some aspects of the world surrounding them, such as
unwanted roles and responsibilities. And the fourth involved living in the present—
a “one day at a time” approach.
Comparing oneself to others is a widely reported positive strategy in developing
or refining self-perception in old age: positive comparisons such as “I am much fit-
ter than others are” or “I can still get around without a wheelchair, unlike my friend”
are used to construct a more positive identity (Johnson and Barer 1997). However,
these positive messages can also be said to emphasize loss of function: “I can still
get around without a wheelchair” or “I can get around without a wheelchair … but
only around the house”. Another strategy that is commonly used is to separate the
mind from the body: for example, “It’s just my knees that are old; my mind is still
sharp”.
The most common strategy in older age is to maintain a sense of control over
both health and lifestyle, perhaps because ageing is a process over which people feel
they have no control (Johnson and Barer 1997). Betts Adams et al. (2010) explored
changes in activity and interest in the third and fourth ages (in their study this
referred to ages 64–79 and 80+, respectively). They referred to the concept of selec-
tivity introduced by Baltes and Baltes (1993), in which older people decided them-
selves where to focus their energies to best advantage. They found that both the
younger cohort (n = 50) and older cohort (n = 128) demonstrated a pattern of disen-
gagement from active pursuits in favour of more passive social and spiritual pursuits
in the fourth age. Heikkinnen (2000) suggested that individuals organize their daily
life in a way that is consistent with their abilities. The participants in her study who
described themselves as feeling old reported that they structured their days around
their physical needs and had replaced earlier activities with more simple tasks.
Nicholson et al. (2012) suggested that these daily routines not only provide a sense
of control, or pass the time, but that they also serve to connect individuals to the past
as well as the present through the provision of a pattern of work and rest. Routine,
they suggest, can also be helpful in distracting the mind from unwanted thoughts of
dependency or decline.
How older people view themselves and their peers has an impact on how they
make choices and whether or how they engage with services. Sarkisian et al. (2002)
found that having low expectations of ageing not only had a negative impact on
preventative health behaviours, but also indicated a low engagement with healthcare
services for conditions such as depression and urinary incontinence. Half of the
participants in their study expected ageing to lead to depression, dependency,
decreased ability to have sex, more aches and pains, trouble sleeping, less energy,
and becoming less attractive. Those with low expectations were less likely to seek
healthcare for age-associated conditions. Levy and Myers (2004) measured the atti-
tudes of older people aged 50–80 years (n = 241) towards their own ageing to
explore how age beliefs predicted a variety of preventative health behaviours and
the impact of these over a 20-year period. Older people with a positive self-
perception of ageing reported engagement in more preventative health behaviours
over the course of the study, with significantly higher self-rated health than those
with a negative self-perception of ageing. This predictive value of ageing self-
perceptions may therefore be valuable to those researching or practising preventa-
tive health behaviours. In contrast, Jopp et al. (2008) found that both young-old and
old-old people showed high levels of valuation of life (VOL), which reduced from
the third to the fourth age. Nonetheless, this study supported earlier work in demon-
strating that, despite high levels of health impairment, the oldest-old can still hold
high levels of VOL through a complex process of balancing the positive and nega-
tive aspects of life. The young-old group in this study placed a higher value on
health factors, while the old-old placed more value on social factors.
Litwin and Stoeckel (2013) examined the associations between social net-
works, life satisfaction and feelings of wellbeing in a young-old cohort (60–
79 years) and an old-old cohort (80 years and over) from the second wave of the
Survey of Health, Ageing and Retirement in Europe study (n = 14,728). They
found that social networks were greatly valued in very old age, but not in the same
way as in younger-old adults: for example the older cohort living with one or
more adult children reported this as having a positive impact on wellbeing, while
the younger cohort demonstrated a negative association between living with adult
children and quality of life. Other opposite findings between the cohorts studied
by Litwin and Stoeckel (2013) included living with a spouse; this related to better
quality of life in the younger group, and was negatively associated with quality of
life by the older participants. Similarly, being in receipt of personal or practical
assistance from someone outside the household had a negative impact on wellbe-
ing for the younger cohort, but a positive impact on wellbeing for the older cohort.
Associations between social networks and life satisfaction were also found to be
opposing between the two cohorts; for example, having a greater number of
grandchildren was associated positively by the younger cohort and negatively by
the older cohort.
Exploring the potential for isolation and loneliness in old-old age was a key part
of a study by Fischer et al. (2008). In interviews with people aged 85 years (n = 15),
120 A. Kydd et al.
they encouraged participants to reflect on their various perspectives on life.

These included important life events, the experience of growing old, experiences of
loneliness, difficult life events, positive life events, and experiences of comfort and
consolation. Four themes emerged: embracing weakness and strength; embracing
slowness and swiftness of time; embracing reconciliation and regret; and embracing
connectedness and loneliness (Fischer et al. 2008). Their findings suggest the
importance of embracing the contradictions and challenges that come with longev-
ity, and echo Erikson’s stages of psychosocial development. This comprehensive
psychoanalytic theory identifies eight stages of life, which occur in healthy develop-
ing individuals from infancy through to late adulthood. The stages unfold as an
individual advances through the life course and each stage is characterized by a
psychosocial crisis of two conflicting forces, those in later adulthood being integrity
versus despair (Erikson 1968). The theory was updated in the late nineties to include
a ninth stage, allowing for the increased ageing of the population (those over 80);
the conflicting forces being dystonic versus syntonic, illustrating a negative or posi-
tive approach to facing the challenges of ageing (Erikson 1997).
8.4 The Creation of the Third and Fourth Age
Distinctions between the third and the fourth age have generally been determined by
the average life expectancy in a population/demography-based or a person-based
equation (Baltes and Smith 2003). In developed countries, a population-based equa-
tion would put the transition from third to fourth age at 80–85, whereas a person-
based equation depends on the estimated maximum lifespan of the individual. The
transition from third to fourth age could be at 60 years for some and at 90 years for
others.
The original concept of the third age is associated with Neugarten (1968) and the
fourth age with Laslett (1994), who both sought to dispel the marginalization of
the old. Neugarten (1968) stated that in social organizations, the relations between
individuals and between groups are organized by age differences, but little attention
had been placed on age grading to show relationships between generations.
Similarly, with reference to age grading, Laslett (1994) argued that after retirement
the “old” were a consumer group of growing importance, with the potential for
achieving personal fulfilment and active participation in the economy, politics, and
policy making, making the newly retired a different group of older people from the
oldest old. This development in ideas about later life served to emphasize autonomy,
agency and self-actualization. It also served to distinguish the concept of the fourth
age, with dependency as a key marker in the transition.
Narratives that describe the third age as an opportunity and the fourth age as a
threat point to a discursive “othering” wherein the fourth age functions as social
imagery of a fear of incapacity, poverty, and decrepitude, rather than age per se
(Higgs and Gilleard 2014). “Within this social imagery, old age is represented less
as a status and more as a state of being, one that is typically envisioned through
discourses about the costliness, the frailties and the indignities of old age” (Higgs
and Gilleard 2014, p. 10).
George (2011) suggested that creating distinctions between a third and fourth
age only serves to postpone the onset of what seems to be old age and creates a more
severe form of ageism for those in the fourth age. She wrote, “Just as the image of
the third age is socially desirable because it is not old age, the image of a fourth age
is socially undesirable because it reinforces negative stereotypes of later life. Fourth
agers will be viewed as frail, dependent, lonely, sick and as coping with impending
death” (George 2011, p. 253).
So how does this creation of a distinction between the active and the dependent
old impact those making the transition from the third to the fourth age?
8.5 The Third Age Distancing Itself from the Fourth Age
Leaving paid employment to pursue hobbies and engage in activities that the time
constraints of work would normally not allow makes retirement, once seen as the
end of one’s life, now attractive (Kuh 2007). Retired active people can partake of
successful active ageing strategies which generally exclude the old-old, the frail old,
and the disabled, who are less likely to be able to pursue these activities (Betts
Adams et al. 2010). Gilleard and Higgs (2011a) suggested that members of the third
age can reject old age as a collective voice through lifestyle choices, but this can
only come with economic stability and health. Where people in the third age are not
conceptualized as being really old, it is argued that this group wish to distance them-
selves from the ageist stereotypes seemingly afforded to those in the fourth age.
This is demonstrated by George (2011, p. 253) who wrote, “The eagerness of many
to proclaim the third age strikes me first and foremost as a desire to avoid or post-
pone being labelled as old and suffering the negative social stereotypes that accom-
pany that label. The image of the third age appears to reflect the same desire to view
oneself and have others view one as not being old.” However, Higgs and Gilleard
(2014) suggested that such distancing, in order to avoid being classed as one of the
oldest old, is potentially damaging to individuals in both age groups.
8.6 Evidence of Distancing
There is very little robust evidence to help understand the concept of distancing
between the third age and the fourth age, especially due to methodological inconsis-
tencies in determining what is meant by “old” and “oldest old”. Characteristics,
personal appearance, identifying traits, and practices that might link a person to the
122 A. Kydd et al.
fourth age are actively forestalled by some. This might be related to how people
seek to maintain their appearance through cosmetic means in the quest to avoid
being seen as one of the “real” old. As Hazan (2009, p. 98) put it, “The liminal
geography of the third age stretches between the face-lifted edges of a dream of
middle age and the murky terrains of lived in and feared old age.”
Avoiding the use of aids and equipment or living in environments that might put
them (in their own and other people’s eyes) in the oldest old category is another way
some older people distance themselves from the fourth age. Distancing is not purely
physical, but can also be demonstrated in attitudes and behaviours. An Israeli study
(n = 955) by Bodner et al. (2012), using the Fraboni Scale of Ageism (Fraboni et al.
1990), found that in cohorts of young (18–39), middle-aged (40–67), and old (68–
98) participants, middle-aged participants were significantly more ageist than
younger and older participants. In all age groups, men showed more avoidance and
stereotypical attitudes toward older adults than women. The authors then subdivided
the old age group and found participants aged 81–98 held more ageist attitudes than
those aged 68–73. The authors concluded that ageism changes across the lifespan
and it is necessary to explore the reasons why ageist attitudes change in different
stages of life. One reason has been suggested by Iecovich and Lev-Ran (2006) in
their examination of the attitudes held by well older people towards disabled older
people living in the same facility (n = 140: age >64). Well older people tended to
hold more negative attitudes towards frail older people when they lived in an inte-
grated facility, with the more able voicing a preference for segregated facilities.
Iecovitch and Lev-Ran suggested that holding these negative attitudes may amelio-
rate the frightening thoughts of one’s own mortality, and recommended that further
gerontological studies examine intergenerational prejudices.
Similarly, Gilleard and Higgs (2011a) reported that some older people avoid
exposure to forms of assessment that may put them in a category for health and
social care services, thereby avoiding “objectification” as a “needy” older person.
Such assessments may result in recommending aids or equipment to the individual
because of physical problems. This may not be acceptable to some who feel this
would then make them look old. However, the consequences of refusing aids and
adaptations can be damaging to the individual, their families, and other people they
are close to. For example, if individuals seek to compensate for and actively hide
disabilities, such as memory loss or hearing loss, they may isolate themselves for
fear of being “found out”. Such avoidance of help was found by Costley (2008) to
be the result of an effort by the old (defined by Costley as ages 69–91) to resist the
social stigma of old age. However, an earlier US study by Hackstaff et al. (2004)
found that some older people refused services for a myriad of personal reasons,
including cost or fear of new people.
Despite the dearth of evidence, there is a clear message that some older people do not
want to be seen as the “burdensome” oldest-old, and that this ageist distancing of the third
age from the fourth age can be detrimental to an individual’s health and wellbeing.
8.7 The Fourth Age
The lifespan is finite and with added years come the losses and illnesses of old age
(Cohen-Mansfield et al. 2013). Whilst these may come at earlier or later stages in
one’s older years, if people live long enough they will experience them, and they
will have to adapt to the changes forced upon them. Lloyd et al. (2014, p. 2) wrote
of the “event horizon” that puts one into the fourth age, which is seen as a point of
no return: “It is within the power of others—professionals and carers—to determine
when an individual has lost the capacity for self-care and management of everyday
life and thus makes the transition over the event horizon into the fourth age.” In
making such a transition, Holstein (2011) suggests that individuals have to reinter-
pret their lives, as some identities they have will disappear and new identities will
appear. However, Chang et al. (2013), in agreeing that frailty, comorbidity, and dis-
ability are common major health problems affecting the oldest old, suggested that
health promotion strategies, careful management of comorbidities, and targeted
strategies to prevent further disability can and should be provided by integrated
knowledgeable teams.
In his seminal text, Why Survive?, Butler (1975) saw the potential in people con-
sidered the oldest old (Achenbaum 2013): “We must ask ourselves if we are willing
to settle for mere survival when so much more is possible” (Butler 1975, p. xiii).
Butler advocated for interdisciplinary care together with enhancement of older peo-
ple’s resources and resilience whilst attending to the health issues that frequently
come with advancing years. He stated that the gains of ageing need to be celebrated
because old people are survivors.
Coleman and O’Hanlon (2004) called for more positive meanings to be associ-
ated with later life, particularly to overcome cultural failures in supporting people’s
end of life needs. Jopp et al. (2008) concurred with Butler (1975) in the findings
from their study of valuation of life in very old age. The participants in this study
were 65–94 years of age (n = 356) and this sample was stratified by gender and age
(5-year age groups). They found that despite increasingly negative conditions such
as physical and social loss, community dwelling older adults maintain a high attach-
ment to, and value of, life. Jopp et al. (2008) suggested the need for professionals to
develop interventions that enhance the positive features of old age and temper the
negative, in order that older people may live a satisfying and valuable life, even if
not always a healthy one.
Developing the work of Butler (1975), Jopp et al. (2008) and Nicholson et al.
(2012) sought to capture the dimensions of social, psychological, and physical
frailty among people aged 86–102 (n = 17), but found that participants did not
describe themselves as frail and gave examples of resilience and capacity in the face
of old declining or failing health status. Nicholson et al. (2012) conceptualized the
social identities of the third and fourth age as liminal—passing from one culturally
124 A. Kydd et al.
defined state or status to another. They considered the transition between ages to
involve three distinct stages: the preliminal, liminal, and postliminal. Liminality is
described as a threshold space, a space between social structures that is fluid and
allows for the potential redefinition of self-identity. Nicholson et al. (2012) sug-
gested that as their participants simultaneously seemed to be living across the third
and fourth ages, then the attributes of people in this space are necessarily ambiguous
both in terms of their inner conflicts and also in relation to the provision of services
by the welfare state. They concluded that frailty is a persistent liminal state, as
there is no movement from one stage to another. Therefore frail older people are
continually modifying their identities through the construction of personal habits,
routines and stories. In order to allow these individuals to lead long and valuable
lives, Nicholson et al. (2012) identified a need for older people and health and social
care professionals to find shared meanings and understandings of the continual and
shifting state of frailty.
A study by Koch et al. (2007) found that ageism was rife in acute hospital set-
tings and that people in the fourth age were most at risk of losing their dignity,
identity, and independence when in contact with health and welfare services.
Lloyd et al. (2014) explored the perseverance, adaptation, and maintenance of
dignity and identity more generally in the fourth age. They found that the way
people dealt with ageing and changed health status was dependent upon their
views of themselves, how they could or should present themselves in public
places, how others behaved towards them, and how accessible the built environ-
ment was. The majority of participants (n = 34) felt negative about ageing, that it
was something that happened to them and for which they could not prepare. In
contrast to these participants, other studies (Kornadt and Rothermund 2014; Koss
and Ekerdt 2016) found that planning and preparatory activities for age-related
changes helped and were organized by life domains. These domains differed
between preparing for the third age (activities peaking around age 65, focusing on
leisure, work, and fitness activities, and appearance) and in preparing for the
fourth age (activities continued linearly up to age 80, focusing on independence,
housing, and financial issues). These preparatory activities also involved accept-
ing, rather than preventing age-related changes. Koss and Ekerdt (2016) focused
specifically on how anticipation of the fourth age influences third age decisions
about housing in later life. These authors suggest that given the strong association
between the fourth age and residential or nursing home care, that where one lives
becomes not only a question of accommodation but also a visible marker of one’s
location in relation to the third and fourth ages. A study by Ayalon (2014) examin-
ing older people’s attitudes on admission to living in Community Care Retirement
Communities (CCRC) in Israel revealed that these communities were viewed
either positively as luxurious hotels, or negatively as the “last stop”.
8.8 Age and Disability
The stress of coping with disability can have a detrimental effect on physiological
wellbeing and quality of life, such as increased falls and their association with
increased morbidities. In relation to the arbitrary differentiation between the third
and fourth age, promoting health becomes even more important when chronic con-
ditions begin to appear and interventions need to be in place to prevent further loss
of function (Levy and Myers 2004; Wells 1992). Yet age does not mean disability.
In an analysis of the health of centenarians, Hitt et al. (1999) observed that health
span equals lifespan. In a later study of American centenarians, Rau and Vaupel
(2014) noted a marked delay in disability towards the end of the centenarians’ long
lives and identified centenarians as models of ageing well. The study concluded that
as one approaches the limits of lifespan; diseases (morbidity) must have been
delayed (or escaped) towards the end of these longest lived lives. This study illus-
trated that instead of the aging myth that “the older you get, the sicker you get”, it
is much more the case that “the older you get, the healthier you’ve been”. These
concepts are important when examining ageing discourses and research findings for
third and fourth age interventions, and how transition points throughout the life
course might be recognized as appropriate mediators in promoting positivity and
wellbeing.
8.9 Discussion
But what does the evidence reveal? A census of the characteristics of fourth agers in
England and Wales in 2011 (Office for National Statistics 2013) showed an increase
of almost 25% in people aged 85 or over since 2001. The number of centenarians
living in the UK has risen by 65% over the last decade, to 14,570 in 2015. In this
group, 850 people were 105 years old or older—double that of 2005 (Office for
National Statistics 2013). Given that frailty is a defining attribute of the fourth age
(Gilleard and Higgs 2011b), it is important to note that in 2010, only 25% of the
85–89 year olds in the UK are classed as frail (Clegg and Young 2011). Later statis-
tics show that in England, for example, 37% of people over 80 are providing 20 h or
more of care a week, while 34% per cent are providing 35 h or more (Age UK
2017). This overlap of third and fourth age characteristics blurs traditionally pre-
scribed transitional boundaries. Kydd and Fleming (2015) suggested that it is an
individual’s periodic vulnerability at any given time that needs to be managed rather
than their age. The fourth age can be seen as a celebration. For example, Tornstam
(2005, 1989) introduced the concept of “gerotranscendence”, which sees ageing as
part of a person’s life-long development and recognizes how individuals embrace
the age they are in at whatever age they are. Koch et al. (2007), recording centenar-
ians’ stories, found an alternative to negative stereotyping in these people’s strong
and resilient sense of self, a finding outlined in earlier work by Kaufman (1986).
126 A. Kydd et al.
The respondents were matter of fact about their difficulties and losses, which they
considered to be a part of life. The overarching finding was that these centenarians
had a sense of self that was strong and resilient (Koch et al. 2007). Similarly, Jopp
et al. (2008) highlighted the resilience of the oldest old, and the gratitude and cele-
bration of having lived a long life. Experience of losses and deficits were not a focus
for these survivors, but were events in their long lives and in no way extraordinary.
This reinforces work by Serra et al. (2011), who referred to this group as the most
celebrated and least understood cohort.
An additional consideration of age and disability is the ageing of the younger
generation. After the 2008 recession, retirement ages have become more flexible,
final salary payments have become rare, and a long paid retirement is not guaran-
teed. The western world is experiencing changes due to digital technology, reduced
unskilled labour, greater consumption of high-calorie, low-nutrient fast foods,
higher unemployment, and sedentary lifestyles. Many of these factors have been
shown to be contributing to a global rise in obesity and accompanying long-term
conditions such as type 2 diabetes, coronary heart disease, and cancer (OECD
2017). As a result, the ageing of this generation is not predicted to be as healthy,
long, and well-funded as the ageing of the “baby boomers” (Age UK 2017).
8.10 Conclusions
Since its definition in the 1960s, ageism has been seen as an uncontested phenom-
enon. It is both universal and individual, and deleterious, but it is also unpredictable
and unique. Age-related changes may be inevitable, but they depend on a range of
physical, social, economic, political, and global factors. At any stage in life, health
promotion and illness prevention strategies will serve to ameliorate certain condi-
tions, and self-care at any age is necessary for physical, psychological, and spiritual
wellbeing.
Although ageing is a natural process, how societies view their older citizens and
how old age is viewed by individuals will colour both the way older people are
treated and the way they view themselves. Chronological ageing is no longer viewed
as an illness, with many older people living well into their fourth age and beyond.
However, the ageing trajectory is unpredictable and the insecurities that come from
not knowing how one will age can manifest itself in a form of ageism—that of not
wanting to belong, or to be seen to belong—to the fourth age. This chapter has
explored the concept of old age and discussed the age stratifications of those classed
as old. The positive aspects of ageing have been seen in the third agers, who are
active, engaged, and pursuing their own interests. This in turn has created the fourth
agers—those (erroneously) classed as the dependent old. At some point in a third
ager’s life, they will reach a point where they need help with their everyday living.
This point may be associated with increased loss of physical function, and may be
labelled as the point, or the event horizon, at which they enter the fourth age. For
this reason, some third agers may strive to avoid entering into this fourth age. For
many this is seen as the point of “no return” and signals the end of life. However,
when reviewing the literature on centenarians, it would appear that this much feared
transition to the fourth age can become a celebration as individuals reach their 100th
year. In fact in many societies, the 100th year is seen as a triumph, as it celebrates
survival and resilience.
At the heart of this discourse is the fear of the unknown. Many people fear depen-
dency, loss of agency, loss of dignity and death. The experience of very old age is
unpredictable and many services are not geared to the needs of the frail old. Perhaps
if people felt more supported within their societies, with health and social care ser-
vices geared to the oldest old, then the fourth age would not be so feared. This is
clearly an area for future research.
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Chapter 9
Pathways from Ageism to Loneliness
Sharon Shiovitz-Ezra, Jonathan Shemesh, and Mary McDonnell/Naughton
9.1 Introduction
Europe is seeing unprecedented growth in the ageing population. The World Health
Organization projects that from 2000 to 2050, the ageing population over 60 years
will triple in size from 600 million to two billion (World Health Organization 2015).
As this trend progresses, governments are faced with the ethical and moral impera-
tive to ensure that older persons maintain a high quality of life as they age.
One of the major hazards to older people’s well-being is loneliness (de Jong
Gierveld et al. 2016). Loneliness is the subjective, unwelcome feeling of lack or loss
of companionship (De Jong Gierveld 1998). It is distinguished from social isolation;
While the latter reflects an objective social situation characterized by lack of rela-
tionships with others (Dykstra 2009), loneliness is a marker of the quality of a per-
son’s social interactions. As such, loneliness develops when one’s social relationships
are not accompanied by the desired degree of intimacy (De Jong Gierveld 1998).
In recent years, interest in ageing and loneliness has grown for two primary rea-
sons. First, loneliness is a socially prevalent phenomenon among old people. In a
representative sample of British community-dwelling older adults, almost 40%
S. Shiovitz-Ezra (*)
The Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of
Jerusalem, Jerusalem, Israel
The Israeli Gerontological Data Center (IGDC), the Hebrew University of Jerusalem,
Jerusalem, Israel
J. Shemesh
Jerusalem, Israel
M. McDonnell/Naughton
Department of Nursing and Health Care, Athlone Institute of Technology, Athlone, Ireland

https://doi.org/10.1007/978-3-319-73820-8_9
132 S. Shiovitz-Ezra et al.
reported experiencing some degree of loneliness (Victor et al. 2005). Similar preva-
lence rates were found in Finland among a random sample of people aged 75 and
over (Savikko et al. 2005). In the United States, Theeke (2007) reports that approxi-
mately 17% of the people aged 50 and above reported feeling lonely. Chronic lone-
liness, afflicting individuals over prolonged periods of time, affects approximately
10% of older people (Harvey and Walsh 2016).
A second reason for the rising interest in late-life loneliness has to do with its
detrimental effects to physical and mental health which have been recorded in
numerous studies. In a population-based study (CHASRS), loneliness was found to
be associated with elevated systolic blood pressure (Hawkley et al. 2006). Moreover,
the researchers found loneliness to be a unique predictor of age-related increases in
systolic blood pressure (Hawkley et al. 2006). Loneliness was also found to com-
promise cardiovascular health (Hawkley et al. 2003), and was identified as a signifi-
cant risk factor for coronary heart conditions (Sorkin et al. 2002; Thurston and
Kubzansky 2009). Furthermore, in a study carried out in the Netherlands among
2788 community-dwelling individuals aged between 55 and 85 years, peripheral
vascular disease, lung disease, and arthritis were found to be associated with greater
loneliness after adjusting for demographic variables and other diseases, such as
stroke and cancer (Penninx et al. 1999). A prospective association between loneli-
ness and mortality years later has been repeatedly reported in the literature (Holt-
Lunstad et al. 2015; Luo et al. 2012; Shiovitz-Ezra and Ayalon 2010).
Along with its adverse effects on physical health, loneliness is also associated
with poor mental health. In both cross-sectional and longitudinal studies, greater
loneliness has been associated with higher levels of depression even after taking
into account central demographic and psychosocial factors (Cacioppo et al. 2006).
Feelings of loneliness are positively associated with psychological distress
(Constanca et al. 2006), hopelessness (Barg et al. 2006), serious thoughts of suicide
and parasuicide (Stravynski and Boyer 2001), passive death wishes (Ayalon and
Shiovitz-Ezra 2011), and negatively associated with emotional well-being (Lee and
Ishii-Kuntz 1987).
Several studies, too, have noted the negative association between loneliness and
cognition in later life. In a cross-sectional community based study, loneliness was
found to be associated with impaired global cognition after adjusting for depres-
sion, social network and demographic characteristics (O’Luanaigh et al. 2012). In a
longitudinal study conducted in Finland, loneliness at baseline predicted cognitive
decline 10 years later (Tilvis et al. 2004). In accordance with these findings, in a
prospective study conducted in the U.S., loneliness was found to be a robust risk
factor for developing clinical Alzheimer’s disease, net of the effect of potential con-
founders including social isolation (Wilson et al. 2007). More recently, in the
English Longitudinal Study of Ageing, loneliness at baseline was found to be asso-
ciated with poorer cognitive functioning, measured by immediate and delayed recall
over a 4-year follow-up (Shankar et al. 2013).
The bio-physiological mechanisms whereby loneliness affects health are not yet
well-understood, but growing evidence links loneliness to inflammation and
metabolic deregulation. Loneliness was found to be associated with p ro-inflammatory
9 Pathways from Ageism to Loneliness 133
cytokine responses. In one study, lonelier participants showed elevated stimulated

pro-inflammatory cytokine production in the presence of acute laboratory stress
(Jaremka et al. 2013). In another study, loneliness was positively associated with
IL-6 responses to acute laboratory psychological stress in an adjusted model that
controlled for socioeconomic background and health behaviors among older women
(Hackett et al. 2012). Loneliness was also independently associated with elevated
HbA1c levels, a bio-marker of metabolic dysregulation (O’Luanaigh et al. 2012).
Considering the high prevalence of late-life loneliness and its deleterious effect
on physical, mental and cognitive health, it is critical that we identify the risk factors
associated with loneliness earlier in the trajectory of ageing so that appropriate pub-
lic policy may be put in place to address the issue. One significant, albeit under-
studied, risk factor for late-life loneliness is ageism – stereotypes, prejudice, and
discrimination against older persons. Below, we review loneliness and ageism sepa-
rately. Following, we outline the pathways whereby ageism may contribute to late
life loneliness, and bring initial evidence supporting the claims.
9.2 Loneliness
Loneliness is a subjective marker for deficits in one’s social relationships and inter-
actions. These social deficits manifest in terms of both quantity (i.e., limited social
interactions or absence of social interactions), and more importantly, quality (i.e.,
lack of intimacy, reliable alliance, and attachment; De Jong Gierveld 1998; Perlman
2004). Loneliness is characterized as a painful, distressing, and unpleasant experi-
ence (Peplau and Perlman 1982) deriving from a perceived discrepancy between
desired and actual social connections. According to the cognitive discrepancy
model, feelings of loneliness arise when there is a mismatch between what individu-
als want, need, or desire on the one hand, and their actual social relations on the
other hand. Predisposing factors include cultural norms as well as precipitating
events such as chronic conditions and widowhood, which become more prevalent in
old age and potentially contribute to a gap between one’s desired and existing social
environment. However, a perceived mismatch does not necessarily entail loneliness.
Several cognitive processes of evaluation mediate between the perceived mismatch
and feelings of loneliness. These processes include causal attributions, social com-
parisons, and perceived control. Past experience and the experience of other people
in the social environment shape this evaluation process. Therefore, people vary in
the way they interpret and react to their social circumstances.
Contrary to other theoretical views of loneliness, such as the social needs
approach (represented by Weiss 1973, 1987), the cognitive discrepancy model of
loneliness suggests an indirect relationship between objective deficits in one’s social
network and feelings of loneliness, which is mediated by cognitive processes of
perception and evaluation (De Jong Gierveld 1998; Perlman and Peplau 1998;
Peplau and Perlman 1982). Therefore, loneliness is only associated with deficits in
one’s objective social situation, but is not synonymous with the circumstances of
that situation. For example, people can feel lonely in the company of many others
(“lonely in the crowd”), or they can be alone for long periods of time without feeling
lonely. Objective isolation does not lead to loneliness when the desired level of
social relations is low; being alone is voluntary, or when the social situation is attrib-
uted to external factors beyond one’s control (Perlman 2004).
Similarly, the evolutionary theory of loneliness (Cacioppo et al. 2015a) views
loneliness as an aversive signal deriving from a discrepancy between desired and
actual social relationships, which motivates people to socially engage and recon-
nect. According to this perspective, loneliness plays a key role in the evolution of
humanity, because reconnection with others is crucial for survival and reproduction
(Goossens et al. 2015). The evolutionary theory argues that loneliness is similar to
other biological needs such as hunger, in that it creates significant feelings of dis-
comfort that motivate individuals to take action and extricate themselves from the
painful and distressing experience.
Recently, a review of the ontogeny of loneliness has differentiated between envi-
ronmental triggers of loneliness across the life span (Qualter et al. 2015). It was
suggested that as of adolescence, romantic relationships become increasingly
important, and that compromised quality of that type of relationship is mostly
related to loneliness. This relationship is also evident throughout adulthood, includ-
ing early adulthood and mid-life, when poor quality of marriage has been found to
explain loneliness. Similarly, marital quality and life partnership fulfill needs for
belonging in old age. However, at this stage of life these needs are challenged as
widowhood, illness, and reduced social activities become sources of loneliness
(Qualter et al. 2015).
Previous studies have mostly attempted to attribute late life loneliness to indi-
vidual (micro) and social network (meso)-level characteristics (Ayalon et al. 2016;
Kahn et al. 2003; Shiovitz-Ezra 2013). However, restricted opportunities for mean-
ingful social participation in old age may bring about feelings of loneliness. The
following section explores how ageism, including stereotypes, prejudice and dis-
crimination against older persons may lead to late-life loneliness.
9.3 Ageism
We live in a society that glorifies youth and dreads old age. We are deeply disturbed
by the appearance of a new wrinkle adorning our face; we balk at the sight of our
ever-expanding forehead gnawing higher and higher at our hairline. Both are
reminders of the incontrovertible truth that we are getting older. A 140.3 billion-
dollar anti-ageing industry capitalizes on these anxieties, selling the public the
products – and promise – to hold off wrinkling, blur pigmentation, eliminate excess
fat, and restore the growth of youthful hair (Zion Market Research 2016).
But people’s concerns about ageing go beyond the cosmetic. The imminent
threats of sickness, disability, cognitive deterioration, loss of independence, and
death, hang over the prospect of old age. Tremendous efforts on the side of scientists
and pharmaceutical companies are made to discover new means to influence the
physiological pathways leading to biological ageing, hoping to set back the clock,
or at least slow it down. Our relentless efforts to hold off ageing and the sentiments
they feed on speak volumes about how we, as a society, regard ageing (one famous
gerontologist characterized these sentiments as “dread, discomfort, and denial”,
Butler 1980, p. 10).
Not only are we disgruntled with our own ageing process, we also harbor ambiv-
alent attitudes towards older people at large. Changes in societal structure over the
past few centuries have rendered older adults “marginalized, institutionalized, and
stripped of responsibility [and] power” (Nelson 2005, p. 208). The industrial revolu-
tion, which brought about increased mobility for workers, also in so doing contrib-
uted to the disintegration of the extended family structure. As a result, grandparents
no longer lived with their families. In the light of technological advances, older
people’s work experience became outdated, and their work obviated. Simultaneous
advances in medicine extended people’s lives, and as the older population grew in
size, they came to be regarded as non-contributing burdens on society (Nelson
2005).
A recent large-scale linguistic analysis encompassing two centuries of written
American English has found that stereotypes of older adults have grown increas-
ingly negative over the years (having started out slightly positive in the 1800s; Ng
et al. 2015). The study found that negativity towards older adults has grown in step
with their relative share within society, presumably due to concerns of the younger
generation that older adults act as a drain on economic resources (Ng et al. 2015).
Complicating matters still, these concerns are not completely unfounded; with fer-
tility rates falling and lifespans extending in recent years, the retired population is
growing larger and larger in proportion to the employed sector, and it is expected
that care for older adults – formal and informal – will impose a heavy cost on soci-
ety (Suzman and Beard 2011).
Negative attitudes towards older adults, including stereotypes, prejudices, and de
facto discrimination based on age, have been termed Ageism. Butler (1980, p. 10)
identified three societal problems posed by ageism: “(1) Prejudicial attitudes toward
the aged, toward old age, and toward the aging process, including attitudes held by
the elderly themselves; (2) discriminatory practices against the elderly, particularly
in employment, but in other social roles as well; and (3) institutional practices and
policies which, often without malice, perpetuate stereotypic beliefs about the
elderly, reduce their opportunities for a satisfactory life and undermine their per-
sonal dignity.” (p. 8).
9.3.1 The Stereotypes of Ageing
What are the major stereotypes that people harbor about ageing? To answer this
question, researchers have asked participants to note the typical traits that came to
their minds when they thought about old people (regardless of whether they believed
them to be accurate or not). Collectively, these studies have yielded seven general
stereotypes, four negative and three positive, shared by people of all ages about
older adults: Severely Impaired; Despondent; Shrew/Curmudgeon; Recluse; Golden
Ager; Perfect Grandparent; and John Wayne Conservative (Hummert 2011).
A complementary approach to age stereotyping relates the stereotypes of older
adults to their perceived status within society. According to the Stereotype Content
Model (Cuddy and Fiske 2002; Cuddy et al. 2005) two core dimensions jointly
determine the content of stereotypes applied to groups within society: those of
“competence (e.g., independent, skillful, confident, able)” and “warmth (e.g., good-
natured, trustworthy, sincere, friendly)” (Cuddy and Fiske 2002, p. 8). Of the pos-
sible constellations of the two dimensions, older adults occupy a quadrant defined
by low competence and high warmth, or as Cuddy and Fiske (2002) put it, ‘dodder-
ing, but dear’. Other groups that fall in this cluster include retarded and disabled
people (Fiske et al. 2002). The prejudices most commonly elicited by people in this
quadrant include pity and sympathy (Fiske et al. 2002). The structural relationships
within society that antecede the competence and warmth dimensions are status and
competition; perceptions of a group as high status indicate its competence, while its
perceived competitiveness designates it as cold (Fiske et al. 2002). Accordingly,
people tend to see older adults as lower-status and relatively uncompetitive (Fiske
et al. 2002). A meta-analysis encompassing decades of research on attitudes towards
older adults confirms that old people are generally perceived more stereotypically,
as less attractive and as less competent than younger adults (Kite et al. 2005). What
is more, it was found that people tended to behave less favorably towards older, as
compared to younger adults (ibid). In sum, evaluations towards older people are
somewhat ambivalent, with a negative predominance.
9.3.2 Neglect and Social Exclusion
What kind of behaviors derive from the stereotypes (doddering, but dear) and prej-
udices (pity and sympathy) towards older adults? Cuddy et al. (2007) found that
perceived warmth of a group correlated with behavioral tendencies of helping,
presumably mediated by pity, while perceived incompetence correlated with ten-
dencies to neglect. This observation, once again, highlights the ambivalent nature
of attitudes towards older adults. Older people are targets for help and sympathy,
and at the same time are often neglected and socially excluded. Two major arenas
where ageist practices are widespread are the health-care system (Ben-Harush
et al. 2016) and the labor market (Pasupathi and Löckenhoff 2002). In both fields
ageist beliefs and attitudes can join and become institutionalized forms of discrimi-
natory norms and practices that intensify social exclusion of older adults. One
prominent example from the labor market is mandatory retirement that occurs at a
certain age without any consideration of whether the older worker prefers to con-
tinue working and contribute in the professional domain. Ending the working
phase has many adverse consequences, including the narrowing of social network
size (greater details about the retirement–social exclusion-loneliness relation will

be provided later in this chapter).
Studies show that age-based discrimination is widespread. In the United States,
29.1% of adults 52 years and older in a sample of 4818 individuals reported being
discriminated against on a range of interpersonal and medical issues, including being
treated with disrespect, being threatened, and receiving worse medical services,
based on their age (Rippon et al. 2015). In the UK, 34.8% of a sample of 7478 respon-
dents reported being discriminated against (Rippon et al. 2015). Across 28 European
countries, about a quarter of adults 62 years and older reported being discriminated
against based on their age, treated with prejudice, with disrespect or treated badly
because of their advanced age (van den Heuvel and van Santvoort 2011).
9.4 Pathways from Ageism to Loneliness
So far we have examined the phenomenon of ageism, as well as the content of age-
ing stereotypes and their societal roots. We have also seen some ways in which older
people are discriminated against, presumably as a result of widespread ageism. As
mentioned earlier, nowadays, one of the major difficulties faced by older adults is
social exclusion and loneliness. The following section will sketch out how negativ-
ity towards older adults may contribute to social exclusion and loneliness.
9.4.1 Social Rejection
One psychological theory accounts for how discrimination against older adults
could result in their progressive withdrawal from social participation and growing
feelings of loneliness. Smart Richman and Leary (2009) propose a model for how
humans, in general, respond to discrimination and stigmatization. While the model
has yet to be applied to older adults, its relevance will briefly become apparent.
“[T]he psychological core of all instances in which people receive negative reac-
tions from other people is that they represent, to varying degrees, threats to the goal
of being valued and accepted by other people.” (Smart Richman and Leary 2009,
p. 373) According to the theory, the primary emotion evoked by feeling socially
devalued, unwanted and rejected is hurt. Smart Richman and Leary report on a
study of emotional word associations (Storm and Storm 1987) which found that
feelings of hurt are most strongly associated the terms neglected, rejected, unwanted,
unwelcome, betrayal, misunderstood, different and isolated.
Following a rejection episode, people typically feel three sets of motives which
may promote competing behaviors: (1) a desire for social connection; (2) antisocial
aggressive or defensive urges, and (3) a drive to withdraw in order to avoid further
rejection. What determines which motive will win out is the affected person’s con-
strual of the rejection event. According to the theory, rejection that is experienced
chronically over a prolonged period of time will increase the likelihood of with-
drawal and avoidance behaviors.
To the extent that elderly people experience discrimination often and for pro-
longed periods of time (as indeed has been found, see the sections above), they would
be expected to respond with behavioral avoidance, and to forego social participation
opportunities. The hypothesis has yet to be directly tested. However, two studies give
initial credence to the logic of discrimination-induced withdrawal in older adults.
Coudin and Alexopoulos (2010) asked older adults to read a text passage, osten-
sibly in order to gauge their language comprehension. The text was said to be taken
from a speech in a gerontology conference, and its content was manipulated so as to
include either positive, negative, or neutral portrayals of older adults. Subsequently
the participants completed a questionnaire measuring their social and emotional
loneliness (adapted from the UCLA Loneliness Scale, a well-known loneliness
scale, Russel 1996). The authors found that the older adults who read the negative
text subsequently reported feeling lonelier than those who had read the positive or
neutral passages. Thus an experience of being negatively stereotyped can immedi-
ately lead a person to feel lonelier.
Sutin et al. (2015) explored the longitudinal relationship between perceived dis-
crimination and subsequent loneliness in a nationally representative sample of
adults 50 years and older in the American Health and Retirement Survey. The study
followed 7622 participants (average age 67.5) over a 5 year period, measuring their
baseline levels of everyday perceived discrimination and subsequent reports of
loneliness. It was found that perceptions of discrimination based on age signifi-
cantly predicted feelings of loneliness 5 years later (other types of discrimination
had a similar effect). Age discrimination, like other forms of discrimination, can
lead to feelings of loneliness that build up over time.
How do the experiences of ageism translate into feelings of loneliness? Vitman
et al. (2014) demonstrate how ageism could lead to social exclusion of older adults
in their neighborhood. In the study, younger adults in three neighborhoods in Tel
Aviv, Israel completed questionnaires regarding attitudes towards older people. As
a measure of social integration, older adults in the same neighborhoods indicated
how often they participated in neighborhood activities, how familiar they are with
neighbors, and to what degree they feel a ‘sense of neighborhood’. Regression anal-
ysis revealed that higher ageism in the neighborhood predicted reduced social inte-
gration. Encountering ageist attitudes in one’s neighborhood may lead to behavioral
withdrawal and avoidance, in line with Smart Richman and Leary’s (2009) theory.
9.4.2 Stereotype Embodiment
Another pathway whereby ageism may affect loneliness is stereotype embodiment.

Stereotype embodiment theory (Levy 2009) proposes that individuals absorb ste-
reotypes present in their surrounding culture, giving rise to self-definitions that, in
turn, affect functioning and health.
Various longitudinal studies have found that the endorsement of elderly stereo-
types by ageing people themselves (called self-perceptions of ageing) foretell sig-
nificant adverse effects to physical and mental functioning, sometimes decades
down the line (Levy 2009). For example, one study, based on the Ohio Longitudinal
Study of Aging and Retirement (utilizing data from 660 individuals) found that
positive self-perceptions of ageing at baseline predicted survival rates more than
20 years later (Levy et al. 2002b). Self-perceptions of ageing were measured using
items such as “Things keep getting worse as I get older” and “As you get older, you
are less useful”. The effect of positive self-perceptions on survival remained signifi-
cant even after controlling for baseline age, socioeconomic status, functional health,
and loneliness. Another study (Levy et al. 2002a) based on a similar dataset found
that positive self-perceptions of ageing at baseline were related to better functional
health more than two decades later, adjusting for baseline functional health, self-
rated health, age, gender, race, and socioeconomic status.
Experimental studies have found that exposing older adults to ageing stereotypes
affects their performance in a stereotype-consistent manner (Levy and Leifheit-
Limson 2009). For example, priming older adults with negative stereotypes of phys-
ical functioning was found to degrade motor performance, while priming them with
negative stereotypes of cognitive function led to decrements in memory perfor-
mance. In other words, the stereotypes people assimilate from the surrounding cul-
ture and identify with may act as self-fulfilling prophecies.
Pikhartova et al. (2016) sought to explore whether late-life loneliness stereotypes
can, too, become self-fulfilling prophecies. The study utilized data from the English
Longitudinal Study of Ageing. First, the authors identified participants who reported
no feelings of loneliness at baseline. Subsequently, these participants’ endorsement
of statements expressing (1) their expectation to become lonelier as they age, and
(2) the stereotype that old age is a time of loneliness, were analyzed and related to
levels of reported feelings of loneliness several years later. It was found that approx-
imately a third of participants expected to become lonelier as they aged, and about
a quarter of the sample endorsed the stereotype that old age is a time of loneliness.
In addition, it was found that both expectations and stereotypes of loneliness in old
age predicted feelings of loneliness several years ahead, even after controlling for
measures of social inclusion and a host of other demographic variables. In other
words, this study found that harboring expectations and stereotypes of old-age lone-
liness – even when one is presently not feeling lonely – could act as self-fulfilling
prophecies.
And yet, evidence that loneliness stereotypes operate as self-fulfilling prophecies
is equivocal. One longitudinal study investigated the link between expectations of
loneliness on the one hand and loneliness, new friendships, and perceived social
support on the other (Menkin et al. 2016). The data were taken from the Baltimore
Experience Corps Trial, a longitudinal volunteer intervention for older adults. The
participants, 424 Baltimore residents age 60 and older, were randomly assigned
either to an intervention group, who was to provide academic support to elementary
school students, or to a control group that received information on other volunteer
opportunities. At baseline, the participants answered a questionnaire measuring
expectations regarding ageing. One and two years later, the participants completed
measures of new friendships forged, perceived and desired social support, and lone-
liness. The expectations about ageing measure included subscales pertaining to
physical health, mental health, and cognitive function. One of the mental health
included items regarding expectations of loneliness, such as “Being lonely is just
something that happens when people get old”.
The researchers found that positive expectations about ageing at baseline pre-
dicted more new friends 2 years later, including close friendships. In addition, it was
found that baseline positive expectations predicted less desire for additional social
support 12 months later. However, expectations regarding loneliness at baseline did
not predict feelings of loneliness at follow-up.
9.4.3 Social Exclusion
Widely held ageist beliefs and attitudes can coalesce and become institutionalized
forms of discriminatory norms and practices. Society-wide ageist norms and prac-
tices can, in turn, act as barriers to older adults’ active participation in social activi-
ties. Here we briefly discuss three domains in which stereotypes, prejudices, and
discrimination against older adults may result in reduced social participation, pre-
disposing adults to late-life loneliness.
One prominent form of social exclusion is mandatory retirement. At a certain
age, people are expected – sometimes pressured, or even forced – to retire (Pasupathi
and Löckenhoff 2002). While some workers welcome retirement, retiring effectively
cuts off a wellspring of social connections, opportunities, and meaning available on
a day-to-day basis. Early retirement – which can be catalyzed by the experience of
ageism at the workplace (Thorsen et al. 2012; von Hippel et al. 2013) – can be par-
ticularly pernicious to older adults’ cognition and mental health (Börsch-Supan and
Schuth 2014). Börsch-Supan and Schuth (2014) found that retirement in general,
and early retirement in particular, are associated with reductions in overall social
network size, and that this reduction is mostly owing to the presence of fewer friends,
colleagues, and other non-family contacts in one’s social network.
Early retirement is sometimes imposed on older adults, since finding a job and
rejoining the workforce over a certain age is much more difficult. Several field stud-
ies have found that companies grossly under-respond to work applications made by
older adults compared to equally capable younger peers (Neumark et al. 2017;
Pasupathi and Löckenhoff 2002). Older workers are perceived to be reliable and
loyal, but at the same time, as less productive, less energetic, technologically savvy,
or trainable than younger workers (reviewed in Swift et al. 2017, p. 206). Further
impediments to hiring older workers include perceptions that older adults demand
higher salaries and incur increased training and health care costs (ibid).
Finally, retirement – whether voluntary or forced – is accompanied by a reduc-
tion in income, which can compromise older people’s ability to afford participating
in activities they enjoy (World Health Organization 2007, p.38). Indeed, low income
has been pinpointed as a strong predictor of loneliness in old age (Luhmann and
Hawkley 2016).
Another domain in which older people regularly experience prejudice and dis-
crimination is healthcare. A review of the literature on age-differentiated behavior
in the medical sphere has found that doctors often misdiagnose and disregard health
complaints made by older adults, as well as emphasize disease management over
disease prevention (Pasupathi and Löckenhoff 2002). These practices may stem
from the underlying assumption that older adults’ health complaints are the inevi-
table result of advanced age, leading health professionals to overlook potential
treatable causes for those complaints. As an example, cognitive deficits in older
adults can be attributed – at least to some extent – to underlying depression.
Attributing cognitive decline to aging alone may lead to older adults’ depression
going unnoticed (ibid).
Neglect, misdiagnosis, and mistreatment of older adults may lead to deteriora-
tion in physical and mental health, as well as in mobility, thereby impeding social
participation. Hawkley et al. (2008) have found that ill health, an inability to satisfy
the desire to engage in social activity, and a small social network (among other risk
factors) jointly contribute to older adults’ risk of late-life loneliness.
Finally, an inconspicuous feature of society that covertly discriminates against
older adults and impedes social participation has to do with the design of the living
environment. A survey conducted among older city dwellers around the world by
the World Health Organization found some of the following features as barriers to
social participation: inaccessibility to social activities due to distance and lack of or
inconvenient transportation, inaccessibility of buildings, and lack of facilities such
as toilets and rest areas (World Health Organization 2007). Some of the respondents
in the survey voiced the belief that the living environment was not designed with
older people’s needs in mind. Such inconspicuous features of the living environ-
ment, such as narrow or cracked sidewalks, lack of resting areas, insufficient light-
ing, and unclear bus route signs, can severely diminish older adults’ ability to remain
physically and socially active.
9.5 Conclusions
Cumulative evidence attests to the negative consequences of loneliness. Its high

prevalence among the older adult population alongside the deleterious effects on
physical, emotional and cognitive health have urged an extensive exploration of its
robust risk factors. Such studies, however, predominately have explored factors at
the micro and meso levels. At the micro level, background factors such as gender,
marital status, socio-economic status and health state are frequently being addressed
as well as experiencing life-time traumatic events (Palgi et al. 2012). Examples for
potential risk factors at the meso level are characteristics of one’s social network
(Shiovitz-Ezra 2013). The quantitative domain but mainly the qualitative nature of
one’s close social relationships have been found to predict late-life loneliness. Much
less attention, however, has been given to the macro-cultural level, i.e. the way older
people are being negatively perceived and the restricted social opportunities that are
available for them to act socially.
The current chapter highlights the macro-cultural level by addressing the poten-
tial pathways from ageism to later-life loneliness and social exclusion. We overview
two theoretical perspectives by which age negative perceptions and age discrimina-
tion potentially lead to feelings of loneliness. The “social rejection” model points to
the negative feelings of being undesired, unwanted, betrayed and socially rejected
that could lead to social withdrawal. The “stereotype embodiment” theory focused
on self-fulfilling prophecies. Older people internalize the prevalent age related neg-
ative stereotypes and act accordingly. For example, when one’s expect to be lonely
at old age and when old age is perceived as a lonely time it seems to become a real-
ity. Another mechanism stresses how ageist practices restrict social opportunities
for older adults, leading to reduced social engagement, and increased late-life lone-
liness. Studies have provided some support for these theoretical assumptions but
this territory is yet insufficiently explored. Future research, for instance, should
address ageism as a significant risk factor for late-life loneliness in a multi-level
analysis where the Micro, Meso and Macro levels are taken into account. The
unique contribution of each of these levels to loneliness experienced in old age is
highly important in formulating causal process of developing loneliness.
A thorough exploration of risk factors is not merely important in the theoretical
sense of gathering a better understanding of the loneliness phenomenon. It is also
crucial in order to combat deleterious phenomena such as loneliness. The literature
on interventions aimed at preventing and coping with loneliness lays out four strate-
gies: (a) improving social skills; (b) enhancing social support; (c) increasing oppor-
tunities for social contact; and (d) addressing maladaptive social cognition. Among
these the latter was found to be the most successful intervention strategy (Masi et al.
2011). Most recently, it has been proposed that integrated interventions which com-
bine (social) cognitive behavioral therapy with short-term adjunctive pharmacologi-
cal treatments are most effective in combating loneliness (Cacioppo et al. 2015b).
We would like to challenge the notion that puts heavy weight on the individual
level when trying to minimize late-life loneliness. Three of the above mentioned
strategies deal with compromised social skills, maladaptive social cognition and
medical treatment for individuals who suffer from loneliness. Therefore, all three
locate the risk factors in the individual. Another strategy looked at the meso level by
addressing lack of social support. Only one strategy of dealing with loneliness
looked at the social opportunities available for older adults and called for increasing
the opportunity for social interactions. This is, however, only one step in taking into
account the Macro-cultural level and in addressing ageism as one of the prime pre-
dictors of late-life loneliness. Increasing social opportunities does not deal with
social rejection that might jeopardize any social contact. It also is not addressing the
negative age-related stereotypes that might create a reality where stereotypes of
weakness, incompetence and sickness become a fact and actively narrow older peo-
ple’s social sphere.
Ageism is not easy to combat. It has profound psychological and sociological

origins that shape the way people get older in a society that admires youth and anti-
ageing. The deleterious effects of loneliness might give a significant incentive for
policy makers and clinicians to develop and construct social plans that take into
account the complexity of ageism. These “anti-ageism” plans should approach dif-
ferent arenas such as the education system (at all levels starting from kindergartens;
see Requena et al. 2018; Chap. 23, in this volume) and the legal system (Doron et al.
2018; Chap. 19; Mikołajczyk 2018; Chap. 20; Georgantzi 2018; Chap. 21, in this
volume). Decisive policy against ageism will potentially advance socially engaged
older people and the perception of old age as a social and meaningful time.
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Chapter 10
Ageism and Sexuality
Ateret Gewirtz-Meydan, Trish Hafford-Letchfield, Yael Benyamini,

Amanda Phelan, Jeanne Jackson, and Liat Ayalon
10.1 Introduction
In contemporary society, sexuality, intimacy, and sexual identities are considered

central to a meaningful personal life, and on a fundamental level, constitute one of
our basic human needs and rights. Until relatively recently however, much of the
literature and discussion on these issues tended not to acknowledge older people
and the topic remained taboo. These silences are further enshrined in many areas of
social policy and practice in relation to ageing support and mirror older people’s
invisibility in other areas of society. This chapter explores some of the dominant
A. Gewirtz-Meydan (*)
School of Social Work, Bar Ilan University, Ramat-Gan 592000, Israel
The Sex and Couple Therapy Unit, Meir Medical Center, Kfar Saba, Israel
T. Hafford-Letchfield
Department of Mental Health, Social Work, Interprofessional Learning and Integrative
Medicine School of Health and Education, Middlesex University, London, UK
Y. Benyamini
Bob Shapell School of Social Work, Tel Aviv University, Tel Aviv, Israel
A. Phelan
School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland
J. Jackson
School of Clinical Therapies and Department of Occupational Science & Occupational
Therapy, University College Cork, Cork, Ireland
L. Ayalon

https://doi.org/10.1007/978-3-319-73820-8_10
150 A. Gewirtz-Meydan et al.
discourses about sexuality, intimacy, and sexual identities in later life. By drawing
on a range of secondary literature, it examines the different positions and contexts
that situate the ‘practice’ (Foucault 1981) of sexuality in later life.
In relation to older people, preoccupation with sexuality and beliefs about ‘nor-
mal’ or ‘appropriate’ sexual behavior remains firmly entrenched in society, despite
popular exposure. Sexuality in later life is mainly addressed from the biomedical
perspective (DeLamater and Koepsel 2015), assuming there is a natural decline in
the individual’s sexual functioning in later life (Gewirtz-Meydan and Ayalon 2017),
which needs to be treated with medication (Gledhill and Schweitzer 2014). Some
other main issues and key myths that have been conceptualized in relation to older
people’s sexuality include: a lack of sexual desire that accompanies ageing; the
physical unattractiveness and undesirability of older people, which is particularly
evident in relation to gender; the idea that it is shameful and perverse for older
people to engage in sexual activity; the invisibility of the older Lesbian, Gay,
Bisexual, Transgender, Queer and Intersex (LGBTQ&I) community, and individu-
als who may need to return to the ‘closet’ in later life (Hafford-Letchfield 2008).
In the current chapter, we explore how ageism is constructed through the influ-
ences of attitudes promoted by the media, attitudes by younger people towards
sexuality in later life, older people’s attitudes towards their own sexuality and atti-
tudes of those who provide care services.
Sexuality is defined by the World Health Organization as the integration of
“somatic, emotional, intellectual and social aspects of sexual being, in ways that are
positive, enriching and that enhance personality, community and love” (WHO,
2006). This holistic definition articulates sexuality as a state of being beyond sexual
activity or sexual relationships. It includes notions of intimacy where there is close
association, familiarity and shared personal knowledge between people, suggesting
a degree of caring, sympathy or emotional understanding. The notion of sexual
identity or sexual orientation adds complex dimensions, which may include politi-
cal and community elements of how people relate to one another. Researchers are
also beginning to note greater fluidity in sexuality over the life span, further compli-
cating our definitions of sexual identities, including gender identities, which may
not coincide with sexual orientation (Willis et al. 2016).
10.2 Attitudes and Perceptions of the Media
The media has an important role in shaping the public image of later life and sexuality.
(DeLamater and Koepsel 2015). In the media “ageing” and “sexuality” are por-
trayed and understood as unrelated concepts. The voices presented in the media
frequently contradict. There is a repeated assertion that sexuality continues to play
an important role as people age (Scherrer 2009). Notions such as ‘sexy senior’ or
‘sexy oldie’ are partly replacing stereotypical notions such as ‘dried up old woman’,
‘nasty/dirty old man’ or ‘asexual oldies’ (Marshall 2011; Steinke 1994; Vares 2009).
Yet, older people who remain sexually active are stereotyped by the popular media,
as well. Heterosexist concepts such as cougar or MILF (Acronym for ‘Mother, I’d
10 Ageism and Sexuality 151
like to fuck’) are introduced by the popular media and represent stereotypical, ageist
approaches towards older people’s sexuality and toward older women in particular
(Alarie and Carmichael 2015). Thus, while these labels acknowledge sexual desire
in older persons, they portray negative aspects and reinforce the concept of most
older persons as asexual (Montemurro and Siefken 2014).
Due to the emphasis on youthfulness by mass media, older men and women are
underrepresented in advertisements. Moreover, when they do appear, they are typically
peripheral, grouped with others or in a specific context such as insurance plans (Hurd
Clarke et al. 2014; Low and Dupuis-Blanchard 2013). Images of older people relating
to specific advertisements, such as pensions or health care products are associated with
notions of burden frailty, loneliness or vulnerability (Media and diversity in an ageing
society, 2002–2004), which reflect stereotypical expectations about later life (Prieler
2012; Williams et al. 2010) and convey them to society. A discourse analysis of how
Canadian newspapers and magazines portray and construct older people’s sexuality is
a good example (Wada et al. 2015). The dominant, idealized notion of remaining
young-looking, physically attractive and sexually active was highlighted, which mar-
ginalized older people who chose not to conform to that ideal or were unable to do so.
This dominant ideal alongside with the successful ageing paradigm that encourages
older people to stay sexually active, have led to a reconstruction of sexuality in later life.
Engaging in sexual activities has become an indicator of success or failure of the
ageing process (Gott 2005; Katz 2002; Katz and Marshall 2003), which vacillates
between ‘normal’ or ‘pathological’ and successful or unsuccessful ageing. Whereas
a more positive image of older people’s sexuality is certainly welcome, these kinds
of advertisements and implicit messages to remain sexually active in older age cre-
ate a division in which those who chose a different way may be defined as nonfunc-
tional or as failing to age successfully. The representations of older people in print
media established and reinforced the paradox that while sexuality is crucial to
remaining youthful and aging successfully, youth and beauty are essential requisites
for active sexual engagement. (Wada et al. 2015). Older people are expected to use
pharmaceutical and medical interventions to sustain and enhance sexual functioning
(Wada et al. 2015; Wentzell 2013) and intercourse is still presented as the “gold
standard of sexuality” in later life (Gott 2005, p.14).
Emphasizing heterosexual ideals (e.g., penetration, orgasm, younger-looking)
enhances ageism and the anti-ageing consumer culture (Hurd Clarke 2010; Katz
and Marshall 2003). In-depth interviews with 44 women, ages 50–70 years, revealed
that women respond to ageism and social obsession with youthfulness and discrimi-
nation against older people by engaging in beauty work such as hair dye, make-up,
cosmetic surgery, and non-surgical cosmetic procedures, in order to fight social
invisibility (Clarke and Griffin 2008). Advertisements for creams that ‘will make
you look 10 years younger’ and the growth of cosmetic surgery are usually aimed
towards the third-age, which is characterized by active sexual engagement. This
creates an artificial distinction between the third age and the fourth age, when older
people are seen as becoming non-sexual (Wada et al. 2015). The consequence of the
divergence between the third and the fourth ages is growing stigmatization and age-
ism towards people as they grow older. The subtext underlying this type of advertis-
ing portrays older people as unattractive. While anti-ageing and pharmaceutical

interventions are portrayed as enabling older people to restore their sexual function-
ing and youthfulness, they shape public perceptions of ageing as a pathological,
rather than a normal, natural process (González 2007; Gott 2005; Katz and Marshall
2003).
It seems that despite the increasing recognition by mass media of older people as
sexual human beings, ageing is still presented in a very narrow and one-dimensional
mode. The gaps between the idealized images of ageing and the subjective experi-
ence can harm older people’s self-image. As a result, sexual desire and enjoyment,
achieving orgasm and frequency of sexual activity might diminish (Koch et al.
2005).
10.3 A
ttitudes and Perceptions of the Young Towards Older
People’s Sexuality
Studies have indicated that younger adults have accepting, tolerant, open-minded
and positive attitudes towards sexuality in later life (Allen and Roberto 2009;
Freeman et al. 2014). A survey of college students regarding their sexual attitudes
and behaviors, both currently and projecting into later life, found that although
younger adults were optimistic about continued sexual enjoyment in later life, they
also believed many of the current myths about ageing. They expected considerably
diminished sexual activity, along with increased sexual problems. Their expecta-
tions regarding sexual activity in later life were more conservative than their current
attitudes were (Floyd and Weiss 2001).
Nonetheless, explicitly ageist attitudes toward sexuality might be difficult to
detect (Thompson et al. 2014) and the implicit and explicit attitudes reported might
diverge (Mahieu et al. 2011; Thompson et al. 2014). Acceptance of sexuality in
older people by younger individuals seems to be a more ‘politically correct’
approach, whereas negative perceptions are portrayed as ‘old-fashioned’ and primi-
tive. Evidence for this was found in a study that used an implicit attitudes test,
which operates beyond conscious awareness (Lai and Hynie 2011). The study was
conducted among 305 young adult university students who rated men and women’s
likely interest in a range of sexual activities. Their responses regarding younger
(their own age) and older (65 years or older) individuals were compared. Participants
perceived older people to be significantly less interested in sexual activities than
were younger generations. However, both older men and older women were rated as
varying between ‘somewhat’ to ‘very interested’ in both traditional and experimen-
tal forms of sexual activity. Another study (Thompson et al. 2014) examined young
adults’ explicit and implicit attitudes regarding the sexuality of older people. The
authors reported that, consistent with other contemporary research (Lai and Hynie
2011), when asked, young adults explicitly reported positive views about the sexu-
ality of older people; however, implicit attitudes towards sexuality and ageing were
negative.
Most of the discussion about sex assumes heterogeneity and lacks awareness of
LGBTQ&I issues. These assumptions sustain a language for discussing relation-
ships and life in a heteronormative way (Hafford-Letchfield 2008). Within the
LGBTQ&I community, ageing issues may not be prioritized, resulting in the lack of
a valued role for older lesbians and gay men. Such experiences, combined with a
history of stigmatization, can subject older LGBTQ&I people to increased risk of
depression, substance misuse, unnecessary institutionalization and premature death.
Similar to misperceptions about older heterosexual people and their sexual lives, the
majority of older LGBTQ&I people continue to have sexual desires and needs. A
Gay and Gray Project study (2006) found that just over three-quarters of respon-
dents said that they had active sexual lives and over half felt that their sexuality had
an important positive impact on their lives. Therefore, adjustment to ageing is sig-
nificantly related to satisfaction with one’s sexual identity and the role society plays
in shaping an individual’s acceptance and sense of fulfillment from life
experiences.
Being lesbian, gay or bisexual is about more than defining your sex life. It shapes the way
you experience life, your interests, likes, dislikes, humor, friendship, and attitudes. A care
plan that neglects to include this huge part of a person’s individuality is clearly incomplete
and is likely to fall short of meeting that person’s needs (Gay and Gray Project 2006).
The LGBTQ&I community, like any other, has some tension between generations
related to sexuality. For example, within the LGBTQ&I community accusations of
ageism are common – older men in particular often report feeling alienated from
younger groups whom they perceive focus too much on appearance (body fascism).
Meanwhile, younger LGBTQ&I people have reported that they are wary that older
LGBTQ&I people only see them through a sexual lens (ILC 2011). Little intergen-
erational work has been done to explore the potential for increasing understanding
in the context of the LGBTQ&I community, even though the old and young
LGBTQ&I live side by side (ILC 2011).
In summary, attitudes held by the younger generations towards older people are
important, as they potentially impact their behavior toward older people, as well as
the beliefs and attitudes of older people towards sexuality.
10.4 Attitudes of Older People Towards Their Own Sexuality
Studies examining sexual behavior and attitudes of older people towards their
own sexuality, reported that most engage in partner or other intimate relationships
and view sexuality as an important part of life (Lindau et al. 2007). Findings from
a study conducted in Nigeria, revealed that older people portray sexuality as an
important aspect of later life, with heterosexual intercourse construed as having
physical and spiritual consequences (Agunbiade and Ayotunde 2015). Yet,
research has consistently found that older people often internalize stereotypes and
myths regarding late-life sex/sexuality and often are hesitant to express their
sexuality.
A particularly significant indication of internalizing ageism is the reluctance of
older people to discuss sexual issues with their primary care physician, due to fear
that sex in later life does not meet with societal expectations and therefore, might be
disapproved of by healthcare providers (Gott and Hinchliff 2003). Implicit in many
stories was the perception that older people are not or should not be sexual beings.
According to Vares (2009), older women internalize societal norms of beauty and
ageism, view themselves as unattractive and perceive their bodies in negative ways
such as ‘wilting’, getting ‘rolls’, ‘sags’ and ‘flabby’.
In an attempt to combat ageism, older people undergo many beauty and anti-
ageing treatments (Vares 2009) and consume pharmaceuticals aimed to enhance
sexual performance (Gledhill and Schweitzer 2014; Katz and Marshall 2003;
Wentzell 2013). Unfortunately, beauty and anti-ageing treatments and pharmaceuti-
cals to enhance sexual performance do not always lead to satisfaction. Older people
reported pharmaceuticals were often prescribed without assessment of the factors
involved and without warning of side effects. They found pharmaceuticals aimed to
enhance sexual performance ineffective and costly (Gledhill and Schweitzer 2014).
Similarly, older women, who knew about vaginal lubricants, said that they felt that
sex was still physically uncomfortable even when using lubrication (Shea 2011). In
addition, while men were concerned about erectile function, women agreed that in
older age, a companion is more important than sex and that they engage in sex as
part of an obligation to sexually satisfy their partner (Baldissera et al. 2012). Shea
(2011) opined that expanding the notion of sexuality beyond sexual intercourse is
necessary. Absence of sexual activity may reflect a desire for liberation from sexual
obligations, an acceptance of changing circumstances or the informed choice of
other social priorities. There are also grey areas in relation to these issues, for exam-
ple, the misunderstood orientation of asexuality, where one’s identity is not aligned
with sexual attraction or activity.
Specific, narrow societal norms and expectations were found to be main barriers
to expressing sexual needs and sexuality, and to raising or discussing sexually-
related issues with professionals. Internalizing societal norms and ageism caused
sexual problems that were attributed to ageing, to be viewed as normal and irrevers-
ible or untreatable (Gott and Hinchliff 2003). Other barriers to discussing sexually-
related issues with physicians were personal embarrassment, lack of knowledge and
awareness, fear of wasting the doctor’s time, or indirect presentation of sexual dys-
function hidden by other symptoms (Gott and Hinchliff 2003; Humphery and
Nazareth 2001). Contextual/structural barriers, such as lack of time, lack of avail-
ability of secondary psychosexual services, lack of doctors’ freedom to prescribe
(Humphery and Nazareth 2001), setting and privacy (Sarkadi and Rosenqvist 2001)
were noted, as well.
10.5 A
ttitudes and Perceptions of Primary Care Providers
and Long-Term Care Staff
Sexual activity in later life is closely linked to physical health, diseases and functional
decline (Dennerstein et al. 2002; Kontula and Haavio-Mannila 2009; Lindau et al.
2007; Mulligan et al. 2006). Therefore it is expected to be addressed by primary care
providers who tend to serve as the primary ‘gatekeepers’ (Hughes and Wittmann 2015).
However, it is unclear, how well primary care providers’ formal education has
prepared them to address sexual health concerns among older people. Primary care
physicians’ knowledge of sexuality in later life was found to vary across studies.
Whereas some studies reported adequate (Hughes and Wittmann 2015) or average/
moderate (Mahieu et al. 2016) knowledge regarding sexual health issues in older
people, others indicated limited and insufficient knowledge (Dogan et al. 2008;
Mahieu et al. 2011; Snyder and Zweig 2010) among physicians. A recent review
found that healthcare professionals often consider older people’s sexuality as out-
side their scope of practice and lack knowledge and confidence in this area (Haesler
et al. 2016). Obtaining relevant knowledge regarding sexuality in later life is espe-
cially important for adequately addressing older patients’ sexual health concerns,
for diagnosing problems, for recommending adequate treatment (Gewirtz-Meydan
and Ayalon 2017) and for assisting older people to overcome barriers to sexual
expression (Rheaume and Mitty 2008). Yet, physicians report they receive inade-
quate and insufficient education about sexuality in later life (Dogan et al. 2008; Gott
et al. 2004). As a result, sexual issues are not raised during routine healthcare visits
or interactions with older people and physicians’ awareness of sexual issues in later
life is very low (Gott et al. 2004).
Maes and Louis (2011) found that only 2% of a random sample of 500 American
Academy of Nurse Practitioners members indicated they always conduct a sexual
history with their patients aged 50 and older, whereas 23.4% never or seldom do
such an assessment. Similarly, a study conducted among 144 psychiatrists in the US
(Bouman and Arcelus 2001) found that sexual history is often omitted in the psychi-
atric assessment of older men. This often results in inappropriate referral and treat-
ment procedures.
Knowledge and attitudes towards sexuality in later life were positively linked in
many studies (Mahieu et al. 2016), making it difficult to determine causality. Ageist
attitudes are not uncommon among health care providers (Dogan et al. 2008;
Langer-Most and Langer 2010) and they have a great effect on the legitimacy of
expressing sexuality in later life. A qualitative study conducted among general prac-
titioners (Gott et al. 2004) revealed clear ageist attitudes toward sexuality of older
people, as discussing sexual health issues seemed more relevant to younger patients,
then older patients. In addition, sex was not recognized as an appropriate topic for
discussion with older people. Nonetheless, no matter what the reasons for differen-
tial attitudes towards older people, it is clear that physicians exhibit strong biases in
their approach to them. A recent study (Gewirtz-Meydan and Ayalon 2017) used
two similar case vignettes, describing young (N = 110) vs. older (N = 126) adults
who presented the same indication for sexual performance anxiety. The treating
physicians revealed an obvious age bias, as adults in the “older” vignette were more
likely to be diagnosed with erectile dysfunction, whereas those in the “younger”
vignette were more likely to be correctly diagnosed with sexual performance anxi-
ety. Moreover, older people’s dysfunction was more likely to be attributed to hor-
monal changes, health problems and decreased sexual desire rather than to
psychological factors. Lastly, physicians were more likely to recommend testoster-
one replacement therapy and products which contain PDE5 inhibitors (such as
Viagra™, Levitra™ or Cialis™), as well as referral to urology for the “older”
vignette, whereas the ‘younger” vignette was more often referred to a sexologist
and received a more positive prognosis. These results clearly demonstrate that older
people’s sexual issues are more likely to be addressed through medical technology,
whereas younger adults are more likely to be offered interventions in line with the
biopsychosocial model, which is currently advocated for sexual issues.
Attitudes towards sexuality in later life, among staff in long-term care (LTC)
facilities, are very relevant to the level of sexual expression among residents (Elias
and Ryan 2011; McAuliffe et al. 2007). Staff attitudes define the institutional stance
on this issue, which can range from restricting sexual expression to being respon-
sive to or even promoting residents’ sexual needs (Roach 2004). Although most
studies indicate that LTC staff have positive attitudes of (Bouman et al. 2007;
Mahieu et al. 2011), they are far from perfect. Staff knowledge regarding sexuality
in later life is limited (Mahieu et al. 2011, 2016), personal comfort discussing
sexually-related issues is low (Gilmer et al. 2010), trivial circumstances required for
sexual expression (as privacy) are not facilitated (Gilmer et al. 2010) and a clear
policy regarding the issue is generally lacking, leaving each institution to formalize
policy regarding this issue independently, if at all (Bauer et al. 2009).
Prior to entering care facilities, prospective residents are not provided with infor-
mation about how their sexual and intimacy needs will be respected (Bauer et al.
2009), nor do nurses routinely enquire about sexual practices and conduct sexual
health assessments among older residents (McAuliffe et al. 2007). In addition, even
though the majority of LTC staff believe residents have sexual needs that should be
acknowledged and supported, the need was not regularly assessed due to discomfort
about the topic among the staff, negative attitudes among the staff towards older
people, as well as a lack of privacy and unclear institutional policy regarding the
issue (Gilmer et al. 2010). Lastly, it should be noted, not all explicit, positive atti-
tudes truly represent inner-thoughts or feelings (Thompson et al. 2014). In a study
conducted among LTC staff, respondents acknowledged the existence of negative
reactions towards masturbation only among other colleagues. When asked for their
own opinion, they stated they viewed masturbation as normal and acceptable behav-
ior (Villar and Serrat 2016). Sexual expression among LGBTQ&I people can be
even more difficult in LTC facilities where any kind of sexual expression is cen-
sored or where judgments are made about those who are not in long-term relation-
ships or have multiple sexual partners. This can be particularly stressful when the
person finds him- or herself in a care environment where they will inevitably have
less personal freedom. When the person also has dementia, sexual disinhibition
might lead to more openly sexual behavior, which might be more quickly labeled as
deviant (Knocker 2012).
Staff perceptions and responses to residents’ sexual behavior were found to be
associated with personal level of comfort related to sexuality issues, the ethos within
the employing organization (Roach 2004) and experience and age of the LTC staff.
Older care staff reflected more positive attitudes towards later life sexuality, as they
have more years of work experience in their field (Bouman et al. 2007). Knowledge
and attitudes proved to be positively related, indicating that greater knowledge of
sexuality among older people is associated with more positive attitudes toward sex-
uality in later life (Mahieu et al. 2016). Attitudes and beliefs towards older people
expressing their sexuality in LTC facilities, including same sex couples and people
with dementia, became more permissive after staff education (Bauer et al. 2013).
Education is an important factor in dispelling commonly held, negative views of
residential care staff about older people expressing their sexuality. Thus, it is very
important to provide this information to LTC and nursing home staff (Bauer et al.
2013; Mahieu et al. 2016).
10.6 Conclusions and Recommendations
Sexuality in later life remains a largely unexplored and taboo topic. It is character-
ized by a dual nature and dominated by social constructivism. Despite recognition
that sexuality is important to the quality of life of older people, this chapter identi-
fies ageist perceptions regarding sexuality in later life among the media, young
people, healthcare service providers and among older people. Any discussion needs
to deconstruct the myths and stereotypes that deny older people their own unique
sense of sexual being and the right to express it (McAuliffe et al. 2007). Rooted in
and compounding ageism, are irrational fears, stereotypical thinking and lack of
knowledge, resulting in attitudes and behaviors that constitute significant barriers to
sexual expression, the enjoyment of sexuality and achieving a sense of self in later
life (Snyder and Zweig 2010). Surveys conducted in several countries consistently
found that older people indicated the importance of remaining sexually active as a
major component of their quality of life and well-being (Kontula and Haavio-
Mannila 2009). Research has shown that older people continue to engage in various
sexual activities, such as penetrative sex, oral sex, and masturbation even in the
eighth and ninth decades of life (Lindau et al. 2007). Hence, the expressed desire to
remain sexually active is often accompanied by corresponding behaviors. Similarly,
researchers have failed to challenge age-related stereotyping by placing older peo-
ple outside the remit of national, population-based surveys on sexuality and sexual
health issues, reinforcing the notion that these are not relevant to this sector of the
community. When studies were conducted, they tended to focus on the more prob-
lematic aspects of sex, such as dysfunction in sexual performance or challenging
behavior associated with cognitive, psychological or biological changes (for
example, disinhibition associated with conditions such as dementia). All of these

serve to promote a medical model of older people’s sexuality (Hafford-Letchfield
2008).
Not least, most research has neglected the voices of older people themselves,
which are essential to capturing the diversity of experiences of sexuality and to chal-
lenging dominant discourses. This requires examination of how older people’s
experiences are incorporated into the discourse of people working with and relating
to them. Sexuality is fundamental to social organization and is an important focus
of power and resilience. Placing it at the center of an analysis of ageing and later life
can provide insights into the possibilities of reworking the stereotypes and social
practices that shape attitudes and subsequent actions when providing services and
support.
Finally, until relatively recently, the research literature has tended not to acknowl-
edge ethnic or cultural diversity. Many studies were framed from a white, middle-
class, male, heterosexual perspective, suggesting a need for more cross-cultural
studies. Fewer studies utilized representative samples exploring the sexual histories
of older LGBTQ&I people and none collected information on gender identity. Due
to a lack of representative, population-based samples, older LGBTQ&I people, and
others with a history of same-sex sexual desire, behavior or identity, remain invisi-
ble (Brown and Grossman 2014).
Concurrently, paradigms for active and successful ageing reinforce high expecta-
tions concerning sexual behaviors, activities and desire, which are often inconsis-
tent with the reality of many older people (Woloski-Wruble et al. 2010). Encouraging
older people to stay sexually active in a way that is inconsistent with their reality, is
another form of ageism (DeLamater and Koepsel 2015; Marshall 2012). Although
it is agreed that some sexual changes and dysfunctions can be due to hormonal and
other physical changes or long-term conditions related to ageing (Dennerstein et al.
2002; Mulligan et al. 2006), focusing on biological aspects alone might facilitate a
narrow, counter-productive perspective (Hillman 2008). A biopsychosocial model is
a multidisciplinary approach to the diagnosis and treatment of sexual problems, as
it considers psychological and social factors such as stereotypes, gender socializa-
tion, partner availability, socioeconomic status, ethnicity, religious beliefs, and sex-
ual orientation, in addition to biological influences (DeLamater and Sill 2005;
Hillman 2008). Professional care providers including medical practitioners, nurses,
social workers, psychologists and physical therapists are required to understand
physiological and psychological factors that may impede the expression of sexual-
ity in order to help older people manage sexual issues (Hillman 2008). Older adults
can incorporate negative perceptions towards older people, which might hinder
sexual expression in later life. Promoting realistic attitudes, alongside overthrowing
ageist perceptions are required in order to enable older people to express their sexu-
ality and sexual identity freely and fully. Open and legitimate discussions regarding
sexuality in later life are needed to enable the expression of older adults’ sexuality
and to promote their sexual health. More robust explorations of ageist myths regard-
ing sexuality in later life including qualitative, implicit and explicit research
p erspectives are required to reach a comprehensive understanding of ageism toro-

wards older adult’s sexuality.
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Chapter 11
Visual Ageism in the Media
Eugène Loos and Loredana Ivan
11.1 Introduction
Since the introduction of the term “ageism” in the literature by Butler (1969), the
number of studies documenting the process of systematic stereotyping and discrimi-
nation against people because they are old, and analysing the way these stereotypes
are shared in the population and how they persist over time (Nelson 2004; Palmore
2001), has continued to expand. In this chapter, we analyse representations of older
people in the visual media—print advertisements, television advertisements, and
television programs. We examine whether older people are represented as third
agers, who are active, enjoy life, and who maintain a healthy life style, which are all
part of the successful ageing discourse (Rowe and Kahn 2015), or as fourth agers,
who are inactive and unable to live independently. We assess empirical evidence
that suggests a shift away from negative representations of older adults in visual
media towards more positive representations, and illustrate the way in which this
change has occurred in advertisements and television programs.
Previous media studies research has mainly focused on the frequency with which
women and various minority groups are characterized in television content and
advertisements. In media research, ageism, like other forms of stereotype, is seen as
“a coherent set of shared ideas and beliefs that constitutes a particular justification
of the interests of dominant groups: the state, employers, hospitals, media”
(Bytheway 1994, p. 130). Albeit not explicitly, media studies have approached age-
ism as an asymmetric power structure based on age, a constructed justification of
E. Loos (*)
Utrecht School of Governance, Utrecht University, Utrecht, The Netherlands
L. Ivan
National University of Political Studies and Public Administration, Bucharest, Romania

https://doi.org/10.1007/978-3-319-73820-8_11
164 E. Loos and L. Ivan
inequalities between age groups (Angus and Reeve 2006), by focusing on groups
that are systematically under- or misrepresented in the media. They criticize the
negative representation of older adults in the media, including the fact that they are
often only given minor or peripheral roles and that they are portrayed with no posi-
tive attributes, and argue in favour of more positive, more realistic and nuanced
representation, in which the portrayals of older adults more accurately reflect the
characteristics of the audience.
Media content, including visual media, is a continuous reflection of societal
practices. It influences everyday interactions, including the way we relate to older
people, as well as the way we see ourselves as “being old.” Media representations
offer a means to examine the logic according to which the social construction of
ageing is made and maintained (Minichiello et al. 2000). However, media studies
are often criticized for the overuse of content analysis as a method, the lack of theo-
retical discussion (Seiter 1986), and the fact that they focus on the sender and
neglect the receiver in the communication process. To address some of these issues,
ageism researchers have started to document the frequency of stereotypic represen-
tations from a communicative perspective, regarding aging as an interactive process
between society and the individual (Nussbaum and Coupland 2004).
We coined the term “visual ageism” to describe the social practice of visually
underrepresenting older people or misrepresenting them in a prejudiced way.
We believe that this concept could be useful in researching the way older people
are presented in visual media content (see also Nelson 2004). Visual ageism
includes older adults being depicted in peripheral or minor roles without positive
attributes; non-realistic, exaggerated, or distorted portraits of older people; and
over-homogenized characterizations of older adults. At the end of this chapter, we
discuss an alternative to reduce visual ageism: the “design for diversity” approach.
11.2 Why Visual Ageism in the Media Matters
Empirical studies conducted by Roy and Harwood (1997) and Walker (2012)
showed that in print advertisements, television advertisements, and television pro-
grams, older adults are sometimes depicted as posing a financial burden on society.
Atkins et al. (1990), Roy and Harwood (1997), Simcock and Lynn (2006), and Van
Selm et al. (2007) showed that older people were often underrepresented in televi-
sion programs, relative to the percentage of older people in the population. According
to Ylänne (2015, p. 370), “under-representation has been found to be particularly
pertinent in relation to people over 65.” An explanation could be that companies
feared that the image of their products and services would suffer if they were associ-
ated with the idea of being old. The portrayals of certain social groups in society, as
well as the type of characteristics depicted in those portrayals, matter in societies
that value social justice and power balance. These representations, visual and other-
wise, can reinforce stereotypes and play a role in stereotype formation. Encountering
such stereotypes in the media can negatively impact the self-esteem, health status,
11 Visual Ageism in the Media 165
physical wellbeing, and cognitive performance of older people (Levy et al. 2002a, b).
As Williams et al. (2009) found, “groups that appear more often in the media are
more ‘vital’ and enjoy better status and power in daily life” (p. 818). Taking this into
account, we agree with Lester and Ross (2003) that “pictures can injure.” The act of
visually underrepresenting older people in the media or representing them in a
stigmatized way is not harmless, as it not only reflects societal practices, but also
produces meaning about these practices (Hall et al. 2013).
11.3 Changes of Visual Ageism in the Media
To gain insight into the under- and misrepresentation of older people in our society,
we reviewed empirical studies that focused on images of older people in print and
television advertisements and television programs. Some authors, such as Ylänne
(2015), have found a steady increase in visibility of older people in the media and a
switch towards more positive portrayals. As Cole (1992) noted, “during the 1970s,
an emerging consensus among health professionals, social workers, and researchers
insisted on a view that was the mirror opposite of ageism: Older people are (or
should be) healthy, sexually active, engaged, productive and self-reliant” (p. 229).
We examined studies conducted in Europe and North America since 1950 to explore
empirical support for this change in visual ageism in print and television advertise-
ments and television programs.
In order to explore changes in visual ageism in the media in detail, we asked the
following research questions:
1. Do changes in the visual representation of older adults in the media relate only
to younger-old (third age) adults, or are older-old (fourth age) adults also
represented?
2. Are changes in the representation of older adults evident only in the attributes of
depictions of older adults, or are they also evident in the roles in which older
adults are depicted?
3. Are these changes in visual ageism consistent with successful aging discourse?
To answer these research questions, we present a narrative literature review (see
Green 2006) of empirical studies that analysed the visual representations of older
people in print and television advertisements and in television programs. We took
the systematic review of television advertising by Zhang et al. (2006) and a study by
Ylänne (2015) on representations of ageing in the media as starting points, using
key references to lead to other empirical studies (see Ridley 2012). We selected only
empirical studies conducted in Europe and North America because (a) most empiri-
cal studies of the representation of older people in the visual media in the past
40 years have been conducted in these socio-cultural contexts; (b) the above-
mentioned changes over time in the way older people are represented in the media
refer specifically to Europe and North America; and (c) successful ageing discourse
is particularly dominant in the West (Kendig 2004).
Table 11.1 illustrates the literature on changes in visual ageism over time. We
looked at the presence of negative versus positive visual representations over time
in terms of roles (peripheral, incidental, or minor roles; major/leading roles; other
roles, such as advisory roles) and in terms of attributes (positive, negative, exagger-
ated). Table 11.1 also shows whether each study differentiated between the younger-
old and older-old, and whether the characteristics used to portray older people
match the successful ageing discourse, in which older people are active, enjoy life,
and maintain a healthy lifestyle (third age: younger old), or whether they are
depicted as passive, dependent, and withdrawn from personal responsibility (fourth
age: older old).
Table 11.1 shows that older people were underrepresented in television and print
advertisements until the 1990s, when older people started to become more visible,
first in television and print advertisements and around 2001 also in television
programs.
These findings are in line with Vickers (2007) and Ylänne (2015). One possible
explanation for this trend could be that at a certain point older people were spotted
by marketing strategists as potential consumers (Loos and Ekström 2014), which is
part of the successful ageing discourse we explore below.
Since the 1990s, older people, particularly the younger-old, have increasingly
been depicted as having positive attributes (see Table 11.1). The older-old age group
has continued to be underrepresented in programs and advertisements and to be
portrayed with fewer positive attributes than younger people. In the last 15 years,
there has been a shift toward another kind of representation, that of younger older
people having the positive attributes—consonant with successful ageing dis-
course—of being active, enjoying life, and maintaining a healthy life style. The data
presented in Table 11.1 show that the change in the way older people are repre-
sented relates solely to their attributes and not to their social roles, as they continue
to be depicted in minor, peripheral, and incidental roles. We found only one empiri-
cal study (Kessler et al. 2010) in which the proportion of older people portrayed in
major roles was higher than in other age groups, and these findings only described
the younger-old group. Kessler et al. (2010) also noted the underrepresentation of
the older-old in the television programs they analysed.
The literature shows that the changes in visual ageism are consistent with suc-
cessful ageing discourse, in which especially the younger-old are depicted posi-
tively as being active, healthy, and independent. In an appeal to our pursuit of
everlasting youth, the advertising industry uses images invoking eternal youth, with
marketers depicting older adults as a wealthy and healthy target group (Loos and
Ekström 2014). The problem of our mortality is “solved” by the concept of the third
age, a long period of wellbeing, which precedes the fourth age, a short, painful
descent into decay (Laslett 1991; Loos 2013). It comes as no surprise that our desire
to remain forever young should be commercially exploited; the narrative of eternal
youth has deep historical roots and taps into the universal yearning to live a long and
healthy life (Loos 2013).
Table 11.1 Changes in visual ageism by media type and time period
Age Differences
Author/ Media Time Representations of of the between younger-
Year typea Country period older people sample old and older-oldb
Television advertisements
Miller TA USA 1950– Increasing trend in 60–74; Older-old
et al. 1990 positive attributes 75+ represented in a
(2002) from 1950–1990 less positive way
than younger-old
Hiemstra TA USA 1981 Underrepresented; 50–59; Older-old
et al. peripheral roles 60+ underrepresented
(1983) for some categories
of products (food,
health, recreation,
services)
Swayne TA USA 1987 Underrepresented; 65+ Older-old
and peripheral roles; underrepresented
Greco advisor roles for some categories
(1987) of products (food,
services)
Atkins TA USA 1990 Underrepresented; 50+ NS
et al. peripheral roles
(1990)
Peterson TA USA 1991 Underrepresented; 45–64; Older-old
and Ross less favourably 65+ underrepresented;
(1997) portrayed (fewer less favourable
positive attributes attributes
than younger (significant
people) differences)
Roy and TA USA 1994 Positive attributes 50+ Older-old
Harwood (3rd age) – food, underrepresented
(1997) retail and health/ (food, retail and
beauty health/beauty)
Van Selm TA Netherlands 2003 More positive NS NS
et al. compared attributes (3rd age);
(2007) to more diverse
1990– attributes;
1994 underrepresented
Lee et al. TA USA 2003 Positive attributes 55+ NS
(2007) (3rd age); minor
roles
Simcock TA UK 2004/2005 Positive attributes 50+ Older-old
and Lynn (3rd age); underrepresented
(2006) underrepresented in (food, retail,
major roles holiday/leisure,
insurance/
financial)
(continued)
Table 11.1 (continued)
Age Differences
Kessler TA Germany 2005 Positive attributes 60+ Older-old
et al. (3rd age); more underrepresented
(2010) present in major
roles
Print advertisements
Ursic PA USA 1950– Overall increase in NS NS
et al. 1980 frequency of
(1986) representations, but
non-significant
roles
Miller PA USA 1956– Negative attributes 55–64; Older-old; fewer
et al. 1996 65–74; positive attributes
1999 75+ (significant
differences)
Lohmann PAc Germany 1989– Negative attributes NS NS
(1997) 1991
Lohmann PAd Germany 1990 Underrepresented; NS NS
(1997) unrealistic portraits
(exaggeration)
Lohmann PA USA 1989– Positive attributes NS NS
(1997) 1991
Williams PA UK 1996– More positive NS NS
et al. 2003 attributes as time
(2007) progresses
Williams PA UK 1999– Positive attributes 60+ NS
et al. 2004 (3rd age)
(2010)
Ylänne PA UK 1999– Positive attributes 60+ NS
et al. 2004 (3rd age)
(2009)
Coupland PAe UK 2004– Positive attributes 50+ NS
(2007) 2005 (3rd age)
Television programs
Aronoff TP USA 1969– Negative attributes NS NS
(1974) 1971
Bosch TP Germany 1982 Underrepresented; NS NS
(1990) peripheral roles;
when present—
active, healthy
Vernon TP USA 1987/1988 Underrepresented:
et al. rather positive
(1990) attributes
(continued)
Age Differences
Harwood TP USA 1999 Negative attributes; 60+ NS
and peripheral roles
Anderson
(2002)
Kessler TP Germany 2001 Positive attributes 60+ Older-old
et al. (3rd age) underrepresented
(2004)
a
TA Television Advertisements, PA Print Advertisements, TP Television Programs; bNS not
specified; cMagazines; dPopular illustrated magazines; eStudy includes print advertisements and
magazines
11.4 N
ew Visual Ageism in the Media: The Trend Towards a
Positive Representation of Older People
The trend towards a positive representation of older people in visual media is

embedded in a larger discourse of successful ageing (e.g., Rowe and Kahn 1997;
Ylänne 2015) and active ageing (e.g., WHO 2014). This discourse empowers older
people to live as healthily as possible, and focuses on the quality of the ageing expe-
rience, described by Rowe and Kahn (1997) as “the avoidance of disease and dis-
ability, the maintenance of high physical and cognitive function, and sustained
engagement in social and productive activities” (p. 433). The positive consequences
of this discourse could include adopting an active lifestyle, maintaining functional
health, and enhancing capacities, such as individual responsibility and civic engage-
ment, which could lead to a reduction of older people’s dependability on public
system provision (Neilson 2006). On the other hand, the possible negative conse-
quences of this discourse, including the marginalization of the ageing process and
the societal exclusion of the older-old, especially those who are no longer able to
enjoy so-called successful ageing, are also being debated in the literature today
(e.g., Cole 1992; Neilson 2006; Rozanova 2010; Ylänne 2012).
Katz and Calasanti (2015) state that the dominant successful ageing discourse
poses at least two negative consequences for the ageing process, which are reflected
in the imagery used in the media. Successful ageing is associated with individual
choices in terms of lifestyle and the level of empowerment: success or failure is seen
as the responsibility of the individual and something which an individual is able to
control. In fact, the lifestyle of an individual is rarely a matter of volition, but an
issue of economic opportunities and constraints, of power and inequalities in access
to resources (Rozanova 2010). Once we categorize older people as “winners” or
“losers”, the social and structural factors involved in people’s “choices” to age suc-
cessfully are ignored. Older people in the so-called fourth age in particular are not
able to meet the obligations imposed on them by the dominant successful ageing
discourse (Loos 2013). As Rozanova (2010) argues, successful ageing is p roblematic

“in prescribing how older adults should age, rather than seeking to understand and
to describe how different people make meaning of their lives as they age” (p. 213).
Successful ageing discourse can be seen as having been produced by a consum-
erist approach, a marketing manoeuvre to make senior consumers treat ageing as a
controllable disease, rather than as a natural, universal process (Vincent et al. 2008).
Trying to eliminate the signs of ageing and to deny the natural process of ageing can
be seen to stem from a fear of the signs of the ageing process, because these signs
act as reminders of our mortality (Martens et al. 2004, 2005). Consumers have only
two options: to continually attempt to control age-related “problems” or to refuse to
incorporate consumerist choices in their life as part of their wellbeing (Ylänne et al.
2009). The anti-ageing trend can be seen as the expression of a marketing discourse
to consumers to take responsibility for their wellbeing, for control of their bodies,
and to avoid social exclusion (Vincent et al. 2008).
Our review of empirical studies showed that although the past decades have seen
a gradual increase in the presence of older people in the visual media, ageism is still
prevalent. In the past, ageism in the visual media was characterized by negative
attributes Aronoff 1974), such as being “ineffective, unattractive and unhappy”
(Vickers 2007, p. 101), “senile, stupid, ugly, unskilled, unproductive, unhealthy,
badly dressed, sedentary, and inactive” (Rozanova 2010, p. 214), and “frail, lonely,
dependent and technologically illiterate” (Joyce et al. 2015). Visual ageism has
changed and older people in today’s society are depicted as having positive attri-
butes, such as being “healthy, sexually active, engaged, productive and self-reliant”
(Cole 1992, p. 229); or “healthy, vigorous, productive, attractive and smart”
(Rozanova 2010, p. 214). Still, as our empirical work shows, not much has changed
in the roles assigned to older people—they still tend to be visually represented in
minor, peripheral, or incidental roles—or in the way older-old adults are visually
represented, namely, as possessing fewer positive attributes than the younger-old
group.
It is also important to remember that what might be considered “positive” attri-
butes in the depiction of old age could in fact be a normative construction which has
nothing to do with the real experience of older people in everyday life (e.g., Katz
and Calasanti 2015). As Ylänne (2015) states: “In particular, what might be consid-
ered ‘positive’ portrayals can turn out to be more ambiguous in their construction of
older age than might at first appear to be the case” (p. 369).
The point we would like to make is that this portrayal of positive attributes of
older people in our society could also have an ageist dimension. As Giddens (1984)
states: “The structural properties of social systems are both medium and outcome of
the practices they recursively organize” (p. 25). New visual ageism in the media
means that, on the one hand, positive attributes associated with older people as part
of the successful ageing discourse encourage them to live as healthily as possible.
On the other hand, this can act as an enabling constraint, suggesting that good health
in later life is fully the choice and responsibility of the individual, and that older
people who fail to age successfully are somehow themselves to blame (Katz 2009).
We are facing a shift from visual ageism characterized by underrepresentation and

the negative representation of older people to a representation of older age
characterized by images of stereotypically third age older adults, in incidental roles,
enjoying life and living their golden years, while older adults in their fourth age
remain invisible.
11.5 D
esigning for Dynamic Diversity: An Alternative
to Visual Ageism
One could ask whether it is possible to visually represent older people in a non-
ageist way. In our opinion, pictures are never neutral, as signifying practices cause
each of us to consume them in our own way (Hodge and Kress 1988; Hall et al.
2013). The prejudicial effects of stereotyped visual imagery injure and exclude, and
should therefore be avoided (Lester and Ross 2003). Several recommendations for
reducing visual ageism have been formulated since the 1980s. For example,
Hiemstra et al. (1983) suggested that educators play a role as social interventionists
and agents of change by teaching people to correct misleading and exaggerated
images, both on the side of the marketers and of the consumers. As our review of
empirical studies revealed, though, visual ageism is still prevalent today. Richards
et al. (2012) referred to the Madrid International Plan of Action on Ageing, which
“identified as one of its objectives the need to facilitate contributions of older women
and men to the presentation by the media of their activities and concerns” (United
Nations 2002, p. 45) and underlined how important it is to create expectations in
both younger and older people about ageing and old age. They pointed to the New
Dynamics of Ageing initiative, “Representing Self—Representing Ageing”,1 which
argues that “new sets of images need to be presented to the media” that counteract
current ageist preoccupations and instead reflect the “contributions, strengths, and
resourcefulness” of older women (United Nations 2002, p. 44).2
Vickers (2007) suggested that an increase in the visibility of older people in
society would foster more respect and a better understanding of old age. She
expressed the hope that visibility advocacy groups succeed in changing our attitudes
towards aging: “Perhaps one day we will turn on the television and see a commer-
cial for an aging cream that brings out the best in your wrinkles rather than trying to
hide them, while sending a message that older people are alive, active, and living
well” (p. 104). In 2007, personal care products brand Dove did just that, by launch-
ing Pro Age as part of their Campaign for Real Beauty.3 It featured several women
1
http://www.representing-ageing.com/
2
http://www.un.org/en/development/devagenda/ageing.shtml
3
See https://www.google.nl/search?q=dove+campaign+older+people&rls=com.microsoft:en-
US:IE-Address&tbm=isch&tbo=u&source=univ&sa=X&ved=0ahUKEwjYk8bi2p3MAhVCD8
AKHaNnCW0QsAQIHw&biw=1920&bih=986
in their 50s and 60s. The campaign captured the imagination of baby boomer
women around the world. The campaign presented images of women who were not
professional models, literally laying bare their age spots, grey hair, and curves, and
demonstrating that women are beautiful at all ages.4,5 Despite critical remarks from
Johnston and Taylor (2008, p. 962), who said that “although broadly accessible,
Dove’s critique of beauty ideology is diluted by its contradictory imperative to pro-
mote self-acceptance and at the same time increase sales by promoting women’s
consumption of products that encourage conformity to feminine beauty ideology”
(p. 962), in our opinion, this is one of the rare efforts to visually depict older people
in a non-ageist way (see also Brossoie 2010 on the societal resonance and success
of this campaign).
Other campaigns, such as those of Specsavers in 20136 and Swiss Life in 2016,7
have tried to do the same. In the Specsavers advertisement an older couple thank-
fully sinks down onto what they think is a bench in a park, but which turns out to be
the seat of a roller coaster. The commercial concludes with a voice-over saying,
“Should’ve gone to Specsavers”. The Swiss Life campaign also makes use of
humour to sell insurance and provide financial advice to older people. In one com-
mercial, an older man is ably competing with a much younger man at the gym.
Unlike the Dove Pro Age Campaign, however, the Specsavers campaign pokes fun
at older people (their poor eyesight causes them to sit on the wrong bench) and the
Swiss Life campaign humorously exaggerates the older person’s ability to perform
as well as his younger counterpart.
Both the Specsavers campaign and the Swiss Life campaign reinforce positive
characteristics, in the sense that they depict older people as active, but their depic-
tions are more in keeping with what we consider to be ageist third age representa-
tions. Our review of empirical studies clearly revealed that visual ageism remains a
challenge. These days, visual ageism in the media tends to come wrapped in the
guise of the positive attributes of third age representations of older people, while
adults in their fourth age continue to be underrepresented. One possible explanation
for this is that healthy third agers might prefer not to be associated with fourth agers,
as they remind them too starkly of what lies ahead in their own near future. Although
this discomfort or even fear about mortality is undeniably common, from a societal
point of view this kind of (self-)ageism is hurtful to fourth agers as a group and in a
sense to third agers as well, as they risk to become fourth agers themselves one day.
Based on the insights of this chapter, we suggest that one way to address visual
ageism is to “design for dynamic diversity”, an approach originally developed by
Gregor et al. (2002) as a method to create interface designs for older people having
“significantly different and dynamically changing needs”. Applied to the visual
representation of older people in the media, this implies the use of a multiplicity
of images and more nuanced imagery to combat the over-homogeneity of
4
See http://advertisingforadults.com/2007/02/dove-pro-age-women/
5
See https://www.youtube.com/watch?v=vilUhBhNnQc
6
See https://www.youtube.com/watch?v=K_nM0y9Hryw
7
See http://creativity-online.com/work/swiss-life-retirement-trainees/45228
representations of older adults (see also Loos 2013). The Dove Pro Age campaign
is a good illustration of this approach that could be a fruitful way to reduce visual
ageism in an ever more ageing society.
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27X06289479
Chapter 12
Ageism and Older Immigrants
Pnina Dolberg, Sigurveig H. Sigurðardóttir, and Ursula Trummer
12.1 Introduction
Since the 1950s, the global economy has been characterized by transnational move-
ments of people in search of better lives and employment opportunities in developed
countries (Castles and Miller 1993; ILO 2011; Sasken 1999). In the past few
decades, the population of older immigrants in Europe has also significantly
increased (Torres 2015; White 2006). This population consists of two main groups:
individuals who migrated as labour migrants during the mass-migration flows, who
then aged in the host country, and individuals who migrated in older age for either
family, amenity, or other reasons (Warnes et al. 2004; Warnes and Williams 2006;
White 2006). The current chapter examines ageism towards these two populations.
Immigration policies are usually designed to meet the host country’s labour mar-
ket needs, as well as demographic trends and objectives. There are several immigra-
tion types. Permanent migration, which characterizes countries such as Australia
and Canada, means a long-term stay of immigrants in their host countries, which
requires their adaptation to local society and culture. In recent decades, these coun-
tries’ policies have become more selective to meet the local economic and labour
market needs. Temporary migration is sought for a limited period of time, and is
P. Dolberg (*)
Ruppin Academice Center, Emek Hefer, Israel
S. H. Sigurðardóttir
Faculty of Social Work, University of Iceland, Reykjavík, Iceland
U. Trummer
Center for Health and Migration, Vienna, Austria

https://doi.org/10.1007/978-3-319-73820-8_12
178 P. Dolberg et al.
aimed at meeting labour force shortages, such as in the fields of domestic care,
construction, and agriculture. A third type is family reunification migration. This
type mostly entails the migration of family members who are considered depen-
dents, usually the spouse and minor children. Family reunification is not recognized
as a universal right, but rather relies on individual nations’ migration objectives. A
fourth migration type is highly skilled migration. These migrants are usually granted
preferential treatment compared with less skilled migrants (United Nations 2013).
The literature describes older immigrants in a variety of terms, such as “older
immigrants” (e.g., Leach 2008; Terrazas 2009), “elderly immigrants” (e.g., Torres
2006), “older migrants” (e.g., Attias-Donfut 2016; Torres 2015; Van der Geest et al.
2004; Warnes et al. 2004; Warnes and Williams 2006), “immigrant seniors” (e.g.,
Koehn et al. 2010), “elderly migrants” (e.g., Bolzman et al. 2006; Ruspini 2010;
Zahlen 2016), “older ethnic minorities” (e.g., Lievesley 2010), and “ethnic minority
elders” (Victor et al. 2012). Other terms emphasize these people’s past as workers,
such as “post-retirement migrants” (e.g., Ackers and Dwyer 2004) and “older labour
migrants” (e.g., Bolzman et al. 2004). The ambiguity caused by such a variety of
terms might partially be due to the neglect of the topic of older immigrants by both
migration and gerontology researchers (Torres and Karl 2016) and also to the lim-
ited public and political discourse regarding older immigrants. The current chapter
uses the term “older immigrants” in order to focus on the important fact of their
having moved to a different country, and to emphasize the immigration’s perma-
nence (in contrast to the focus on movement that is embedded in the term
“migration”).
At the beginning of 2015, there were nearly 53 million persons living in EU
member states who had been born outside their current countries of residence. The
age structure of this population was younger than the EU countries’ national age
structure (Eurostat 2016). The exact number of older immigrants in Europe is dif-
ficult to calculate, because of the group’s heterogeneity (Ruspini 2010; Torres 2006)
and because data are only sporadically available. Not all countries and regions have
data on their older immigrant population, and the different measurement tools they
use make the existing data not readily comparable (White 2006). According to one
estimate, as of 2006, there were more than 2.5 million older non-nationals aged 55
and older resident in EU member states, with approximately 30% of this group aged
65 or older (Dwyer and Papadimitriou 2006). Later estimations suggest an increase
in numbers of older immigrants in Europe from 7 million in 2008 to 15 million in
2015 (Ruspini 2010). Different estimates suggest that the current number of older
immigrants is increasing and will continue to grow substantially during the coming
years (Eurostat 2016; Lievesley 2010; Warnes et al. 2004; White 2006).
Because being an older adult and an immigrant might place an individual at risk
of experiencing a double jeopardy of marginalization and social exclusion, the pres-
ence of this population raises specific questions regarding ageing, welfare needs,
and policy responses (Torres and Lawrence 2012). In this chapter, we examine older
immigrants’ characteristics and policies regarding older immigrants, and discuss
these characteristics and policies within the context of ageism. We examine the
existence and weight of the age factor in immigration policies as well as policies
12 Ageism and Older Immigrants 179
concerning age-related issues such as health and retirement that affect immigrants.
We examine whether a migrant status constitutes a situation of increased vulnerabil-
ity to ageism. First we discuss the association between ageism, ageing destination
countries, and immigration policies. Then we outline the disadvantages of older
immigrants who have aged in the host country and the countries’ immigrant age
limitation policies, and discuss these within the context of ageism. The chapter con-
cludes with recommendations and implications given current immigration waves.
12.2 A
geism, Ageing Destination Countries,
and Immigration Policies
Ageism has been defined as a complex and often negative socially constructed per-
ception of old age (Bytheway 1995; Palmore 1999) that takes place at the institu-
tional and cultural level (macro-level), in social networks (meso-level), and on the
individual level (micro-level) (Iversen et al. 2009). Ageism may be expressed in
both positive and negative forms (Cuddy and Fiske 2002; Levy and Banaji 2002).
Ageism includes behavioural (e.g., discriminating), cognitive (e.g., stereotyping),
and affective components (e.g., positive or negative feelings) (Iversen et al. 2009).
Ageism can be either implicit or explicit; in other words, even without intention
or awareness, people might discriminate against older people (Iversen et al. 2009).
Explicit ageism can be direct (and therefore not “politically correct”) or indirect,
hidden in various practices (e.g., employers’ justification of ageism based on unre-
lated grounds) (Cheung et al. 2011; McVittie et al. 2003).
Ageism may frequently form as a double jeopardy, because it is easier to use
ageist attitudes and behaviours against socially disadvantaged groups (Dowd and
Bengtson 1978). The literature reveals older immigrants’ vulnerabilities to poverty
(e.g., Terrazas 2009), health problems (e.g., Beiser 2005; Jass and Massey 2004),
mental health problems (e.g., Bhugra 2004; Pumariega et al. 2005), and social isola-
tion (e.g., Victor et al. 2012); yet most immigration studies have failed to examine
ageism towards older immigrants.
The association between ageing, ageism, and migration is reflected in various
ways. Classic modernization theory (Cowgill and Holmes 1972) suggests that as
societies become more industrialized and modernized, younger people tend to leave
their extended families and establish their households in modern cities. According
to this theory, Zimmermann (1995) argued that stagnating and aging populations
tend to attract migrants, while young and large populations generate more mobile
individuals. The migration targets tend to be industrialized countries with a high
demand for workers (Castles and Miller 1993; ILO 2011; Sasken 1999).
Consequently, in the sending countries, older people might be left behind, without
their children to look after them (Van der Geest et al. 2004; Warnes et al. 2004), and
the economic and social vitality of the countries of origin might therefore be threat-
ened (Warnes et al. 2004).
Recent data regarding asylum seekers in Europe shows that in 2016, more than
1,200,000 people applied for asylum for the first time in the EU-28 member states.
Among them, more than 83% were younger than 35 years old (Eurostat 2017). This
is not a unique situation; the history of immigration to Europe since 1945 shows that
asylum seekers are usually young (and usually men). Young men were also the first
labour migrants who immigrated to Europe during the period of “blooming econo-
mies” in the 1950s and 1960s. Many were later followed by their family members
(Hansen 2003).
Industrialized countries that demand workers are usually ageing countries
(United Nations 2013). The case of Austria may serve as an example: similar to
other European countries, Austria has an ageing and shrinking population, with
positive net immigration being the only demographic driver of population growth.
The total fertility rate was 1.44 children per woman in 2013, measured by the “net
reproduction rate” such that the generation currently at reproductive ages will
numerically reproduce itself by only 69%. Population forecasts based on 2013 data
foresee a share of 28% being 65 and older in 2050 (Statistik Austria 2014). If so,
contemporary Austria (like other industrialized countries) is a country that depends
on immigration to compensate for an ageing and shrinking population.
Immigration policies usually assume that immigration is an option which is
intended and appropriate for young people (Harper 2011; Van der Geest et al. 2004;
Vullnetari and King 2008). Younger people are perceived as replacements of the
ageing labour force, assuming that higher immigration and higher economic activity
might slow the economic consequences of structural ageing (Aydemir 2013; Harper
2011). For instance, migration is a valid policy approach in the context of worker
deficit in the UK; immigrant workers fill both the demand for highly skilled workers
and the gap in unskilled employment (Harper 2011). Furthermore, immigrants are
often perceived by host countries as having larger families than the local population
have, and therefore as a potential means to raise the number of births in the country.
This perception is associated with the view of immigrants as a potential means to
delay population ageing and to maintain the support ratio (Aydemir 2013; Harper
2011). Hence, age and ageing are significant parts of the current migration pro-
cesses (Van der Geest et al. 2004).
12.3 D
isadvantages of Older Immigrants Who Aged in Their
Immigration Countries
This section describes the multiple disadvantages of older immigrants who aged in
their immigration countries. This population consists largely of older labour
migrants and their family members.
Economic Difficulties Older immigrants are over-represented among the vulner-

able, marginalized, and disadvantaged sections of the population (Bolzman et al.
2004). Because older immigrants are often employed in poorly paid jobs, with
limited job security and poor pension rights, they depend on state pensions in retire-
ment (Ahmed 2016; Nazroo 2006). If they have an occupational pension, it is typi-
cally low, due to unemployment or early retirement (Bolzman et al. 2004). One
particular disadvantaged group in Europe is that of older non-European immigrants.
This is because EU immigrants are able to transfer some pension rights, but non-
European immigrants usually cannot. In addition, non-Europeans are characterized
by higher rates of unemployment, and their concentration in low-skilled or unskilled
sectors is associated with lower levels of occupational pension (Dywer and
Papadimitriou 2006).
Inferior Health Evidence from different countries demonstrates the inferior health
state of older immigrants. According to Nazroo (2006), ethnic inequalities in health
increase markedly with age, and are largely driven by economic inequalities.
Moreover, Nazroo (2003) showed evidence of the significance of racism and dis-
crimination to the life chances of older immigrants who migrated to the UK in the
1950s and 1960s. In Switzerland, a high proportion of older immigrants was forced
to retire early because of health problems. For example, half of the older immigrants
in Switzerland who had worked in construction left the labour market before the
official retirement age and received a disability allowance (Bolzman et al. 2004).
This syndrome has been referred to as the “exhausted migrant effect” (Bollini and
Siem 1995, cited in Bolzman et al. 2004): immigrants who arrived in their host
countries in good health and after years of hard manual work, problematic living
conditions, and an insecure legal status, developed health problems.
Limited Welfare and Health Entitlements As workers, immigrants contribute to

public welfare funds: immigrants’ age structure usually denotes little demand on
public sector finances (Harper 2011). However, immigrants’ welfare rights eligibili-
ties are linked to their location within a particular state (Dywer and Papadimitriou
2006). For instance, according to Bolzman et al. (2004), Swiss cantons and com-
munes pay supplementary benefits to those whose old-age pensions are insufficient
to cover their basic needs. In the case of immigrants, access to supplementary ben-
efits depends on nationality and the existence of bilateral social agreements with
Switzerland, and on the duration of residence in both Switzerland and the canton.
Immigrants must have an unbroken 10-year residence to qualify for supplementary
benefits. Older immigrants are less likely to have supplementary health insurance
than locals. The Swiss case exemplifies the high cost of supplementary health insur-
ance, as well as the low probability that older immigrants, even if they have worked
in Switzerland for years, are eligible for supplementary benefits (Bolzman et al.
2004).
Limited Access to Services Older immigrants’ access to various governmental

services and entitlements is limited. Various reasons have been suggested to explain
this disadvantage: inadequate language ability, lack of education and cultural capi-
tal, lack of information, poor local social networks, and low ability to deal with
bureaucracy. As a result, older immigrants in need usually turn to their families or
communities (Bolzman et al. 2004; Warnes and Williams 2006; White 2006).
Professionals and planners who work with older immigrants tend to attribute the
under-use of services to the characteristics of the immigrants and not to the nature
of the organization or the services provided (Patel 2004, as cited in Ruspini 2010).
However, according to Bolzman et al. (2004), services tend not to be accessible for
older immigrants because of the absence of policies to ensure the inclusion of this
population in society, including insufficient attention to older immigrants on the
part of many mainstream institutions, and insufficient training in multicultural
approaches to health and social work. Ahmed (2016) discusses older immigrants in
the UK as a group that social care services have traditionally disregarded.
Lack of Policy or Insufficient Policy Despite the fact that the regulation of migra-
tion is prominent in contemporary European social policy discourse, the discourse on
migration policy has habitually focused on immediate and short-term economic
issues. A failure to look ahead at the consequences of ageing among immigrants is
manifested through the neglect of many issues concerning ageing and immigration:
long-term socio-cultural issues as well as health and welfare issues (Warnes and
Williams 2006). Failing to plan for the specific needs of a population subgroup can
constitute a form of social exclusion (White 2006). This maintains their perception as
“birds of passage” rather than as accepted elements of society (Bolzman et al. 2004).
Some countries have a statutory policy concerning one of the immigrant groups
(e.g., immigrants who aged in the host country) but not for the other (e.g., people
who immigrated in older age). Israel, for example, regards its Jewish immigrants as
a returning diaspora and is committed to their integration (Semyonov et al. 2015).
Israel’s Law of Return does not impose any age limits on Jewish immigrants and
their descendants (Israeli Ministry of Foreign Affairs n.d.). Moreover, Israel holds a
statutory supporting policy concerning immigrants who have immigrated to Israel in
older age: in Israel, older people are entitled to older-age state pension if they have
accumulated seniority through their old-age insurance. However, older immigrants
who have not accumulated the required seniority receive a special benefit from the
National Insurance Institute, funded by the Ministry of Finance (National Insurance
Institute of Israel n.d.). In addition, special grants and benefits are given to this
group of older immigrants by the Ministry of Immigrant Absorption and the Ministry
of Social Affairs and Services. Services such as nursing homes, older adults’ clubs,
and counselling, are available in many immigrants’ languages. However, this policy
usually does not include immigrants who moved to Israel earlier in life and aged in
Israel, as they are not entitled to special support (Dolberg 2013).
Another example comes from Iceland, a country that has experienced a signifi-
cant increase in immigration in the last decade (Vinnumalastofnun n.d.). In 2007,
the Icelandic government released the first Icelandic state policy of integration of
immigrants, which emphasized that immigrants should have access to health care
and municipal resources as non-residents (Iceland’s Ministry of Social Affairs
2007). Older immigrants are subject to the same rules as other older persons in the
social security system: in order to be entitled to an old age state pension, the person
must have resided in Iceland for at least three calendar years between 16–67 years
of age. Old age state pensions are paid as a proportion of the period of residence
between the ages of 16 and 67. Over the past 4 years, there has been a substantial
increase in the population of older foreign citizens receiving financial assistance.
The numbers have increased from 2.7% to 5.2%. The reason for this increase is that
they are not entitled to full social security benefits because of their short time of
residence (Municipality of Reykjavik 2016). In a policy plan on care of older people
in Iceland for the period 2003–2015, the special needs of older people with a foreign
background were emphasized (Iceland’s Ministry of Healthcare and Social Security
2003). However, a specific policy regarding older immigrants has not yet been
formulated.
Risk of Being Portrayed as a Social Problem Holding a statutory policy regard-
ing older immigrants might also be associated with exclusion and marginalization,
as the Swedish case demonstrates. In the late 1990s, the Swedish government
appointed a committee to develop elderly care policies. The purpose was to “take
into consideration the growing number of elders with foreign backgrounds and the
problems that they might pose” (Statens Offentliga Utredningar 1997, 2002, p. 413,
as cited in Torres 2006, pp. 1341–1342). According to Torres (2006), at the core of
the equation “elderly immigrants = special needs” lies the assumption that older
immigrants are disadvantaged. One of the reasons for this assumption is that almost
all research on older immigrants in Sweden (until 2006) focused on immigrants
who came outside Europe, and were usually less privileged in terms of continuity of
social rights. In fact, older immigrants in Sweden are an extremely heterogeneous
group. These previous studies might be partially responsible for perpetuating a
potentially damaging stereotype, as new generations of Swedish care planners and
providers have learned to regard these elders as “problematic others” (Torres 2006).
12.4 Immigrant Age Limitation Policies
Individuals who aim to migrate in older age for family, amenity, or other reasons,
might be subject to age discrimination in the form of nations’ age limitation policies
(Warnes et al. 2004; Warnes and Williams 2006; White 2006). Two main forms of
discrimination are presented as examples: discrimination against skilled older work-
ers and discrimination against older family members.
Discrimination Against Skilled Older Workers A substantial number of western
countries impose age limitations on potential immigrant workers by relying on
points-based assessments to obtain skilled immigrants. Points-based systems
attempt to capture a multi-dimensional notion of human capital. In most points-

based systems, age is one dimension according to which points are allocated. Other
dimensions are education level, professional experience (or previous earnings),
factors that might influence integration costs (such as language ability or previous
in-country work experience), and current national demand for particular skills
(Parsons et al. 2014).
Although points-based systems vary across countries and the age criterion has a
different weight in each, age usually has a high weight in the total multi-dimensional
score (Parsons et al. 2014) and might be a barrier for applying for an immigration
visa. For instance, applicants for Australian skill stream visas must be under 50 years
old (this age threshold was changed from 45 to 50 in July 2011) (Van de Ven et al.
2014). Moreover, age has the heaviest weight of all factors in the Australian skilled
migration system, as it may provide the applicant with the maximum number of
points—30 out of a minimum of 60 points required as a threshold (Facchini and
Lodigiani 2014). However, only 25–32-year-old applicants can receive 30 points for
age; 33–39-year-old applicants receive 25 points, 40–44-year-old applicants receive
15 points, and 45–49-year-old applicants do not receive any points for age
(Australian Visa Bureau n.d.), and therefore, their chance of passing the 60-point
threshold might be low.
Another example is that of Austria’s recent “Red-White-Red Card” criteria-
based immigration scheme, introduced in 2011. The program was introduced in
order to regulate immigration of qualified third-country workers and their families
with a goal of permanent settlement in Austria. In order to receive a Red-White-Red
Card, the applicant has to achieve a sufficient number of points (e.g., for education,
professional experience, age, language skills). Again, the prioritization of young
migrants is demonstrated by the points given for age when applying for the Card: 20
points for an age up to 35, 15 points for ages 35–40, and 10 points for ages 40–45.
No points are given after the age of 45. The minimal pass mark point score is 70, out
of a possible 100 (Migration.gv.at n.d.).
The award of points for age represents an attempt to reward experience along
with selecting younger migrants, who could potentially contribute to the work force
of host countries for a longer time than older migrants. Following this rationale,
people in their late 20s to early 30s are awarded the most points (Parsons et al.
2014). However, these policies might represent a type of institutional ageism. Under
this system, older people who wish to immigrate might not be able to, and therefore
might be excluded from being part of society merely due to their age.
Discrimination Against Older Family Members Older people who wish to
immigrate for family reasons sometimes face another form of direct ageism.
Research has shown that these older people might face more discrimination than
younger people who wish to immigrate on the same basis. One example comes from
Canada, where Family Class immigrants account for almost 80% of the immigrants
who arrive in Canada after the age of 60. In British Columbia, older Family Class
immigrants are dependent on their family sponsors, who are expected to support
them financially for 10 years, a considerably longer period than for other family
class groups (the period for a sponsored spouse, for example, is 3 years). During
that period, older immigrants are usually not eligible for public benefits (Koehn
et al. 2010; Koehn and Kobayashi 2011).
In the past two decades, several governments have been changing their policies
regarding older immigrants who apply for family reunification. For instance, in
1997, Sweden introduced restrictive rules for family reunification. The age limit for
family reunification was lowered to children under 18 years old. The ability of older
parents, especially widows and widowers, to unite with their adult children in
Sweden was restricted (Migrationsverket n.d.-a, b) solely to cases in which the fol-
lowing can be shown: (a) a relationship of dependence between relatives such that
it is difficult for them to live apart; (b) the older parent and the sponsor (the adult
child in Sweden) lived in the same household immediately before the adult child
moved to Sweden; (c) the older parent’s application was submitted soon after the
adult child settled in Sweden. However, even under these restrictive limitations, this
regulation includes a warning concerning the “difficulties of applying for reunifica-
tion directly after the sponsor settled in Sweden” (Government Bill 1996/97:25,
p. 113, as cited in Riekkola and Nilsson 2011).
A more recent change occurred in the UK in 2012, with the new Adult Dependent
Relatives rules. Previously, UK permanent residents’ parents or grandparents over
the age of 65 (or under 65 in exceptional circumstances), who had no other family
abroad and were financially dependent on their UK relatives, were able to apply for
settlement in the UK. The UK sponsor was required to commit to a 5-year sponsor-
ship without recourse to public funds (UK Visas and Immigration (n.d.), Immigration
Directorate Instructions 2012, as cited in JCWI 2014). Under the new rules, older
parents and grandparents asking to reunite with an adult child or grandchild in the
UK should prove that, due to age, illness, or disability, they require long-term per-
sonal care to perform everyday tasks and are unable to obtain the required level of
care in their country of origin, even with the financial and practical support of their
UK sponsor (Immigration Directorate Instructions 2012, as cited in JCWI 2014).
The likelihood of the older parents or grandparents of a UK permanent resident
receiving a settlement visa of this category is practically negligible (JCWI 2014).
These changes to the Adult Dependent Relatives rules in the UK prompted reac-
tions from NGOs as well as from Parliament members. According to the Joint
Council for the Welfare of Immigrants report (JCWI 2014), the Adult Dependent
Relatives rules prior to the changes were not a significant burden on the taxpayer.
This is because parents and grandparents of UK citizens and settled residents con-
sistently represent less than 1% of the overall net migration and less than 3% of
grants of settlement in the category “Family Formation and Reunion” since 2005.
According to the report, the cost-benefit analysis in the government’s impact assess-
ment is primarily focused on partners coming to the UK. Therefore, the report sug-
gests that the UK government’s proposed policy objectives of “reducing the burden
on taxpayers, promoting integration, preventing abuse and contributing to reducing
net migration” are not met by the new rules, and that “there is a complete rationale
disconnect between the harshness of the rules and the aims they are meant to
achieve” (JCWI 2014, p. 43).
Hence, governments’ objectives to reduce net migration and to reduce the burden
on taxpayers by disadvantaging older immigrants might appear as discriminative.
The next section discusses whether this practice might be considered ageist.
12.5 Summary and Conclusions
Europe is ageing, and so is its immigrant population. Moreover, the older immigrant
population in Europe is expected to grow substantially in the coming years. This
chapter examined policies concerning older immigrants and the disadvantages that
characterize this group within the context of ageism. This was done in order to
examine whether migration status and old age increase vulnerability to ageism.
Two types of discrimination against older immigrants were presented. The first
type of discrimination against older immigrants consists of the various disadvan-
tages that older migrant workers often face. These disadvantages include inferior
health, economic difficulties, limited welfare and health services, limited access to
services, a lack of policy or insufficient policy, and the risk of being portrayed as a
social “problem”. The second type of discrimination consists of age constraints in
immigration policies. This category includes discrimination against skilled older
workers and discrimination against older family members. The question that arises
is whether these discriminatory practices and disadvantages could be referred to as
ageist.
We will start this discussion with regard to the various disadvantages older
migrants are exposed to. Short-term policies concerning immigrants represent a
failure to look ahead at the consequences of immigrants’ ageing (Warnes and
Williams 2006; White 2006). Turning a blind eye on the later phases of immigrants’
lives in this way can be interpreted as passive ageism: a lack of policies that meet
the needs of older adults (Bugental and Hehman 2007; North and Fiske 2013; Rosen
and Persky 1997). Here we wish to emphasize that older immigrants are one seg-
ment of the wider ageing community, which should be equally treated, yet might be
an easier target for discrimination or neglect.
The host country should consider the entire life course of immigrants’ lives and
the lives of their relatives. Stereotypical generalizations about older adults and fail-
ure to take into account the later phase of immigrants’ lives represent an exclusion
of older immigrants and therefore, in our opinion, might be referred to as ageist.
Attempts to address the needs of this heterogeneous population without “other-
ing” them—that is, without assuming that they are “problematic others” who might
have “special needs” (Torres 2006)—is a multifaceted task. This mission requires a
careful study of each cultural group, and thorough research concerning the charac-
teristics and needs of older adults within each cultural group. The different issues
and needs of immigrants who aged in the host country and people who immigrated
as older adults should be examined. Because countries differ in policies, each cul-
tural group should be studied in its own context in order to better understand the
intersection between the infrastructure of the country and older immigrants’ needs.
Caution should be exercised regarding stereotyping older immigrants and “other-
ing” them; the heterogeneity of the older immigrant population must be taken into
consideration (Torres 2006).
To address the multiple disadvantages of older immigrants, we recommend
allowing older immigrants efficient access to services. Moreover, we recommend
implementing services that target older immigrants, such as translators, cultural
brokers, and older adult care services. Because the care of older immigrants often
lies with their families, beyond the relief of the older immigrants themselves, these
services could assist the families and further strengthen their bond with the local
community and the country.
The other type of discrimination against older immigrants consists of age con-
straints in immigration policies. Because older immigrants have the right to apply
for public funds in their countries of immigration in some of the cases, policies that
discriminate against older immigrants on the grounds of age might rely on the idea
that public resources are limited. Because immigration policies are usually designed
to meet the country’s labour market needs, as well as demographic trends and objec-
tives (United Nations 2013), the decision to restrict immigration by age could be
regarded as being simply due to economic efficiency. Hence, age constraints on
immigration may not unequivocally be seen as discriminatory.
However, when people are banned from immigration because of their age, and
are therefore excluded from being part of a society due to their age, we see it as age
discrimination, which might involve both explicit and implicit ageist policies.
Furtheremore, placing age limits on immigrants sends a clearly age-discriminatory
message not only to potential immigrants but also to the country’s native born peo-
ple. Though protective laws against age discrimination have come into force in vari-
ous countries (Kapp 2013), many older adults who wish to be part of these countries
are being discriminated against.
Social identity theory (Tajfel and Turner 1979; presented by Lev et al. in this
volume) includes the idea that foreigners become an easy target for discriminatory
responses. One possible grounds for discrimination is age. Following this line, as
foreigners, immigrants might be subject to age discrimination more than non-
immigrants. Therefore, countries that hold protective laws against age discrimina-
tion might still discriminate against older immigrants.
In summary, the older immigrant population in Europe has grown in recent
decades and is expected to continue to grow. This chapter aims to raise awareness
about older immigrants and their unique characteristics, as well as the restrictive
policies and disadvantages they might face. We argue that these experiences of older
immigrants can be viewed within the context of ageism.
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Chapter 13
Ageism in the Health Care System:
Providers, Patients, and Systems
Mary F. Wyman, Sharon Shiovitz-Ezra, and Jürgen Bengel
13.1 Introduction
According to the World Health Organization, 23.1% of the global burden of disease
(measured in disability-adjusted life years, or DALYs) can be attributed to illness in
persons aged 60 years and older (World Health Organization 2008). Throughout
much of the world, the ongoing demographic shifts in the population has resulted in
the steady growth of the older adult patient group in the health care system (Thiem
et al. 2011). Further, despite general agreement that older adults do not access medi-
cal care as frequently as needed (European Commission 2008), per-person health
care spending is much higher for older adults than for younger adults. In the USA,
for example, those over 65 years make up less than 15% of the population but
account for over 36% of total health care costs (Jecker 2013). In Germany, older
citizens with multiple medical conditions comprise the 5% of health care users
responsible for over 30% of prescription drug costs (Kuhlmey et al. 2003). Within
M. F. Wyman (*)
W. S. Middleton Memorial Veterans Hospital and University of Wisconsin School of
Medicine & Public Health, Madison, WI, USA
University of Freiburg, Freiburg im Breisgau, Germany
S. Shiovitz-Ezra
The Paul Baerwald School of Social Work and Social Welfare, The Hebrew University of
Jerusalem, Jerusalem, Israel
Jerusalem, Israel
J. Bengel

https://doi.org/10.1007/978-3-319-73820-8_13
194 M. F. Wyman et al.
the National Health Service in the United Kingdom, older persons make up two-
thirds of all care consumers (United Kingdom Department of Health 2001). The
growing group of “old-old” patients (those aged 85+) with complex medical needs
accounts for an over-proportionate amount of health care spending in Europe (Konig
et al. 2013; Kuhlmey et al. 2003; Lehnert et al. 2011).
Thus, older adults represent a highly significant group of users of the health care
system, and their care has a major impact on health care costs. Additionally, being a
regular consumer of medical services is a significant part of daily life for many older
adults around the globe. As the “third age” has been extended through longer average
lifespans, so too are older persons living with more chronic and acute health problems
and relying on care through the health system to maintain functioning and prolong life.
Despite their importance as health care consumers, a recent report issued by the
Institute of Medicine (Institute of Medicine 2008) argues that negative attitudes
towards older adults persist in the health care community, across professional disci-
plines, and across care settings. Ageist stereotypes, prejudice, and discrimination
are potential barriers for health equality, in terms of the quantity and quality of care
provided to older patients and their health-related outcomes (Courtney et al. 2000;
Robb et al. 2002). Ageism is similar to other known forms of discrimination such as
gender-based discrimination (sexism) and ethnicity-based discrimination (racism).
Whereas sexism and racism rely on biological attributes which are life-long and
usually cannot be changed, however, the bias against older persons will affect all of
us who live long enough (Levy and Banaji 2002; Palmore 2001). In the words of
Robert Butler (1975), who coined the term, ageism results in older persons being
“categorized as senile, rigid, and old-fashioned in morality and skills. Ageism
allows those of us who are younger to see old people as ‘different.’ We subtly cease
to identify with them as human beings, which enables us to feel more comfortable
about our neglect and dislike of them” (p. 894). More recently, Iversen and col-
leagues proposed a comprehensive description of ageism with the goal of further
refining the operationalization and conceptualization of the construct in research
(Iversen et al. 2009). This definition encompasses dimensional concepts already
well-established in social psychology: (1) cognitive dimension (stereotypes); (2)
emotional dimension (prejudice); and (3) behavioral dimension (discrimination).
This dimensional approach reflects the fact that, on the basis of age-based categori-
zations or stereotyping, people can have biased thoughts or feelings about older
people and/or engage in discriminating behavior toward older people. These authors
go on to state that ageism can be conscious (explicit) or unconscious (implicit), and
can be expressed at three levels: interpersonally, among individuals (the micro
level); intra-group, that is, within social networks (the meso level); and through
institutional policies or cultural traditions (the macro level).
There are a number of theories which attempt to explain the origin of ageism.
Two theories in particular are highly relevant to healthcare providers and have
received considerable attention (Nelson 2005). The functional approach theory
(Snyder and Miene 1994) views stereotyping as serving an important function in the
cognitive realm (e.g., using rapid categorization to enhance efficiency) and social
realm (e.g., identifying oneself with the social in-group). Categorization may serve
13 Ageism in the Health Care System: Providers, Patients, and Systems 195
an important function for clinical decision making. This theory, along with the
Terror Management Theory (Greenberg et al. 2002), also emphasizes that a negative
bias against older persons acts as an ego-protective mechanism, used to deny and
distance ourselves from the negative aspects of old age. According to the Terror
Management Theory, ageism is closely associated with a human desire to dissociate
one’s self from reminders of one’s own inevitable death, leading to attitudes and
behaviors that reinforce separation from individuals or groups that arouse fear of
death, such as older persons (Greenberg et al. 2002). As old age is also closely asso-
ciated with deteriorating health, diminishing functional abilities, and lower social
status, which leads to low self-esteem (Martens et al. 2005), the adoption of ageist
attitudes and behavior serves to enhance our identification with our social in-group,
and to help us dissociate ourselves from reminders of our own future decline.
One can understand intuitively that anxiety regarding severe illness or death may
be highly relevant within the health care setting. Health care professionals often have
prolonged exposure to the most infirm, ill, and senile older adults, which may bias
their perspective and intensify their willingness to disassociate from the older popula-
tion through ageist practices (Kearney et al. 2000; Lookinland and Anson 1995;
Palmore 1990). There is some empirical support for the association of more negative
attitudes with higher anxiety about ageing among health care workers (Liu et al. 2015).
This chapter presents a focused look at age bias as it is manifested in the health
care setting. Of note, in this chapter we concentrate on the medical care setting,
whereas the chapter by Bodner and colleagues (2018; Chap. 15) in this volume
explores ageism within the mental health care system, and the chapter by Fialova and
colleagues (2018; Chap. 14) is focused on pharmacological treatments and ageism.
We leave a detailed critique of research methodology in this area to Buttigieg and
colleagues (2018; Chap. 29) in this volume. Within the micro level (provider to
patient), we review research examining attitudes toward, beliefs about, and clinical
practices with older patients. On the macro (policy and cultural) level, we examine
geriatric care and reimbursement policy across countries, and look at the very limited
presence of older patients in the development of new therapies and within health care
training curricula. We briefly consider the challenge of distinguishing between dis-
crimination based on age and reasoned, conservative care provided by clinicians to
their older patients. Finally, we offer conclusions and recommendations for the future.
13.2 Providers and Patients: Ageism at the Micro Level
13.2.1 A
geist Attitudes and Practices Among Health Care
Professionals
There is an ample body of literature documenting negative attitudes towards older

patients among health care providers, though conclusions are limited due to the use
of a wide range of measurement approaches (for example, a number of different
instruments have been used to assess “ageist” attitudes). Lookinland and Anson
(1995) reported that registered nurses, as well as high school students interested in
becoming nurses, exhibited negative attitudes and stereotypical beliefs related to
ageing and older adults, with the latter exhibiting the least favorable attitudes and
views. One study found that nurses tend to assign a lower status to geriatric nursing
compared to other practice areas (Wells et al. 2004) and in another study, nursing
trainees indicated a general lack of interest in working with older adults (Hayes
et al. 2006). However, a recent survey study (Boswell 2012) among health care
students in an undergraduate course on ageing found no clear tendency toward more
negative or positive attitudes.
Several review articles have focused on attitudes toward older adults among
health care providers. Attitudes among physicians are complex and mixed (Meisner
2012), with some studies of this population demonstrating clearly negative evalua-
tions of older adults and others more neutral or positive evaluations. This also
appears to be true of studies of attitudes toward ageing among nurses (Liu et al.
2013). There may be shifts in attitudes among health care professionals over time:
results of a recent systematic review suggested an improvement in medical students
and physician attitudes since 2000, but a decrease from positive to more neutral
attitudes towards older people among nurses and nurse trainees (Liu et al. 2012). A
review of studies examining nurses working in the acute health care setting revealed
primarily positive attitudes toward ageing, though some studies reported negative
attitudes, mainly reflecting a negative emotional evaluation of patients (Courtney
et al. 2000). Most concerning, these authors found evidence in their review for an
association between negative attitudes and clinical practice decisions.
Discrimination based on age may be reflected in clinical practice and decision-
making among health care providers. Studies using both hypothetical decision-
making scenarios and patient record review have demonstrated age-based disparities
in diagnostic procedures as well as in the types of treatment offered to patients.
These reports emerge from various fields of medicine including cardiology (Bowling
1999), oncology (Kagan 2008), and stroke treatment (Hadbavna and O’Neill 2013).
For example, a study conducted in England revealed that though the prevalence of
breast cancer is considerably higher among older women compared to younger
women (40% of cases are over age 70), only 11% of these older women had received
breast cancer screening examinations by their physician. Moreover, only 7% of the
physicians participating in that study conducted breast examinations on older female
patients on a routine basis (Haigney et al. 1997). A study conducted among
physicians and second-year medical students indicated an age bias in beliefs regard-
ing follow-up treatment for patients undergoing surgery for breast cancer (Madan
et al. 2001, 2006). Younger patients described in vignettes were significantly more
likely to be recommended for breast-conservation therapy, whereas a higher per-
centage of older patients were recommended for modified radical mastectomy. This
study also found that younger patients were more likely to be recommended for
breast reconstruction procedures following mastectomy. Among lung cancer
patients in the U.K., the likelihood of being referred for surgery was lower for older
people, despite clinical evidence that post-operative recovery outcomes are not
dependent on age (Peake et al. 2003). The same trend has been found in cardiology:
coronary heart disease in older patients, specifically older women, is more likely to
be treated pharmacologically rather than surgically (Wenger 1997). A U.S. study
found evidence of age-related under-treatment of heart attacks relative to national
treatment guidelines, with older patients less likely to receive standard diagnostic
procedures and recommended treatments (McLaughlin et al. 1996).
13.2.2 Ageist Communication by Health Care Professionals
Another aspect of age discrimination relates to the way health care providers com-
municate with older adults. A number of studies provide evidence that patronizing
and ineffective communication can characterize discourse between providers and
older patients (Ambady 2002). Overall, physicians involve older patients in medical
decisions less frequently than they involve younger patients. Further, physicians
tend to be less patient, less respectful, less involved, and less optimistic with older
patients compared to younger patients (Greene et al. 1996). While there is certainly
individual variability in patient preferences for the type of communication with a
health care provider, there is no evidence that these attributes of interpersonal com-
munication are preferred by older persons. Above and beyond the potentially nega-
tive emotional experience for older patients and family members in the face of a
provider’s “poor bedside manner,” provider communication styles may have sub-
stantive negative health consequences for the patient (Nussbaum et al. 2005). For
example, one research study analyzing videotaped encounters between a physical
therapist and an older patient found that distancing and indifferent behaviors (e.g.,
not smiling; looking away from the client) were related to more negative short- and
long-term cognitive and physical health outcomes for the patient (Ambady 2002).
In a study of nurses, the quality of communication with and care provided to
older patients was found to be associated with attitudes toward ageing (Caris-
Verhallen et al. 1999). More negative nurse attitudes were related to shorter, more
superficial, and more task-oriented conversations with older patients. The nurses
tended to speak to the older patients in a patronizing tone and did not involve them
in consultations or decisions. In a similar vein, McLafferty and Morrison (2004)
found that nurses’ negative attitudes towards older patients were reflected in low
expectations for rehabilitation as well as in more detached treatment of the patients.
In this study, nurses were less likely to use humor with their older patients, and were
less likely to remember the names of older patients compared to younger patients.
A recent qualitative study which compared physicians, nurses, and social workers in
Israel found that exclusion of older patients from conversations about their own
medical care characterized the interactional styles across disciplines. These health
care professionals tended to either “bypass” the older patient by approaching
younger family members, or to make clinical decisions without any meaningful
patient input. In follow-up interviews, health care providers listed several primary
reasons for this type of communication style: (1) lack of self-awareness of this pat-
tern; (2) “choosing the way that is easiest” (i.e., it is simpler to have health care
discussions with a younger family member rather than the older patient); and (3) the
provider “not relating to the patient [as a person]” (Ben-Harush et al. 2016).
An operant-observational study conducted in a nursing home revealed yet
another detrimental pattern of communication between staff and residents, termed
the “dependency-support script” (Baltes et al. 1980). Findings showed that nursing
assistants were more positively responsive to dependent behaviors than to expres-
sions of independence, and reacted with a dependence-supporting response (i.e.,
praising residents for their acceptance of help). The authors asserted that this type
of communication reinforces dependency and discourages independent behavior in
older adults. This association was identified in the Ben-Harush et al. (2016) study as
well, as described clearly in a quote by a social worker:
When an older person enters the hospital, there is a certain approach towards them that
makes them more dependent. The patient can be a very independent person… and somehow
the attitude of the personnel towards them makes them change…they immediately put a
diaper on people who did not need a diaper before… Something about entering a hospital
promotes a regression for every person, and for older adults the regression is even harsher.
They put a diaper on so fast because they don’t want to deal with it. Someone has to help
these patients stand and walk them to the bathroom… there is no time… (Ben-Harush et al.
2016).
13.2.3 Factors Associated with Ageism in the Medical Setting
Factors Associated with Health Care Personnel A handful of studies have exam-
ined predictors of ageist attitudes among health care providers. Among nursing stu-
dents and registered nurses in Sweden, younger age (<25 years old) and male gender
were associated with more negative attitudes toward ageing (Lookinland and Anson
1995; Soderhamn et al. 2001). These associations were confirmed in a study con-
ducted among Greek nursing students; young age and male gender were associated
with increased ageism, as measured by more negative attitudes towards older adults
and less accurate knowledge about ageing (Lambrinou et al. 2009). Similarly, char-
acteristics of physicians that were associated with more positive attitudes towards
older people included being older and being female, as well as having more years of
education, previous working experience with the geriatric population, having higher
interest in care of older people, and having more frequent social interaction with
healthy older people (Leung et al. 2011). A recent systematic review of 25 studies
across different countries, however, suggested that age and gender are not reliably
associated with nurse’s attitudes toward older patients, whereas preference to work
with older patients and level of knowledge related to ageing are more consistent
predictors (Liu et al. 2013). These same two factors, along with high anxiety about
one’s own ageing, were the strongest predictors of negative attitudes toward ageing
among nurses (Liu et al. 2015). Further, in a sample of junior doctors in Singapore,
personal and professional background characteristics such as age, marital status,
living arrangements and years in medical practice were not associated with attitudes
towards older adults (Lui and Wong 2009). Harries and colleagues (Harries et al.
2007) found no effect of medical specialty on attitudes and clinical decision making
in response to patient vignettes. However, other researchers report such differences,
e.g. that surgeons tend to hold more negative attitudes toward ageing compared to
other medical subspecialties (Krain et al. 2007). Taken together, the available evi-
dence on health care provider characteristics which may serve as predictors of age
bias is mixed and inconclusive, and further research in this area is warranted.
Factors Associated with the Older Patient Some characteristics of the older
patient may increase the likelihood that negative age stereotypes are activated and
that age-based discrimination can occur. We will first address how older patients’
health and functional status may influence attitudes toward ageing, and then discuss
the concept of “self-ageism” and its impact on health and health care.
Past research on patient factors in ageism, which has been primarily conducted
among mental health providers, spawned the term “healthism” to describe negative
perceptions of others based on poor health status, not purely on age (Gekoski and
Knox 1990; James and Haley 1995). Because poor health is strongly associated
with old age and older adult identity (Coupland and Coupland 1994; Vauclair et al.
2015), the potential impact of “healthism” on the quality of patient-provider interac-
tions and on care in the health care system is worthy of brief discussion. (Bodner
et al. 2018, Chap. 15 provide additional details on this construct in their chapter on
ageism in the mental health care setting, in this volume.)
Health care providers may develop attitudes toward older patients based on their
medical diagnoses, functional deficits, or symptoms. A bias against older adults
who are medically ill was demonstrated in a sample of mental health therapists
(James and Haley 1995). Among medical providers, Gunderson and colleagues
(Gunderson et al. 2005) found that rurally-based physicians in the U.S. endorsed
more negative views of “nursing home patients” compared to typical “older”
patients, in terms of patients’ ability to change health behaviors and to learn new
health-related information, their ability to offer important input during a medical
visit, and their personality traits (e.g., “less warm and accepting”). Healthism may
be related to the increasing “medicalization” of old age in Western societies identi-
fied by some scholars (Ng et al. 2015). Increased focus on the medical aspects of
being old – to the exclusion of other dimensions of older age – is reflected at the
level of policy and reimbursement in the geriatric health care setting, and has a clear
impact on provider choices, service availability, and quality of care (Binney et al.
1990). A recent sociological study of changes in culture-based age stereotypes
appearing in print over the past 200 years in the USA found an increasing associa-
tion over time between the mention of an older adult and references to the medical
status of that person, using words such as “sickness” or “stamina” (Ng et al. 2015).
This increasing medicalization of old age was associated with increasingly negative
age stereotypes, leading the authors to conclude that this increasing negativity
toward older adults is systemic and pervasive throughout the culture.
The construct of healthism may be related to self-ageism (see below). In an effort

to distance themselves from stereotypical views of old age and their own aging
experience, older adults may tend to deny health problems to order to more eas-
ily present as exemplifying “healthy ageing” (Tanner 2003).
13.2.4 Self-Ageism in the Health Care Setting
Ageist biases or assumptions held by older adults themselves (i.e. “self-ageism”)

may also impact their interactions with the medical system and quality of health
care. Among older adults, the development of negative attitudes toward ageing or
older people can be considerable, and in fact may be inevitable in an ageist society
(Levy 2001). These biases may lead to irrational illness perceptions, for example,
that pain and suffering are to be expected in old age. One recent qualitative study on
back pain – one of the most common medical conditions among older adults around
the globe – found that many older patients believe that pain is a “normal” part of old
age (Makris et al. 2015). They are less likely to seek treatment for unmet medical
needs, due to low expectancies of being helped because of their advanced age
(Walters et al. 2001). These self-directed biases can also impact health and health-
care outcomes for the geriatric patient. Over a series of studies, Levy and colleagues
have demonstrated a relationship between negative age self-stereotypes and health
outcomes (Hausdorff et al. 1999; Levy and Banaji 2002). For example, one longitu-
dinal study found that the endorsement of negative statements about older adults
(e.g., “old people are helpless”) was related to a higher risk for cardiovascular
events over the next 38 years, controlling for cardiovascular risk factors (Levy et al.
2009). A more recent report revealed an association between negative age stereo-
types held earlier in life and a later increased risk for Alzheimer’s brain pathology
(Levy et al. 2016). Moreover, a meta-analysis of 19 longitudinal studies concluded
that positive subjective ageing (defined as positive ageing attitudes and youthful
identities) contributes to better health and increased longevity in later life (Westerhof
et al. 2014). Potential explanations may include that self-ageist ideas or negative
views on ageing make it less likely for older adults to embrace positive health
behaviors such as physical activity (Wurm et al. 2010), take preventive health mea-
sures, or adhere to recommended treatments (Levy and Myers 2004).
In summary, there is evidence of age-based bias at the micro, or interpersonal,
level. This is reflected in attitudes and behaviors toward older adults among health
care workers, and research suggests that these attitudes affect clinician behavior and
clinical decision making. Patient factors, such as self-ageism, also impact the pro-
cesses and outcomes of health care. Thus far, data regarding specific provider or
patient factors which may predict prejudice and discrimination based on age in the
health care setting appear to be mixed. In the next section, we examine ageism at the
macro-level within this setting.
13.3 S
tructural Factors that Impact Care for Older Persons:
Ageism at the Macro Level
Macro-level ageism refers to age-biased attitudes and practices present at the cul-
tural and institutional levels. This form of ageism has an important impact on health
care for older adults. Numerous scholars have acknowledged the impact of age dis-
crimination on continued inequalities in the health care system. Atul Gawande, in
his recent popular book “Being Mortal,” argues that despite the world-wide demo-
graphic changes resulting in an unprecedented number of older adults in the popula-
tion – due in part to improvements in health care services – “…medicine has been
slow to confront the very changes it has been responsible for – or to apply the
knowledge we have about how to make old age better” (Gawande 2014, p. 34). He
goes on to opine that health care consumers and policy makers “have not insisted on
a change in priorities [in the health care system] ... when the prevailing fantasy is
that we can be ageless, the geriatrician’s uncomfortable demand is that we are not”
(p. 46). As Prince et al. (2015) note, “the fitness for purpose of health services and
systems for older adults and their complex, interacting, chronic medical and social
difficulties is open to question” (p. 557).
There is general agreement that age discrimination is present in the systems and
policies of health care services, though conclusive data on health care access for older
persons in Europe is generally lacking (European Commission 2008). Highlighting
the impact of cultural and institutional tradition on health care practice, a 2001 United
Kingdom Department of Health publication noted that “…too often the financial com-
mitment to older people in these core public services has not been translated into a
cultural and institutional focus on the needs of older people….Instances of adverse
discrimination have usually been inadvertent, a result of the survival of old systems
and practices [emphasis added] that have failed to keep pace with changing attitudes
or advances in the capacity of professionals to intervene successfully” (United
Kingdom Department of Health 2001). This section will briefly review systemic and
policy issues which demonstrate the existence of “institutional” or “structural” ageism
(AGE Platform Europe 2016; International Longevity Center 2006) within health care.
13.3.1 Age Discrimination Exists in the Health Care System
Complaints of age bias in care, beyond the level of provider attitudes or provider-
level behaviors, have been reported within a variety of health care systems (European
Commission 2008; International Longevity Center 2006; Jacobsen 2015; Williams
2009). A recent European Union-commissioned study across several EU countries
reported that the frail, medically complex older adults comprise one of the popula-
tions at risk of “falling through [the] safety net” of public health care coverage
programmes, resulting in reduced access to quality health care (European
Commission 2008). This study found evidence, across most nations examined, of
less access to necessary medical care among older adults compared to younger
adults. Multiple so-called “supply-side” or system-level barriers to health care
access for older adults were identified. These included requirements for patient-
borne cost sharing of services and medications, which can result in a deleterious
interaction between older adults’ higher service needs and more limited financial
resources; geographic barriers and lack of transportation options, resulting in lim-
ited access to care due to mobility restrictions; inadequate numbers of geriatrics-
trained providers; a shortage of preventive and rehabilitation-focused care options
for older patients; and age-discriminatory clinical decision making by providers.
“Demand-side” or patient-level factors contributing to health disparities for older
EU citizens include lower expectations of health care services, leading to minimal
demand for change; more limited health literacy; and heightened challenges in man-
aging their own care within a bureaucratic, fragmented service organization
(European Commission 2008). As others have noted (Nies and Berman 2004),
despite the fact that care coordination has long been identified as a quintessential
pillar of quality geriatric care, current geriatric health care systems in the EU are
generally not based on principles of collaborative partnership with social care sys-
tems and informal caregivers.
Access to care following a stroke, or cardiovascular accident (CVA), is one
example that has been studied by researchers. In general, age-based bias in stroke
treatment – referring to differences in care that are not justified by clinical evidence
or best-practice guidelines – appears to be quite common, according to a recent
systematic review (Luker et al. 2011). One study found a significant impact of age
of the patient on the quality and type of immediate care for CVA in several UK
countries, with older persons less likely to receive care consistent with current
guidelines (Rudd et al. 2007). Another large pan-European study found that while
older stroke patients have equal or better access to specialized stroke care, rates of
standard diagnostic and therapeutic procedures, as well as rehabilitation services,
were lower for older patients compared to their younger counterparts (Bhalla et al.
2004). These results are concerning in light of data that suggest that health outcomes
after stroke do not vary by age when guideline-level care is provided (Saposnik et al.
2009). Of note, it is likely that the age-based differences identified in these studies
represent the interaction of micro-level age-based attitudes (such as clinician deci-
sions or patient preferences) and institutional or cultural norms in stroke care.
However, clear instances of age-related bias in formal policy regarding stroke care
can be found in a number of countries. For example, Greece has a policy governing
decisions in inpatient stroke care, with patients over 65 sent for admission to a gen-
eral internal medicine ward rather than a neurology specialty service (Theofanidis
2015). In Finland, a recently revamped policy does not provide coverage for medical
rehabilitation – services to address deficits in activities of daily living following an
illness – for persons over age 65 (AGE Platform Europe 2016), despite functional
rehabilitation being part of standard care for many patients with stroke.
How health care services are reimbursed can differently affect older adults com-
pared to younger patients. Health care reimbursement is a topic of great interest
currently, as policy makers in many different countries work to address anticipated
budget shortfalls due to ageing populations. As others have noted, current payment
mechanisms incentivize medical procedures and technology-driven tests, but do not
reimburse providers for the often complicated and time-consuming process of geri-
atric care (Alliance for Aging Research 2002). In addition, in many publicly-funded
health care systems, there is an ongoing and heated debate about the rights of older
persons to receive any health care benefits, and about how to manage the financial
“burden” related to the care of older persons. Surveys within such countries reveal
public opinion supporting the idea of an age cut-off for medical services; for exam-
ple, in Belgium, persons over 85 years old are considered by many citizens as “not
worthy of care” (AGE Platform Europe 2016). Within the UK’s National Health
Service, discussions about rationing of care have frequently pointed to long-standing
age-based discrimination at a systemic level (Shaw 1994). For example, until
recently, the UK’s National Health Service breast cancer screening program offered
regular mammography only to women under the age of 65 (the program has recently
been extended up to age 70). A performance indicator in the United Kingdom sets
the undesirable outcome “premature death” as occurring at or below age 75. Thus,
this is a policy which does not differentiate patients based on comorbidities or clini-
cal presentation, but on age alone. The policy also implies that human life after age
75 has less inherent worth compared to life at a younger age (AGE Platform Europe
2016). Vascular disease screening invitations in the UK are also age-based, despite
the high prevalence of cardiovascular disease among older adults (Lievesley 2009).
These are not isolated examples. Upper age limits on funding for diagnostic tests,
screening procedures, and health-related social benefits are part of policy in many
European countries (AGE Platform Europe 2016).
In the US, the existence of the federally funded and regulated Medicare health
care insurance program for citizens over age 65 has resulted in a health care cover-
age system for older adults that is effectively separate from coverage programs for
other age groups. Medicare policies on reimbursement for medications, equipment,
and services have a profound and wide-reaching effect on health care for older
adults in the US. One example is Medicare’s payment policy for inpatient rehabili-
tation, usually provided within a long-term care setting. Current Medicare benefits
provide for a maximum of 100 days of reimbursement, creating an incentive for
facilities to keep patients in the rehabilitation setting for this full time period,
whether or not the patient is benefitting from the care or able to participate in reha-
bilitation treatments such as physical therapy. Medicare reimbursement policies are
not structured to provide incentives to delay or prevent entry into a long-term care
facility. There was no coverage for preventive care until recently, and preventive
services that would benefit a majority of older adults (and reduce health care costs),
such as a falls risk screening or home safety assessment, are still excluded. Medicare
neither reimburses comprehensive outpatient geriatric care, despite evidence of
good outcomes (Boult et al. 2001), nor the relatively low costs of part-time custodial
care at home (e.g., assistance with cooking, cleaning, shopping, bathing) to keep
frail patients safe and functioning outside of an institution. Of note, until recently,
Medicare did not provide reimbursement for care costs incurred during participa-
tion in clinical research trials.
It should be noted that changes in the US public health care programs are gradually
occurring as the Patient Protection and Affordable Care Act (ACA) of 2010 continues
implementation, and there may be additional positive impacts on health care services
for older adults (Goyal et al. 2012). The ACA includes a mandate for the expansion of
the scope of routine care to include mental health care and chronic disease self-man-
agement, and places an emphasis on a patient-centered care experience and quality of
life as measurable outcomes. Financial payment incentives are being realigned, espe-
cially for primary care providers who work in geriatrics, and there is increased atten-
tion to the development of care coordination and disease management programs for
older adults to prevent unnecessary medical interventions and reduce costs. Thus,
there may be reduction of age bias at the systemic level as we move toward the future.
13.3.2 Older Persons Participate Minimally in Clinical Trials
Another aspect of age bias at the structural level concerns clinical research trial
participation. As Topinkova and colleagues note (Topinkova et al. 2012), “the health
care industry and regulatory authorities have for a long time negated the age-specific
needs of older drug consumers. Only recently the European Medicines Agency has
begun recognizing the need for a specific ‘geriatric’ approach in both drug develop-
ment and registration” (p. 479). Older patients are typically excluded from the
development and testing of new compounds, from ongoing drug efficacy monitor-
ing programs, and from undergoing age-appropriate outcome evaluations. In clini-
cal drug trials for cancer and coronary artery disease, both conditions for
which incidence increases with age, persons over the age of 65 are systematically
underrepresented (Witham and McMurdo 2007). The same trend can be seen in
research on intervention for strokes and on stroke rehabilitation: in both cases, there
is global evidence of age bias, as the mean age of participants in clinical trials
reported in the stroke literature was a decade younger than the average age of stroke
patients (Gaynor et al. 2014; Hadbavna and O’Neill 2013).
A systematic review of recruitment of older cancer patients into clinical trials
identified age-related barriers to equal inclusion in four broad domains: trial design,
physician factors, patient factors, and trial logistics (Townsley et al. 2005). In the
majority of clinical trials, protocol design stipulates exclusion criteria such as
impaired functional status, past cancer illnesses, and medical comorbidities. This
effectively screens out many older patients. Indeed, in a recent prospective study,
not being eligible was the most common reason for lower enrollment of older per-
sons (Javid et al. 2012). Further, a recent study of heart failure trials (Cherubini
et al. 2011) found that almost 50% of the trials included what the authors termed
“poorly justified” exclusionary criteria, resulting in lower participation by patients
over 65 years old. At least one study has found similar age-based bias in non-
pharmacological health behavior clinical research (Levy et al. 2006).
Physician-related barriers to referral of older adults to clinical trials include pro-
vider concerns about co-morbidities and potential adverse events related to study
participation, factors which are evaluated in the context of patient age (Townsley

et al. 2005). There is no evidence that provider characteristics impact referral
rates. A U.S. study compared rates of physicians offering clinical trial participation
to older versus younger breast cancer patients, and found no significant associations
with physician demographic or professional experience variables. Patient age and
stage of disease were the only significant predictors of referral (Kemeny et al. 2003).
In terms of patient-level barriers, both older and younger patients most frequently
explained their nonparticipation in trials by a reluctance to experience limitations on
their choice of treatment. Some scholars, however, assert that older adults’ health
literacy and knowledge about participation in clinical trials may be at a lower level
compared to younger persons, preventing fully informed decision-making in these
situations (Townsley et al. 2005).
Factors related to patient safety and scientific integrity, such as risk of adverse
events and ensuring sample homogeneity, are often cited for this age-based exclu-
sion. These are important concerns. However, the nonparticipation of older patients
in clinical trials likely has a profound impact on health care for older adults. Lack of
older adults’ participation prevents the generalization of study results to older
patients and therefore may contribute to “double discrimination”: without clinical
evidence supporting the use of novel treatments in the older population, the chance
is reduced that older patients will receive these treatments. This may happen due to
age-biased beliefs that continue unchallenged without newly emerging research on
older populations, or due to clinicians’ uncertainty about safety and benefits for
older patients and a resultant reluctance to pursue screening or treatment (Walter
et al. 2005). Thus, age-based barriers to access to medical therapy might be partially
attributed to the under-representation of the older age population in clinical trials.
Further, the treatments that older adults receive should be based on solid clinical
evidence relevant to that population, which is not currently the case (Cherubini et al.
2011). Indeed, it can be argued that underrepresentation of the older patient popula-
tion in clinical trials is not only one of the consequences of ageism in medicine, but
may also be one of its major perpetuating factors.
13.3.3 Training of Health Care Professionals
Another systemic factor which may sustain the age bias which exists within the
health care system is the type of training received by health care professionals.
Several scholars have argued that training programs do too little to actively combat
existing negative views of older adults and to positively promote geriatrics or ger-
ontology as practice fields. Some years ago, Levenson (1981) asserted that “medical
students’ attitudes have reflected a prejudice against older persons surpassed only
by their racial prejudice” (p. 161). More recent research has demonstrated that med-
ical residents perceive themselves to have a gap in geriatric training and exposure to
older patients (Chodosh et al. 1999), and that both US and European nursing stu-
dents and nurses viewed the care of older people as a topic that currently receives
too little attention in professional education programs (Kydd et al. 2014). Of note,
however, a recent study of US medical schools reported improvements in the past
decade in geriatric-specific physician training (Bragg et al. 2012). Thus, while inad-
equate training in geriatrics remains a problem to solve, it appears that institutions
charged with health care education may be progressing in the right direction.
Health care represents a key domain of civilized life, and provides services to all
members in a society. Indeed, bioethics scholars debating about the rationing of
health care to address rising costs have argued that protecting health is of “special
moral importance”, also noting that health care systems are not prepared to meet the
challenges of the ageing of the global population (Daniels 2013). There is ample
research evidence demonstrating that age-based discrimination is common and
long-standing among health care providers, within health care systems, and in
health care policies. Further, there are systemic forces which have an impact on
geriatric health services before the older patient even feels the need to seek care –
for example, the lengthy process of developing, testing, and monitoring medica-
tions, which has excluded older adults to a significant extent. On the positive side,
there is increasing recognition of these manifestations of ageism at all levels, and
there is increasing support for interventions to change negative attitudes and reduce
age discrimination. The landscape of health care is not static. This may be espe-
cially true in the area of geriatrics, as countries around the globe scramble to prepare
for the ever-increasing numbers of complex older patients.
An important additional point is this: given the complexities of health care, it is
sometimes difficult to distinguish between inappropriate and discriminatory age-
based bias – “ageism” – and prudent, carefully reasoned decisions by clinicians in
their care of older adults. Multiple patient-level and institutional-level factors
impact clinical decision-making about screening, diagnostic tests, and treatment
(e.g., Breslau et al. 2016). Clinical decision-making for older patients is often a
highly complex task which is not made easier with the dearth of clinical evidence
regarding appropriate treatments for this population. Clinical practice is guided by
familiarity and routine as well as evidence, and some categorizing or stereotyping
of patients by risk or potential outcome is sometimes necessary to make treatment
decisions. One might ask: how much of “ageism” in clinicians can be attributed to
the perpetuation of outdated ideas regarding good clinical care for older adults,
rather than purely to age-biased attitudes and behaviors? Is age bias merely reflec-
tive of our human affinity for tradition and resistance to change? This begs the ques-
tion, however, of why health care systems have been so very resistant to change and
slow to embrace proven approaches to improve services for this large group of con-
stituents. Older adults comprise the most frequently seen, and costliest, consumer
group in health care. Their numbers are increasing. Yet, there is a pronounced lag in
the development of widespread implementation of well-accepted clinical guidelines
for this population, despite adequate evidence documenting the benefits (Boult et al.
2001). Do ageist stereotypes and prejudices – in the provider, in the patient, in the
system – play a role? We believe they do. Thus, while we acknowledge that age-
based bias may not always be specifically reflective of negative age stereotyping, we
believe ageism remains a powerful force within the health care setting. Identifying
ageist attitudes and practices is the first step to eliminating this bias and improving
health care for persons of all ages.
The task remains to define and describe health care for older adults that is not
ageist. What does this look like? We believe that a non-ageist approach to develop-
ing health care services for older persons does not mean standardizing assessment
and treatment procedures and processes across the age span. We, like other authors
(Bodner et al. 2018, Chap. 15, this volume), believe that health care equity for older
adults refers to equality in the adequacy and case-appropriateness of diagnosis and
treatment, rather than to uniformity in the evaluation and treatment itself. It means
creating care that respects the unique needs of the aged, that results in high patient
satisfaction, and that achieves success in reaching desired outcomes. High quality
medical treatment is always relative to what is required and what is adequate for that
particular patient. It requires an individualized, person-centered approach to care
(Breslau et al. 2016), and is in keeping with the anti-ageist ideology inherent in the
principles of modern geriatric practice (Coupland and Coupland 1994). It supports
the potential for the field of geriatric medicine not only to treat health conditions
and reduce suffering in older persons, but also to “engage in work either to endorse
or to reconstruct patients’ [ageist] conceptions of their own ageing and health”
(Coupland and Coupland 1994). It is our view that the health care system has an
obligation to actively address ageism – in patients, in the professionals working
within the system, and in the systems themselves.
In conclusion, the health care system can be improved for patients and health
care providers alike through acknowledging and working to eliminate ageism. To
this end, continued research in this area is certainly needed. Future research efforts
should strive be more theoretically-based, and might focus on further uncovering
factors that influence the development and maintenance of age discrimination in this
setting. Hagestad and Uhlenberg (2005) argue that micro-level bias results in
macro-level bias through the isolation of social sub-groups and subsequent reduced
inter-group contact. Social networks – the meso-level at which ageism can be mani-
fested – may be an important area for future research and intervention to address
ageism in the health care setting. Certainly, improved education and training of the
key players at all levels of geriatric health care is vital to reducing age bias. This
includes hospital administrators, physicians, nurses, personal caregivers, and asso-
ciated health professions. Acknowledging and working to reduce ageist attitudes in
patients and their family caregivers cannot be neglected in these efforts, as ample
evidence points to the important impact of self-directed ageism on health. We can
take a cue from best-practice geriatric health care: these efforts need to be coordi-
nated and collaborative, taking into account all sources and factors of age bias and
discrimination, in order to address this problem. As stated quite succinctly by the
physician who coined the term “ageism,” Robert Butler: “ultimately, such initiatives
will benefit all who would grow old” (Butler 2009). That means all of us.
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Chapter 14
Ageism in Medication Use in Older
Patients
Daniela Fialová, Ingrid Kummer, Margita Držaić, and Marcel Leppee
14.1 Introduction
Medications and doses are often similarly prescribed to older and younger adult
patients (Somers 2016). This is a problem that must be viewed as ageist, because
pharmacological studies have shown for decades that many medications act differ-
ently in older and younger people due to the physiological and pathological changes
that accompany ageing. Many medications have different efficacy and safety profiles
in younger and older age groups (American Geriatrics Society (AGS) 2015; Fialová
and Onder 2009; Pazan et al. 2016). For this reason, treating older adults the same as
younger adults when prescribing medication, without respecting age-specific needs
in terms of such issues as individual dose adjustments, geriatric drug forms, and
geriatric medication management, can be seen as a form of ageism. Among older
adults, the selection of medication, dosing schedules, and combined drug regimens,
as well as appropriate follow-up and management of medication treatment, should
always be age-specific and highly individualized. Unfortunately, this is not a com-
mon clinical practice (Fialová and Onder 2009; Petrovic et al. 2016).
The appendix for a list of abbreviations used in this chapter is located at the end of the chapter.
D. Fialová (*)
Department of Social and Clinical Pharmacy, Faculty of Pharmacy in Hradec Králové,
Charles University, Prague, Czech Republic
Department of Geriatrics and Gerontology, 1st Faculty of Medicine and General Teaching
Hospital, Charles University, Prague, Czech Republic
I. Kummer · M. Držaić
Gradska Ljekarna Zagreb, Zagreb, Croatia
M. Leppee
Department of Public Health and Department of Pharmacoepidemiology, Andrija Stampar
Institute for Public Health, Zagreb, Croatia

https://doi.org/10.1007/978-3-319-73820-8_14
214 D. Fialová et al.
In 1969, Butler defined ageism as “systematic stereotyping and discrimination

against older people because of their higher age” (Achenbaum 2014). Based strictly
on this definition, non-discrimination of older adults in medication use could be
understood as providing the same treatments to older adults as to younger adults.
However, this “age-blind” approach has actually translated into some discrimina-
tory practices towards older patients, including not prescribing safer and equally
economically available drugs with lower therapeutic risks, not selecting geriatric
low-dose drug regimens, prescribing medication with unknown efficacy in older
patients with the potential to cause substantial harm, prescribing risky polyphar-
macy, and so on (Fialová et al. 2005; Fialová and Onder 2009; Petrovic et al. 2016).
This age-blind approach leads to a variety of direct and indirect forms of ageism
(Coupland and Coupland 1993, 1998 Ouchida and Lachs 2015). Implicit ageist atti-
tudes may be present as negative thoughts, feelings, and behaviours toward older
people that may occur without conscious control and awareness. These can be
reduced by self-assessment methods and training techniques aimed at overcoming
implicit ageism (Adelman et al. 2000; Levy 2001). Explicit ageist attitudes may be
exacerbated by persistent misconceptions that older patients are often demented,
incontinent, depressed, and somehow “unsalvageable”. Higashi et al. (2012)
described some of these ageist attitudes among young medical trainees. For exam-
ple, one of the trainees said, “It’s always a bigger save when you help a 35-year-old
woman with kids than it is to bring an altered 89-year-old woman with a urinary
tract infection back to her semi-altered state” (Higashi et al. 2012). Direct ageism
also occurs when it is considered normal and expected to have side effects from
medications because “that’s just the way it is when people are old” and when health-
care professionals consider older patients to be just “poor old dears,” unable to look
after themselves (Brossoie 2013). Becoming aware of these attitudes is one of the
first steps in reducing ageism and is the responsibility of every healthcare profes-
sional caring for older persons (Brossoie 2013).
“Hidden” forms of ageism may also occur, for example, as a consequence of
poorly coordinated, non-appropriately managed geriatric care (Ouchida and Lachs
2015). Moreover, fragmented healthcare systems limit healthcare communication,
especially with older people, and reduce older patients’ access to adequate care
(Adelman et al. 2000). For additional information on ageism in the healthcare sys-
tem, see Wyman, Shiovitz-Ezra, and Bengel, 2018, Chap. 13 in this volume.
14.2 A
spects of Ageism and Inappropriate Medication Use
in Older Patients
For many frequently prescribed medications (e.g., some cholinesterase inhibitors,

antidepressants, and antivertiginous agents), clinical data from randomized con-
trolled trials (RCTs) on standard dosing, clinically approved indications, and spe-
cific risks in geriatric patients are not available (Fialová and Onder 2009). This is
14 Ageism in Medication Use in Older Patients 215
because, in the past, older patients were explicitly excluded from RCTs due to their
higher age and higher probability of drug risks (Crome et al. 2011). During work on
the new “Fit fOR the Aged” (FORTA) geriatric recommendations, Wehling and his
team (Wehling 2016) reviewed the German Association of Scientific Medical
Societies Guideline Register and found that only 2 out of 926 clinical guidelines
explicitly addressed geriatric patients. One guideline dealt with nutrition in older
patients and the other addressed the treatment of urinary incontinence. Information
in other guidelines on specific aspects of drug therapy in older patients was short
and vague, not addressing the complexity of clinical needs in older patients (Wehling
2016). However, the majority of current users of medication are geriatric patients.
They are often prescribed multiple drug combinations despite a substantial gap in
our knowledge about the efficacy and safety of multiple drug regimens in older
adults. This gap is a direct product of ageist practices, which excluded older adults
from clinical trials. These ethical problems also contribute to ageism in medication
use.
Existing studies have described discrimination towards older patients in the pro-
vision of drug treatments. For example, sometimes treatable pathologies are dis-
missed because they are considered just common problems in old age. This
phenomenon frequently leads to underdiagnosing and undertreating pain, depres-
sion, dementia, and other comorbidities in older adults (Cherubini et al. 2012).
Other age-related drug provision problems include indication of a new drug or
drugs for wrongly diagnosed drug-related problems (DRPs) and not reducing a dose
or not withdrawing harmful medication (Kane et al. 2004; Routledge et al. 2004).
Also, unnecessary overuse of some diagnostic tests and failure to provide appropri-
ate geriatric care in poorly coordinated and fragmented healthcare systems are
forms of ageism that can result in inadequate drug treatment for older adults (Fialová
and Onder 2009; Qaseem et al. 2012).
In addition to an age-specific approach, highly individualized drug therapy is also
necessary, particularly when treating older adults with complex conditions. Some
older patients suffer from several disorders, disability, and are frail; they may use
multiple medications (polypharmacy) and may be exposed to a variety of risk fac-
tors, such as memory problems, decreased ability to handle medication, and eco-
nomic and social problems. Older patients should therefore be specifically protected
from adverse drug outcomes by highly individualized medication treatment and
highly individualized care that not only includes age-specific approaches, but also
considers individual risk factors and individual goals of care (Fialová and Onder
2009; Petrovic et al. 2016). By not providing such highly individualized care, health-
care professionals and sometimes even healthcare managers promote ageist attitudes
and approaches which compromise the health and wellbeing of older adults.
This chapter focusses on the association between ageism and three types of inap-
propriate medication use in older patients: inappropriate prescribing, polypharmacy
and/or polyherbacy, and medication nonadherence. Definitions, risk factors, and
negative outcomes of these three phenomena are comprehensively described (for an
overview of negative outcomes see Table 14.1), as well as future possibilities for
improvements.
Table 14.1 Negative consequences of polypharmacy, suboptimal prescribing and medication

nonadherence
PIM use
Increased use of healthcare resources
Higher occurence of adverse drug events (ADEs) / adverse drug reactions (ADRs) / drug-
interactions → lead to „prescribing cascades“, geriatric syndromes, medication nonadherence
Higher disability
Higher morbidity and mortality
Polypharmacy/Polyherbacy
Increased healthcare costs
Adverse drug events (ADE)/adverse drug reactions (ADR) → lead to „prescribing cascades“
Drug-interactions (drug-drug interactions; drug-disease interactions; drug-herbs/herbal
supplements interactions, drug-lab tests interactions)
Medication nonadherence
Inappropriate drug use
Reduced functional capacity
Higher occurrence of geriatric syndromes, such as cognitive impairment, falls (orthostatic
hypotension), urinary incontinence, malnutrition, psychiatric morbidity (e.g., deliria,
depressions)
Nonadherence
More frequent physician office visits
Additional laboratory tests
Unnecessary additional treatments, polypharmacy
ADRs / ADEs, more frequent emergency department visits
Higher hospital or nursing home admissions
References: Abdulraheem (2013), Akazawa et al. (2010), ASA/ASCPF (2006), Gurwitz et al.
(2003), Leendertse et al. (2011), Maher et al. (2014), Sabaté (2003), Scheen and Giet (2010),
Spinewine et al. (2012), Strandberg (1984), and Vermiere et al. (2001)
14.3 I nappropriate Prescribing in Older Patients

and Aspects of Ageism
14.3.1 D
efinitions and Epidemiology of Inappropriate
Prescribing in Older Adults
Inappropriate prescribing in older patients is understood in many studies to be the

prescribing of medication that is potentially inappropriate in older age. These so-
called PIMs (potentially inappropriate medications) have been identified by a con-
sensus of expert panels as medications that carry more risks than benefits for older
adults. While safer alternatives exist in the pharmaceutical market, PIMs should not
be prescribed to older patients because of their higher risks of drug-therapy prob-
lems. The best-known clinical criteria for describing these medications are the
Beers Criteria (AGS 2015) and STOPP (Screening Tool of Older People’s
Prescriptions)/START (Screening Tool to Alert to Right Treatment) criteria
(O’Mahony et al. 2015).
Unfortunately, previous studies have documented a high prevalence (14.6–44%)
of PIMs being used in hospitalized older adults (Hajjar et al. 2005; Onder et al.
2003); 19.3% in older patients admitted to emergency department units (Chen et al.
2009); up to 48–59.2% in community-residing older patients (Baldoni et al. 2014);
and 43% in older adults residing in nursing home facilities (measured as overall
weighted point prevalence in a systematic review of studies) (Morin et al. 2016).
Prescription of PIMs, however, presents only one piece of suboptimal prescrib-
ing in older patients. Hanlon et al. (2001) define suboptimal prescribing in the geri-
atric population using the following three categories:
• Overprescribing or overuse of medicines: application of higher doses of medi-
cine than is clinically necessary; excessive or inappropriate polypharmacy; long-
term use of medication without proved efficacy; use of medication in vague
indications
• Underprescribing or underuse of medicines: use of lower than optimal doses; not
prescribing medications known to be effective and safe in geriatric patients
• Inappropriate prescribing: prescribing PIMs in geriatric patients; prescribing
despite known drug-drug or drug-disease interactions
Inappropriate medication use is a general term describing a range of problems
arising from the prescription, administration, and storing of medication, as well as
problems with medication nonadherence (Griese and Leikola 2014). According to
the Pharmaceutical Care Network of Europe (PCNE), all of these problems are clas-
sified as drug related problems (DRPs). A DRP is by definition “an event or circum-
stance involving drug therapy that actually or potentially interferes with desired
health outcomes” (Griese and Leikola 2014; Somers 2016) and can include adverse
drug reactions (ADRs), drug-disease interactions, drug-drug interactions (DDI),
drug therapy failures, inadequate dosing, drug use without indication, patient non-
adherence, and many other DRPs.
14.3.2 R
isks Factors of Inappropriate Prescribing in Older
Patients
Inappropriate prescribing in older patients is usually the result of multiple risk fac-
tors, such as:
• Inadequacies in the provision of healthcare, such as ineffective care at the inter-
face between hospital and primary care and inappropriate systems for repeated
prescriptions;
• Lack of geriatric knowledge among prescribers or inadequate use of some thera-
peutics in relation to multimorbidity (e.g., some high-risk medications such as
nonsteroidal anti-inflammatory drugs, anticoagulants, diuretics, psychotropics),
and inadequate training in recognizing adverse drug interactions and reactions;
• Clinical guidelines aimed at managing single but not multiple conditions;
• Failure to recognize the need to stop inappropriate treatments;
• Psycho-social reasons on the side of prescriber, such as the desire to please

patients, feeling pressured to prescribe medication, and balancing between pre-
scribers’ experiences and clinical evidence (Cullinan et al. 2014; Fialová and
Onder 2009; Petrovic et al. 2016).
Older patients are often treated by several healthcare professionals, including
different prescribing physicians, which may lead to duplicate prescribing and seri-
ous problems with inappropriate prescribing. There are also inconsistencies in
updates on information about indications, duration of therapy, monitoring of adverse
reactions and follow-up of safety and effectiveness of medications prescribed to
older patients. Problems also arise from the lack of training in undertaking complex
medication reviews among prescribers and the fact that prescribers often do not
have time to undertake such reviews in routine clinical practice (Avery et al. 2012).
The risk factors positively associated with prescribing medications that are
potentially inappropriate for older adults (see Table 14.2) include the following:
polypharmacy; psychotropic drug use; polymorbidity (mostly colinear with poly-
pharmacy); specific health conditions, such as depression and psychoses; socio-
demographic factors, such as low socioeconomic status, low income, low education
level, illiteracy, and being single. Some risk factors relate to management and qual-
ity of healthcare, such as hospital stay of ten or more days; institutional care; longer
stay in the nursing home; having more than one prescriber; and frequent physician
visits (Baldoni et al. 2014; Chen et al. 2012; Fialová et al. 2005; Haasum et al. 2012;
Lin et al. 2011; Niwata et al. 2006; Undela et al. 2014; Vieira de Lima et al. 2013;
Zhan et al. 2001). Studies have found that older patients with psychiatric disorders
had up to five times higher risk of being prescribed PIMs than other older patients
(Vieira de Lima et al. 2013), and that a diagnosis of acute illness increased the risk
of PIM prescribing more than eight times (Lin et al. 2011).
Many of the risk factors described above may indicate ageist attitudes and behav-
iour. When older patients frequently visit the physician’s office, require acute care,
or stay longer in nursing homes, they run a higher risk of being prescribed PIMs.
More frequent use of PIMs has also been documented among older patients already
at higher risk of adverse drug events (ADEs) for other reasons, such as in polymor-
bid older patients using polypharmacy and those using psychotropic drugs (Baldoni
et al. 2014; Chen et al. 2012; Fialová et al. 2005; Haasum et al. 2012), even though
drug risks should be rigorously reviewed in these groups of patients. Zhan et al.
(2001) discussed, based on their findings, that visits at physicians’ offices may
frequently end with drug prescription in order to satisfy the patient. Some studies
also showed that if older patients were more dependent on the prescriber (e.g., when
they suffered from psychiatric illness, were in a poor economic situation, or did not
have a partner) they were at significantly higher risk of inappropriate prescribing
(Baldoni et al. 2014; Fialová et al. 2005; Qato and Trivedi 2013; Vieira de Lima
et al. 2013). These examples suggest ageist behaviour, even though ageism has not
yet been thoroughly studied in relation to prescribing practices.
PIMs include older medicines that have been available in the pharmaceutical
market for decades. They can be cheaper than safer drug alternatives and are usually
Table 14.2 Risk factors associated with use of potentially inappropriate medications (PIMs)
Positively associated Negatively associated
Demographic factors/ Age groups from 65 to 80/85 years (in the Very old patients 85+ (in
socio-economic majority of studies) (*)female gender (in the the majority of studies) $
factors majority of studies, usually collinear with
having more health compliants and using
polypharmacy) $ (*)
Living alone/not having a partner (*) Not visiting a physician
(in some studies collinear
with living along and not
having a caregiver)
Poor economic situation, low income (*)
Illiteracy (*)
Disease- related Psychiatric disorders (*) Hypertension
factors
Rarely other disorders (e.g. neurological Cognitive impairment /
disorders, cardiac arrhytmias; congestive severe cognitive
heart failure;et al.) impairment, mental illness
Impaired physical functioning, disability (*)
Diagnosis of acute diseases (*)
Polymorbidity (*)
Medication use and Polypharmacy (5+/6+,9+/10+), number of
medication drugs (*)
prescribing- related
factors
Psychotropic drug use (1 and more) (*)
Antianxiety drugs (1 and more) (*)
Higher medication costs (*)
More than 1 prescriber (*), prescribers’ age
>35 years
Frequent physician visits (*)
Healthcare provision- Hospital admission (*)
related factors
Longer hospital or nursing home stay (*)
Living in a institution (*)
References: Akazawa et al. (2010), Fialová et al. (2005), Chen et al. (2009), Chen et al. (2012), Lin
et al. (2011), Niwata et al. (2006), Onder et al. (2003), Qato and Trivedi (2013), Undela et al.
(2014), and Vieira de Lima et al. (2013)
Footnote: Many of above stated risk factors may be directly or indirectly linked to ageism (*)
$ – in some studies, positive association of PIM use with male gender and age group of patients
85+ have been also documented
available without co-payments. For this reason, PIMs are often more economically
available to poor older adults than safer drug alternatives (Fialová et al. 2005). This
form of ageism occurs at the drug regulatory level, when safer drug alternatives are
less available to older patients with economic difficulties due, among other things,
to higher co-payments.
14.3.3 N
egative Consequences of Inappropriate Prescribing
in Older Patients
As emphasized by many previous review studies, older patients suffer more often
from drug-related problems and negative outcomes than younger adults (Beard
1992; Spinewine et al. 2012; for an overview of negative consequences see
Table 14.1). At least 20–30% of patients in the 70–79 year old age group suffer from
ADEs compared to 3–6% among the 20–29 year old age group (Beard 1992; Fialová
and Onder 2009; Spinewine et al. 2012). ADRs among older patients in acute care
setting range between 5.8% and 46.3% (Alhawassi et al. 2014), and for older people
the risk of ADR-related hospitalization is 4 times higher than for younger adults
(16.6% vs. 4.1%) (Beijer and de Blaey 2002). However, in older patients, up to 88%
of the ADR-related hospital admissions may be preventable, while for younger
adults it is only 24% (Beijer and de Blaey 2002). The extensive Hospital Admissions
Related to Medication (HARM) study identified several risk factors for adverse
drug outcomes due to inappropriate prescribing, namely: being 65 or older, poly-
pharmacy (>5 chronic medications), nonadherence, decreased cognitive function,
renal impairment, four or more co-morbidities, and living alone (Leendertse et al.
2008).
Inappropriate prescribing substantially contributes to higher morbidity and
mortality among older adults and significantly raises overall medication costs
(e.g., cost of more frequent ambulatory office visits, costs associated with drug-
related health complications, and cost of drug-related admissions to acute hospital-
ization) (Bordet et al. 2001; Johnson and Bootman 1995; Leendertse et al. 2011).
These costs are estimated to be 3–4 times higher than direct medication costs, and
they substantially contribute to higher total expenditures for drug treatment in the
healthcare system (Bordet et al. 2001; Johnson and Bootman 1995; Leendertse
et al. 2011).
14.3.4 S
trategies to Reduce Inappropriate Prescribing in Older
Patients and Aspects of Ageism
Several studies have reviewed strategies for reducing inappropriate prescribing in

older patients (e.g., Petrovic et al. 2016). Studies aimed at reducing inappropriate
prescribing have used a variety of tools: decision-making support aids for prescrib-
ers; computer alerts for prescribing errors; medication reviews; training and learn-
ing methods; patient reminder systems; and novel methods of service provision
(Duerden et al. 2013). In the United Kingdom, the PINCER trial was undertaken to
evaluate whether a complex IT-based intervention was more effective than simple
feedback in reducing medication error rates in general practices (GPs). At 6 months’
follow-up, the GPs that received both computerized feedback and pharmacist
support had significantly fewer prescribing errors than the GPs that received com-
puterized feedback alone (Avery et al. 2012). Studies have shown that effective
interventions improving drug prescribing must combine several methods and that
multidisciplinary cooperation and the provision of clinical medication reviews are
crucial to successful intervention (Petrovic et al. 2016). One simple strategy would
be also to avoid prescribing highly complex drug regimens (polypharmacy) and
PIMs.
The number of drugs approved for clinical use has increased exponentially on the
US and European pharmaceutical markets. As described in the publication of
Bernhardt et al. (2017), global pharmaceutical consumption has increased four
times since 1970, with estimations of 760 billion dollars spent annually in 2015
(Bernhardt et al. 2017). Pharmaceutical firms and regulatory agencies have been
found to switch more medications to over-the-counter (OTC) status (Francis et al.
2005). Some PIMs for older patients are already available as OTC medications
(Francis et al. 2005), such as contact laxatives, loperamide, proton-pump inhibitors,
and nonsteroidal anti-inflammatory drugs for systemic use. Increasing the number
of registered active substances, brand names, drug forms, and OTCs contributes to
more frequent medication errors (e.g., transcription errors during the prescribing
process; drug duplication; dispensing errors; and errors in the use of medicines by
patients themselves). Controlling drug prescribing and drug use appropriateness has
become more and more complicated.
Considering the vulnerability of older adults to ADEs as well as the increase
in population ageing, the trends described above can be seen to reflect ageism at
the level of regulatory institutions as well as in society in general. Significant
discrepancies in providing standard healthcare to older adults already exist, and
population ageing and the concomitant lack of adequate numbers of healthcare
professionals raise worries that the prevalence of ageist attitudes and inappro-
priate prescribing in geriatric patients might increase in the future. Solutions to
this problem can potentially begin at the regulatory level, by more strictly regu-
lating the availability of risky medications to geriatric patients; by regulating
drug advertisements and internet sales; and by stricter regulations on switching
more risky medications to OTC status. In many European countries, there is still
insufficient support of safer, more geriatric-oriented clinical practice, and insuf-
ficient support of clinical pharmacy, and clinical pharmacology services that
create important feedback (Fialová et al. 2005; Fialová and Desplenter 2016;
Spinewine et al. 2012). In some EU countries, such as the UK, the Netherlands,
Belgium, and several other countries, patients already benefit from clinical
pharmacy services that significantly help to improve appropriateness of drug
prescribing and reduce overall healthcare costs and ADEs in older adults
(Fialová and Desplenter 2016). More support of these positive feedback strate-
gies could help to optimize medication treatment in vulnerable populations,
including geriatric patients.
14.4 P
olypharmacy and Polyherbacy in Older Patients
14.4.1 D
efinitions and Epidemiology of Polypharmacy
and Polyherbacy
The majority of older adults, approximately three quarters of geriatric patients

(Anderson 2010), suffer from multiple chronic conditions and are consequently pre-
scribed multiple medications (Lorgunpai et al. 2014). Polypharmacy describes an
individual’s use of multiple medications; however, a uniform definition for poly-
pharmacy has not yet been set (Votova et al. 2013). “Polypharmacy” is usually
defined as the concurrent use of five or more medications (Hoffmann et al. 2011),
whereas “excessive polypharmacy” refers to the simultaneous use of more than ten
prescribed medications (Jyrkkä et al. 2012). The term polyherbacy (Ness et al.
2003) is defined as the use of multiple natural health products, which include dietary
supplements, vitamins, minerals, and herbals.
Today, polypharmacy and polyherbacy present important and growing public
health problems, as their prevalence among older adults is high and rising and may
significantly differ from country to country as well as regionally. In the United
States, the concurrent use of five or more prescribed medications among older
adults increased from 30.6% (2005–2006) to 35.8% (2010–2011) (Qato et al. 2016).
Similar trends have been observed in Europe. In Sweden, the increase in excessive
polypharmacy was 15.7% between 2005 and 2008 (Hovstadius et al. 2010).
Observed use of dietary supplements in the United States increased from 51.8%
(2005–2006) to 63.7% (201–2011) (Qato et al. 2016).
14.4.2 R
isk Factors of Polypharmacy and Polyherbacy in Older
Patients
The risk factors of polypharmacy and polyherbacy can be classified into three
groups: demographic risk factors; health status-related; and access to healthcare-
related risk factors (see Table 14.3). Demographic characteristics of the older popu-
lation cannot be influenced; however, interventions can be made to patients’ habits
and healthcare providers’ practices to reduce the risk of polypharmacy.
14.4.3 N
egative Consequences of Polypharmacy
and Polyherbacy in Older Adults
Like inappropriate prescribing and medication nonadherence, polypharmacy and

polyherbacy in older patients have numerous negative consequences on both the
patient and the healthcare system (see Table 14.1). They are associated with greater
Table 14.3 Risk factors associated with polypharmacy

Demographic factors Increased age (*)
White race
Education
Female gender
Health factors Poorer health (*)
Comorbidities (cardiovascular disease, hypertension, asthma, diabetes
mellitus)
Use of >9 medications (*)
Access to healthcare Number of healthcare visits (*)
Supplemental insurance (?*)
Multiple providers (*)
Due to healthcare Presuming that patient expects prescription medication
providers (*)
Prescribing drugs without sufficient investigating of clinical situation
Providing unclear, complex or incomplete instructions how to take
medicines
Not simplifying medication regimens, when it is possible
Not conducting patient’s medication review regularly
Ordering automatic refills without adequate follow- up
Lack of knowledge of geriatric clinical pharmacology
Stacking and insisting on using drugs that are no longer necessary
Due to patients Inaccurate report to physicians of all medicines that patients are using
simultaneously
Not reporting symptoms patients are experiencing (these can be also
drug-induced)
Having duplicate prescriptions
Using additional drugs to treat symptoms, disorders (also OTC drugs)
or also drug-related symptoms
Using medications for a very long period, without appropriate follow
–up
Influence of patients’ daily manners on the action of medications (i.e.
smoking, changes in activity level, food and fluid intake)
References: Abdulraheem (2013), Hajjar et al. (2007), and Hovstadius et al. (2010)
healthcare costs and an increased risk of ADRs and other complications, such as
drug-interactions, medication nonadherence, reduced functional capacity, and mul-
tiple geriatric syndromes (Maher et al. 2014).
Polypharmacy has been found to be associated with a higher risk of outpatient
visits, hospitalizations, taking PIMs, and with an approximate 30% increase in med-
ical costs (Akazawa et al. 2010). The risk of ADRs and other ADEs may be substan-
tially increased by a higher number of prescribed drugs and OTC medication.
Polypharmacy and polyherbacy sometimes lead to so-called prescribing cascades
that begin when an ADR is misdiagnosed as a new medical condition and, conse-
quently, a new medicine is prescribed. The patient is then exposed to a risk of devel-
oping additional adverse effects (Rochon and Gurwitz 1997). The potential for drug
interactions increases exponentially with the number of applied medicines. Doan
et al. (2013) found that a patient taking 5–9 medications had a 50% probability of a
drug-drug interaction (DDI), and a patient taking 20 or more medications had a
100% probability of developing DDIs.
Studies that analysed the correlation between polypharmacy and underprescrib-
ing have had conflicting results. Some researches consider the number of medica-
tions to be a risk factor for underuse of highly effective drug treatment strategies
(Kuijpers et al. 2008), whereas others did not find an association (Gallagher et al.
2011; Ryan et al. 2009; Ryan et al. 2013; Wright et al. 2009). It is important to
identify which pharmacological groups and risk factors are linked with polyphar-
macy and underprescribing, and to examine this possible relationship (Blanco-
Reina et al. 2015) with an aim to achieve improvements in pharmacotherapy
(Franchi et al. 2013). As confirmed by previous studies, the main determinants of
underprescribing in older patients are comorbidity, polypharmacy, ageism, lack of
or scanty evidence concerning the efficacy and safety of drugs in older patients, fear
of ADRs, and economic constraints (Cherubini et al. 2012).
Polypharmacy and polyherbacy are also associated with medication nonadher-
ence. One of the most important negative consequences of polypharmacy/polyher-
bacy is the higher risk of occurrence of geriatric syndromes. This includes increased
risk of cognitive impairment, falls, urinary incontinence, and reduced functional
capacity (Maher et al. 2014). Also, a patient’s nutritional status can be affected by
polypharmacy. Jyrkkä et al. (2011) found that 50% of patients taking ten or more
medications were malnourished or at risk of malnourishment, mostly because of
frequent indigestion and other gastrointestinal problems caused also by the mixture
of chemical substances interacting in the gastrointestinal tract and consequently
decreased food intake.
14.4.4 S
trategies to Reduce Inappropriate Polypharmacy
and Polyherbacy in Older Patients
We argue that the issue of the increasing prevalence of polypharmacy in older

patients (and consequently increasing problems of side effects, geriatric syndromes,
malnutrition, hospitalizations, higher healthcare costs, and other negative conse-
quences) is strongly linked to ageism. In the current world of “consumer” health-
care, the consumption of medications and the phenomenon of polypharmacy both
increase (Bernhardt et al. 2017; Hovstadius et al. 2010). Older patients and their
informal caregivers generally cannot judge whether multiple drug prescription is
appropriate or not and they are fully dependent in this respect on the decisions,
skills, and attitudes of healthcare providers. Because of strong pressure on drug
market sales, patients and healthcare providers are (intentionally or unintentionally)
pressured to prescribe and consume more medicines, having less time to thoroughly
consider their long-term benefits and risks (Bernhardt et al. 2017; Petrovic et al.
2016). Polypharmacy becomes a common practice, particularly in older patients
with complex disorders (Petrovic et al. 2016). Patients, carers, patient organiza-
tions, healthcare providers, and regulatory institutions should jointly support strate-
gies against ageist medication-related practices which may increase in the future
because of increased consumption of medicinal products.
When treating patients with complex medical issues and high-risk patient groups,
such as older adults, it is particularly important to obtain a balance between differ-
ent therapeutic goals and the expected efficacy and possible risks of medications for
the ageing organism, and to practise more frequent reviews of medication and over-
all health status than in younger patients (Steinman and Hanlon 2010). The pre-
scribing physician or consulting clinical pharmacist should evaluate the use of
appropriate medication; minimize doses of medication without affecting treatment
efficacy; readjust inappropriate doses of drugs, such as doses beyond the drug safety
margin; and rectify any incorrect or inappropriate use of medication by older
patients (Simonson and Feinberg 2005; Steinman and Hanlon 2010). Medication
regimens of older patients should be evaluated at least twice a year, ideally monthly,
to reduce the incidence and adverse effects of polypharmacy (Rochon 2016). Even
for older patients who have been using the same drug regimen for a long time, medi-
cation reviews are necessary, because physiological changes associated with ageing
can alter drug pharmacokinetics and increase the risk of ADRs (Corsonello et al.
2010; Routledge et al. 2004; Sokol et al. 2007). Treatments should be designed to
prioritize improvements in health, functional status, and quality of life (Blanco-
Reina et al. 2015). Some studies have found that physicians already consider medi-
cation guidelines to be too rigid, resulting in individuals with multiple disorders
receiving an increasing number of different drugs (Hovstadius et al. 2010; Moen
et al. 2010). Clinical care is structured and organized mainly to treat a single health
problem at a time or to treat the various illnesses a single patient has as if they were
independent of each other and isolated from the individual who suffers from them
(Starfield 2006). Unfortunately, physicians often add medications without being
aware of potential interactions with other medications and/or diseases (Blanco-
Reina et al. 2015). If different specialists are involved in the care of the same patient,
a risk of fragmented care occurs, due to frequent failures of communication among
healthcare professionals (Green et al. 2007; Hajjar et al. 2007). Poor communica-
tion can result in conflicting or poorly coordinated treatment goals, inadequate
monitoring of the patient’s therapeutic regimen, and inappropriate expectations and
definitions of success, which may contribute to patients’ overall negative outcomes
and negative perceptions of the healthcare system (Makris et al. 2015).
Chronic drug therapy in older patients should generally be started with the low-
est possible dose, following the well-known geriatric phrase, “Start low, go slow,”
and both physicians and patients should be aware of the general rule that “Less is
more” (Steinman and Hanlon 2010). At first, more physiological, nonpharmacologi-
cal strategies should be promoted, if appropriate (e.g., physical exercise, sun expo-
sure, nutritional interventions, and rehabilitation) (Abraha et al. 2015; Naci and
Ioannidis 2013; Taylor et al. 2014). It is also important to regularly identify and
eliminate unessential drugs and duplicate prescriptions for the same condition or
disease (Dagli and Sharma 2014).
Many existing studies warn that polypharmacy in older patients is becoming

more common and is strongly associated with higher mortality, faster functional
decline, malnutrition, severe drug therapy problems, and often undertreatment of
major disease conditions (Bourgeois et al. 2010; Jyrkkä et al. 2011; Kojima et al.
2012; Shah and Hajjar 2012). Ageism can be seen to be in effect in prescribing
polypharmacy and in poor or no monitoring of drug efficacy and safety, and the
patient’s functional status and quality of life during treatment. A large number of
older patients in a variety of care settings are currently prescribed multiple medica-
tions. Vulnerable older patients are among the biggest “consumers” of polyphar-
macy (Chau et al. 2016). As shown in the European project AdHOC (Aged in Home
Care, 2001–2005), 22% of home care older clients used polypharmacy (9+ medica-
tions) in 8 European countries, however medication reviews provided on a regular
basis at least every 6 months have been documented in only 11% of older patients
in home care (Fialová et al. 2005).
It is essential to continuously create healthcare systems that optimize the use of
medication and where older patients can obtain maximum benefits from their medi-
cation with the least harm (Duerden et al. 2013). The strategy of identifying and
avoiding risky polypharmacy can lead to better outcomes in older patients and can
help improve their quality of life (Dagli and Sharma 2014).
14.5 M
edication Nonadherence in Older Patients
14.5.1 D
efinitions and Epidemiology of Medication
Nonadherence
The scientific literature uses a variety of terms to describe medication-taking behav-

iours, including medication compliance, adherence, persistence, and concordance
(American Society on Aging/American Society of Consultant Pharmacists
Foundation (ASA/ASCPF) 2006; Chakrabarti 2014; Krueger et al. 2003; Sabaté
2003). Adherence is the most often used term, defined in the 2003 report of the
World Health Organization (WHO) as “the extent to which a person’s behaviour –
taking medication, following a diet, and/or executing lifestyle changes, etc. corre-
sponds with agreed recommendations from a healthcare provider” (Sabaté 2003).
The previously used term compliance has come into disfavour because of its con-
notation of patients passively following doctors’ recommendations. Adherence, on
the other hand, requires the patient’s agreement with the physician’s recommenda-
tions (Sabaté 2003). Persistence is defined as the ability of a person to continue in
medication treatment for the intended course of therapy (whether for months, years,
or for the rest of the patient’s life). Non-persistence is when the patient does not fill
his or her prescription or discontinues therapy too early (ASA/ASCPF 2006; Krueger
et al. 2003). A newer term, concordance, takes into account agreement between the
clinician and the patient on medication therapy as well as each other’s views and
perspectives about medication-taking. It describes a broad process in which, after

education and discussion with the patient, the physician should respect the patient’s
choice and views on the therapy, even if they are different or conflict with the clini-
cian’s views (Chakrabarti 2014). The evolution of the terms compliance, adherence,
and concordance indicates a striving towards active patient involvement and a
patient-centred approach in the medication treatment process (Chakrabarti 2014).
Medication nonadherence is the most frequently used term in the literature.
Taken broadly, it includes different types of nonadherence, noncompliance, and
nonpersistence, for example:
• Taking less or more of a medication/medications than prescribed, omitting a
dose, taking a dose at the wrong time, taking a dose with prohibited foods, liq-
uids, and other medication
• Improper administration of medication, including also improper use of adminis-
tration devices, such as inhalers, injections, etc.
• Taking outdated medication or damaged medication, or storing medication
improperly
• Taking a medication prescribed for someone else
• Prematurely discontinuing medication, failing to initially fill in a prescription or
failing to refill a prescription as directed. (ASA/ASCPF 2006; Krueger et al.
2003)
Nonadherence to medication is a very frequent problem, particularly in
community-dwelling older adults, where the prevalence of nonadherence has been
reported to be between 43–100% (Vik et al. 2004).
14.5.2 N
egative Consequences of Medication Nonadherence
in Older Patients
There are various negative consequences of medication nonadherence: less than

optimal management and control of the illness, medical and psychosocial complica-
tions of the disease, reduced patient quality of life, and increased use of medical
resources, such as physician visits, laboratory tests, unnecessary additional treat-
ments, emergency department visits, and hospital or nursing home admissions (see
Table 14.1) (Col et al. 1990; Gurwitz et al. 2003; Scheen and Giet 2010; Strandberg
1984; Vermiere et al. 2001).
Problems with medication nonadherence have been documented as a contribut-
ing factor in more than 20% of preventable ADEs in older patients in ambulatory
care settings (Gurwitz et al. 2003). Studies have also found that more than 10% of
older adults’ admissions to acute care may have been caused by nonadherence to
medication regimens (Vermiere et al. 2001). Col et al. (1990) described in his study
that one-third of older persons admitted to the hospital had a history of nonadher-
ence, and Strandberg (1984) found that nearly one-fourth of admissions of older
adults to nursing homes were due to their inability to self-administer medication.
14.5.3 R
isk Factors of Medication Nonadherence and Aspects
of Ageism
Medication nonadherence is a multidimensional phenomenon which is determined

by the interplay of different sets of risk factors, termed “dimensions” according to
WHO (Sabaté 2003). These are namely:
• Socioeconomic risk factors
• Healthcare system and provider-related risk factors
• Condition-related risk factors
• Therapy-related risk factors, and
• Patient-related factors
Some of these risk factors may be directly or indirectly related to ageism (see
Table 14.4); however, the relationship between medication nonadherence and ageist
attitudes and behaviours has not been yet thoroughly studied.
The common belief that older persons are mostly nonadherent with medication
can be seen as an ageist attitude. Published evidence confirms that all age groups are
prone to nonadherence and that older persons are not an exception (Cooper et al.
2005; Culig et al. 2011; Topinková et al. 2012). Another common belief is that indi-
viduals are solely responsible for taking their medication appropriately, but this
belief reflects a misunderstanding of the fact that a range of factors, including non-
personal patient-related factors can strongly affect medication-taking behaviour
(ASA/ASCPF 2006; Sabaté 2003). This misunderstanding may contribute to age-
ism when no help is provided to older patients with complex disease conditions that
require compliance support, or to older adults who are cognitively impaired or oth-
erwise have problems administering or taking drugs. Many older patients are pre-
scribed several medications without any education on how to take and manage them
appropriately. In one of the study of the European Commission project, Aged in
Home Care (AdHOC) project (2001–2005), more than 2700 home care older
patients were assessed in metropolitan areas of 8 EU countries. Of these older
patients, 12.4% reported no help with medication compliance and managing their
medications despite an objective need (Fialová et al. 2005).
When older people forget to take medication regularly (on time or in a prescribed
dose) they are often viewed as senile, which is ageist attitude, whereas the same
behaviour in a younger person is explained without these stereotypes. Culig et al.
(2011) found in his study that the majority of subjects cited forgetfulness as the
main reason for skipping drug dosing (60%), followed by not being at home
(45.4%), and having run out of the drug (44.4%). However, with the simple help of
pill boxes and adherence reminders, even forgetfulness is a modifiable risk factor of
nonadherence that can be easily resolved (Culig et al. 2011). Not providing compli-
ance support tools to geriatric patients should be viewed as a lack of age-specific
care, and therefore as ageist behaviour.
Medication adherence depends on patients’ comprehension, their attitudes to
disease and need to control the disease, reliance on their own capability to manage
Table 14.4 Risk factors associated with medication nonadherence

Patient- related factors
Physical factors Visual impairment (*) Patient sleepiness (e.g. drug-related
sedation) contributing to inability to
take medicine (*)
Hearing impairment (*) Decreased dexterity (*)
Cognitive impairment (*) Swallowing problems (*)
Impaired mobility (*)
Psychological/ Medication knowledge (*), Motivation (*)
behavioral factors education (*)
Health literacy (*) Beliefs about medicines (*)
Forgetfulness (*) Attitudes to medication treatment (*)
Decreased self-performance Social support (*)
(*)
Alcohol and substance abuse
(*)
Other factors Demographic factors: Age Patient-prescriber relationship(*)
(*), gender, ethnicity, marital
status
History of good adherence Not at home
Therapy-related Treatment complexity(*) Route of administration (*)
factors
Duration of the treatment Taste of the medication (*)
period (*)
Medication side effects or Requirements for drug storage
adverse drug reactions (*)
Therapies that are Medications with a social stigma
attached to its use (such as
inconvenient or interfere with
a person’s lifestyle (*) antidepressants, antipsychotics) (*)
Lack of accessibility of Administration of a medication
medication(*) requiring the mastery of specific
techniques (injections, inhalers) (*)
Provider- and Accessibility of healthcare Difficulty in getting prescriptions
healthcare system- provider (*) filled (*)
related factors Long waiting time or making Lacking continuity of provider care
appointments difficult (*) (*)
Unhappy clinic visits(*) Using restrictive formularies/
changing formularies (*)
Physician’s readiness to High drug costs, high copayments (*)
change compliance
assessment method
Condition/disease Severity of the disease (?*) Disease symptoms (*)
related factors
Social and economic Cost and income (*) Inability to take time off work (*)
factors
Poor social support (*) Lack of health insurance coverage (*)
Homelessness (*)
References: Aggarwal and Mosca (2010), Crowley et al. (2013), Harris et al. (2011), and Munger
et al. (2007)
the use of medicines, their expectations concerning the drug therapy, and their
behavior when the results of therapy are unsatisfactory (Casula et al. 2012). Patients’
behaviour is a complex phenomenon significantly influenced by patients’ home
environments, the healthcare system, and healthcare professionals (ASA/ASCPF
2006). Table 14.4 shows there are many risk factors and groups of risk factors that
contribute to lower adherence of patients to their medications. Some of these risk
factors are related to ageism, for example, poorly coordinated care, inappropriate
expectations of carers from the patient, inadequate education of older adults about
medication because of physician’s perceived lack of time, and so on (ASA/ASCPF
2006; Sabaté 2003; Scheen and Giet 2010).
14.5.4 S
trategies to Reduce Medication Nonadherence
in Older Patients
For a number of chronic medical conditions, such as diabetes, hypertension,

hypercholesterolemia, and congestive heart failure, higher rates of medication
adherence have been found to be associated with lower rates of hospitalization.
For example, for diabetes and hypercholesterolemia, better compliance to medi-
cation was associated with lower disease-related medical costs (Sokol et al.
2005).
Several publications and website sources have summarized the prerequisites for
good adherence to medication regimens that require that a person will
• Show interest in his or her health and understand the diagnosis and potential
impact of the diagnosis
• Believe that the prescribed treatment will help
• Know exactly how to take the medication and know the duration of therapy (it is
possible to assess the patient’s understanding of the disease and the treatment
regimen and provide information where knowledge gaps exist)
• Find ways to fit the medication regimen into his or her daily routine, use adher-
ence aids, such as medication organizers and charts
• Value the outcome of treatment more than the cost of treatment
• Believe that he or she can carry out the treatment plan and is actively involved in
the treatment process.
• Get support from the healthcare team, both professional support (e.g., by simpli-
fying medication regimens) and human support (e.g., by recognizing any diffi-
culties in coping with or recognizing other socio-behavioural issues that may
affect the person’s ability to follow the treatment regimen)
• Believe that the healthcare practitioners truly care about him/her as a person
rather than as a disease to be treated. (ASA/ASCPF 2006; Krueger et al.
2003)
Studies have shown that single interventions are not usually adequate to
improve adherence (Hughes 2004) and almost all effective interventions for
improving patient adherence long-term have been complex (including a combina-
tion of different intervention strategies, such as patient counselling, patient self-
monitoring, medication use reminders, telephone follow-up, psychological
therapy, crisis intervention, supportive care, and so on) (Haynes et al. 2008). In
clinical practice, many interventions focus on providing only one strategy (if any):
for example, education to increase knowledge; simplifying the medication regi-
men (e.g., prescribing fixed-dose combination pills and slow-release drug forms
for once-daily dosing) (Schroeder et al. 2004), using adherence aids, or using refill
reminders. However, simplifying a dosage regimen alone cannot positively influ-
ence adherence if a person does not believe that drug treatment will be effective.
It has been demonstrated that comprehension of drug therapy alone is insufficient
for keeping good medication adherence (ASA/ASCPF 2006; Haynes et al. 2008;
Hughes 2004).
Some disease-specific health education programmes (e.g. for diabetes and
hypertension) were found to be effective in improving patients’ adherence
(Balamuguran et al. 2006), but in the absence of such formal programmes, physi-
cians can use other educational resources (e.g., pharmacists’ counselling, interac-
tive web-based materials, etc.). The more empowered older patients feel, the more
likely they are to be motivated to manage their health and adhere to their medica-
tions. Ageist practices contributing to medication nonadherence can be reduced
by physicians, carers, and patients being motivated to be actively involved in drug
treatments. A comprehensive approach requires team-based care that includes
non-physician staff (such as nurses and pharmacists) to perform assessment and
management of medication adherence. It might require some of the duties tradi-
tionally performed by physicians to be transferred to non-physician staff. This
strategy allows physicians more time for diagnostic procedures and interpretation.
Recently, motivational interviewing—a counseling technique originally devel-
oped to help treat addiction (designed to help patients identify and overcome rea-
sons they may be reluctant to change their behaviour)—is also recommended
(Miller 2010).
Healthcare providers can significantly influence patients’ healthy behaviour.
Atreja et al. (2005) reviewed interventions that helped to improve patients’ adher-
ence to medications and summarized them into several simply remembered recom-
mendations under the acronym “SIMPLE”:
1 . Simplifying regimen characteristics;
2. Imparting knowledge;
3. Modifying patient beliefs;
4. Patient communication;
5. Leaving the bias; and
6. Evaluating adherence.
In conclusion, the most important measures for improving medication adherence

in older patients are: (a) increase training and education of healthcare providers and
patients in adherence support, team-based approach, active patient involvement,
motivation to use appropriate treatment, and continuous research in specific aspects
of aging; (b) empower and educate older patients; and (c) utilize appropriate screen-
ing and treatment methods for improving adherence among older patients.
Medication adherence is an important contributor to improved patient health. In
order to reduce ageist behaviours stemming from ageist attitudes, healthcare sys-
tems must ensure that sufficient time in daily clinical practice is allocated to the
appropriate management of adherence in older patients (Abbo et al. 2008).
14.6 Conclusions
It is important to take an active, more realistic role in confronting and preparing

healthcare systems for the ageing of the population. Selection of age-specific
approaches (e.g., the right geriatric drug, dosing schedule, drug combination, and
appropriate geriatric recommendations during the drug treatment process) are cru-
cial first steps in the area of appropriate medication use in older patients. Prescribers
currently tend to follow mostly nongeriatric recommendations, which are not rele-
vant to potentially frail, polymorbid, and highly complex older adults (Steinmann
and Hanlon 2010; Wehling 2016). Part of the problem is due to missing evidence
from randomized controlled trials on effective and safe medication and dosing for
geriatric patients. Novel evidence from specifically geriatric studies is necessary,
ideally for specific groups of geriatric patients. Individualization of drug regimens
and adherence support under close clinical surveillance must be also used to improve
appropriate medication use in older patients. Further training of physicians, nurses,
and pharmacists in these techniques, in patient active involvement, and in team-
based care is needed.
Today’s healthcare provision and drug use in the geriatric population is clearly
not meeting the specific needs of older patients. Older adults are often either
untreated in situations where treatment is relevant and necessary, or they suffer
inappropriately from adverse drug reactions or unnecessary and aggressive treat-
ments. These extremes represent a significant shortage in the appropriate managing
of healthcare needs for older patients in the area of medication use and must be
addressed by more individualized, age-specific, integrated care.
Appendix: List of Abbreviations
ADE(s) Adverse Drug Event(s)

AdHOC Aged in HOme Care project
ADR(s) Adverse Drug Reaction(s)
AGS American Geriatric Society
ASA/ASCPF American Society on Aging/American Society of Consultant
Pharmacists Foundation
DDI(s) Drug-Drug Interaction(s)
DRP(s) Drug- Related Problem(s)
FORTA List (of Fit fOR the AgeD List (of medications)
medications)
GP(s) General Practice(s)
HARM study Hospital Admissions Related to Medications study
OTC Over-the-Counter (Over-the Counter Medications)
PCNE Pharmaceutical Care Network of Europe
PIM(s) Potentially Inappropriate Medication(s)
PINCER trial A Pharmacist-led information technology intervention for medication
errrors’ trial (called PINCER trial)
RCTs Randomised Controlled Trials
STOPP/START Screening Tool of Older Person’s Prescriptions/Screening Tool to Alert
criteria Doctors to Right Treatment Criteria
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Chapter 15
Ageism in Mental Health Assessment
and Treatment of Older Adults
Ehud Bodner, Yuval Palgi, and Mary F. Wyman
15.1 Ageism Among Mental Health Clinicians and Patients
15.1.1 A
geist Attitudes and Perceptions Among Mental Health
Clinicians
As mental health clinicians, we strive to meet, treat, and be with our patients through
their own experiences, tribulations, and personal journeys. However, when a psy-
chotherapist (for example, a social worker, a psychologist, or a psychiatrist) encoun-
ters an older patient, he or she may be subject to ageist judgements which stem from
a stereotypical view of older adults in general, regardless of how the individual
patient presents him or herself. Perhaps the seed of these ageist attitudes among
psychotherapists can be located in Freud’s view (1905/1953) on the lack of mental
flexibility of older adults, which, he argued, impedes their ability to benefit from
psychotherapy. Seventy years later, this scepticism among psychotherapists toward
the value of both psychotherapy and medical treatment for the aged was character-
ized by Butler (1975) as “therapeutic nihilism.” According to Butler, such an
E. Bodner (*)
Interdisciplinary Department of Social Sciences and Department of Music, Bar Ilan
University, Ramat Gan, Israel
Y. Palgi
University of Haifa, Haifa, Israel
M. F. Wyman
W. S. Middleton Memorial Veterans Hospital and University of Wisconsin School of
Medicine & Public Health, Madison, WI, USA

https://doi.org/10.1007/978-3-319-73820-8_15
242 E. Bodner et al.
attitude represents a self-fulfilling prophecy, generated by ageist behaviors, which

prevents clinicians from examining the validity of their views about the aged.
Ageism in the form of age discrimination and age stereotypes is considered a
domain-specific phenomenon (see Voss et al.’s Chap. 2). A lot has been written in
general about ageism in the domains of health care systems and long term care (see
the chapters in this volume by Wyman et al. Chap. 13 and Buttigieg et al. Chap. 29).
However, less has been published about ageism in the domain of mental health.
Nevertheless, a number of studies over the last three decades have demonstrated the
existence of negative attitudes toward older adults among psychotherapists. For
example, Dye (1978) found negative views regarding the ageing process, and a pref-
erence against working with older patients, in a large sample of clinical and coun-
seling psychologists in the USA. Older persons were described by the psychologists
as being rigid, as having difficulties in learning new material, and as lacking the
required energy and resilience for therapeutic growth. Two other studies eliciting
assessments of standardized case vignettes from 179 psychiatrists (Ford and
Sbordone 1980), and from 407 licensed clinical psychologists in the U.S.A (Ray
et al. 1987) found that older patients consistently received less favorable prognoses
than their younger counterparts and were perceived as less ideal for therapy.
Moreover, in Israel, 55% of a sample of clinical psychologists indicated their reluc-
tance to work with older patients (Shmotkin et al. 1992), and in Great Britain, psy-
chiatrists were less likely to recommend psychotherapy for sexual dysfunction to an
older patient compared with a younger patient (Bouman and Arcelus 2001; see
Gewirtz-Meydan and colleagues in this volume).
In Australia, Helmes and Gee (2003) presented 414 psychologists and 293 coun-
selors with a vignette describing a fictitious case, and found that an older patient
was rated as less able to create proper therapeutic relationship, as having a poorer
prognosis, and as being less appropriate for therapy compared with a younger
patient with the same symptoms. More recently, a review demonstrated an age bias
among psychotherapists, with many expressing the view that depression in late life
is a natural consequence of old age and that old age is a phase of life associated with
less satisfaction and diminished personal growth (Laidlaw and Pachana 2009). In
Portugal, Gonçalves and colleagues (Gonçalves et al. 2011) found that compared
with nursing and social work undergraduates, psychology students expressed the
most negative attitudes, the lowest level of knowledge, and the lowest level of inter-
est in working with older adults.
An urgent issue which emphasizes the existence of negative attitudes toward
older adults among psychotherapists concerns the legitimacy of suicide in older
adults. Uncapher and Arean (2000) found that USA physicians were less interested
in treating older adults with suicidal tendencies than they were in treating younger
patients with identical problems. According to the physicians’ view, the existence of
suicidal tendencies among older adults was seen as logical and normal. Hence they
were less willing to use therapeutic strategies to address suicidal thinking in older
patients. In another study (Barnow et al. 2004), German medical professionals (phy-
sicians and nurses working in psychiatric institutions), in response to a vignette
describing an older client, were less likely to suggest treatment to patients exhibiting
15 Ageism in Mental Health Assessment and Treatment of Older Adults 243
suicidal tendencies compared to an identical vignette featuring a young client. Here,

too, health professionals working in psychiatric institutions expressed less willing-
ness to treat older compared to younger suicidal patients.
These biases against older patients appear to be formed well before mental health
clinicians enter the professional world. A survey of clinical psychology trainees
(Lee et al. 2003) revealed predominant perceptions of older adults as being people
who are resistant to new things, have limited opportunities, demonstrate rigidness
and inflexibility, and have a very limited potential to change, as they are too close to
the end of their lives. Many of the trainees believed that psychotherapy was prob-
lematic in this age group due to cognitive problems, such as difficulties with mem-
ory (74.4%), concentration (61.2%), and mental rigidity (60.4%). The
psychotherapists also identified other challenges to working with older patients,
such as a decline in hearing (60.4%), apathy (57.1%), passivity (46.6%), difficulties
in learning new material (45.3%), problems in changing habits (44.5%), and a lack
of psychological mindedness (56.9%).
To sum up, evidence from across the globe over the last 30 years demonstrates
that many mental health clinicians are less willing to work with older adults, have
negative assumptions about the effectiveness of psychotherapy with older adults,
and lack professional knowledge of the geriatric population.
15.1.2 T
raining in Geriatric Mental Health and Exposure
to Older Patients
Curriculum content in mental health training programs has traditionally been lack-
ing in material related to geriatric patients and in clinical skills for working with the
older population (e.g., Qualls et al. 2002). Subsequent professional work experi-
ences often do not allow for adequate exposure to older patients. For example, data
on the current major fields of APA members in 2015 show that only 240 health
services providers out of 43,353, reported Geropsychology as their main area (APA
Center for Workforce Studies 2015 reported in American Psychological Association
2015). A survey in Australia also found that only 6% indicated they were specialists
in aged care, and 40% of the sample reported having no contact at all with older
patients (Koder and Helmes 2008). In the UK, similar figures were reported (Bryant
and Koder 2015).
As a result, many mental health professionals report a lack of specific knowledge
about psychopathology and psychotherapy with older adults. For example, in
Britain, trainees in psychotherapy expressed a lack of information about psycho-
therapy with older adults (Scott and Bhutani 1999), and recruiting psychologists to
work with older adults has been challenging (e.g., Britton and Woods 1996).
American psychologists reported minimal formal education in geropsychology and
endorsed the need for additional training (Qualls et al. 2002). A survey among 200
clinical psychologists in training programs found that many reported having “less to
offer” to older patients compared to patients from other age groups (Lee et al. 2003).
Another study in Britain (Richards et al. 2007) conducted 30 interviews with health
and social care practitioners currently working with older people. This study found
that the practitioners lacked essential theoretical and research-based knowledge in
the field of ageing and old age; rather, they primarily made use of common organi-
zational policies and personal experience with ageing family members to analyze a
clinical vignette presented to them.
In summary, the lack of knowledge and training in geriatric care, especially in
the field of clinical psychology, presents a global problem, in particular in the con-
text of demographic trends toward an increase in the aged population. Lack of spe-
cialized geriatric knowledge was found to be an influential factor in the negative
attitudes of psychologists toward older adults (Koder and Helmes 2008). This prob-
lem begins at the undergraduate psychology education level, as most courses do not
include content on the psychology of old age, and continues through the advanced
training of clinical psychologists specializing in geriatric care (Bryant and Koder
2015; Qualls et al. 2002). This lack of knowledge in geriatric mental health and the
minimal exposure to older patients among mental health clinicians may be the main
reason for their reluctance to work with older adults and a primary contributing fac-
tor to stereotyped “ageist” attitudes. Therefore, clinical exposure to the aged has
frequently been suggested as a means to mitigate pre-existing negative stereotypes
concerning older adults (Bryant and Koder 2015; Koder and Helmes 2008).
Nevertheless, the factors underlying age-based bias in mental health care are
numerous. Research suggests that an additional reason for these attitudes among
clinicians may be the way elderly patients internalize ageist social stereotypes, and
how the patients themselves perceive their psychiatric problems (Laidlaw and
Pachana 2009). In the next subsection we will change our perspective from the psy-
chotherapist to the patient, discuss self-ageism among older mental health patients,
and elaborate on the effect of self-ageism on the encounter between older mental
health patients and clinicians.
15.1.3 Self-Ageism Among Older Patients with Mental Illness
One out of five persons above the age of 65 suffers from some form of mental illness
(e.g., Karel et al. 2012). The majority of these older adults prefers to consult a pri-
mary general practitioner and does not seek out mental health clinicians (Lerner and
Levinson 2012). Unfortunately, primary general practitioners encounter barriers to
the management of mental illness both at the individual and the system levels
(Ayalon et al. 2016). But more importantly, when referrals to mental health practi-
tioners are made, older adults are unlikely to follow through on these referrals, and
thus further assessment often does not occur (DiNapoli et al. 2015). Therefore, it is
essential to examine the reasons for older adults’ reluctance to use mental health
services.
When older adults relate to a social group which may be discriminated against,
based on their skin color, race, gender, or being a cultural minority (see Krekula
et al.’s Chap. 3 on gendered ageism, and also Dolberg et al.’s Chap. 12 on ageism
and older immigrants), they may experience double- jeopardy and stigmatization.
This may also be the experience of older adults who suffer from mental health prob-
lems. One unique problem that older adults with mental illness face is “double stig-
matization,” which refers to negative attitudes toward old age combined with
negative attitudes toward mental illness (Werner et al. 2009). “Self-double stigmati-
zation” is the internalization of these stigmas by those who are the target of double
stigmatization (Rush et al. 2005). Self-double stigmatization may have a negative
effect on the ability of older adults with psychiatric conditions to seek help from
mental health professionals. Studies have shown that internalized stigma related to
mental illness (e.g., schizophrenia) makes it more challenging for the patient to seek
therapy (Fung et al. 2007) and to comply with recommendations in psychotherapy
(Mackin and Arean 2007).
Several researchers have examined double stigmatization associated with depres-
sion in old age. Depression is one of the most prevalent mental illnesses in the popu-
lation of older adults, with a prevalence estimates in the general elderly population
ranging from 1–4% for major depression, 4–13% for minor depression (Blazer
2003), and 8–16% for significant depressive symptoms (Blazer 1989). Depression
is a stigmatized illness and may be seen as a sign of personality weakness and as
something to hide. Therefore, there are societal negative attitudes toward depressive
patients (e.g., Boardman et al. 2011). It has been suggested that negative attitudes
towards depressive patients harm self-esteem and can worsen symptoms (Fung
et al. 2007).
In addition, negative self-perceptions of ageing are associated with increased
depressive symptoms in later life (e.g., Wurm and Benyamini 2014). Two cross-
sectional studies have pointed to the link between more positive attitudes toward
ageing and less depression (Bryant et al. 2012), which has also been found in rela-
tion to subsyndromal depressive symptoms (Chachamovich et al. 2008). Moreover,
a recent study of over 2000 older military veterans in the U.S. has found that those
who had more negative stereotypical perceptions of their own ageing, reported a
higher frequency of psychiatric symptoms, in comparison with those who had fewer
negative stereotypical perceptions of ageing (Levy et al. 2014). Group differences
were found in rates of suicidal ideation (30.1% vs. 5.0%), anxiety symptoms (34.9%
vs. 3.6%) and Post Traumatic Stress Disorder (PTSD) symptoms (18.5% vs. 2.0%),
and were maintained after relevant sociodemographic variables were controlled for.
Whereas higher negative self-perceptions of ageing are associated with more
severe psychopathology, double stigmatization further impedes the tendency of
older mental health patients to seek help from mental health professionals (e.g.,
Fung et al. 2007). Several researchers have suggested that the underutilization of
mental health services by older adults may result from the internalization of ageist
attitudes by older patients (Levy 2003). Consequently, the difficulties that older
patients experience in mental health treatment likely increase as their mental condi-
tion persists or even worsens as a result of their inability to receive help.
When trying to understand the mechanisms responsible for the association

between negative self-perceptions of ageing and proneness to severe psychopathol-
ogy, ageism can be identified as a stressor in its own right. According to Ingram and
Luxton’s (2005) stress and vulnerability model, exposure to various environmental
stressors is linked with an increased risk for developing psychiatric conditions.
Following this line of thought, people who hold negative attitudes toward their age-
ing may be less willing to take part in positive social activities (Weiss and Lang
2012), and may hold negative images of age-related health problems. This may in
turn result in an increased vulnerability to depression, that is, a type of “self-
fulfilling prophecy” (Kessler and Bowen 2015). In contrast, positive attitudes toward
ageing may act as a buffer against mental distress, as older adults with more positive
attitudes toward ageing seem to become more involved in healthier ways of living,
such as maintaining a nutritious diet (Huy et al. 2010) or engaging in regular physi-
cal activity (Levy and Myers 2004).
There is also empirical evidence indicating that ageism is associated with height-
ened ageing anxiety (Bodner et al. 2015a). These concerns act as stressors that
increase sensitivity to physical symptoms (Poon and Knight 2009), and become
associated with higher levels of depression during midlife (Barrett and Robbins
2008), as well as with other symptoms of mental distress (Bodner et al. 2015b). Of
note, these findings are also consistent with the behavioral model of late life depres-
sion (Fiske et al. 2009), which regards negative cognitions about the self and the
future as risk factors for depression in late life.
In summary, older adults with mental health problems may hold both ageist neg-
ative attitudes toward themselves as well as negative attitudes toward mental illness.
This self-double stigmatization may have an impact on their symptoms and their
interactions with the mental health care system. Following this line of thought, in
the next subsection we will discuss the objective difficulties clinicians face when
diagnosing mental health problems in older adults. Then, we will examine how age-
ist attitudes of both clinicians and patients may impact the accuracy of several men-
tal health diagnoses and subsequent treatment recommendations.
15.2 D
ifficulties in the Assessment of Older Persons
with Mental Health Problems: The Impact of Ageism
15.2.1 O
bjective Difficulties in Assessing Psychiatric
Conditions in Old Age
For a number of reasons, the assessment of mental health disorders in older adults
can be complex and often requires a high level of expertise, effort, and time. In old
age, there is an overlap between some psychiatric symptoms and symptoms related
to changes in hormone levels (Sternbach 1998), declines in cognition (Petersen
2004), physical disability (Milaneschi and Penninx 2014), and physiological
processes (McKinney and Sibille 2013). These non-psychiatric symptoms are often
part of normal ageing. For example, needing less sleep, changes in diet and diges-
tive functioning (Elsner 2002), reduction in energy, and slowed information pro-
cessing are considered normal age-related changes (Whitbourne and Krauss 2011).
However, these symptoms can also be part of the clinical presentation associated
with common disorders such as anxiety or depression (Fiske et al. 2009). Teasing
apart the etiology or multiple etiologies of such symptoms can be very challenging
when working with an older patient.
Another challenge to accurate diagnosis of mental health problems in older
adults lies in the limitations of available psychiatric assessment tools. Mental health
symptom questionnaires and interview instruments have been criticized for inade-
quately discerning between age-related problems and psychiatric symptoms (Eisner
et al. 1999) and may not have been validated with older adult samples (Owens et al.
2000). Despite the fact that many scholars have studied this issue and considered
potential solutions (e.g., Hendrie et al. 1995), there is, as of yet, no clear consensus
on an optimal approach to the assessment of mental health conditions in older
adults. Moreover, as noted above, many mental health clinicians have not received
adequate basic education in geriatric mental health and thus may experience addi-
tional challenges in providing assessment and treatment for complicated older adult
cases (Halpain et al. 1999). If we add to this the fact that older adults prefer primary
general practitioners, and refrain from seeking out mental health clinicians (Lerner
and Levinson 2012), we end up with another almost impossible challenge for the
practitioner – to make a psychiatric diagnosis and treat other medical age-related
conditions in the brief time allotted to that patient.
A further issue concerns the clinical presentation of mental disorders. Clinicians
and researchers have long reported age differences in symptom constellation of
some mental disorders, such as depression (see Blazer and Hybels 2005) and PTSD
(Palgi 2015; Pietrzak et al. 2012). However, age-based comparisons of symptom
presentations have found mixed results (e.g., see Luppa et al. 2012 for evidence sug-
gesting an increase in depression with aging, and a review by Debast et al. 2014,
reporting age differences in somatoform disorders). The mixed results in the litera-
ture have not helped to decrease clinician bias and confusion in this domain. Adding
to this is the mounting evidence that subthreshold mental disorders are more preva-
lent than diagnosed disorders in late life and are associated with significant disabil-
ity and comorbidity (e.g., Meeks et al. 2011). Together, these factors make the
diagnosis of mental disorders in old age more difficult.
Eliciting older patients’ own attributions for their problems, whether physical or
emotional, is an important piece of the diagnostic process for the clinician. However,
when the etiology of the symptoms is unclear, such attributions may further compli-
cate the clinical picture. Research suggests that older adults with depression may
tend to blame themselves and their lifestyle choices for their own medical symp-
toms, while making different attributions for the same symptoms in others (Benedict
1995). They may attribute physical symptoms (for example, fatigue, concentration
problems, and weight loss) to medical diagnoses and not to psychiatric conditions,
which may affect responses on self-report mental health measures and in
interview-based assessments. In addition, older adults may not endorse the “impair-
ment in social or occupational functioning” needed to meet DSM diagnostic criteria
for mental disorders. It can be difficult for both patient and clinician to identify
impaired functioning when a retired or disabled older adult has few social roles or
formal responsibilities (Hendrie et al. 1995). Further, willingness on the part of
older adults to admit impairment may be related to ethnicity or cultural values (e.g.
Apesoa-Varano et al. 2015).
To sum, the interaction between age-related changes and the clinical phenome-
nology of psychiatric problems in old age makes it more challenging and time-
consuming for patients and clinicians to accurately perceive and diagnose psychiatric
conditions. It can be especially problematic when these objective difficulties in
diagnosing psychiatric syndromes in late life are combined with stereotypes based
on age, in both patients and clinicians.
15.2.2 P
sychiatric Diagnoses Biases in Late Life: The Role
of Ageism
In this subsection we discuss four specific psychiatric syndromes which can be dif-
ficult to diagnose in old age. We raise concerns about the possibility that a lack of
knowledge among both older patients and clinicians regarding the ageing process
may contribute to age-related biased attributions, which may in turn be associated
with typical biases in making these psychiatric diagnoses. Such a lack of knowledge
may contribute to the attribution of debilitating clinical symptoms primarily to the
ageing process, as if these symptoms are natural and “to be expected” in old age
(Laidlaw and Pachana 2009). For some clinicians, this lack of knowledge likely also
contributes to the difficulty in differentiating between signs of normal age-related
deterioration and symptoms associated with treatable mental health problems.
Finally, as later elaborated, paternalistic attitudes toward older adults and a view of
these patients as incompetent may partially contribute to the problem of overuse of
neuroleptic medications and reluctance to refer them for psychological or psychiat-
ric treatments (Bronskill et al. 2004). Some of these typical biases may be evident
in the following diagnoses.
Psychosis Distorted thinking and abnormal perceptual experiences are the hall-
mark symptoms of a primary psychotic disorder. These symptoms can also be con-
cordant with conditions such as delirium, dementia, medication, and medical illness
(Reinhardt and Cohen 2015), all of which can be relatively common in late life.
Subsequent therapeutic decisions regarding psychotic symptoms require a high
level of psychogeriatric-specific knowledge and a careful process of exclusion of
potential causes. At the same time, a lack of psychogeriatric-specific knowledge,
which may be reflected in ageist assumptions regarding older adults (e.g., “dis-
turbed thinking in an older person means he or she have dementia”), can lead
primary general practitioners to the misdiagnosis of psychotic syndromes by attrib-
uting these symptoms to dementia, rather than to a primary psychotic disorder.
Depression In several past studies, the prevalence of depression in older adults was
lower compared to younger adults (Blazer and Hybels 2005). However, a recent
meta-analysis suggested that rates of depressive disorders increase dramatically in
the oldest old compared to the young-old. For example, rates of depression among
those 85 years and older were almost 25% higher compared with those 75–79 years
old, and 30 to 50% higher among persons 90 years and over (Luppa et al. 2012).
This inconsistency might be accounted for in several ways; one main factor might
be problems in the diagnosis of depression in older adults. For example, evidence
shows that compared to younger populations, a smaller percentage of older adults
suffers from a major depressive disorder but a higher percentage experiences sub-
syndromal depressive symptoms (Meeks et al. 2011). Furthermore, in many cases,
it can be difficult to distinguish between diagnosable depression, subsyndromal
depressive states, and normal ageing among older adults (Fiske et al. 2009).
Part of this diagnostic conundrum may be due to differences in clinical presenta-
tion. For example, older adults who suffer from depressive symptoms may be less
likely than younger adults to endorse sadness or low mood, or they may present
primarily with less common symptoms such as apathy, possibly due to neurological
changes (Alexopoulos et al. 2013). This phenomenon, known as “depression with-
out sadness” or “masked depression” may lead to misdiagnosis (Covinsky et al.
2014). A lack of consensus on how to classify subsyndromal depressive symptoms
or depressive presentations that are atypical may lead to misindentification of these
syndromes (Ludvigsson et al. 2014). Furthermore, somatic elements which are
prevalent in old age (e.g., physical disability, functional limitations, fatigue, diges-
tive problems, and physical pain) may also cause emotional distress, leading to a
clinical picture that, in some ways, resembles a depressive syndrome. We believe
that a lack of knowledge about these changes in old age among both clinicians in
geriatric mental health and patients may lead in some cases to overdiagnosis (and
overtreatment, particularly with medication) of depression (Parmelee et al. 2013).
In addition, cognitive deficits may present as part of a psychiatric syndrome such
as depression. Scholars have written extensively on “pseudo-dementia,” a clinical
presentation of depression distinguished by cognitive decline as the hallmark com-
plaint (Burns and Jolley 2015). This syndrome is more common among older adults
compared to younger adults, and assessment may be complicated by the presence of
changes in cognition due to normal ageing or medication effects – both frequent
among elderly patients (Lamberty and Bieliauskas 1993). In the case of pseudo-
dementia, an emphasis by a clinician solely on the presentation of cognitive deterio-
ration may reflect an ageist assumption that dementia is an unavoidable part of old
age. At times this will result in the underdiagnosis of depression.
Anxiety Disorders Schuurmans and Balkom (2011) point to the fact that while
there is a high prevalence of anxiety disorders in late life, these disorders are not
easily diagnosed in older adults. The authors opine that older adults with anxiety use
avoidance behaviors and thus run “under the radar” – resulting in significant underi-
dentification and under-diagnosis. They explain the ability of older adults to avoid
certain activities as being supported by the tendency of others to hold stereotypical
views of older persons as incapable of completing tasks that require physical ability.
They further note that family members have a tendency to aid the older adult by
replacing him/her in performing these chores. This tendency may result from atti-
tudes which are described by Palmore as “positive ageism”, defined as attitudes
toward older adults which may seem prosocial, but are, in essence, patronizing
(Palmore et al. 2005). Schuurmans and Balkom (2011) also contend that ageism
may be linked with a tendency to interpret anxiety and avoidance behaviors in late
life (e.g., reluctance to leave the house, or to travel by bus) as adaptive or “realistic”
reactions to age-related physical illnesses (e.g., arthritis affecting the person’s
mobility), or to life events (e.g., a previous fall on the street or on the bus). Moreover,
the authors refer to the lack of knowledge about anxiety in late life among general
practitioners, which makes it difficult for these clinicians to identify avoidance
symptoms). They also note the fact that current diagnostic instruments may not
identify the specific age-related factors of late-life anxiety disorders.
Another problem with anxiety disorders lies in the overlapping symptoms
between Generalized Anxiety Disorder (GAD) and depression (Roy-Byrne and
Wagner 2004). For example, fatigue and other physical symptoms, as well as nega-
tive ruminations, can be part of both syndromes. When GAD presents together with
depression, primary care physicians tend to devaluate the persistent worries and to
over-evaluate the negative mood, ending up with a diagnosis of depression (Calleo
et al. 2009). Taken together, the evidence suggests that there is a lack of training in
anxiety disorders in late-life and that these disorders are generally underindentified
in clinical practice. We further suggest that the misdiagnosis of anxiety is related to
a common stereotypical belief that old age is full of stressors and that older adults
are “normally” distressed, worried, and avoidant.
Personality Disorders Personality disorders (PDs) were previously believed to be
stable and unchanging conditions. However, it is unclear as to whether they are as
stable across the life span as they were once assumed to be (Debast et al. 2014). In
this respect, it is uncertain whether age-related changes in values and behaviors may
be counted inappropriately as diagnostic symptoms of PD, or alternatively, whether
these changes might conceal existing symptoms in a way that would disguise the
existence of PDs. For example, studies have suggested that PDs may be manifested
differently in later life compared to in younger adulthood due to cognitive decline,
somatic comorbidities, and increased medication use (van Alphen et al., 2012).
In a recent study, older adults exhibited a higher level of avoidant personality
symptoms compared to younger adults, yet showed lower levels of paranoid, schiz-
oid, schizotypal, antisocial, borderline, histrionic, and narcissistic personality
symptoms (Debast et al. 2014). This finding does not answer the question of
whether current criteria for a PD diagnosis can be applied to older adults with clini-
cal validity, or whether changes in these symptoms reflect a real change in the ways
PDs are manifested in old age. In this vein, several items in diagnostic question-
naires have been reported to be less applicable for older adults compared to younger
patients. For example, the item “avoids occupational activities”, which is one of the
criteria for avoidant PD, refers to a life domain that may be irrelevant in the assess-
ment of a retired elderly person (Tackett et al. 2009). In a similar manner, the item
“neither enjoys nor experiences sexual relations,” which is one of the criteria for
schizoid PD, may have a different relevance for younger versus older adults. These
examples provide a glimpse into the numerous questions and challenges in assign-
ing psychiatric diagnoses to older patients. Unfortunately, there is a dearth of litera-
ture in this area, despite the importance of personality in navigating the many
changes and stressors of ageing. We suggest that the limited interest to date in
studying age-related changes in PD stems from a narrow psychological perspective
on human development. This perspective perceives adulthood as the end point of
personality development and does not acknowledge late life as a stage in life which
has an important effect on the individual’s personality (in this respect, see Carstensen
et al. 2011).
In summary, overdiagnosis, underdiagnosis, and misdiagnosis of the abovemen-
tioned diagnoses is related to the fact that diagnostic criteria and diagnostic tools
have generally been normed on younger adults and may not be appropriate for use
with older adults. Lack of knowledge and training represent additional factors.
Finally, in some cases, ageist, stereotypical perceptions of older adults add to the
difficulties in assessing psychiatric conditions in old age.
15.3 A
geism in Treatment: Providing Psychotherapy
to Older Persons
In this subsection we aim at providing answers to the following questions: what are
the adaptations required for psychotherapy with older adults, and what possible
impact may negative age-related attitudes have on these adaptations? Are there spe-
cific age-related issues concerning the relationship between psychotherapists and
older patients, and what is the potential effect of ageist attitudes of both partners on
the therapeutic relationship? What is the possible effect of ageist attitudes on the
implementation of interventions for mental health problems which are common in
old age?
15.3.1 A
ttitudes and Adaptations in Psychotherapy with Older
Patients
When working with older patients, certain adaptations can make almost any thera-
peutic approach more effective in reaching treatment goals. At the same time, age-
based prejudice and discrimination can impact the provider-patient relationship and
hinder the therapeutic work. When working with an elderly patient, for example,
there may be a greater likelihood of encountering difficulties with transportation to
appointments, medical health symptoms, conflicts with care-giving obligations, and

financial constraints. These difficulties may activate stereotyped and ageist attitudes
on the part of the psychotherapist. If the psychotherapist follows Freud’s view
(1905/1953) on therapy in old age, and perceives older adults as passive, rigid, stub-
born, unwilling to invest efforts in changing, or as lacking the flexibility required to
engage in psychotherapy, he or she may view these barriers not as problems to be
solved in order to continue in psychotherapy, but as resistance on the part of the
patient. Such a stance by the psychotherapist may be perceived as an insult by a
patient who is facing these serious difficulties (Wyman et al. 2011). Ageist attitudes
may also impede the flexibility of psychotherapists to consider relevant issues of
access to psychotherapy and psychotherapy location, session’s length and continu-
ity. Therefore, psychotherapists may fail in adapting the psychotherapy to settings
which are more available for older patients (e.g., primary care medicine settings,
adult day health centers). When the patient is a frail older adult, ageist attitudes
which attribute communication problems only to cognitive impairment (e.g., “all
older adults are senile and confused”) might hinder psychotherapists in taking steps
toward helpful adaptations for working with such patients (e.g., audiotaping therapy
sessions for review at home, ensuring good lighting in the therapy room, slowing
the pace of speech and lowering the tone of voice, etc. See Wyman et al. 2011).
15.3.2 P
sychotherapists’ and Patients’ Ageist Attitudes
and the Therapeutic Relationship
Psychotherapists and patients might bring into the therapeutic relationship responses
that were learnt in other interpersonal contexts. Knight (2004) suggests that the
terms “transference” (the feelings and thoughts the patient has about the psycho-
therapist) and “countertransference” (the feelings and thoughts the psychotherapist
has about the patient) can be used to understand how age-related stigmas affect the
psychotherapeutic relationship with older patients. Stereotypes and attitudes related
to age can affect the internal representations each party establishes regarding the
other, which are not based on real people or on what really happens in therapy
(Knight 2004). On both sides of the psychotherapeutic relationship, age-biased atti-
tudes can impact how the other is viewed.
Psychotherapists may adhere to stereotypes pertaining to the age group of older
frail adults and fail to acknowledge the strengths and resources of these patients. In
some cases, the psychotherapist might interact with the patient as a parent or a
grandparent figure. This may lead to overcautious and unassertive approaches by
the therapist during the course of psychotherapy. Moreover, when working with an
older patient, psychotherapists may overlook erotic transference or react to it nega-
tively, as erotic transference contradicts society’s ageist perceptions about sexuality
in old age (Wyman et al. 2011). Older patients may stigmatically define their psy-
chotherapist as belonging to an age group of younger and healthy adults, who
“knows nothing about the experience of being old and frail.” They might also relate
to a younger psychotherapist as a child or grandchild, and not acknowledge his or
her professional abilities (Knight 2004). These transference and counter-transference
attitudes are based on negative age-related biases which likely have a negative
impact on therapeutic outcome.
15.3.3 A
geist Attitudes and Specific Psychotherapeutic
and Drug Interventions in Old Age
Geriatric mental health scholars agree that evidence-based psychotherapy

approaches (e.g., cognitive-behavioral therapy, interpersonal therapy, problem solv-
ing therapy) are appropriate and effective for use with older adult patients, with
some adaptations (Wyman et al. 2011). An in-depth review of these approaches is
beyond the scope of this chapter. However, a brief discussion of the effects of ageist
attitudes on the implementation of therapies for mental disorder with older patients
is in order. We will then relate to the possible impact of physicians’ ageist attitudes
on their tendency for overuse of psychiatric medications in older adults.
Cognitive behavioral therapy (Beck 1995) is effective for older adults suffering
from depression (Arean and Cook 2002) and anxiety (Nordhus and Pallesen 2003).
However, an ageist approach which perceives older patients as generally frail and
incompetent may cause the psychotherapist to assign fewer tasks for patients to
complete between therapy sessions, though these “homework assignments” are con-
sidered fundamental to treatment success in this modality. In addition, when the
psychotherapist’s stereotypical, and likely subconscious, beliefs about the elderly
(e.g., “older adults who are not working, are a societal burden”) correspond to auto-
matic maladaptive thoughts held by the patient (e.g., “As a retired worker, I'm no
use anymore”), it is quite challenging for a psychotherapist to identify these mal-
adaptive thoughts and engage the patient in correcting them.
Interpersonal therapy also has a strong evidence base for use with older persons
(Arean and Cook 2002) and focuses on symptom relief and on the improvement of
interpersonal coping strategies in depression (Klerman et al. 1984). However, it may
be difficult for a psychotherapist who perceives older patients as incompetent, dis-
abled, and inflexible to acknowledge the changes that come with age, in their
patients’ social roles within the family and work environment, to understand the
impact of the loss of loved ones, or to be aware of potential intergenerational con-
flicts that may exist for the patient (Wyman et al. 2011). Such stereotypical attitudes
toward ageing can hinder the psychotherapist’s insight into these issues and pose a
real threat to the effectiveness of interpersonal therapy.
In problem-solving therapy, which views a deficit in problem-solving skills as
one of the causes for depression, the psychotherapist and patient work together to
identify problems patients are currently facing and solve them in a series of standard
steps (Nezu et al. 1988). However, the implementation of this form of therapy with
older adults requires the understanding that a number of problems which present in
later life are not “solvable” in the commonly-understood sense. For example, some
illnesses cannot be cured, and the loss of close relatives and friends cannot be
reversed. It may be difficult for a psychotherapist who does not accept his or her
own ageing to assist patients to effectively accept these inevitabilities and apply the
therapeutic tools to problems that can be effectively managed to improve mood.
Here too, negative beliefs about old age as a time of resignation, slowed or absent
personal growth and passivity might block the psychotherapist’s ability to most
effectively work with this therapeutic approach.
Psychotherapeutic treatment, or “talk therapy,” is not the only mental health
treatment approach that is impacted by ageism. The overuse of psychiatric medica-
tion in older adults is well documented in the literature and is a rising concern (for
a review, see Ruxton et al. 2015; see also Fialova and colleagues in this volume).
This tendency is pronounced in long-term care facilities, where a particularly high
consumption is reported for benzodiazepines, antipsychotics and antidepressants
(Anrys et al. 2016). These trends continue despite clear evidence of the heightened
risks of certain medications for the elderly – including accidents and falls, cognitive
impairment, and a development of tolerance and addiction to these drugs – and
despite the existence of evidence-based guidelines for prescribing (Schuurmans and
Balkom 2011).
According to some researchers system-based ageist attitudes (e.g. perceiving
older adults as “beyond help”, “useless”, or perhaps undeserving of equal attention
to quality mental health care) plays a role in maintaining the gap between best prac-
tice and reality (Kolanowski et al. 2009). For example, one qualitative study on the
use of non-pharmacological interventions in nursing homes identified the typical
reduced evening and weekend staffing patterns, and the resultant time pressure on
personnel, as a significant barrier to using behavioral approaches to address prob-
lem behaviors versus medications (Kolanowski et al. 2009). These authors con-
cluded that a culture change related to use of medication in older patients is
necessary, noting that successful use of nonpharmacological interventions requires
“the right staff with the right education at the right time” (p. 1). Similar concerns
have also been demonstrated in primary care settings (Cook et al. 2007) and relate
to impatience of primary doctors and nurses, who may quickly opt to use benzodi-
azepines when faced with agitated behaviors in an older person (Ayalon et al. 2013).
Medications require less effort and less time, and are more cost-effective for the
medical system, at least in the short term.
A second reason for the frequent use of medications to treat mental disorder is
related to the belief that “older patients don’t want psychotherapy.” This is a widely-
held misconception, despite the evidence for a “positive cohort shift” in the attitudes
of healthy older adults to seek help for mental health difficulties (Woodward and
Pachana 2009) and evidence to the contrary from large-scale clinical trials (Gum
et al. 2006). We argue that age stereotypes play a role in perpetuating this miscon-
ception, and that addressing ageism needs to be part of the culture change away
from overuse of medications and toward increased use of behavioral interventions
for older patients.
15.3.4 Recommendations for Mental Health Clinicians
In summary, the assessment and treatment of older adults within the mental health
setting presents many challenges even to seasoned clinicians. These challenges
include complicated symptom presentations, inadequate professional training and
exposure to geriatric syndromes and psychiatric conditions in late life and a limited
set of assessment tools which are appropriate and valid for use with older patients.
Psychotherapy with older adults is frequently less straightforward and requires
adaptations of commonly used therapeutic approaches to address the unique prob-
lems and difficulties faced in the later years in order to maximize the chances of
therapeutic success.
Ageism presents another important, though often overlooked, challenge. Ageist
attitudes of both patients and psychotherapists present as transference and counter-
transference phenomena. Ageist attitudes of the psychotherapists can interact in
various ways with different methods of therapy which are used for treating older
adults. When adapting different methods of therapy to older adults, psychothera-
pists should strive to identify their own ageist biases which may be at play and to
remain flexible in adapting their approach.
In order to neutralize the effect of ageist attitudes, professionals working with
older adults should first strive to understand the meaning of “ageing” and “old age”
for their older patients as well as for themselves. They should reflect on their own
attitudes toward the ageing of loved ones and themselves, and become aware of the
ways in which they want to be seen by their older patients (Wyman et al. 2011).
Psychotherapists also need to be able to acknowledge not only the weaknesses but
also the strengths of older patients. Ageist attitudes may lead psychotherapists to
ignore internal and external resources and to focus only on the patients’ shortcom-
ings. Such an attitude may cause psychotherapists to perceive their older patients as
more helpless than they truly are, and is compatible with the tendency described by
Palmore as “positive ageism”: an attitude toward older adults which may seem (in
this case – to the psychotherapist) as beneficial, but is, in essence, patronizing
(Palmore et al. 2005).
Further, we strongly encourage professionals to directly address age-related stig-
mas, including self-ageism and “self-double stigmatization” and misperceptions
with their older patients. For example, a mental health provider might raise ideas
related to stigmatization of mental illness and therapy with their patients for discus-
sion (for example, the common concern that “receiving therapy means I’m weak”),
as well as age-related stigmas (e.g., “younger psychotherapists will never under-
stand me”; “I’m too old to change”). A mental health clinician can encourage the
patient to express these concerns by being proactive and raising frequently asked
questions, and can provide written educational materials addressing these issues.
Addressing age- and mental illness-related stigmas with patients can increase older
patients’ attendance and engagement in psychotherapy, regardless of the therapeutic
approach (Wyman et al. 2011).
15.4 General Conclusions and Recommendations
In this chapter, we have explored how negative ageist attitudes on the part of both
mental health care providers and older patients may contribute to challenges in the
diagnosis and psychotherapy of mental disorders in older adults. We note the inher-
ent challenges in diagnosis and therapy of mental disorders in older adults, which
are due to complex clinical presentations and comorbidities. We argue that – in
general – mental health clinicians continue to be less equipped to work and do psy-
chotherapy with older adults compared with younger adults, hold generally negative
assumptions about older adults as psychiatric patients and lack adequate profes-
sional knowledge of the geriatric population. In addition, internalized ageism (self-
double stigmatization) impacts the interactions of older patients with the mental
health care system and can contribute to a reluctance to seek mental health care
services.
Changing these attitudes and misconceptions requires a combined effort of both
governments and mental health clinicians. Governments have to allocate more
financial resources for mental health services for older adults and for geriatric train-
ing and education for both providers and consumers of mental health care. In this
regard, several specific recommendations for mental health clinicians can be made:
(1) Providers should be supported in seeking out appropriate training on working
with older adults and the developmental changes that occur in late life. Training
programs that acknowledge the uniqueness of the older adult population are needed,
especially in countries without a presence of the psychogeriatric field (e.g., Israel,
as of this writing).
(2) Scientific study is needed to ensure that mental health diagnostic criteria and
available assessment instruments are valid for use with older adults. (3) Further
scientific investigation is also required for the adaptation of therapies for use with
older adults. (4) Mental health clinicians will benefit from self-reflection to increase
awareness of ageist attitudes which impact their work with older patients. (5)
Improved collaboration and an exchange of knowledge among health professions in
the field of gerontology (e.g., occupational therapists, physiotherapists,
psychologists, psychiatrists and psychogeriatricians) can improve assessment and
therapeutic abilities.
As for the elderly consumers of mental health care services, several steps can be
done in order to change their negative views about the ageing process and about
mental health services: (1) Patients’ education about the benefits of mental health
psychotherapy at all ages, and about effective engagement in mental health services
might increase the use of psychological and psychiatric therapy for older adults. (2)
Psychoeducation for older mental health patients could help to reduce self-ageism
among this patient group.
In conclusion, we agree with other authors in this volume (e.g., Wyman et al.,
Fialova et al., Gweyrtz-Meydan et al., Evans) that addressing ageism within health
care is vital in improving services and achieving optimal treatment outcomes. We
believe that, while mitigating ageism among mental health clinicians, older mental
health patients, and their family members and friends may not add years to their
lives, it can add lives to their years – which might be even more important.
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Chapter 16
Ageism and Dementia
Simon Chester Evans
16.1 Dementia and Its Prevalence As a Function of Age
The term ‘dementia’ covers a range of neurological diseases whose most common
symptoms include memory loss, disorientation, behavioural changes and difficul-
ties with thinking or problem solving. Dementias are progressive, which means that
the structure and chemistry of the brain become increasingly damaged over time.
Alzheimer’s Disease (AD) accounts for approximately 60% of dementias but there
are many other types including Vascular dementia, dementia with Lewy bodies and
Fronto-temporal dementia. Each of these has different neurological characteristics
and causes specific symptoms, but it is important to recognise that the experience of
dementia, whatever the type, is unique for each individual person.
The number of people affected by dementia worldwide is predicted to rise from
47 million in 2015 to 75 million by 2030 and 130 million by 2050. This situation
has led to calls for dementia to be recognised as a global public health priority from
the EU (European Parliament 2010), the World Health Organisation (2015) and
many individual countries.
Although dementia is not an unavoidable consequence of ageing, and the phe-
nomenon of early-onset dementia is widely recognised, increasing age is undoubt-
edly the biggest risk factor. For example, the number of people who develop AD
before the age of 65 only represents 5% of all those with the disease. The prevalence
of dementia increases exponentially with age in all parts of the world. Prevalence
doubles with every 5.5 years of age in North America, 6.5 years in West and Central
Europe, 6.6 years in South Asia, and 10.6 years in Southeast Asia (Prince et al.
2015).
S. C. Evans (*)
Association for Dementia Studies, University of Worcester, Worcester, UK

https://doi.org/10.1007/978-3-319-73820-8_16
264 S. C. Evans
So, while dementia is not an inevitable part of ageing, the chances of getting
dementia increase incrementally with age. As a result, people with dementia are
likely to experience the stigma that is specifically associated with the disease as well
as the broader stigma of ageism. This has been called the ‘double stigma of demen-
tia’ (Urbańska et al. 2015).
16.2 The Impact of Dementia-Related Stigma
Goffman first used the term ‘stigma’ in social sciences (Goffman 2005), describing
it as the relationship between a particular trait and social stereotypes. Link and
Phelan (2001) characterised stigma as a multistage process based on labelling, ste-
reotyping, alienation, loss of social status, discrimination and emotional reactions.
At an individual level, stigma has been associated with low self-esteem, feelings of
shame, a sense of dehumanisation and experiences of social isolation (Urbanska
et al. 2015).
There is currently no cure for dementia and the evidence for the effectiveness of
treatments that aim to ameliorate the symptoms is not strong. This, combined with
growing awareness of the disease and its effects, such as ailing memory, has led to
considerable fears of getting dementia (Corner and Bond 2004). One effect of such
fears is that a high level of stigma has become attached to dementia, as witnessed by
the growing voice of those living with the disease. Because age is the major risk
factor in developing a dementia, those with the condition often experience the
effects of dementia stigma in addition to ageist discrimination and the distinction
between the two types of stigma often becomes blurred. There is substantial evi-
dence that stigma exists towards dementia worldwide (Moniz-Cook and Manthorpe
2009; Prince et al. 2011). Cultural factors can be important. For example, some
Asian traditional spiritual beliefs about the causes of dementia can lead to attempts
to conceal it within families. There is now a widespread recognition of an urgent
need to reduce the stigma and negative connotations associated with Alzheimer’s
disease and other dementias more broadly (Batsch and Mittelman 2013; Jolley and
Benbow 2000).
A 2014 meta-analysis of 99 research papers (Werner 2014) found substantial
evidence of stigma in relation to people living with dementia. The most common
negative emotions associated with stigma were shame, humiliation and disgust.
Stigma can occur at three levels: self-stigma is the internalisation by individuals of
ideas and reactions; public stigma is evident through the reactions of lay persons
towards stigmatised individuals or groups; while stigma by association comprises
the emotions and beliefs of those surrounding people with dementia, including fam-
ily members and professionals.
Werner reported that stigma is perceived as pervasive and is associated with neg-
ative consequences at four levels. At the individual level it can lead to low self-
esteem, feelings of shame and humiliation, and social isolation. For families, stigma
can also cause increased burden, depression, concealment, decreased use of services
16 Ageism and Dementia 265
and feelings of moral failure. At the professional level it can lead to differential or
delayed diagnosis or treatment, while the effects of stigma at the societal level
include differential access and use of services and increased institutionalisation.
Anger and fear were found to be the primary emotions contributing to stigmatic
behaviours in relation to mental illness, while for Alzheimer’s Disease it was feel-
ings of rejection including ridicule, shame and impatience. Lower levels of stigma
were associated with AD than other dementias. This review found limited use of
operational or conceptual definitions or theoretical background when considering
stigma and dementia. Where theories were included they were predominantly modi-
fied labelling theory (stigma as a social construct reflecting power relations at a
society level) and attribution theory (stigma as a process in which cognitive attribu-
tions (stereotypes) are followed by emotional responses (prejudices) and behaviour
reactions (discrimination).
It is also important to consider the impact of stigma on the families of people
with dementia, who often provide much of the high levels of care and support that
are required. This role is crucial to maximising quality of life for people with
dementia and delaying moves to institutional care (Brodaty and Donkin 2009).
While there are many positive aspects attached to family caring, it can also bring
challenges including increased stress, social isolation and economic burden. In the
UK there are 670,000 carers of people with dementia, whose caregiving saves the
economy an estimated £11 billion a year.
Providing effective support for carers, including psycho-social interventions, is
therefore essential to maintaining quality of life for the person with dementia, but
good quality support is not always available when required (Manthorpe et al. 2004).
When combined with stereotypes that are associated with ageing more generally
across a broad age spectrum from fourth grade school children (Seefeldt 1984) to
older adults (Dobbs et al. 2008), this kind of ‘stigma by association’ can lead to both
people with dementia and their family carers experiencing double discrimination.
This means that they are likely to be discriminated against as a result of having
dementia in addition to the wider discrimination that often occurs against people
due to their age.
16.3 Media Portrayals of Dementia
In many countries across the world dementia has been recognised as a ‘crisis’,
resulting in a surge in policies and strategies aimed not only at finding a cure but
also at helping people to ‘live well with dementia’ (Department of Health 2009),
partly by improving the responses of individuals, organisations and professionals.
Public awareness has been identified as a key factor, with the media having a central
role in creating and reflecting attitudes and opinions. A UK study (Peel 2014) that
drew on 350 national newspaper articles and interviews with family carers found
that dementia was frequently portrayed as catastrophic. ‘Tsunami’, ‘a bomb ready
to explode’, ‘Alzheimer’s epidemic’ ‘brain-wasting’, ‘terrrible affliction’ and
266 S. C. Evans
‘worse than death’ are just a few of the newspaper headlines that are quoted.
Reporting of this sort can lead to people with dementia experiencing discrimination
because of their condition as well as their age.
There are many similarities between the language that was used in the 1980’s in
relation to HIV/Aids, despite the fact that dementia is neither contagious nor pre-
ventable in any straightforward way. Many of the same terms and assumptions are
applied to describe ageing in general, which associates ageing with a range of nega-
tive experiences and attributes such as dementia. The author contrasted this to other
media discourses around more ‘controllable’ and treatable chronic conditions. For
example, people with cancer tend to be portrayed in a more positive way and are
often said to be ‘fighting’ the disease. The limited presence of people living with
dementia themselves in media coverage was also noted, with a much greater focus
on the views of representatives from medical and charitable organisations.
Language is an important element in how health related conditions are repre-
sented in the media and more generally, as increasingly acknowledged:
A casual misuse of words or the use of words with negative connotations when talking
about dementia in everyday conversations can have a profound impact on the person with
dementia as well as on their family and friends. It can also influence how others think about
dementia and increase the likelihood of a person with dementia experiencing stigma or
discrimination. (Alzheimer’s Australia)
16.4 Dementia and Health and Social Care Services
For many people, health and social care services are the main source of information
and support for their dementia. However, rates of diagnosis vary considerably across
Europe. Most countries report missing 40–60% of expected dementia diagnoses and
that when a diagnosis is made, the dementia is often already at a moderate or late
stage. Rates of diagnosis vary considerably across the world. For example, one
study suggests that 90% of people with dementia remain unidentified in India, while
in England the diagnosis rate is 38% and rising. A European study (Brooker et al.
2014) found that while most countries reported missing 40%–60% of expected
dementia diagnoses, some countries reported missing above 60%, and some reported
missing only 30%. Most also reported that when a diagnosis is made, the dementia
is already at a moderate or late stage. A diagnosis of dementia is often a key crite-
rion for accessing the services that statutory health services offer, which makes the
generally low rates of diagnosis a major challenge for many people living with
dementia.
The findings from Alzheimer Cooperative Valuation in Europe (ALCOVE), a
Joint Action co-financed by the European Commission, suggest that few family
doctors have adequate training in recognising symptoms of early dementia which,
combined with insufficient understanding or clarity regarding their role, can result
in low rates of timely diagnoses (Brooker et al. 2014).
A growing body of evidence suggests that timely diagnosis and intervention can
be important in maintaining quality of life for people living with dementia and their
families (Banerjee and Wittenberg 2009; Mittelman et al. 2008). In addition, early
intervention can delay cognitive decline, maintain functional abilities and delay
admission to institutional care (Waldemar et al. 2007; Banerjee and Wittenberg
2009; Prince et al. 2011), as well as leading to improved outcomes for family mem-
bers, delayed placement into long-term care and increased carer coping (Mittelman
et al. 2006, 2007).
It can be argued that these low rates of diagnosis are at least partly due to the
negative images that are associated with dementia as well as to the blurred percep-
tion of dementia as being an inevitable consequence of old age (Brooker et al.
2014). Similarly, limited understanding on the part of caregivers and physicians of
the difference between memory processes in aging and Alzheimer’s Disease can be
a barrier to timely diagnosis (Knopman et al. 2000). This provides another example
of how those who have dementia, a disease linked to ageing, are likely to experience
double discrimination. Stigma can be a major factor in the person’s willingness or
reluctance to seek diagnosis and subsequently to seek support (Milne 2010;
Burgener and Berger 2008). Similarly, the standard of care provided to people with
dementia is often lower due to the impact of stigma on the health care profession
(Devlin et al. 2007; Benbow and Jolley 2012). A study based on interviews with
family doctors in the North of England (Gove et al. 2016) concluded that there is a
need to separate personal fears from professional judgements, and called for train-
ing and support in addressing patient fears and exploring early symptoms.
Even when a diagnosis is received, the ALCOVE study suggests that the provi-
sion of support is sparse, with 61% of respondents saying that they always’ or
‘often’ provided information about dementia following diagnosis, and 39% provid-
ing education and social support. There is also evidence that some treatments that
would benefit people with dementia are not offered because of a belief on behalf of
some healthcare professionals that rehabilitation is not possible for people living
with dementia, despite evidence to the contrary (Evans 2008).
People with dementia are also likely to have a high prevalence of other comorbid
medical conditions, many of which are undiagnosed and preventable, for which
they are less likely to receive the same treatment than people without dementia
(Scrutton and Brancati 2016). Research suggests that 61% of people with
Alzheimer’s disease have three or more comorbid diagnoses, while the rate of
comorbid conditions increases with the severity of the dementia (Fillit 2000; Murali
Doraiswamy et al. 2002). This can lead to a range of discrepancies in health out-
comes for people with dementia including faster deterioration in daily functioning,
a reduced quality of life, and earlier death. For example, UK hospital patients with
dementia are over three times more likely to die during their first admission for an
acute medical condition than those without dementia. Similarly, urinary tract infec-
tions are one of the principal cause of hospital admission for people with dementia
(Sampson et al. 2009), despite both conditions being avoidable and relatively easy
to manage if treated promptly. More than 50% of patients in America with moder-
ately severe dementia who are admitted to hospital with hip fracture died within
268 S. C. Evans
6 months, a much higher rate than for patients without dementia (Morrison and Siu
2000). An Australian study suggested that dementia patients are more likely than
those without dementia to develop preventable comorbidities whilst in acute hospi-
tal (Bail 2013).
Poor pain management is another common feature of care for people with
dementia, with patients with advanced dementia and a hip fracture in America being
prescribed one-third of the analgesia compared with other patients (Morrison and
Siu 2000). This has far reaching implications because it can lead to unnecessary
suffering as well as the potential inappropriate use of psychiatric medications, par-
ticularly towards the end of life (Sampson 2006). Reasons for these inequalities
include care systems that focus on the dementia rather than the needs of the indi-
vidual, a lack of dementia training among health professionals, poor medication
management, and mis-interpretation of atypical symptoms. These deficits mean that
many people are receiving poorer services due to having dementia in addition to the
broader manifestation of ageism in the healthcare system, which can also lead to
reduced access to services. Further information on this can be found in the chapter
on ageism and the healthcare system (Wyman et al. 2018; Chap. 13)).
16.5 Social Contact and Engagement
The value of social interaction and participation in group activities is widely recog-
nised. Enjoying good social relationships with family, friends and neighbours and
engaging in a large number of social activities are key elements of quality of life for
older people (Bowling 2011). There is also a strong argument that having opportu-
nities for social interaction is a basic human right for every citizen, irrespective of
their health condition. In this section, we explore the impact of growing old on
levels of social interaction and how this is exacerbated for people who have
dementia.
Much of the literature suggests that older adults tend to experience a reduction in
the size of their social network in later life, along with a decrease in the frequency
of their social contacts (for example, Lang and Hornburg 1998; Okun and Keith
1998). It is often suggested that this is partly due to significant life events, such as
reduced mobility and the death of a partner and peers. A meta analysis by Pinquart
and Sorenson (2001) concluded that greater social contact is associated with lower
levels of loneliness, although other factors such as the emotional quality of contacts
are also likely to be influential.
While it is important to note that the experience of loneliness is a subjective mat-
ter, so that someone who has little social contact may not feel lonely, while another
person might feel lonely despite a very active social life, there is widespread agree-
ment that for many people growing older comes with increased feelings of loneli-
ness. Pinquart and Sorensen (2001) also suggested that between 5% and 15% of
those aged over 65 frequently feel lonely, although this is likely to be an under-
estimate, while for those aged 80 or over the figure is closer to 50%. In addition,
they concluded that loneliness is more widespread in older age groups, largely due
to reductions in the frequency of social contact related to the death of peers
(including partners), the loss of social roles and physical/sensory limitations. Lower
levels of activity and sensory capacity can hinder social contact and are associated
with higher levels of loneliness. In the UK, it has been estimated that about 10% of
the general population aged over 65 is lonely all or most of the time (Bolton 2012),
which equates to over 900,000 older people. Levels of loneliness among ethnic
minority elders are generally higher, with 15% reporting that they always or often
feel lonely. Institutionalisation can also be associated with increased loneliness,
partly because people who move to residential settings tend to be those with fewest
family members who also lack informal support systems.
There are several theories concerning why social contact is of such value to indi-
viduals, as summarised by Bolton (2012). For example, the ‘stress regulator’
hypothesis suggests that social relationships provide resources that aid adaptation to
stressful events, including illness and life transitions, and enable positive behav-
iours such as healthy eating. Under the ‘main effects’ model, social relationships
have a more direct protective effect on health through cognitive, emotional, behav-
ioural and biological influences. The effects of loneliness are therefore substantial
and can include higher cortisol levels, reduced protection against infection, increased
risk of heart disease, higher blood pressure, disrupted sleep, greater levels of depres-
sion and even higher mortality (Bolton 2012. One study (Holt-Lunstad et al. 2010)
has shown that having weak social connections is, in health terms, equivalent to
smoking up to 15 cigarettes a day as well as being twice as harmful as obesity.
For people living with dementia, social interaction has specific benefits that can
contribute towards a good quality of life, including reductions in agitation and other
behavioural symptoms (Cohen-Mansfield and Parpura-Gill 2007). However, main-
taining social contact can be particularly challenging for people living with demen-
tia as well as their family carers. In a UK report (Alzheimer’s Society 2013), 33%
of those living with dementia said they lost friends following a diagnosis and 39%
said they felt lonely, compared with 24% of over 55 s in general. The figure increased
to 62% for people with dementia living on their own. The report called for greater
understanding on the part of local government and other commissioners about the
needs of people with dementia living within the community, and the provision of
services to ensure that they are not socially isolated or lonely. Examples of how to
support social interaction include dementia cafés, walking groups, befriending ser-
vices and accessible transport to allow people with dementia to attend social clubs
or other services.
In summary, for a number of reasons, including ageism, older people often expe-
rience an increase in loneliness and lose the direct protective effect on health that
social relationships. The situation can be accentuated for people with dementia, an
age-related condition, because of the frequent loss of friendships due to the stigma
associated with the disease. Therefore, it appears that older adults who suffer from
dementia are susceptible to loneliness due to the double jeopardy associated with
old age and dementia status.
270 S. C. Evans
16.6 Research Funding
In the UK, government spending for medical research is increasing year on year,
while spending on dementia research was £66 million in 2015. That is double the
figure for 2009–2010, but it is important to note that much of this is on bio-medical
studies that aim to find a cure for dementia. Relatively little is spent on psycho-
social research that aims to improve quality of life for those living with dementia,
which has potential to be more effective in the short to medium term in the absence
of a cure. UK charities also make a substantial financial investment in dementia
research, a figure of approximately £20 million a year. However, the total govern-
ment and charitable spend on cancer research is almost 7 times greater, despite the
fact that similar economic costs are associated with the two conditions.
It is also interesting to note that, in addition to impacting on the receipt of care
and support, stigmatisation can be a barrier to participation in research (van der
Vorm et al. 2008). This can be exacerbated by barriers imposed by gatekeepers
towards people with dementia, often based on stereotypes concerning their com-
munication abilities and their interests (Brooks et al. 2017; Sherratt et al. 2008).
16.7 Recent Changes and Potential Lessons Learnt
Recent years have seen a major change in how governments across the world
approach dementia, largely driven by recognition of the personal, social and eco-
nomic costs of the rapidly increasing numbers of people living with the disease. In
many countries, this approach is based on a national plan, strategy or framework
that aims to improve diagnosis, treatment and support. The majority of these
approaches include dementia awareness campaigns, based on a recognition that the
stigma that is widely associated with dementia can prevent people from seeking a
diagnosis and therefore from having the opportunity to access appropriate care and
support. This was captured in one of the recommendations of the ALCOVE project,
which stated that ‘Decreasing fear and stigma about dementia is a necessary pre-
cursor for increasing the numbers of people coming forward for diagnosis’ (Brooker
et al. 2014). Dementia awareness campaigns were reported by almost all countries
provided for both professionals and the general public, but 32% reported a lack of
legislation to protect people with dementia, and nearly 50% reported no legislation
for advance statements/directives. Where legislation existed, it was often inconsis-
tently implemented, supported or promoted particularly in the promotion of advance
directives. This suggest that in many countries people experience discrimination in
terms of the care and support they receive as a result of having dementia, in addition
to any discrimination that occurs as a result of ageism. A total of 43% countries
reported having specific policies in place to improve the quality of diagnosis.
Countries that did have policies in place reported diagnosis being made at an earlier
stage.
Attention on dementia has also been focused and coordinated through a range of
international initiatives including the Paris Declaration, the G8 dementia summit,
the World Dementia Council, the WHO global dementia observatory and a European
Parliament declaration, all of which recognised the need to increase awareness and
address stigma as part of the ‘fight’ against dementia. However, there is no evidence
for the impact of policy based initiatives such as these.
Another initiative to reduce stigma and discrimination is the ‘dementia-friendly
communities’ movement that has been adopted in in several countries including the
UK, India, France, Ireland and Canada (Wiersma and Denton 2013). In the UK,
over 120 communities are now registered as dementia-friendly, using an overarch-
ing framework to monitor their progress. This covers a range of key areas: the
involvement of people with dementia from diverse groups; challenging stigma and
building understanding; ensuring an early diagnosis; providing consistent and reli-
able travel options; developing easy to navigate environments; and promoting
respectful and responsive businesses and services. This movement overlaps consid-
erably with the age-friendly cities and communities movement that has been led by
the World Health Organisation (WHO 2007) with the aim of improving quality of
life for older people and reducing ageism.
The independent sector has also made a significant contribution towards increas-
ing awareness of dementia and tackling stigma. This has taken place at national
levels, as demonstrated by the actions of the Alzheimer’s Society in England, and
internationally through the work of Alzheimer’s Europe. Alongside this, in some
countries there has been a growth in the dementia rights movement, which has seen
the voice of people with dementia and their family carers become a major force for
change in social perceptions of people with dementia and how they are treated
within society, including by health and other public service providers. In the UK,
this has been a key factor in a government commitment to enabling people to ‘live
well with dementia’, particularly through the Dementia Strategy, the Prime Ministers
Dementia Challenge, and the Dementia Friends approach. These initiatives appear
to have led to a growing awareness of the need to raise awareness of dementia across
society, to improve services for people living with dementia and the importance of
adopting a truly person-centred approach.
16.8 Conclusion
The information presented in this chapter suggests that people living with dementia
experience a double stigmatization, due to old age and dementia, which can lead to
people feeling excluded from many of the activities that most of us take for granted.
However, there are some important differences between general ageism and demen-
tia stigma. For example, discrimination and stigma are based on judgements con-
cerning a person’s characteristics and membership of particular ‘group’. Therefore,
everyday ageism against an individual is often based on the perception that they
belong to the group of ‘older people’. For dementia the situation is different because
272 S. C. Evans
it is not generally possible to tell that someone has dementia by looking at them.
Therefore, the operationalization of stigma against individuals with dementia is
usually only possible for those who have access to knowledge of their condition.
This tends to be the professionals and organisations that are responsible for deliver-
ing health and social care services, but might also include friends, relatives and
neighbours. Another important difference is that increasing age is often associated
with some positive stereotypes, such as wisdom and high morals, whereas it is dif-
ficult to find any positive attributes that are commonly associated with dementia. It
is also important to note that, as discussed in other parts of this book, widespread
ageist views often lead to an assumption that older people have symptoms of ‘senil-
ity’, such as memory problems and other forms of cognitive impairment.
Swaffer (2014) puts it well when writing about stigma, language and dementia:
In short, social action is needed to ensure that we engage people with dementia, not just the
wider community in understanding dementia and in that way reduce the social isolation,
discrimination and stigma that people with dementia experience. We want to access ser-
vices and to participate in the community the way everyone has a right to expect, and to
have our disabilities respected with acceptance, support and enablement. (p. 714).
Finally, the study of ageism and dementia is relatively new and there is a need for more
specific research in this area. Work of this kind will enable us to develop a more nuanced
picture of discrimination and stigma in a range of countries and settings and to explore how
it can best be addressed. Reducing stigma is a crucial element in the challenge of supporting
people to live well with dementia and reducing the ‘double stigma’ that they frequently
experience in addition to ageism.
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Chapter 17
Ageism and Neuropsychological Tests
Boaz M. Ben-David, Gali Malkin, and Hadas Erel
17.1 Introduction
Increase in life expectancy is one of the core characteristics of the modern life
(Schneider 1999). However, whereas medicine and technology enable relatively
good health (Eggleston and Fuchs 2012), the apparent cognitive decline is still con-
sidered one of the most central aspects of ageing (for an overview see, Craik and
Salthouse 1992; but for a steady age-related advantage in vocabulary, Ben-David
et al. 2015; also see Evans 2018; Chap. 16, in this volume). It is one of the most
feared aspects of growing old (Morley 2004). In this context, accurate measures of
cognitive decline have become increasingly important. These typically involve the
assessment of core cognitive skills, such as memory, language proficiency, intelli-
gence and executive functions (for a review see, Monge and Madden 2016).
Older adults’ performance on cognitive assessment tests has important implica-
tions both on the individual level and on the societal level. For individuals, perfor-
mance is a marker for cognitive ability, influencing self-image and life choices. For
society as a whole, performance sets the perspective (and expectations) on the capa-
bilities of older people in general, contributing to ageism. Cognitive assessment
tests are administered with two (dependent) implicit assumptions: (a) the tests are a
B. M. Ben-David (*)
Communication, Aging and Neuropsychology Laboratory (CANlab), Baruch Ivcher School
of Psychology, Interdisciplinary Center (IDC), Herzliya, Herzliya, Israel
Faculty of Medicine, Department of Speech-Language Pathology, University of Toronto,
Toronto, ON, Canada
Toronto Rehabilitation Institute – University Health Network, Toronto, ON, Canada
G. Malkin · H. Erel
Communication, Aging and Neuropsychology Laboratory (CANlab), Baruch Ivcher School
of Psychology, Interdisciplinary Center (IDC), Herzliya, Herzliya, Israel

https://doi.org/10.1007/978-3-319-73820-8_17
278 B. M. Ben-David et al.
valid gauge of performance in older adults and (b) cognitive abilities decline in
older age. Because test performance is taken to provide a good estimate of abilities
in older adults, reduced test performance is interpreted as reflecting an age-related
cognitive decline. If one assumes an age-related cognitive decline, reduced perfor-
mance in cognitive tests can be seen as further support for test validity. In the cur-
rent chapter, we wish to challenge these assumptions, questioning the validity of
cognitive tests as an unbiased gauge of older adults’ abilities, and as a result, ques-
tioning the extent of age-related cognitive decline.
As a first step, we review evidence suggesting that performance on cognitive
tests is affected by sensory decline. Currently, cognitive tests are not designed to
take this factor into account. Specifically, sensory decline in ageing degrades the
information processed, impairing cognitive processing (Schneider and Pichora-
Fuller 2000). Indeed, age-related changes in cognitive performance (on several
tests) can be minimized (or even effaced) when sensory decline is controlled for, or
by changing the sensory context of the test (vision: Ben-David and Schneider 2009;
auditory: Ben-David et al. 2011a).
In the second part of this chapter, we discuss evidence of the impact of age-based
stereotype threat on test performance. Specifically, the predicament arising from
negative ageing stereotypes on cognitive decline can be experienced as a self-
evaluation threat (Steele and Aronson 1995), leading to decreased performance,
thus fulfilling the ageist prophecy (Hess et al. 2003). Here, too, there is evidence to
suggest that elevating stereotype threat may minimize age-related changes in per-
formance (e.g., Mazerolle et al. 2017). Finally, notwithstanding age-related neuro-
logical changes (as frontal and hippocampal decline; West 1996), this chapter
suggests that the common assumption on the extent of age-related decline in cogni-
tive abilities may be exaggerated, and the respective role of the sensory and social
contexts on performance is considerably ignored.
To understand the interplay between the implicit assumptions and the sensory
and social contexts, consider the following example. A 75-year-old goes to a univer-
sity lab to be tested for cognitive abilities, or to a clinic to be tested for cognitive
impairment, when decline (or even dementia) is suspected. The mere presentation
of the test may elicit the expectation to perform poorly, negatively affecting perfor-
mance. Auditory and visual information, such as test material and instructions, pres-
ent a greater sensory challenge due to age-related sensory decline, again negatively
affecting performance. Reduced performance serves to further validate common
stereotypes about the rate and extent of cognitive deterioration with ageing, as the
test is taken as valid and unbiased. Simply put, performance on tests, which may be
biased due to sensory and social aspects of ageing, confirms assumptions of reduced
cognitive abilities in ageing.
In sum, our analysis of the literature focuses on the two main threats to the valid-
ity of neuropsychological assessment in ageing: the sensory context and the social
context. These contexts not only describe the mechanisms underlying biases in
evaluating cognitive performance in older age, but also offer insights that can
improve the validity of such tests. Targeting the sensory and social context in
17 Ageism and Neuropsychological Tests 279
n europsychological assessment may assist in reducing age-bias (leading to ageism)

in the scientific, medical and general community.
17.2 A
geing and the Sensory Context of Neuropsychological
Assessment
17.2.1 Age-Related Sensory Decline
Ageing is commonly accompanied by a sensory decline (Crews and Campbell

2004), indicated by an increase in the use of sensory aids, such as hearing devices
and glasses (Roberts and Allen 2016). To focus our discussion, we target auditory
and visual age-related decline in healthy ageing. Auditory decline in healthy ageing
is related to neural changes across different auditory areas in the brain, as well as
cochlear changes in the ear (Gordon-Salant et al. 2010). Auditory changes lead to an
increase in hearing thresholds, where one needs louder target sounds for correct
detection (Roberts and Allen 2016), and supra-threshold changes (Glasberg and
Moore 1992), such as distortion of the incoming stimuli (Grose and Mamo 2010).
Ageing is also marked by less efficient auditory scene analysis (Bregman 1990),
where both top-down and bottom-up processes impact difficulties in segregating the
target speech from competing sound sources in the background (e.g., other people
talking; Tun and Wingfield 1999). Visual changes in healthy ageing typically include
retinal degeneration (Monge and Madden 2016), and presbyopia (Scialfa 2002).
These changes degrade basic visual processes, such as near-term vision (Spear
1993), visual acuity (clarity of vision, Owsley 2011), contrast sensitivity (the ability
to detect luminance differences to distinguish objects from background, Greene and
Madden 1987) and colour perception (e.g., Nguyen-Tri et al. 2003).
Intelligence Tests The age-related sensory decline discussed above is likely to
have an impact on cognitive processing, and therefore, on neuropsychological
assessment (Roberts and Allen 2016; Schneider and Pichora-Fuller 2000). Perhaps
the most striking evidence comes from a line of studies on age-related sensory
decline and scores on different intelligence batteries (e.g., Anstey et al. 2001;
Lindenberger and Baltes 1994). Findings show that visual and auditory acuity
scores (near and far visual acuity, pure tone auditory acuity) could account for
93.1% of the age-related variance in intelligence scores (with 156 participants aged
70–103). These findings were later replicated and extended on a larger sample (687
participants), with a larger age range (25–103 years, Baltes and Lindenberger 1997)
and to longitudinal data (Ghisletta and Lindenberger 2005). In sum, evidence sug-
gests that sensory decline is closely related to a decline in performance on neuro-
psychological assessment.
17.2.2 T
heories on the Interaction of Sensory and Cognitive
Ageing
How to explain this link between sensory and cognitive ageing? Four possible
hypotheses have been discussed (Schneider and Pichora-Fuller 2000, see also
Wayne and Johnsrude 2015): (1) Sensory deprivation hypothesis. Sensory decline,
over time, leads to a cognitive decline due to social isolation and reduced use of the
relevant cognitive functions (Lin et al. 2013); (2) Cognitive load hypothesis.
Cognitive decline leads to a decline in perceptual processes (the interpretation of the
sensory input). This is based on the idea that cognitive load can impair even simple
sensory tasks (Li et al. 2001; Lindenberger et al. 2000) (3) Common cause hypoth-
esis. Degeneration in the central nervous system causes a deterioration of both per-
ception and cognition (Baltes and Lindenberger 1997). Indeed, cardiovascular risk
factors have been associated with both hearing loss and cognitive decline (Roberts
and Allen 2016); finally, (4) Information degradation hypothesis. Unclear and dis-
torted perceptual information delivered to the cognitive system directly impairs
cognitive performance, due to an increase in the resources required for the percep-
tion process and errors embedded in the input (Schneider and Pichora-Fuller 2000).
These hypotheses are not necessarily mutually exclusive. Clearly, the interaction
of sensory and cognitive processing suggests that each factor can affect the other,
with similar biological changes influencing both (Baltes and Lindenberger 1997).
However, the information degradation hypothesis presents the framework for under-
standing the possible age biases in neuropsychological testing that may lead to age-
ism. If perception and cognition are taken to comprise one integrated system
(Wingfield and Tun 2007), where both processes share the same pool of resources
(Glisky 2007), then when perceptual processing requires more resources due to age-
related sensory decline, less resources are available for cognitive processing
(Heinrich et al. 2008). Furthermore, cognitive processing demands more resources
when it is based on degraded sensory information, tapping into the already reduced
pool. This model suggests that sensory degradation (i.e., the reduced quality of sen-
sory information) is an alternative explanation for age-related declines in perfor-
mance. Thus, it directly challenges the two implicit assumptions underlying
neuropsychological testing in ageing: test validity and the extent of age-related cog-
nitive decline. The validity of this model can be tested very easily with simple
experimental manipulations (see Monge and Madden 2016). This hypothesis also
affords a possible remediation for neuropsychological assessments in older age.
Mainly, ameliorating the sensory input (or removing them all together, Ben-David
and Icht 2017), can minimize age-related differences.
In the next sections, we discuss the assessment of three main cognitive abilities,
taken to represent age-related cognitive decline: inhibition, speech comprehension
and memory. We offer evidence to suggest that the neuropsychological assessment
can be drastically impacted by age-related sensory degradation in vision (inhibi-
tion), in hearing (comprehension) or both (memory).
17.2.3 I nhibition: An Example of the Effect of Visual

Degradation on Neuropsychological Tests
The need to inhibit irrelevant information is a central cognitive ability in daily activ-
ities. For example, when driving a car one must attend to the road, while ignoring
irrelevant visual distractors, such as billboards. Similarly, when reading this text,
one needs to ignore irrelevant dimensions, such as the size and shape of the page,
and focus on the content of the words. One of the prominent theories on cognitive
changes in ageing suggests that this specific process deteriorates in ageing (Hasher
and Zacks 1988). The age-related decrease in the efficiency of inhibitory processes
is a part of a general theory on a decrease in executive functions – a decrease in
monitoring and control of behaviour (Baddeley 1996). This cognitive decline is
generally attributed to selective prefrontal deterioration in ageing (Dempster 1992).
However, recent studies suggest that visual sensory degradation can explain some of
the age-related variance in performance (see a discussion in Ben-David et al. 2014a).
The ‘gold standard’ for evaluating inhibition in ageing is the colour-word Stroop
test (Stroop 1935; see Melara and Algom 2003 for a relevant review). In this para-
digm, participants are asked to name aloud the font colours of printed words, ignor-
ing their content. For example, saying aloud “blue” when presented with the word
RED printed in blue. The latency advantage for naming the font colour of a colour-
neutral word (e.g., TABLE printed in blue) over an incongruent colour-word (RED
in blue) is termed Stroop interference. An age-related increase in Stroop interfer-
ence has been shown repeatedly in the literature (for reviews, see Ben-David and
Schneider 2009; McDowd and Shaw 2000). It is commonly interpreted as reflecting
an age-related decrease in the efficiency in inhibition (e.g., Troyer et al. 2006).
In the past decade, a line of studies by Ben-David and colleagues suggest that
variance in colour-vision (in people with clinically normal colour-vision) can medi-
ate performance on the Stroop test in various populations: healthy ageing (Anstey
et al. 2002; Ben-David and Schneider 2009), people with dementia (Ben-David
et al. 2014b) and people with traumatic brain injury (Ben-David et al. 2011b, 2016).
In a meta-analysis (Ben-David and Schneider 2009), an age-related increase in
colour-naming latencies (naming the font colour of a colour-neutral word) was
found to be significantly larger than an age-related increase in reading latencies
(reading a word printed black on white). This increased difficulty in colour-vision
processing was found to be a possible source for reduced performance on the Stroop
test, beyond any changes in inhibition. In a follow-up study, to simulate an age-
related colour deficiency, the Stroop test was presented with desaturated colour-set
for a group of younger adults. By reducing the amount of colour information avail-
able, Ben-David and Schneider (2010) were able to “age” younger adults, generat-
ing the age-related increase in Stroop interference. Somewhat similar results were
obtained in other inhibition test. For example, Bertone et al. (2007) simulated age-
related visual acuity degradation by fitting younger adults with occlusion filter
lenses to blur their vision (e.g., to 20/40), severely reducing performance on an
inhibition test.
In sum, mimicking an age-related decrease in colour perception in younger

adults was sufficient to lead to Stroop interference that is similar to that found in
older adults. Because the colour-word Stroop test is widely used in clinical, neuro-
psychological and experimental screening tests as a measure of inhibitory control in
older participants, there is reason to question the validity of inhibition diagnosis and
the extent to which the inhibitory process in ageing decreases.
17.2.4 C
omprehension: An Example of the Effect of Auditory
Degradation on Neuropsychological Tests
Age-related auditory degradation impairs speech perception on various levels:

single-word identification, sentence comprehension, source localization and the
ability to segregate the source speaker from a noisy background (Ben-David et al.
2012; Humes and Dubno 2009; Schneider et al. 2002). This is supported by a line
of studies showing that when the listening situation is adjusted to match older and
younger adults’ auditory abilities, speech processing can be equated (for a review,
see Schneider et al. 2010). For example, (Ben-David et al. 2011b) used an eye-
tracking paradigm to measure age-related effects on speech processing, as the spo-
ken word unfolds in time. The study found equivalent online speech processing for
older and younger adults, when speech was presented in quiet. When the noise level
was tailored to compensate for age-related auditory changes (by setting different
signal-to-noise ratios to equate single-word identification across age-groups), again,
online speech processing was mostly not affected by ageing (for possible cognitive
effects, see Hadar et al. 2016).
Age-related changes in speech perception, as presented above, can directly affect
performance on neuropsychological tests. Generally, basic test instructions are spo-
ken, presenting a possible source for misunderstanding. The additional effort for
deciphering spoken instructions may also decrease available resources and induce
stress (Schneider et al. 2010). Importantly, in many cognitive tests, test stimuli are
spoken rather than printed, presenting further sources for biases. For example,
Schneider et al. (2000) asked older and younger participants to listen to lectures
(8–13 min) on a noisy background and to later answer questions concerning their
content. When both age groups heard the lecture at the same sound level (mimick-
ing conditions in the clinic), significant age-related differences were found.
However, when auditory conditions were individually adjusted to compensate for
sensory degradation, these differences were eliminated. In other words, older adults
were able to perform as well as younger adults, even in a complex listening compre-
hension task, when sensory degradation was compensated for (for replication, see
Lu et al. 2016). These results may be further supported by a recent study indicating
that younger adults with hearing impairment show equal cognitive performance to
older adults with similar sensory decline (Verhaegen et al. 2014). Noting that
declines in comprehension are often interpreted as a direct indication of age-related
cognitive decline and even pre-dementia (Schneider et al. 2005), these findings
present implications for various neuropsychological assessment tools.
17.2.5 M
emory: An Example of the Effect of Auditory
and Visual Degradation on Neuropsychological Tests
As discussed in the second section of this chapter, memory deterioration is one of

the most prominent stereotypes in ageing. Research presents abundant evidence
suggesting an age-related decline in a variety of memory tasks (Craik and Jennings
1992; Zacks et al. 2000). Yet, like comprehension, memory was also shown to
depend on the perception of the auditory stimuli (Peelle and Wingfield 2005).
Consider studies of spoken word-pairs, where listeners are presented with a list of
spoken word-pairs, and later asked to recall a target word when given its pair. In an
early study (Murphy et al. 2000), memory performance of older adults listening in
quiet was nearly equivalent to that of younger adults listening in noise. Later,
Heinrich and Schneider (2011) adjusted signal-to-noise ratios to equate identifica-
tion of a single spoken word across age-groups (i.e., louder background noise was
presented to younger adults). In this condition, memory performance of older adults
matched that of younger adults, when ample time was given.
Visual decline was also shown to impair performance on memory tests. For
example, Dickinson and Rabbitt (1991) occluded younger adults’ vision to mimic
older adults’ visual perception when asked to read aloud a passage for later recall.
Memory performance was severely diminished, even though no errors were per-
formed during reading. In other words, the additional toll on processing (generated
by visual degradation) can affect non-perceptual, higher-order cognitive processes,
even when visual processing is still intact. Finally, visual sensory degradation was
also correlated with other visual memory tasks (Stevens et al. 1998).
Dementia Screening Tests Age-related sensory degradation was not only found to
impact memory tests in healthy ageing, but also dementia assessment, with severe
implications for false positive mistakes (e.g., Feldman et al. 2008). We focus on
commonly used screening tests for dementia such as the Mini-Mental State
Examination (MMSE; Folstein et al. 1975) and the Montreal Cognitive Assessment
(MoCA: Nasreddine et al. 2005). These tests are considered accurate tools for iden-
tifying indicators for pre-dementia and mild cognitive impairment (MCI: Luis et al.
2009). Yet, there is a body of evidence in the literature to indicate that these tools
can be affected by sensory degradation as well. For example, Dupuis et al. (2015)
found that older adults with sensory loss (whose vision and\or hearing scores did
not meet the criteria for healthy ageing) were twice as likely to score below the cut-
off point for potential pre-dementia as older adults with clinically normal visual and
auditory thresholds. Indeed, in a different study, one third of older adults with hear-
ing loss, who were already diagnosed with dementia, were reclassified as having a
lesser degree of dementia when the MMSE was administered using sound
a mplification (Weinstein and Amsel 1986). Similarly, significantly better MMSE

scores were documented when older adults with hearing loss were using fitted hear-
ing aids (Acar et al. 2011). Dementia measures are also affected by age-related
sensory decline that is still within clinically normal boundaries. For example, tailor-
ing stimuli contrast level for older participants to resemble contrast perception of
younger adults was sufficient to erase all age-related differences in a digit cancella-
tion task (another indicator for pre-dementia) with healthy adults. When the same
manipulation was conducted with older adults diagnosed with dementia, it signifi-
cantly minimized performance decline (Toner et al. 2012). In sum, age-related
visual and auditory decline can lead to overestimation and false-positive diagnosis
of dementia. Results call for a careful examination of test results in light of age-
related sensory decline.
17.2.6 C
linical Implications: Compensating for Sensory
Degradation
Simple actions may overcome the sensory bias in neuropsychological testing. We

recommend adjusting test stimuli and instructions to compensate for age-related
sensory changes. These include sound amplification, reducing background noise
and increasing target sound level (enhancing signal-to-noise ratio), enhancing stim-
uli visual contrast, using larger font size, increasing the amount of light in the room,
careful choice of colours and so on. We also recommend assessing the visual and
auditory abilities of older participants in all cases of neuropsychological assess-
ments. It is imperative to ensure the use of corrective aids (visual or auditory) when
these are needed, as hearing and visual loss can severely reduce performance. These
sensory scores can also serve to statistically adjust neuropsychological assessment
scores to better reflect abilities (e.g., the Stroop task, Ben-David and Schneider
2010). In sum, to avoid a false diagnosis of a clinical cognitive decline one must not
ignore or underestimate sensory decline.
17.2.7 Sensory Context: Summary
In the first section of this chapter, we discussed evidence showing that physical
aspects of the test material (and instructions) present a direct threat to the validity of
neuropsychological testing in ageing. Namely, age-related decline in performance
on assessment tools may reflect, at least in part, a sensory rather than a cognitive
decline. When reduced performance is evident, it is likely to be attributed to lower
cognitive ability of the older test taker, rather than transient sensory contextual fac-
tors. This ageist bias might serve to further validate negative ageing stereotypes,
resulting ultimately in the negative portrayal of older adults across both scientific
literature and every day cultural representations. In the following section, we dis-
cuss how such age-based stereotypes may have a negative impact on performance,
suggesting that the social aspects of the test may also put into question the validity
of neuropsychological testing in ageing.
17.3 T
he Social Context of Neuropsychological Assessment
in Ageing
Stereotype threat, one of the most widely investigated topics in social psychology
(Pennington et al. 2016) occurs when underachievement among stigmatized group
members is rooted in the situation more than in the individual (Leyens et al. 2000).
The existence of a negative stereotype about a person’s group means that in situa-
tions where the stereotype is applicable, the person will be at risk of confirming it
as self-characteristic (Aronson 2002). In the seminal work of Steele and Aronson
(1995), African American participants were tested on a verbal reasoning task. When
the task was presented as a diagnostic indicator of intellectual ability, the perfor-
mance of African-Americans (a population that generally suffers from a stereotype
on intellectual abilities) was significantly worse compared to that of their Caucasian
peers. When the task was presented as non-diagnostic, these differences in perfor-
mance were eliminated. Therefore, making the racial stereotype about intellectual
ability relevant to test performance impaired African Americans’ performance rela-
tive to Caucasian participants.
Stereotype threat effects have been studied across different stereotyped social
groups including women (e.g., Spencer et al. 1999), individuals from low socioeco-
nomic status (e.g. Spencer and Castano 2007), gay men (Bosson et al. 2004), and
older adults, as we will review in the next sections.
17.3.1 Age-Based Stereotype Threat
Older adults face pervasive negative stereotypes portraying them as forgetful,

incompetent, and cognitively inferior to younger adults (Hummert et al. 1994; Kite
and Wagner 2002). These stereotypes were found to have a negative impact on older
adults’ performance across diverse domains, and on their general well-being. A
recent meta-analysis of 32 studies, covering more than a decade of research (Lamont
et al. 2015), suggests that age-related reduced performance on memory tests and
other cognitive measures may be vulnerable to age-based stereotype threat (with a
moderate effect size, d = 0.36 − an effect size measures the strength of a phenom-
enon, Sawilowsky 2009). In the current section of the chapter, we focus on how
older adults’ negative beliefs about their memory and other cognitive abilities can
impact their performance on assessment tools.
Age-based stereotype threat is typically induced in the lab by manipulating the

relevance of the stereotype to task performance. Most studies usually invoke age-
based stereotype threat by presenting participants with fictitious information con-
firming that cognitive abilities decline with age, by emphasizing the task’s evaluative
nature, or by implying an age-based comparison. One of the pioneering investiga-
tions of age-based stereotype threat is a study by Hess et al. (2003). In this study,
stereotype threat was manipulated by informing younger and older adults about
research findings depicting either the negative impact of ageing on memory (threat
condition), or describing that memory is maintained across the lifespan (no-threat
condition). Participants were then given a free recall memory test. Consistent with
the stereotype threat framework, no age-related differences were noted in the no-
threat condition. However, in the threat condition, recall was higher for younger
than for older adults. In sum, traditional findings on a significant age-related
decrease in performance on memory tasks might be affected by the activation of
pervasive negative ageing stereotypes.
Real-world testing situations, such as testing in the clinic or a research lab, may
induce a stereotype threat by nature, without requiring any special manipulations
(Spencer et al. 2016). Simply taking a test in a negatively stereotyped domain, in the
context of performance evaluation in ageing, is enough to trigger stereotype threat.
Consider again a memory test. The typical procedure for testing the memory abili-
ties of older adults (Hughes et al. 2013) involves multiple stereotype threat cues.
These include the testing location: a college campus where older adult participants
are surrounded by younger adults, or a hospital clinic highlighting sickness and dis-
ability. Test instructions may also trigger stereotype threat as participants are
informed that their memory will be tested, with the commonly implicit assumption
that their performance will be compared to that of younger adults. In fact, recruiting
participants based on their age, or merely asking them to indicate their age in a
demographic questionnaire can serve as a cue (Kang and Chasteen 2009). All of
these cues may potentially lead to performance decrement, ultimately resulting in
an over-estimation of age-related memory decline.
17.3.2 Clinical Implications of Age-Based Stereotype Threat
Perhaps the most striking indication of the consequences of age-based stereotype

threat on assessment arises from two seminal studies on dementia assessment.
Mazerolle et al. (2017) used the most common brief neuropsychological assessment
batteries in ageing, MMSE and MoCA (as discussed in the previous part of this
chapter). Experimenters simply informed all participants that they would perform a
memory task and that both younger and older adults are taking part in the study
(threat condition). In the reduced-threat condition, participants were also informed
that typically there are no age-related differences in this task. Results show that 40%
of the sample of community-dwelling older adults met the screening criteria for pre-
dementia in the threat condition. However, only 10% of the participants in the
reduced-threat condition met these criteria. This finding is further supported in a

study by Haslam et al. (2012) investigating a commonly used measure for early
dementia detection (ACE-R). When participants were self-categorized as old, and
were also led to expect that age-related cognitive decline is all-encompassing (rather
than limited to a specific domain), 70% met the diagnostic criterion for dementia.
By contrast, only 14% on average met this criterion in all other (lower-threat) condi-
tions. In sum, stereotype threat may lead not only to overestimation of cognitive
decline but also to the false-positive diagnosis of pre-dementia, suggesting potential
severe implications in real life.
It is important to note that age-based stereotype threat does not begin and end in
the testing situation alone. There is evidence that older adults perform worse on a
memory test following negative, rather than positive, age-related subliminal primes.
That is, when words associated with negative aspects of aging (e.g., DEMENTIA)
were presented at a speed allowing perception but not awareness (i.e. subliminal
presentation), performance on a subsequent memory test was worse than when a
positive word (e.g., SAGE) was subliminally presented (e.g., Hess and Hinson
2006; Levy 1996; Levy and Leifheit-Limson 2009). These implicit stereotypes may
generate expectations that act as self-fulfilling prophecies (Levy and Leifheit-
Limson 2009), which may be at the root of the motivation of the older adult to
search for a neuropsychological evaluation in the first place (Régner et al. 2016).
For example, when an older adult is placed in situations predominantly occupied by
younger adults (i.e., stereotype threat), typical memory lapses may be interpreted as
abnormal age-related decline. There is evidence that both younger and older adults
attribute older adults’ memory failures to internal, stable factors (Erber et al. 1990).
Older adults may refer to a case of forgetfulness as their “senior moment” (Barber
2017). Interpreting every-day memory failures as a sign for a need for intervention
(Erber et al. 1990) may lead the older person to search for clinical assessment.
Because the clinical assessment is also negatively affected by stereotype threat, this
person may perform below his/her abilities, with profound clinical, social and eco-
nomic consequences. Moreover, even if the person does in fact suffer a probable
cognitive impairment, the debilitating effects of stereotype threat may be especially
prominent for him/her (Scholl and Sabat 2008). These effects may influence the
choice of suitable treatment options, and the adherence to treatment, resulting in an
entirely different course of disease.
Eliminating age based stereotype cues calls for a multi-faceted approach, as
demonstrated by Sindi et al. (2013). The authors compared younger and older
adults’ salivary cortisol levels, as a measure for stress, and performance on a mem-
ory neuropsychological test. The focus of the study was a manipulation of the envi-
ronments to be stressful (unfavourable condition) or not stressful (favourable
condition) for each age group. The unfavourable condition for older adults included:
(1) A testing location known to young adults but not to older adults (university cam-
pus); (2) Testing performed in the afternoon, a non-optimal time for testing older
adults, but optimal for younger adults; (3) A younger adult research assistant; (4) A
memory task with which older adults, as opposed to younger adults, were not famil-
iar (word list recall); (5) Instructions emphasizing the memory component of the
task, matching the negative stereotype for older, but not for younger adults. In con-
trast, the favourable condition for older adults included: (1) A testing location that
was known to older adults, but not to young adults (an older adult community cen-
tre); (2) Testing performed in the morning, an optimal time for testing older adults,
but not for younger adults; (3) An older adult research assistant; (4) A memory task
that was developed based on learning capacities of older adults (a face-association
memory task, as older adults perform better when asked to recall relevant informa-
tion, rather than unrelated words); (5) Instructions excluding an explicit indication
that the task is testing memory. As expected, higher cortisol levels and lower mem-
ory performance were found for older adults in the unfavourable as compared to the
favourable conditions. However, younger adults were not affected by the testing
conditions. Although it is impossible to identify the relative contributions of each of
these situational factors, this study demonstrates that many facets in the testing
environment may be experienced differently by older and younger adults.
17.3.3 Understanding Stereotype Threat Effects
Generally, stereotype threat may arise from any situational cue indicating that an
individual is at risk of confirming the stereotype, reminding the individual of cultur-
ally held stereotypes (Spencer et al. 2016). The literature has identified multiple
reasons for the effects of stereotype threat on performance among younger adults.
One of the first mechanisms offered to understand stereotype threat effects is
Negative Affect (Steele and Aronson 1995). In particular, increased levels of anxiety
have been offered to mediate the effects of stereotype threat on performance.
However, results regarding this hypothesis have been mixed (see a review by
Pennington et al. 2016), with several studies failing to establish this relationship
(e.g., Spencer et al. 1999). Therefore, while anxiety may play a role in explaining
stereotype threat effects (especially when assessed via indirect measures, Bosson
et al. 2004), it is likely not the only or the key explanation.
Taking a cognitive resources perspective, the Process Model (Schmader et al.
2008) suggests that stereotype threat disrupts performance via three distinct, yet
interrelated, mechanisms: (a) triggering physiological stress response; (b) trigger-
ing a tendency to actively monitor performance, aimed to detect self-relevant infor-
mation and signs of failure; (c) triggering efforts to suppress negative thoughts and
emotions. Each of these mechanisms consumes cognitive resources that are required
for successful performance on a given task. Generally speaking, there is ample
direct and indirect evidence consistent with cognitive resource depletion in stereo-
type threat (Pennington et al. 2016).
Focusing specifically on older adults, the mechanisms underlying age-based ste-
reotype threat are not fully understood, and may not be generalized from studies
conducted among younger adults. With regard to affective factors, similar to younger
adults, little evidence has been found for anxiety mediating the effects of age-based
stereotype threat on performance (Chasteen et al. 2005; Hess et al. 2003; but see
Swift et al. 2013). Inconsistent support has also been noted for the cognitive-
resources hypothesis in older adults (Brelet et al. 2016; Mazerolle et al. 2012 vs.
Hess et al. 2009; Popham and Hess 2015).
Why is it so difficult to fully understand stereotype threat effects among older
adults? The answer may lie in the treatment of stereotype threat as a unitary con-
cept, tailored by younger adults’ experiences and perspectives. For example, accord-
ing to Barber (2017), the reason cognitive depletion does not necessarily explain
stereotype-threat effects in older adults may relate to their favourable emotion regu-
lation abilities. Namely, regulating the negative affective states (such as anxiety and
stress) induced by stereotype threat is resource demanding for younger adults.
However, for older adults, regulating aversive emotions is less resource demanding
(Scheibe and Blanchard-Fields 2009), suggesting a smaller role for this
mechanism.
If stereotype threat effects are not fully explained by cognitive-resources deple-
tion or by negative affect, what can explain them? Current literature appears to sup-
port the regulatory fit hypothesis in explaining stereotype threat effects in older age.
According to this view, stereotype threat may elicit a prevention focus (Seibt and
Förster 2004), in which participants aim not to be their worst, as opposed to striving
to be their best. As suggested by the regulatory focus theory (Higgins 1997, 1999),
this prevention focus will result in more cautious, error-free and loss aversion strate-
gies. Consistent with the idea of a prevention focus, older adults under stereotype
threat have been found to be more risk-averse in their decision making compared to
non-threatened older adults (Coudin and Alexopoulos 2010), and respond more
slowly (Popham and Hess 2015). In addition, stereotype threat was found to reduce
older adults’ (veridical) recall and recognition, but improve memory accuracy
(Barber and Mather 2013b; Wong and Gallo 2016).
The fact that stereotype threat may elicit a prevention focus does not necessarily
mean that it will result in decreased performance. There is evidence that stereotype
threat could even improve older adults’ performance when the task is framed as
relating to losses rather than gains. For example, Barber and Mather (2013a) tested
older adults on a working memory task, after inducing an age-based stereotype
threat. When the tests were focused on gains (i.e., money earned for correct
responses), stereotype threat was found to impair performance. However, when the
tests were focused on losses (i.e., money lost for incorrect responses) threat
improved performance. These findings were replicated using other memory tasks
(MMSE, Word List Memory; Barber et al. 2015). This line of findings can support
the regulatory fit (Higgins 2000) framework. According to this view, when task
demands match the person’s regularity focus, performance will increase, while a
mismatch will decrease it. In sum, the reported negative effects of stereotype threat
on older adults’ performance may stem from a mismatch between the task structure
and the threat-induced prevention focus (Grimm et al. 2009).
17.3.4 Social Context: Summary
Findings presented in this section suggest the pervasive negative impact of age-
based stereotype threat on performance in neuropsychological assessment. Evidence
in the literature also suggests that this effect can have severe consequences, as pre-
dementia may be falsely detected in healthy older adults in the presence of stereo-
type threat cues. These cues are not only the outcome of laboratory manipulations,
but may be present in the daily testing of older adults in the clinic or a university lab.
It is important to recognize these cues in order to shape testing environments that
evince the accurate capacities of older adults.
Although the mechanisms underlying threat effects in older adults are yet to be
fully understood, the possibility that in some cases, activating negative age-based
stereotypes does not necessarily result in performance decrement, is another prom-
ising direction. Changing the reward structure of the task to be loss-based (for
example by emphasizing accuracy and minimization of mistakes), may also have
important clinical implications.
Speaking more broadly, while several critiques have questioned whether stereo-
type threat actually generalizes from the laboratory into real-world testing situations
(e.g., Sackett et al. 2004), when focusing on older adults, we believe that stereotype
threat is responsible for an over-estimation of age-based cognitive decline among
both scholars and practitioners. In some cases, this may lead to crossing a clinical
boundary from normal to abnormal impairment (Haslam et al. 2012). Indeed, :“it is
hard to imagine a social psychological effect that could have greater clinical rele-
vance” (p.782).
17.4 General Discussion
The goal of this chapter was to test the two implicit assumptions underlying neuro-
psychological testing in ageing: test validity and the generalized view of the extent
of age-related decline in cognitive abilities. We presented evidence from the current
literature on the negative effects of age-related sensory decline and age-based ste-
reotype threat on test performance. Our findings challenge these two assumptions,
suggesting that age-related changes may not be as severe as previously suggested.
Namely, age-related sensory decline and stereotype threat were shown to influence
the context of the neuropsychological assessment and lead to an inaccurate measure
of cognitive performance. In extreme cases, their influence may cause false diagno-
sis of pre-dementia, i.e., crossing a clinical boundary from normal to abnormal
impairment. These contextual factors are not only the outcome of laboratory manip-
ulation, but may be present in daily testing of older adults in the clinic or a univer-
sity lab. It is important to account for these factors in order to shape testing
environments appropriate for older adults.
The pair of implicit assumptions appears to be embedded in test administration

and scoring in many of the available tools. Generally, test materials are not format-
ted to meet age-related sensory degradation, and administration protocols specify
neither the sensory context (such as illumination and noise levels) nor the social
context (how to minimize stereotype threat) of the test. In most tests, normative
scores are adjusted separately for each age group to compensate for the expected
age-related decline (e.g., Stroop, WAIS). Simply put, the same score on a neuropsy-
chological assessment may reflect normative performance for 70 year olds, but
flawed performance for 20 year olds, echoing the pair of assumptions. Thus, test
results, coupled with these assumptions, may provide support for ageism, affecting
both the scientific and medical community and the public at large.
The evidence presented in this chapter has implications outside of the clinic/lab.
Consider the office environment. The lighting and the noise level may be challeng-
ing for older employees. Thus, employees may have more difficulties in processing
the written information, and in taking an active part in conversations. The resources
allocated for deciphering the sensory input are not available for further cognitive
processing. As a result, it is more difficult for older employees to utilize the full
potential of their cognitive abilities. In turn, both colleagues and managers may
perceive reduced performance as reflecting internal factors (an attribution
error) − i.e., an age-related cognitive decline − judging older employees more
harshly. This will lead to an atmosphere engendering stereotype threat. Taken
together, daily activities in the office may be perceived by older employees as a test
for cognitive abilities, where they are expected to underperform, and where sensory
conditions place them at a disadvantage. By considering the sensory and social
contexts, employers can improve the quality of work of older employees, extending
their participation in the labour market and improving their quality of life.
Finally, upon reading this chapter, one may be reminded of the seminal book by
Guthrie, “Even the Rat Was White: A Historical View of Psychology” (Guthrie
1976). Guthrie exposed how racist views shaped by studies in the early twentieth
century affected the implementation and analysis of intelligence assessment tools at
that time. Those studies suggested that the tone of skin was directly related to a
decline in cognitive performance, and were guided by implicit assumptions on (1)
test validity and (2) a racially-based decline in cognitive performance. Guthrie dem-
onstrates the devastating implications of such tests by citing the following conclu-
sions of a study by Philips, 1914: “If the Binet tests are at all a gauge of mentality,
it must follow that there is a difference in mentality between the coloured and the
white children. And this raises the question, should the two groups be instructed
under the same curriculum?” (as quoted in Guthrie 1976:55). We hope that we can
avoid repeating history, making the same mistakes in the twenty-first century. If
researchers and clinicians acknowledge the current sensory and social biases of
cognitive testing in older adults, it will set us on a promising path towards the design
of more accurate assessment tools.
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Chapter 18
Introduction to the Section: Against
Ageism
So far, the chapters in this book have provided convincing evidence that ageism is
bad for you.” It is bad for the individual, as it potentially affects wellbeing, quality
of life, social life, sexuality, and the type and quality of health and mental health
services one receives. It is also bad for society at large, as it creates divisions
between generations and potentially establishes power imbalances that can prevent
older adults from realising their full potential (see Chapters 1–17 in this volume). It
is not surprising, then, that in 2016, the World Health Organization received a man-
date to combat ageism (Officer et al. 2016).
The present section contains five chapters on interventions against ageism. The
first four chapters are focused on policy and legal interventions to target ageism,
whereas the latter chapter is a case example of an educational intervention to fight
ageism.
The chapter by Doron, Numhauser-Henning, Spanier, Georgantzi, and
Mantovani (2018; Chap. 19) presents a legal framework for European law to fight
ageism. The chapter starts by describing the slow progression of the field of elder law.
The fact that elder law is a relatively new phenomenon presents an obstacle to protect-
ing older adults’ rights and fighting ageism. Old age is not mentioned as a potential
basis for discrimination in the Universal Declaration of Human Rights, adopted by the
United Nations General Assembly in 1948, nor in any other UN declaration since
then. This hampers the ability of legal authorities to address issues associated with old
age discrimination and the violation of older people’s rights.
The chapter by Mikołajczyk (2018; Chap. 20) provides a specific overview of
the Council of Europe’s approach towards ageism. The author concludes that
addressing the rights of older people through the Council of Europe is a relatively
new and still under-developed phenomenon. Ageism is hardly ever recognized in
L. Ayalon (*)
C. Tesch-Römer (*)

https://doi.org/10.1007/978-3-319-73820-8_18
official documents of the Council of Europe. Like Doron et al. (2018), Mikołajczyk
(2018) argues that the Council of Europe is just beginning its fight against ageism.
The chapter by Georgantzi (2018; Chap. 21) provides a complementary but less
favourable view of ageism and law in Europe by focusing on the European Union’s
approach towards ageism. The author argues that although the EU advocates for a
society for all ages, which is free of discrimination, age categorization remains a
justifiable and acceptable form of inequality. Georgantzi implies that the EU is con-
cerned with population ageing, but equates it with dependency, frailty, and burden,
rather than focusing on the protection of the rights of older adults and ensuring their
equal participation in society.
In contrast to chapters 19-21, which address the macro-level in Europe and point
to the current inadequacy of the system, the chapter by Larsson and Jönsson (2018;
Chap. 22) provides a more local outlook on the fight against ageism by drawing on
Sweden as a case example. The authors propose that the equal rights framework in
Sweden ensures that young people with disability are able to fully participate in
society. Older people with disability, however, suffer from institutional ageism,
which prevents them from obtaining similar rights. The authors argue that older
adults in the third age, who represent the active ageing model, should serve as a
typical group, against which older adults with disability could be compared in order
to improve the long-term care provided to them.
The concluding chapter in this section, by Requena, Swift, Naegele, Zwamborn,
Metz, Bosems, and Hoof (2018; Chap. 23), takes a completely different look at
interventions to target ageism. Drawing from intergroup contact theory, the authors
demonstrate the effectiveness of an educational intervention that brings young and
old people together as members of the same community. The authors outline an
intervention which addresses communication style between the generations as a
way to potentially reduce ageism.
Overall, these five chapters demonstrate that we are only at the beginning of the
journey to combat ageism. Whereas the negative consequences and manifestations
of ageism are well-documented, much less is known about fighting ageism.
Literature on psychological interventions, such as campaigns to raise awareness
about ageism (Mendonça et al. 2016), or educational interventions to improve
knowledge and attitudes about ageism, such as (“Combating Ageism: Change in
Student Knowledge and Attitudes Regarding Aging,” Cottle and Glover 2007)
would be helpful complements to the chapters presented here.
The diversity of theoretical explanations used to account for ageism suggests that
there are multiple pathways to combat ageism. For instance, terror management
theory (Martens et al. 2005) might suggest that disassociating old age from death
and disability could be a useful way to combat ageism. Alternatively, de-sensitizing
people to death and disability could also be an effective tool in the fight against
ageism. Because older adults can be seen as a symbolic or realistic threat to younger
generations (North and Fiske 2012), emphasizing older adults’ contribution to soci-
ety could be another means to combat ageism.
It is important to note that there is still a need to fine-tune the messages delivered
to potentially reduce ageism. Do we want to foster feelings of empathy and pity or
would a message of admiration of older adults be more beneficial? Should we target
knowledge about older adults or attitudes towards older adults? Should we focus on
18 Introduction to the Section: Against Ageism 301
hard laws enforced by legal and political authorities, or should we strive for a bot-
tom-up change in the way we view and behave towards older adults? To date, these
questions have not been comprehensively addressed, but the chapters in this section
introduce some compelling and fresh perspectives.
References
Cottle, N. R., & Glover, R. J. (2007). Combating ageism: Change in student knowledge
and attitudes regarding aging. Educational Gerontology, 33(6), 501–512. https://doi.
org/10.1080/03601270701328318
Larsson, A. T., & Jönson, H. (2018). Ageism and the rights of older people. In L. Ayalon &
Mendonça, J., Mariano, J., & Marques, S. (2016). Lisbon street campaign against ageism: A prom-
ising multi-stakeholder initiative. Journal of Intergenerational Relationships, 14(3), 258–265.
erational roots. Psychological Bulletin, 138(5), 982.
Officer, A., Schneiders, M. L., Wu, D., Nash, P., Thiyagarajana, J. A., & Bearda, J. R. (2016).
Valuing older people: Time for a global campaign to combat ageism. Bulletin of the World
Health Organization, 94(10), 710.
Requena, M. J., Swift, H., Naegele, L., Zwamborn, M., Metz, S., Bosems, W. P. H., & Hoof,
J. (2018). Educational methods using intergenerational interaction to fight ageism. In L. Ayalon
& C. Tesch-Römer (Eds.), Contemporary perspectives on ageism: Vol. 19. International per-
spectives on aging (pp. 383–402). Berlin: Springer.
Chapter 19
Ageism and Anti-Ageism in the Legal
System: A Review of Key Themes
Israel (Issi) Doron, Ann Numhauser-Henning, Benny Spanier,

Nena Georgantzi, and Eugenio Mantovani
19.1 Introduction
This chapter provides an overview of legal frameworks relevant for addressing the
social phenomenon of ageism in Europe. In writing this chapter, we have been inter-
ested in how sources ascribable to law and ageing in Europe can grasp ageism, “a
process of systematic stereotyping and discrimination against people because they
are old” (Butler 1975).
This chapter is one of three others included in this book that are differently
related to legal institutions and legal frameworks which are relevant to ageism in
Europe. The reason for including three different chapters stems from the need to
accommodate the diverse legal regimes and constructions that are available under
different European jurisdictions.
This chapter provides a general overview of the inter-relationships between law,
ageing and ageism including the presentation of some illustrative examples. It
places the overview in the European historical context and discusses specific the-
I. Doron (*)
The Center for Research and Study of Aging, Department of Gerontology, University of
Haifa, Haifa, Israel
A. Numhauser-Henning
Faculty of Law, Lund University, Lund, Sweden
B. Spanier
The Center for Research and Study of Aging, University of Haifa, Haifa, Israel
N. Georgantzi
National University of Ireland Galway, Galway, Ireland
AGE Platform Europe, Brussels, Belgium
E. Mantovani
LTST – Law, Science, Technology & Society Studies, Vrije Universiteit Brussel (VUB),
Brussels, Belgium

https://doi.org/10.1007/978-3-319-73820-8_19
304 I. Doron et al.
matic cases, such as compulsory retirement and empirical studies regarding the
European Court of Human Rights and the Court of Justice of the European Union.
The second chapter (2018; Chap. 20) moves from the general to the specific,
focusing on a central European institution, the Council of Europe. Founded in 1949,
this regional organization promotes human rights in Europe. This chapter discusses
law and ageism through the lens of the Council of Europe’s instruments and bodies:
the European Social Charter, the jurisprudence of the European Court of Human
Rights, and the Council of Europe non-binding “soft-law” means.
The third chapter (2018; Chap. 21) focuses on the European Union. The European
Union operates on a legal basis, the EU Treaty of the functioning of the European
Union (TFEU), and structures that are autonomous and different from that of the
Council of Europe. This chapter broaches ageism under the light of the EU Charter
of Fundamental Rights, of the European Union’s directives and policies on ageing,
and of the case law of Court of Justice of the European Union.
By combining general and more specific legal perspectives, this triad of contri-
butions provides, it is hoped, a resourceful and comprehensive source to understand
how ageism and law interact within the European context.
The present chapter is structured as follows: Part One, describes the develop-
ment of the field of “law and ageing” in Europe from a historic perspective. It
detects in the equality provisions, as rooted in international and European human
rights law, the main place for the (potential) emancipation of older persons from
stereotypes and prejudices. Part Two provides a general overview of ageism and
international human rights law. It describes the current tensions surrounding the
debates around the need for a new specific international convention for the rights of
older persons. Part Three provides specific “case-studies” of the inter-relations
between law and ageism: one – focuses on EU law and compulsory retirement;
two – focuses on a quantitative analysis of case-law from the European Court of
Human Rights (ECoHR) and the Court of Justice of the European Union (CJEU);
and three – draws the attention to existing studies regarding the relationships
between law and ageism on the micro level, and in specific how law and ageism is
perceived by lawyers and older clients.
19.2 Part One – Law and Ageing: A Short History
Before the early 1970s, the area of legal inquiry that is today referred to as “elder
law” or “law and ageing” was virtually unknown in the field of law (Levine 1982;
Bogutz 2008). Equally, the study of the relationships and interconnections between
law, older persons and/or the ageing process was latent in the debates of social ger-
ontologists (Doron 2009). This state of affairs changed dramatically with the emer-
gence, almost 50 years ago, in the United States, of “law and ageing” as an
autonomous field of legal scholarship and practice. The emergence of law and age-
ing as a field of legal studies and practice in the United States in the early 1970s can
be ascribed to three factors: first, the demographic ageing of American population
19 Ageism and Anti-Ageism in the Legal System: A Review of Key Themes 305
and the social changes that this wrought on all fields of life, demanding a social
response; second, the awareness on the part of private bar and private lawyers that
their clients were growingly older. This has pushed lawyers from different branches
of law to “specialise” in the field of elder law. Third, and finally, the academia and
the research community at large realised the opportunity and need to explore this
new field of law. As an outcome of the combination of these three factors, the field
of “elder law” has become recognised as a unique field and expertise in law, in the
United States in particular, with its specific law journals, professional bodies, as
well as new programs and classes have been established within law schools.
Unlike the United States, continental Europe has been much slower in develop-
ing and recognising elder law as a specific field of knowledge within the legal pro-
fession and academic circles (Evrard and Lacour 2012). One could argue – only in
passing, as there is no place to hold this discussion here (Doron 2009) – that this is
due to a combination of the history of the notion of citizenship in Europe, with the
continental-law tradition of universalism which makes it difficult to justify the “sep-
aration” of the rights of older persons from the general law on human rights.
However, from the beginning of the 1990s, a growing body of research has emerged
on the rights of older persons (Doron 2009; Soden and Doron 2012). Today, the
Norma Elder Law Research Environment, developed with the Norma Research
Programme at Lund University, Sweden, is arguably the most well-established
example of a legal laboratory in Europe that concentrates on the legal status and
position of older persons within legal systems and in society (Norma Research
Programme 1996).
Social gerontology was also slow in recognizing the importance of the intercon-
nections between law and ageing. In short, social gerontologists became interested
in elder law when they recongised that the law, for instance, on access to training, to
health, is also part of our culture and understanding of social ageing experiences
(Levine 1982). Since then, a growing body of inter-disciplinary projects has sought
to bring together lawyers and social-gerontologists. These efforts have led to new
approaches and outcomes, such as what is called “jurisprudential gerontology” or
“geriatric jurisprudence” (Doron 2006). These outcomes, while reflecting a very
much “work in progress” situation, testifies to the increasing consensus among
scholars that, on the one hand, the law cannot ignore the ageing of human society
and that, on the other hand, social gerontology, cannot ignore the legal impact and
inter-connections associated with being old. This means that, when exploring and
trying to better understand social phenomena such as ageism one should also look
at and into the ways law incorporates, supports, or attempts to oppose it.
19.3 Part Two Ageism and International Human Rights
A key theme at the intersection of law, ageing, and ageism in Europe concerns the
human rights status of older persons. The aim of this descriptive analysis is to gain a
better understanding of how human rights law seizes ageism. A starting point for
306 I. Doron et al.
discussing ageism from a positive, international human rights law perspective is

arguably the Universal Declaration of Human Rights (UDHR), adopted by the
United Nations (UN) General Assembly in 1948. The Universal Declaration of
Human Rights recognises that all humans are born free and equal in dignity and
rights (art. 1). “Everyone”, continues article 2, is entitled to all the rights and free-
doms set forth in it, “without distinction of any kind, such as race, colour, sex, lan-
guage, religion, political or other opinion, national or social origin, property, birth or
other status.” While arguably, being “old” can certainly be covered under “other sta-
tus” – it is interesting to note that “age” does not specifically appear in this article.
Moreover, ageism can act as a barrier to the enjoyment of the inherent entitle-
ment of all human beings to human rights, such as the right to adequate standard of
living, to health, to access justice, to live free from violence and abuse (OHCHR
2012). The stereotyping and discriminating against individuals or groups on the
basis of their age (Butler 1975) may be “under the skin” of social norms and preju-
dices, but lead to very concrete and overt age discrimination (Chung 2010, p.4;
Herring 2009, p.12). Employers, for instance, who struggle with their own sense of
ageing, may more easily make discriminatory choices in hiring older persons.
In the international human rights system, there is no general legal instrument to
dispel prejudices against older people. However, starting from the 1990s and with
increasing momentum in the last decade, human rights law actors have begun to
study how human rights can combat ageism. In 1996, General Comment (n. 6) of the
Committee supervising, the Covenant on Economic Social and Cultural rights
(IESCR) had clarified that the list of forbidden grounds of discrimination contained
in the core human rights treaties must be interpreted as including age (CESCR 1996);
13 years later, in 2009, the same committee recognised age as a “prohibited ground
of discrimination in several contexts”, e.g., against unemployed older persons in
finding work, in access to training and retraining, and on discrimination in access to
universal old age pension due to place of residence” (our italics, CESCR 2009). In
1989, a different UN body, the UN Human Rights Committee, the body that moni-
tors and receives complaints under the 1966 International Covenant on Civil and
Political Rights (ICCPR), clarified in General comment No. 18 that the non-discrim-
ination clause extends to any pieces of legislation adopted by a State party. While not
mentioning age, the comment indicates that states adopting laws providing, directly
or indirectly, for distinctions on the basis of age can also come under scrutiny of non-
discrimination. Under other UN Conventions, the Committee supervising the con-
vention on the Elimination of all forms of Discrimination against Women (CEDAW)
recognized ageism as a human rights issue in its general recommendation no. 27
when it reminded that States ‘have an obligation to eliminate negative stereotyping
and modify social and cultural patterns of conduct that are prejudicial and harmful
to older women’ (CEDAW 2010, para 36). One year later, in 2011, the UN warned
against the “ingrained stigma and discrimination- the ageism- which many older
people are subjected to” in access to primary care and health prevention (Grover
2011; UN Human Rights Council 2011). The UN Independent Expert on the
Enjoyment of All Human Rights by Older Persons was appointed in 2014. In her
2015 report, she pointed out how “Ageist attitudes still persist throughout the world,
leading to discriminatory practices towards older persons, including in care settings.

Age-based discrimination generates a lack of self-esteem and disempowerment, and
undermines an older person’s perception of autonomy” (Kornfeld-Matte 2015).
Arguments like these have been put forth, more recently, to advocate for a more
affirmative specification of a human rights law (Mégret 2011; Doron and Apter
2010; De Hert and Mantovani 2011; Seanad Public Consultation Committee 2012).
The failure of the existing mechanisms to adequately address ageism at the different
levels and spheres of social life is one of the arguments of the proponents for a new
Convention, which include primarily Latin American and Caribbean States (ECLAC
2007), more recently joined by African and Asian countries. In this debate European
States have remained skeptical (Helpage International 2013).
19.4 P
art Three: The Real Context of Law and Ageism –
Three Examples
After providing a broad overview of elder law in general, and the international con-
text of human rights law and its relevance to older persons, this part offers three
specific examples which are representative of the diverse and complex ways in
which law and ageism interact.
19.4.1 E
xample 1: Ageism, Non-discrimination
and Employment Law in the EU
This section will present a more specific legal framework regarding age discrimina-
tion under the European Union law. From the legal science point of view there is a
special and close connection between ageism and non-discrimination regulation.
The reason for choosing the example of “discrimination” – or discriminatory behav-
ior – is that it is an integral part of most definitions of ageism (Iversen et al. 2009).
Moreover, non-discrimination regulations are important tools to come to terms with
ageism.
In general, equal treatment and non-discrimination regulation play a central role
in today’s legislation. As noted earlier, there is yet no international convention
proper on older persons’ rights in general or against discrimination on the grounds
of (old) age more specifically. However, the right not to be discriminated against on
the grounds of age has been increasingly constitutionalized in the last decades
(O’Cinneide 2015). O’Cinneide delineates how national apex courts, despite the
uncertain status of age discrimination as such in constitutional and international
human rights law, to a certain extent have been willing to review the degree to which
age-based distinctions stand up to constitutional requirements regarding equal treat-
ment and non-discrimination. Already in 1967, age joined sex and race as a ground
308 I. Doron et al.
for discrimination in the United States, and age as a prohibited ground has subse-
quently appeared in the constitutions of countries such as Canada, South Africa and
Finland. In the EU, the Amsterdam Treaty of 1997 (now Article 19 of the Treaty on
the Functioning of the European Union -TFEU) provided new competences for EU
institutions to take measures against discrimination inter alia on the grounds of age.
In its Article 2,1 the EU Charter of Fundamental Rights (which after the Lisbon
Treaty became part of the primary EU law) contains a ban on discrimination con-
cerning, among other grounds, age (Meenan 2007). To date, EU law prohibits dis-
crimination on the ground of age only in the field of employment. Things may
change as the Council of the EU, leveraging on article 21 of the Charter of
Fundamental Rights and article 19 of the Treaty on the Functioning of the European
Union, may adopt a directive on ‘horizontal’ age discrimination that will expand the
age discrimination clause to new areas (European Commission proposal European
Commission Proposal for a Council Directive 2008).
19.4.1.1 Age Discrimination in Employment Under EU Law
In the EU, after the Amsterdam Treaty of 1997, the Council adopted Directive
2000/78/EC, the Employment Equality Directive, a regulation which provoked
interest in the topic of age discrimination in employment among European scholars
(Fredman and Spencer 2003; Meenan 2007; Sargeant 2008; Schlachter 2010;
Hendrickx 2013; Numhauser-Henning and Rönnmar 2015). The Directive includes
a non-discrimination clause on the ground of age among other grounds but also
admits – in its article 6 – the possibility to justify direct age discrimination. In con-
trast to the US, where the Age Discrimination in Employment Act (ADEA) of 1967
is purposefully targeting older workers, the Directive 2000/78/EC is not specific to
old age, but it instead covers discrimination against all ages (Tobler 2015).
However, as the Directive targets the labour market, it is relevant for persons who
are approaching their post-employment years or who are being just above 50 years
of age and older (Julén Votinius 2016). As anticipated, a key provision is article 6,
which provides that differences of treatment on the ground of age ‘shall not consti-
tute discrimination, if, within the context of national law, they are objectively and
reasonably justified by a legitimate aim, including legitimate employment policy,
labour market, and vocational training objectives, and if the means of achieving
that aim are appropriate and necessary.’ In essence, the directive proscribes direct
age discrimination which is not justified by a legitimate aim (article 6.1. provides a
non-exhaustive list of examples) and which is attained by means that are dispropor-
tionate to the aim.
Being open to justification, one important theme in the literature is whether age
discrimination in itself is more acceptable than other forms of discrimination. Age-
based distinctions are not linked to historically embedded patterns of group subor-
dination and thus, do not have a negative impact upon human dignity to the same
degree as do distinctions based on archetypical non-discrimination grounds such as
gender and race (O’Cinneide 2015, p 14). Dagmar Schiek, apart from the ‘common
rationale’ of discrimination law related to ‘ascribed otherness,’ also distinguishes

policy aims related to both the sustainability of future pension claims and the ban’s
dysfunctional nature in relation to hitherto established labour law (Schiek 2015).
These rationales have also been discussed in terms of a ‘double bind’ associated
with the age discrimination ban (Hendrickx 2013; Numhauser-Henning 2015;
Schiek 2011). They include on the one hand, the ‘collective’ interest approach in
terms of social and economic policy planning (such as compulsory retirement but
also active ageing strategies); and on the other hand, the ‘individual’ interest
approach such as the pursuit of freedom of choice and dignity at the individual level.
Macnicol draws attention to the application of Art. 6.1 as an accepted expression
of statistical discrimination. On the one hand, writes Macnicol (Macnicol 2006,
p.11), age as a proxy ‘lumps together a wide range of abilities.’ This, he suggests, is
manifestly unfair, given the great heterogeneity that exists amongst older persons.
On the other hand, ‘age proxies can also be seen as cheap, convenient and quick
methods of decision-making, based upon judgements about working capacity which
are fundamentally correct in the aggregate, even if their use may involve individual
cases of injustice’ (Macnicol 2006, p.11).
This weaker format of the EU ban on age discrimination is an important reason
why age discrimination has been the subject of so many Court of Justice of the
European Union decisions. The balance to be struck between the individual approach
and the collective approach is achieved precisely in the case law of the Court of
Justice of the European Union and here is where the compatibility of age-based
distinctions in national law has been brought to test. In the case Mangold (CJEU,
C-144/04), the Court of Justice of the European Union ruled that ‘the principle of
non-discrimination on the grounds of age must be regarded as a general principle of
Community law’ (paragraph 75). The conceptualization of equality on the ground
of age as a general principle of EU law has been qualified in subsequent decisions,
such as Kücükdeveci (CJEU, C-555/07) and Prigge (CJEU, C-447/09).
Overall, it is possible to say that the Court has remained stable on the position
taken in Mangold, acknowledging the existence of a general principle of non-
discrimination on grounds of age in European Union law. As for the content of the
substance of the discrimination test, however, O’Cinneide’s comment is that the
court has been prone to apply ‘a light rationality’ test accepting justifications such
as policy promoting intergenerational employment, whenever ‘they can be shown to
be rationally linked to the achievements of a legitimate aim’ (O’Cinneide 2015,
p 59). Similarly, Meenan concludes her analysis of the case law of the Court of
Justice of the European Union on age discrimination suggesting that, in practice,
age discrimination in itself has proven a more acceptable ground than other forms
of discrimination (Meenan 2007). For others, the court has applied a lenient propor-
tionality test in relation to issues such as compulsory retirement, and a somewhat
stricter test in cases involving pension reforms and pension-related benefits
(Schlachter 2011; Kilpatrick 2011). Fudge, who distinguishes three different sets of
proportionality tests, argues that the strictest test applies to occupational require-
ments (Fudge 2016).
310 I. Doron et al.
A ban on age discrimination is thus per se an example of ‘anti-ageist’ legislation.

What makes the EU ban double-edged is the scope for justification of direct dis-
crimination. The ‘anti-ageist’ effect of the ban relies on the interpretation of this
scope according to Article 6.1 in the Employment Equality Directive. At the domes-
tic level, ageism in other fields (e.g. finances) has not been put to the test in case law
to any greater extent, despite empirical studies revealing its existence (Meenan
2007, p 282). However, non-discrimination regulation is typically ‘elitist’ in charac-
ter – meritocracy is generally speaking the hidden norm – and truly anti-ageist prac-
tices can be said to often require a working life adapted to older workers’ special
needs, such as flexible work arrangements and so on (Ilmarinen 2001; Numhauser-
Henning 2013). In contrast with disability discrimination, accommodation is not an
integrated requirement concerning age discrimination. If and when positive action
elements exist, these are often related to age as a traditional stratifier in labour law
and standard employment contract perceptions – be it seniority rules in redundancy
situations or seniority wage-setting (Foubert et al. 2013; Numhauser-Henning
2015). Age-related active measures are known to exist, however, by means of both
legislation and collective bargaining (ter Haar and Rönnmar 2014; Rönnmar 2015).
19.4.1.2 The Case of Compulsory Retirement
One could ask how is it possible that what appears to be age discrimination in
employment may be legitimate and proportional decision-making in matters of per-
sonnel management. An important example of the double bind conundrum is com-
pulsory retirement.
Pension system sustainability is one of the great challenges in relation to an age-
ing population for EU Member States. Public standard pension schemes were
mainly developed during the twentieth century as a response to standard employ-
ment and traditional labour law (Freedland 2013; Strauss 2013). In the case law of
the European Union Court of Justice, e.g., Palacios de la Villa (CJEU, C-411/05),
Age Concern England (CJEU, C-388/07), Rosenbladt (CJEU, C-45/09), and
Hörnfeldt (CJEU, C-141/11), the question that arises is whether acceptance of con-
tinued compulsory retirement is justified under article 6.1 of the Employment
Equality Directive or whether the age discrimination ban instead should be uphold.
In the case Hörnfeldt, the Swedish government argued for yes, ‘the 67-year rule [for
compulsory retirement]’, says Sweden ‘seeks, firstly, to avoid termination of
employment contracts in situations which are humiliating for workers by reason of
their advanced age’. And added that ‘the age-limit reflects the political and social
consensus which has long prevailed between the social partners’ (Hörnfeldt, para-
graphs 26 and 27). The court limited itself to observe that ‘automatic termination of
the employment contracts of employees […]has, for a long time, been a feature of
employment law in many Member States and is widely used in employment relation-
ships. It is a mechanism which is based on the balance to be struck between politi-
cal, economic, social, demographic and/or budgetary considerations and the choice
to be made between prolonging people’s working lives or, conversely, providing for
early retirement’ (Hörnfeldt, paragraph 28 – citingthe Rosenbladt case [CJEU,

C-45/09], paragraph 44) where it was first formulated).]
As indicated above, a good number of scholarly articles have concentrated on the
proportionality test (i.e. a key legal principle which limits the Court’s intervention)
applied and its strictness in comparison with other cases. Another set of articles has
concentrated on understanding the why (e.g. the reasons and rationale) of this con-
tinued practice of compulsory retirement (Schiek 2011; Suk 2012; Numhauser-
Henning 2015). The Court of Justice of the EU has accepted the following as
legitimate aims: intergenerational fairness in terms of access to employment, pre-
vention of humiliating forms of employment termination, and a reasonable balance
between labour-market and budgetary concerns. The existence of a right to a pen-
sion has also played a significant role in the continued acceptance of compulsory
retirement, though rather at a system level than in the individual case (CJEU,
C-411/05 and C-141/11). The Court of Justice of the EU’s acceptance on grounds of
intergenerational fairness contrasts with economic research (of both a theoretical
and empirical nature), which emphasizes the ‘lump of labour fallacy,’ and opposes
propositions that compulsory (or premature) retirement schemes will help to com-
bat youth unemployment or that older workers crowd younger workers out of the
labour market (Dewhurst 2013). Behind the humiliation argument lies the fact that
in upholding the ban against age discrimination, dismissal cases would be all about
ability – or rather lack thereof. An extrapolation of this line of arguments is the risk
of weakening European-style employment protection altogether – and, moreover,
furthering flexible employment (Numhauser-Henning 2013, 2015). This line of
argument can be said to be confirmed by the UK’s experience after abolishing com-
pulsory retirement as the general rule (Manfredi and Vickers 2016). In the UK, the
continued opening for an ‘Employer-justified Retirement Age’ is an issue of con-
cern – not least in a university context (Barnard and Deakin 2015; Dewhurst 2016).
In an overall perspective – and despite the Court of Justice of the EU’s acceptance
hitherto – the practice of compulsory retirement is no doubt losing ground in the EU
Member States.
19.4.2 Example 2: Law, Ageism, and Courts
Courts, and case-law, play an important role in the development of jurisprudence in

the field of ageism and elder law. However, and despite the growing interest and
awareness to ageing and ageism within the European legal system and within inter-
national human rights bodies, not much empirical research has been conducted in
this field. While specific cases – as presented in the previous sections– serve as
precedents of legal policy, questions still remain regarding the broader legal work
done by courts when it comes to ageism or older persons. In this section, two empir-
ical studies regarding case law and ageism will be presented: The first, from the
European Court of Human Rights; and the second from the Court of Justice of the
European Union.
312 I. Doron et al.
The importance of empirical studies of court rulings is underlined in legal theory,

which sees courts as social institutions, playing an important role as a tool for social
change. Both in North America and Europe, courts have been used as strategic tools
by individuals or human rights organization in order to promote the rights of minor-
ity or excluded social groups. It is against this backdrop and from this symbolic
perspective that both the European Court of Human Rights as well as the Court of
Justice of the European Union are analysed in the following paragraphs.
19.4.2.1 Empirical Study of the European Court of Human Rights
The European Convention on Human Rights does not explicitly address the rights
of older persons as such. This is in-and-by itself an interesting point: older persons,
as a unique social group – are “invisible” in Europe’s key human rights instrument.
To the extent that older people are to enjoy human rights, they need to find “aus-
pices” within the context of the convention’s general articles. It is not surprising,
then, that to date the sphere of elder rights has practically not been studied at all
within the context of the European Court of Human Rights. Until recently, even the
Court itself did not address elder rights as a unique legal subject. This changed only
in the last years, when the Court published a document in which it reviewed, in an
unsystematic manner, the main judgments dealing with the subject.1
A recent study by Spanier et al. (2013), on which the following lines are based,
offers a general, descriptive investigation of the extent to which the rights of older
persons are discussed in this Court. The methodology of the research included an
empirical analysis of the case law of the European Court of Human Rights, retriev-
ing varied background data about judgments involving older persons from the
Court’s website (HUDOC).2 Due to limited time and resources, a stratified random
sampling of 226 judgments were analyzed for this study. In general, the number of
judgments delivered to persons aged 60 or above, out of all judgments delivered by
the Court in the same years, are represented in percentage in the following graph
(Fig. 19.1).
The period of time under scrutiny corresponds to the years following the entry
into force of protocol 11 (1998), which introduced a reinforced judicial mechanism,
allowing any individual claiming to be the victim of a violation of the Convention
to bring a complaint directly to the European Court of Human Rights. After an ini-
tial stage in which an increase in applications by older persons was registered, in
line with the general increase that followed the entry into force of Protocol 11, the
relative rate of older persons’ applications stabilized; an average of 11.9% of judg-
ments were delivered to older persons throughout the period 2000–2010.
1
Elderly People and the European Convention on Human Rights, available at: http://www.echr.
coe.int/Documents/FS_Elderly_ENG.pdf (Last visited November 2014).
2
Available at:
http://www.hudoc.echr.coe.int/sites/eng/Pages/search.aspx#{“documentcollectionid2”:[“GRA
NDCHAMBER”,”CHAMBER”]} (Last visited November 2014).
14.8 15.4 15.9

14.5 14.0 13.8
12.2 11.4
4.3
2.4 1.6
2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010
Source: Spanier, Doron, & Milman-Sivan, 2013: pg. 411.
Fig. 19.1 Percentage of judgments given to older persons in relation to all the judgments made in
each year (Source: Spanier et al. (2013): pg. 411)
These findings can be interpreted in different ways. Considering that older per-
sons are relatively poor and potentially more disabled, accessibility to the legal
systems is more complex for this than for other age groups. Hence, these data can
be interpreted positively, in spite of difficulties, older persons do reach the European
Court of Human Rights. On the other hand, one must recall that Europe has the larg-
est older population in the world (160 million), about 20% of the entire population
of Europe (approximately 800 million) (UN Secretary General 2009). Hence, the
percentage of judgments dealing with older persons in Europe is still lower than the
relative percentage of older adults in the population.
In a second phase, the study on older persons and the European Court of Human
Rights looked beyond the mere number of applications into the substantial legal
issues raised by older persons. For an application to be accepted to the Court, the
applicant must prove that the act in question violates one (or more) of the articles of
the Convention. In this study, we examined the main provisions mobilized in Court
in older persons’ applications. The provisions that were mostly mobilized in appli-
cations lodged by older persons were:
First Type of Cause: Article 6, Right to a Fair Trial The largest number of cases
brought to the Court by older persons activate article 6. The Court has heard under
this article cases in which the reasonable time to obtain justice and redress, the
accessibility to legal systems, and the failure to enforce judicial decisions were at
stake. In the case of Romanika v. Poland of 2006 (ECtHR Application no. 53284/99),
the applicant, aged 78, took Romania to the Strasbourg court after lamenting the
excessive length of the civil proceeding he had been involved in: some 13 years, for
the dissolution of a co-ownership. The Court, “having regard to the applicant’s age,”
ruled that it could “not accept the Government’s opinion that special diligence was
not called for in the present case” (paragraph 62).
Second Type of Cause: Protocol 1, Article 1, Right to the Enjoyment of

Possessions this category comprises cases dealing with claims of older persons
regarding the right to the enjoyment of possessions. According to the Court’s judg-
ment, this is a comprehensive right, including not only property rights, but also the
rights to a salary, welfare payments, pension rights (Harris et al. 2009).
314 I. Doron et al.
18
Art - 8,10,11 23
Art - 2,3,5
Protocol - 1(1) 159 70
Art - 6(1)
Source: Spanier, Doron, & Milman-Sivan, 2013: pg. 413.
Fig. 19.2 Distribution of number of cases according to main articles (Source: Spanier et al.
(2013): pg. 413) (In many cases, Section 6(1) is only part of the application. The applications join
it onto other sections, which, they believe, were violated according to the Convention. It should be
noted that, because some cases overlap, the number of judgments described in the table is larger
than the sample number of 226. Therefore, the numbers stands for the cases and not percentages)
Third Type of Cause: Articles 2, 3, 5, Breach of the Right to Life and

Liberty The sections in this type of cause usually deal with loss of life (Frederic
2007), caused by the state (Gandaloyeva v. Russia (2008) ECtHR Application no.
14800/04), or by the police (Ramsahai and others v. The Netherlands (2007) ECtHR
Application no. 52391/99). What emerges from this case law is that in some cases
older persons are themselves victims of death or damage caused by poor hospital
conditions and/or inappropriate treatment, involuntary transfer (article 2), inhuman
or degrading punishment or treatment (article 3), deprivation of liberty or confine-
ment (article 5) (Fig. 19.2).
19.4.2.2 A
n Empirical Study of the Court of Justice of the European
Union
Similar to the previous study, the research on the Court of Justice of the European
Union (CJEU) delves on cases drawn from the court’s database, obtained by typing
search keywords (e.g. elderly, senior, old etc.), and by screening for cases relevant
for the rights of older persons (for a detailed description of the methodology see
Doron 2013). As a result, 123 cases were analyzed, covering a period of time from
1994 to 2009.
Almost half the cases (58/47.2%) pertained to “Social Policy” issues. e.g. calcula-
tion of the pension rights (39%) and equal treatment for men and women (31.7%,
while the two other major legal areas were free movement of persons (29/23.6%) and
social security for migrant workers (26/21.1%). Only very few elder rights cases
involved issues like Competition (3 cases), or Principles of Community Law (1 case).
The vast majority of cases involved pensions: either state funded pensions (61/49.6%)
or employer-based occupational pensions (36/29.3%). The rest of the cases were
mostly about age discrimination, mandatory retirement or attendance/home care (all
of them 6 cases each). There were only 2 cases involving health care issues, and one
case involving the regulation of nursing homes. Overall, a “typical” elder rights’ case
discussed under the Court of Justice of the EU is likely to be dealing with pensions’
rights legal issues around its calculation or gender equality in pension treatment.
On the escort of this statistics, one could suggest, on the one hand, that the
amount of elder rights’ cases brought before the Court of Justice of the EU is very
low compared to the overall case load (more than 6000 throughout the relevant pre-
iod). When they arrive at the Court of Justice of the EU, the focus is around eco-
nomic issues (pensions) or discrimination in treatment on the ground of sex Major
legal issues in the field of elder rights such as patients’ rights, health-care, institu-
tional or community-based long term care, housing or employment – are almost
non-existent.
On the other hand, within these limited numbers of cases and narrow scope of
legal decisions, the outcomes are encouraging. In the majority of the cases, the court
rules in favor of older persons. It seems that there is significant awareness for the
illegality of sex-discrimination in old age and of the illegality of governments’
attempts to hinder the pension rights of older Europeans. In the context of specific
countries, such as Germany or Belgium, there is a strong awareness and usage of
local courts to the Court of Justice of the EU role.
19.4.3 Example 3: Ageism, Lawyers and Older Clients
Our final example is focused on empirical studies regarding the ageist (or anti-
ageist) experiences of lawyers, judges, and older clients. In general, it could be
stated that in Europe, there is a very small and limited body of direct empirical
research on ageism within the legal system (e.g. lawyers, judges) or from the older
persons’ perspectives on the legal system. In Israel, several small scale studies have
been conducted in these fields. One example can be found in a small scale quantita-
tive study measuring ageism among lawyers (Untzik-Heilbrun and Or-Chen 2014).
This study found that while their general knowledge on aging (using PFoAQ) was
low, the level of ageist attitudes of lawyers in Israel (based on a convenience sample
of 225 Israeli lawyers) was better (less-ageist) compared with Israeli professionals
in the medical fields (e.g. nurses), but worse (more-ageist) compared with Israeli
travel-agents.
Another example can be found in an Israeli case-study analysis regarding the
narrative construction of old age in an Israeli case involving the legality of nursing
home contract (Doron 2012). This study found that one can find in the rhetoric of
the courts a combination of both stereotypical negative depiction of old age, as well
as a non-ageist, an emancipatory and empowering picture of older persons as auton-
omous and independent agents. Finally, another small scale study in Israel looked
into the experience and attitudes of older persons with regards to the legal system
(Segal et al. 2014). This quantitative study (based on a convenience sample of 219
older Israeli – 60 years old and above) found that in general, the attitudes of older
persons towards the Isreali legal system were negative. However, in a qualitative
study regarding the accessibility of the courts to the older population in Israel, the
participants described how judges gave them special respect once in the court room
due to their old age (Ben-Eliezer and Doron 2011).
316 I. Doron et al.
19.5 Concluding Remarks
This chapter has provided an overview of the field of law, ageing and ageism; a
general description of existing international norms in the field of ageism; and three
specific examples on how law and ageism inter-relate. This chapter joins two other
chapters in this book (2018, Chaps. 20–21) which together provide a descriptive
analysis of how European legal frameworks are relevant for older persons in gen-
eral, and how they can potentially assist in combating ageism in particular.
This general descriptive picture provides key considerations and recommenda-
tions for future research. It seems that overall there is relatively limited awareness
to ageism and to “older persons” as a unique and distinguished social group within
European jurisprudence. Therefore, there is a need for more research and debate on
the impact that “elder-specific” mechanisms or initiatives, such as the complaints
instigated by association and heard by the European Social Committee, could have
on the perception of ageism and discrimination on the ground of age. Moreover,
there is a lack of empirical research about how national courts of law respond to the
problem of ageism. The methodology and the research offered in this chapter on the
case law of the European Court of Human Rights could be replicated in the context
of the Council of Europe’s European Social Charter as well as national constitu-
tional courts. Empirical research in the field of law, ageing and ageism could also be
more targeted and, for instance, embrace real life experiences. In this connection,
one notes an almost total a lack of empirical studies regarding the attitudes of law-
yers towards older clients, and regarding experiences of older clients in their
encounter with lawyers and with the legal system. More empirical research is
needed in this field in order to better understand the inter-connection between law
and ageism and to allow for the development of a theoretical framework that will
explain this reality.
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Chapter 20
The Council of Europe’s Approach
towards Ageism
Barbara Mikołajczyk
20.1 Introduction
Robert Butler coined the term ageism almost 50 years ago to describe symptoms
and roots of unequal and degrading treatment of older persons (Butler 1975, 1969).
Ageism in the twenty-first century continues to be a rampant and widespread phe-
nomenon. Epidemic ageism (Palmore 2001, p. 574) is believed to affect more than
164 million seniors living in Europe (Age UK 2011), which means that a signifi-
cantly higher proportion of Europeans are exposed to ageism than to sexism or rac-
ism (Grześkowiak 2012). Not surprisingly, ageism is becoming a question of
common concern in European forums, including the Council of Europe—an inter-
governmental organization of 47 European countries, including the 28 European
Union member states.
According to Article 1 of the Statute of the Council of Europe, one of the main
aims of the Council is “to achieve a greater unity between its members for the pur-
pose of safeguarding and realising the ideals and principles [through] discussion of
questions of common concern and by agreements and common action in … the
maintenance and further realisation of human rights and fundamental freedoms”
(Council of Europe 1949). This provision clearly indicates that the Council of
Europe is a forum for discussion in which democratic and human rights standards
are worked out. While it does serve as a platform for discussion, the Council, unlike
the European Union, does not have at its disposal any strict (financial) sanctions. It
does, however, have some organizational sanctions, such as suspending the rights of
representation stipulated in Article 8 of the Statute.
The substantial legal output of the Council of Europe bodies and the establish-
ment of mechanisms controlling and monitoring the fulfilment of obligations a rising
B. Mikołajczyk (*)
Faculty of Law and Administration, University of Silesia, Katowice, Poland

https://doi.org/10.1007/978-3-319-73820-8_20
322 B. Mikołajczyk
from human rights treaties makes it possible to speak of a Council of Europe “mega-
system” of human rights protection (Madsen 2007, p. 154), covering over 820 mil-
lion people in Europe, including older persons. For this reason, the Council of
Europe appears to be a legitimate forum for taking up the issues of ageing, the status
of older persons and, finally, ageism, because, as social challenges, they fully match
the goals of this organization. Ageism is assuredly a very arduous matter for inter-
national lawmakers, more so even than racism and sexism. When working out stan-
dards for the protection of rights of older persons, the Council of Europe bodies
should take into account not only cultural, economic, and social differences between
groups living in member states, but also the various concepts, forms, and symptoms
of ageism, which are quite often imperceptible at first glance.
In this chapter, I examine the degree of interest in ageism among Council of
Europe members, and the degree of interest in its elimination through the Council
of Europe forum. I also examine the interpretation of the concept of ageism by vari-
ous Council of Europe institutions. Finally, I explore the Council’s willingness and
ability to eliminate or at least mitigate ageism effectively.
It may be assumed that the Council of Europe has appropriate instruments with
which to fight ageism, but these tools appear to be scattered across its various bod-
ies. That is why, in order to identify the Council’s potential to fight ageism, it is first
necessary to extract these tools and examine them separately. Second, taking into
account the thousands of documents issued by the Council’s many bodies, it is also
necessary to single out relevant acts for examination. As a result, this chapter is
divided into two parts. The first is a short description of the selected Council of
Europe institutions and their competences. The second is dedicated to the Council
of Europe’s output on the subject of the rights of older persons, including treaties
and not legally binding acts.
20.2 Council of Europe Institutions Relevant to Ageism
The rights of older persons and their protection from ageism is increasingly to
become a subject of interest to various Council of Europe institutions. Generally,
most of the Council of Europe bodies have the power to take on the problem of age
discrimination, stereotypes of older persons, and ageism. However, this chapter
focuses mainly on the current outputs of the Parliamentary Assembly and the
Committee of Ministers, which are supported by their advisory committees (Bond
2010), and on the work of the main treaty bodies—the European Court of Human
Rights and the European Social Committee.
The Parliamentary Assembly is a deliberative body consisting of representatives
from national parliaments. The most important European human rights issues are
discussed in the Parliamentary Assembly. According to Article 29 of the Statute, the
Parliamentary Assembly is entitled to issue resolutions embodying recommenda-
tions and proposals for discussion to the Committee of Ministers. This happens
quite often in response to current political and social issues.
20 The Council of Europe’s Approach towards Ageism 323
Composed of the foreign ministers of all the member states (in accordance with
Articles 13–14 of the Statute), the Committee of Ministers is the main decision-
making body. Its decisions are embodied in legally binding conventions or in the
form of recommendations addressed to governments. The Committee of Ministers’
recommendations are usually reactions to previous initiatives of the Assembly
(Świtalski 2009). According to Article 15 of the Statute, at the recommendation of
the Parliamentary Assembly or on its own initiative, the Committee of Ministers is
competent to consider actions required in order to further the aim of the organiza-
tion, including the conclusion of conventions or agreements, as well as the adoption
of common policy. In addition, the conclusions issued by the Committee may take
the form of recommendations to the governments of member states, and the
Committee may monitor the member states’ actions with regard to such
recommendations.
The Council of Europe Commissioner for Human Rights is another institution
relevant to the problem of ageism. The Commissioner is an independent body with
the objective of promoting respect for human rights in the member states (Sivonen
2012). Among other initiatives, the Commissioner’s awareness-raising activities are
crucial to the fight against ageism. The situation of older adults, including age-
related aspects of issues such as housing, poverty, and institutional care, are within
the scope of the Commissioner’s interest. Thomas Hammarberg, who was
Commissioner in 2006–2012, placed special attention on the situation of older
adults in Council of Europe member states in the context of an information cam-
paign against elder abuse and other symptoms of ageism. In his country reports and
“Human Rights Comments” he referred to the dilemmas of “whistle-blowers”
(Jones and Kelly 2014) and the adoption of relevant legislation to better protect
personnel working in various types of institutions for older persons when reporting
poor conditions or abuses (Council of Europe Commissioner for Human Rights
2011). He branded bad practices and harmful legislation and pointed out successful
initiatives such as the Irish NGO programme, “Older & Bolder”, aimed at identify-
ing negative stereotypes against older adults (Cantillon and Vasquez del Aguila
2011; Hammarberg 2012). The steps taken by the Commissioner for Human Rights,
as well as the potential for future steps, contribute to shaping European awareness
about the rights of older persons and the threats of ageism.
Another group of institutions are those established by virtue of treaties ratified by
the Council of Europe member states. They are not the Council of Europe’s organs
as such, but they are firmly placed within the structure of the Council of Europe.
First, the European Court of Human Rights, an international court established in
1959, rules on applications by individuals or states with allegations of violations of
the civil and political rights set out in the European Convention on the Protection of
Human Rights and Fundamental Freedoms (European Convention on Human
Rights). The Court’s case-law makes the Convention a powerful living instrument
for meeting new challenges in Europe.
Two other independent committees should be noted. The European Committee
of Social Rights evaluates legal and practical steps taken by the state parties to the
European Social Charters and their conformity with the provisions of these treaties.
324 B. Mikołajczyk
The Committee of Social Rights also adopts conclusions on national reports submit-
ted by states. If a member state ratifies a particular protocol, the Committee is also
able to consider collective complaints submitted by civil society organizations and
to make decisions based on these complaints.
Finally, the main competence of the European Committee for the Prevention of
Torture and Inhuman or Degrading Treatment or Punishment (the Committee for the
Prevention of Torture)—a non-judicial mechanism existing alongside the judicial
mechanism of the European Court of Human Rights—is to visit places of detention,
such as prisons, police stations, psychiatric hospitals, and other closed institutions,
to assess how individuals deprived of their liberty are treated. After each mission,
the Committee sends a detailed report to the state concerned, containing the
Committee’s findings, recommendations, comments, and requests for information.
The institutions listed above were established on a variety of legal bases, and
have different natures and competences. Regardless of these differences, they have
a common goal of facilitating economic and social progress, achieving greater unity
between Council of Europe members, ensuring the protection of human rights, and
achieving the ideals and principles that constitute the common European heritage
(Table 20.1).
20.3 Treaty Law
The main way to harmonize and unify human rights standards in Europe is for states
to adopt treaties in the Council of Europe forum. Benoît-Rohmer and Klebes (2005)
state that, “by creating a common legal area, they make the member states more
cohesive—democratically, socially and culturally” (p. 85). As a result, over 200
treaties and additional protocols have been adopted through the Council of Europe
forum. The treaties ideally help member states cooperate on many sensitive issues,
including ageing and ageism. However, no convention referring to the elimination
of ageism has been adopted at the Council of Europe forum, and no treaty has yet
explicitly discussed the rights of older persons or referred to the fight against
ageism.
20.3.1 T
reaties Protecting the First Generation of Human
Rights
The principal Council of Europe treaty, the previously mentioned 1950 European
Convention on Human Rights (Council of Europe 1950), and its additional proto-
cols, form what is known as the first generation of human rights, being essentially
linked with dignity, liberty and participation in political life. Rights belonging to
this generation are more of a civil and political nature and include, among other
things, the right to life, a ban of torture and degrading treatment, equality before the
Table 20.1 European institutions competent to take action against ageism

Body Legal basis Status Members Selected competences
Parliamentary Statute of the Statutory Serving as a platform
Parliamentarians
Assembly Council of organ for discussion; issuing
from the member
Europe of states resolutions; inspiring,
1949 proposing, and helping
to shape new national
laws
Committee of Statute of the Statutory Foreign ministers Acting as a “guardian”
Ministers Council of organ of the member of the fundamental
Europe of states or their values of the
1949 deputies organization;
monitoring member
states’ compliance;
developing international
law through
conventions; adopting
recommendations and
resolutions; supervising
states’ implementation
of the European Court
of Human Rights’
judgements
Commissioner Resolution Independent “Eminent Fostering the effective
for Human (99) 50, personality of a observance of human
Rights adopted by the high moral rights; assisting member
Committee of character having states in implementing
Ministers on 7 recognised human rights standards;
May 1999 expertise in the promoting education in
field of human and awareness of human
rights” according to rights; taking part in
Article 10 of the proceedings before the
Resolution (99)50 European Court of
Human Rights
European Court European Treaty body Independent judges Issuing judgements and
of Human Rights Convention on decisions in cases
the Protection submitted by individuals
of Human against member states;
Rights and issuing judgements in
Fundamental inter-state cases;
Freedoms of interpreting the
1950 European Convention
on Human Rights
(continued)
326 B. Mikołajczyk
Body Legal basis Status Members Selected competences
European European Treaty body Independent Monitoring
Committee of Social Charter experts implementation of the
Social Rights 1961 1961 European Social
Revised Charter, its additional
European protocols, and the 1996
Social Charter Revised European
of 1996 Social Charter;
examining states’
reports and adopting
conclusions; considering
collective complaints
and issuing decisions
European European Treaty body Independent Visiting member states
Committee for Convention for experts on a periodic basis to
the Prevention of the Prevention assess how individuals
Torture and of Torture and deprived of their liberty
Inhuman or Inhuman or are treated; making
Degrading Degrading observations, public
Treatment or Treatment or statements, and
Punishment Punishment of recommendations;
(European 1987 preparing reports;
Committee for setting up standards
the Prevention of
Torture)
law, the right to fair trial, the prohibition of slavery, freedom of speech and religion,
and voting rights (Vasak 1977). The Convention refers to the rights and freedoms of
“everyone” and does not contain any specific reference to the rights of older per-
sons, or even to age discrimination, which is inextricably linked to ageism.
Article 14 of the Convention on Human Rights, which prohibits discrimination,
does not explicitly specify age for non-discrimination. It states: “The enjoyment of
the rights and freedoms set forth in this Convention shall be secured without dis-
crimination on any ground such as sex, race, colour, language, religion, political or
other opinion, national or social origin, association with a national minority, prop-
erty, birth or other status.” However, the last premise of “other status” suggests that
no-one shall be discriminated against on any other ground.
It is also easy to notice that this provision has a non-autonomous character, which
means that it is tied only to the rights contained in the European Convention on
Human Rights and its additional protocols. Unfortunately, ageism also affects peo-
ple in spheres beyond the scope of the Convention—that is, in social areas not cov-
ered directly by this treaty. Protocol No. 12 to the Convention (Council of Europe
2000a) has removed this limitation and now it establishes a general standard of
non-discriminatory treatment by public authorities (Martin et al. 2015), but it failed
to expand the list of premises prohibiting discrimination. It was explained that fur-
ther inclusion was considered unnecessary from a legal point of view, because the
list of non-discrimination grounds is not exhaustive (Council of Europe 2000b,
para. 20). It was also proved in the case Schwizgebel v. Switzerland considered by
the Court (European Court of Human Rights 2010a). In this case, the author of the
complaint was a 47-year-old single woman who, due to her age, had been refused
permission to adopt a child. The Court, invoking the principle of the best interest of
a child, did not find a violation of Article 14 in connection with Article 8 of the
European Convention on Human Rights (respect for private and family life) but it
finally considered age as a premise covered by Article 14. This case should be rec-
ognized as exceptional, because the European Court of Human Rights tends to be
cautious about issuing judgements referring solely to age. When the Court does
refer to an applicant’s age, it is usually in combination with questions of health and
conditions of detention, procedural safeguards, or gender discrimination (De Pauw
2014). The case of Schwizgebel v. Switzerland did not refer to ageism, but the rec-
ognition of age as a separate premise may be the first step toward a deeper consid-
eration of age-related issues, including ageism, by the Court. It should be
remembered that the European Court of Human Rights might, within the framework
of its dynamic interpretation of the European Convention on Human Rights
(Dzehtsiarou 2011), refer to ageism as a source of discrimination or as a unique or
special form of discrimination. Nevertheless, in the Tyrer v. United Kingdom ruling
the Court described the Convention as “a living instrument, which must be inter-
preted in the light of present-day conditions” (European Court of Human Rights
1978). Moreover, in the judgement of 13 June 1979, Marckx v. Belgium, the Court
stated that member states are obliged to provide effective and reasonable possibili-
ties to their citizens to benefit from the Convention (European Court of Human
Rights 1979). The doctrines set out in these rulings allow the expectation that vic-
tims of ageism will not be excluded from the protection offered by the European
Convention on Human Rights. However, it appears that currently compared to vic-
tims of racism and sexism, a person suffering from any form of ageism is put at a
disadvantage in asserting his or her rights (Wintemute 2004; Meenan 2007;
Mikołajczyk 2013).
Because “age” is not listed among the premises, older Europeans are often not
aware of the possibilities provided by the Convention. Despite quite a significant
number of older (over 60) complainants submitting applications to the European
Court of Human Rights, it is unclear whether they have submitted claims because
they feel that their human rights were violated exclusively due to their age (Spanier
et al. 2013; Mikołajczyk 2013). Moreover, the concepts of ageism and even age
discrimination have never appeared in claims submitted to the Court in obviously
“old age related” cases. These include the involuntary transfer of an older person
from one care home to another, as in Watts v. the United Kingdom (European Court
of Human Rights 2010b); forced placement in a nursing home, as in H. M. v.
Switzerland (European Court of Human Rights 2002a); and the limitation of night-
time care in the case of McDonald v. the United Kingdom (European Court of
Human Rights 2014). Other cases include the divestiture of individuals of their legal
capacity, as in X and Y v. Croatia (European Court of Human Rights 2011a); the
insufficiency of old-age pensions to maintain an adequate standard of living, as in
328 B. Mikołajczyk
Larioshina v. Russia (European Court of Human Rights 2002b) and Budina v.

Russia (European Court of Human Rights 2009); and poor hospital conditions,
inappropriate treatment, or negligence by nursing home staff, as in Volintiru v. Italy
(European Court of Human Rights 2008a) and Dodov v. Bulgaria (European Court
of Human Rights 2008b).
However, this is not to say that the jurisprudence of the European Court of Human
Rights does not contribute at all to limiting ageism in the Council of Europe member
states. For example, in the case Heinisch v. Germany, the Court found a violation of
Article 10 of the European Convention on Human Rights (freedom of speech) and
argued in its judgement, among other things, that the information provided by the
applicant (a nurse reporting on poor conditions in a geriatric nursing home where
she had been employed) had been disseminated in the public interest, which ranked
over the employer’s interest (European Court of Human Rights 2011b). This case
should be considered in the context of the protection of whistle-blowers, which was
revealed by the Council of Europe Commissioner for Human Rights.
Obviously, this judgement is significant for the fight against elder abuse. It has
also become an important element in the campaign to raise awareness of the situa-
tion of older persons and, as a result, is important to the anti-ageism campaign.
When discussing elder abuse, we should also take into consideration the
European Convention for the Prevention of Torture and Inhuman or Degrading
Treatment or Punishment of 1987 (Council of Europe 1987). Although this
Convention does not refer directly to older persons, its essence is to protect people
placed not only in prisons (some of whom might be older adults), but also in other
institutions where people are de facto deprived of their liberty. As mentioned in the
beginning of this chapter, the European Committee for the Prevention of Torture,
established on the basis of Article 1 of this Convention, organizes visits to various
places of detention in the member states, including hospitals, psychiatric hospitals,
and care centres, in order to assess how individuals placed in such institutions are
treated. To date, the notion of ageism has not appeared directly in reports, standards,
or conclusions of this Committee. However, the Committee does take into account
the situation of older prisoners and older patients of psychiatric establishments. For
example, in the Committee’s standards, revised in 2015 (European Committee for
the Prevention of Torture and Inhuman or Degrading Treatment or Punishment
2015a), referring to involuntary placement in psychiatric establishments, the
Committee stresses the patients’ right to privacy and the needs of older patients in
this sphere, especially in relation to personal hygiene. The Committee reproached
many practices encountered during the country visits in relation to older persons,
which might have been rooted in intentional or implicit ageism. For example, the
Committee observed that the practice in “some psychiatric establishments of con-
tinuously dressing patients in pyjamas/nightgowns is not conducive to strengthen-
ing personal identity and self-esteem; individualisation of clothing should form part
of the therapeutic process” (European Committee for the Prevention of Torture and
Inhuman or Degrading Treatment or Punishment 1998, sec. 34).
It is also worth mentioning this Committee’s questionnaire for visits to social
care institutions (European Committee for the Prevention of Torture and Inhuman
or Degrading Treatment or Punishment 2015b). The questionnaire does not have a

legal, but rather a practical nature, containing a long list of questions that may con-
tribute to the identification of ageism. The checklist includes such questions as: Is
there ill-treatment by staff (physical and/or verbal)? Is there inter-resident violence?
Do members of staff react and intervene promptly in case of incidents? Are mea-
sures taken to protect particularly vulnerable residents? Regarding the allocation of
different groups of residents, are there placement policies? Regarding residents’
privacy, are there individual wardrobes? Lockable space for personal belongings?
Can residents keep personal belongings in their room? What types of restraint are
used? Seclusion? Physical restraint? Mechanical restraint (straps, straitjacket, bed
sides, net bed, etc.)? Chemical restraint? Other types? Are staff properly trained
(including in non-physical de-escalation techniques)? Certainly, these questions
may be very useful in detecting ageist behaviour/approaches of the staff in a given
institution. However, the results of this procedure will also depend on the awareness
and sensibility of the inspectors.
20.3.2 The Council of Europe’s Social Law
Civil and political rights contained in the European Convention on Human Rights
are complemented by social and economic rights set out in the European Social
Charter adopted in 1961 (Council of Europe 1961) and amended by three protocols
(Council of Europe 1988a, 1991, 1998) as well as in the Revised European Social
Charter of 1996 (Council of Europe 1996a). They guarantee a broad range of every-
day human rights related to employment, housing, health, education, social protec-
tion, and welfare. The European Social Charter of 1961 Articles 12–15 contain
rights of significant importance for older persons: the right to social security, to
social and medical assistance, to benefit from social welfare services, and the right
of a disabled person to independence, social integration, and participation in the life
of the community. However, it cannot be assumed that the authors of the Charter in
the early 1960s intended to relate it in any way to ageism or similar phenomena,
because at that time, this issue went beyond the sphere of interest of the interna-
tional community, and age (including old age) was not considered as a separate
premise of non-discrimination in human rights law. Some progress in this field can
be observed in the case of Article 4 of the Additional Protocol of 1988 to the
European Social Charter, which was subsequently copied in 1996 by Article 23 of
the Revised European Social Charter. Article 23 provides for the right of older peo-
ple to social protection. Parties are obliged to ensure the effective exercise of this
right by adopting appropriate measures: “to enable elderly persons to remain full
members of society for as long as possible, by means of: (a) adequate resources
enabling them to lead a decent life and play an active part in public, social and cul-
tural life; (b) provision of information about services and facilities available for
elderly persons and their opportunities to make use of them”; “to enable elderly
persons to choose their life-style freely and to lead independent lives in their
330 B. Mikołajczyk
familiar surroundings for as long as they wish and are able, by means of: (a) provi-
sion of housing suited to their needs and their state of health or of adequate support
for adapting their housing; (b) the health care and the services necessitated by their
state”; and “to guarantee elderly persons living in institutions appropriate support,
while respecting their privacy, and participation in decisions concerning living con-
ditions in the institution” (Council of Europe 1996a). Although the Protocol and the
Revised European Social Charter do not explicitly mention ageism, all the itemized
elements of social protection for older persons have tackled the most ageist, age-
sensitive situations. Furthermore, the Explanatory Report to the Protocol clarifies
that “the expression ‘full members’ means that elderly persons must suffer no ostra-
cism on account of their age” (Council of Europe 1988b, p. 7, para. 54). It could be
assumed that ostracism may be construed here as one aspect of ageism, and there-
fore all the measures taken under Article 23 seem to be crucial for combating age-
ism as well.
It should also be mentioned that the Revised European Social Charter encom-
passes other rights that are connected with the situation of older persons in contem-
porary Europe. The first section of Article 26 touches upon the right to dignity at
work, aiming to prevent sexual harassment in the workplace. However, the second
section aims at awareness, information, and the prevention of recurrent reprehensi-
ble or distinctly negative and offensive actions directed against individual workers
in the workplace or in relation to work. It also means that the states are obliged to
take measures that encompass actions protecting older workers against ageist
behaviours of employers and other employees.
The Revised Charter also contains an anti-discrimination clause—Article E,
which is based on Article 14 of the European Convention of Human Rights (Council
of Europe 1996b, para. 136), so as a result, the premise of age is not on the list.
Both Social Charters contain mandatory and non-mandatory provisions. A con-
tracting party should elect to be bound by a specified number of non-mandatory
provisions. However, Article 23—potentially the most anti-ageist provision in the
Council of Europe social law—is not among the mandatory provisions of the
Charter. As a result, member states tend not to be willing to be bound by these obli-
gations, deeming them too demanding.
As stated above, not all 47 member states of the Council of Europe are parties to
the charters. Only 27 are, and most of them also ratified the Revised European
Social Charter, which is binding on 34 states.1 As parties to the Charters, the ratify-
ing states had to accept the reporting mechanism, but only 15 of them agreed to
collective complaints being submitted to the European Committee of Social Rights
by social partner organizations and non-governmental organizations against a given
state. However, in the Committee’s conclusions in reference to Article 23, the notion
of ageism was not touched upon. Neither was it discussed when the Committee
examined collective complaints on the grounds of Article 23 in the cases related to
old age submitted in International Federation of Human Rights Leagues (IFHR) v.
Ireland, complaint 42/2007 (European Committee of Social Rights European
July 2017.
1
Committee of Social Rights 2008) and The Central Association of Carers in Finland
v. Finland, complaint No.70/2011 (European Committee of Social Rights 2011).
20.4 Beyond the Council of Europe Treaties—Soft Law
Because ageism and anti-ageism norms do not appear explicitly in the Council of
Europe treaties, it is reasonable to focus on the Council of Europe non-binding
documents, which are often concerned with soft law covering a wide range of
instruments of varying natures and goals. There are various concepts of soft law in
the international law doctrine, and various acts issued by international bodies are
classified as soft law. There are opinions contesting the existence of this kind of law,
but opposing views recognize it as a new quasi-source of international law. Shelton
(2000) defined these norms as “normative provisions contained in non-binding
texts” (p. 292). There are also opinions that soft law, just as legal norms, is not bind-
ing, but that the norms might influence the development of international customary
law which is, alongside treaties, the most important hard law source. Moreover, soft
law still might be used by courts to interpret binding norms contained in treaties
(Terpan 2015; Spanier et al. 2016).
Soft law may not only affect the interpretation of treaties by relevant bodies, but
may also fill in the gaps or supplement the hard law instruments (Shelton 2003).
This soft law function appears fundamental in the absence of a treaty dedicated to
older adults. Finally, it might be observed that currently non-binding instruments
have strong enforcement mechanisms, sometimes even stronger than treaties
(Terpan 2015), so the differences between binding and non-binding acts may turn
out to be “really blurred” (Shelton 2003, p. 8). It might be assumed that significant
potential power is embedded in the Council of Europe’s activity beyond the con-
cluded treaties, especially in the resolutions and recommendations of the
Parliamentary Assembly and the Committee of Ministers.
20.4.1 A Piecemeal Approach
The acts adopted by the Council of Europe organs can be divided into two groups of
documents: those directly referring to older persons’ issues of age in Europe; and
those that are part of a wider issue, such as social cohesion, mental health, family
policies, dependence, old age pensions, health care in prisons, and the full participa-
tion of people with disabilities in society. Although they do not refer to ageism
explicitly, all the documents belonging to the latter group affect European opinion
on the situation of vulnerable people, including older adults. Therefore, relevance to
ageism should also be sought in documents dedicated specifically to ageing and
older persons.
332 B. Mikołajczyk
As it happens, only a few resolutions and recommendations of the Committee of

Ministers and the Parliamentary Assembly address ageism. Most of documents
dedicated to ageing and senior citizens do not refer to ageism at all. Some of these
acts indirectly, and just barely, tackle ageism, such as the “Guiding Principles to be
Taken Into Account When Taking Measures Concerning Elderly People” enclosed
in the Committee of Ministers Recommendation (94) 9 (Committee of Ministers
1994). These guidelines stressed the crucial role of the media, appropriate informa-
tion, and education. According to this document, adequate steps taken should
increase family and public sensitivity to issues of relevance to seniors, and in par-
ticular should enhance the positive perceptions of the role of older people in
society.
In Recommendation 1428 (1999), Future of Senior Citizens: Protection,
Participation, Promotion, the Assembly requested the Committee of Ministers to
consider the possibilities of asking the member states to take relevant steps in the
area of raising awareness and training of welfare and medical staff to detect mis-
treatment in any environment in which older people might be living, and to encour-
age states to create different, more positive images of older adults. Hancock (1999),
the author of the Explanatory Memorandum to Recommendation 1428, clarified the
background of the Recommendation by indicating that “the right to dignity would
be clearly backed up by greater respect for older persons, particularly in public life
and in terms of the image projected of them” (Council of Europe 1999, para. 40).
Parliamentary Assembly Resolution 1793 (2011), Promoting Active Ageing—
Capitalising on Older People’s Working Potential, should also be recognized as an
important document. For the first time, the Assembly used expressis verbis the term
“ageism,” confirming that, although it is less well known than racism or sexism, it
is nevertheless “a harmful prejudice that results in widespread lack of respect for
older people, whether through the media, which promote stereotypical and degrad-
ing images of older people, within society, where they are the victims of physical
and financial abuse, in the workplace, where they are subject to unequal treatment,
or in the health sector where they do not always receive appropriate medical care
and services” (Parliamentary Assembly 2011, para. 1).
In the report that served as a basis for this Resolution, Jacquat (2011) noticed that
differences in treatment between individuals or groups on the grounds of age are
often based on generalized assumptions or casual stereotypes. Even if direct dis-
crimination is forbidden by law, negative attitudes towards older workers are still
deeply rooted in our contemporary work culture. Older workers have more limited
chances of finding a new job and of accessing training and education. Quite often
they are forced to give up work against their will. Because age discrimination and
age-related harassment in the workplace demean older people’s dignity and damage
their self-esteem, the creation of a more positive approach among employers of
older workers is a requisite. Hence, special emphasis should be placed on highlight-
ing the positive aspects of employing older workers, and measures should be taken
to ensure that the advantages of employing older workers are more widely acknowl-
edged (Council of Europe 2011).
Finally, Parliamentary Assembly Resolution 1958 (2013), Combating
Discrimination Against Older Persons on the Labour Market, is another document
that explicitly addresses ageism. In this document, the Assembly identifies age dis-
crimination, including discrimination in the field of recruitment and work relations,
as one of the most widespread forms of discrimination, and indicates substantial
differences between the Council of Europe member states in terms of awareness of
the problem and the scale of efforts undertaken to combat it. What is more impor-
tant, according to the Parliamentary Assembly, “age discrimination goes hand-in-
hand with the more general phenomenon of ‘ageism’, driven by a negative view of
ageing in society” (Parliamentary Assembly 2013, para. 4). The Parliamentary
Assembly is of the opinion that it is vital to strive to change beliefs and attitudes in
order to eliminate stereotypes, as well as build a positive and true image of workers
in all age groups. Therefore, the Assembly invited the Council of Europe member
states to support information campaigns aimed at changing attitudes about ageing,
to raise public awareness of the experiences of older workers, to encourage mentor-
ing programmes, and to facilitate intergenerational dialogue. This Resolution was
based on a report by Sahiba Gafarova (Council of Europe 2013) which contains
more references to ageism. Gafarova defined age discrimination as “differential
treatment and denial of rights or opportunities unjustified on any other grounds.
This form of discrimination has become a sociological concept in its own right
known as ageism. Like racism and sexism, ageism concerns prejudices on the part
of one group against other groups” (Council of Europe 2013, B1. 2).2
Gafarova also observed that ageism in the area of employment is reflected in
discriminatory language, attitudes, and practices based on age. It may be conscious
or unconscious and is guided by various stereotypes. Moreover, providing argu-
ments for the submission of the draft of Resolution 1958 (2013), she identified a
number of prejudices affecting the ageing population, including: physical difficul-
ties (being slow, requiring rest periods, physical inability to perform work duties);
mental and cognitive difficulties (elderly workers deal poorly with emergency situ-
ations; they are not self-confident); proneness to mistakes and accidents (as a result,
older workers are associated with extra costs); inability to concentrate; limited
skills; lack of creativity or capacity for innovation; being too old for training; having
difficulties in relations with young people; and being resistant to changes.
Finally, in May 2017 the Parliamentary Assembly issued the Resolution 2168
(2017) entitled Human Rights of Older Persons and Their Comprehensive Care
dedicated to improvement of care for older persons and preventing their social
exclusion. In this new Resolution the Assembly calls on the member states to take
measures with a view to combating ageism. These measures should, inter alia, pro-
hibit, in law, age discrimination in the provision of goods and services and promote
a positive attitude to ageing through awareness-raising campaigns targeting the
media (Parliamentary Assembly 2017). Thus, “ageism” is used for a third time in
the text of the Assembly’s resolution, indicating that ageism and its symptoms are
becoming increasingly better identified within the Council of Europe.
2
The author of the report confirmed that there are many types of ageism, which also affect young
people, but the report and the drafted Resolution did not cover these.
334 B. Mikołajczyk
20.4.2 A Holistic Approach
The most crucial document relating to older persons is the Committee of Ministers
Recommendation CM/Rec(2014)2 to Member States on the Promotion of Human
Rights of Older Persons of 19 February, 2014 (Committee of Ministers 2014). It is
a complex response to previous initiatives of the Parliamentary Assembly and
applies a human rights-based approach to the situation of all older persons. The
main assumption of this Recommendation is that older adults should enjoy their
fundamental rights and freedom on an equal basis with other people. Its main goal
is to eliminate barriers denying senior citizens their rights.
The Recommendation to Member States on the Promotion of Human Rights of
Older Persons is of a new generation. It consists of two parts: a recommendation,
and an appendix containing guidelines and good practices in the areas of non-
discrimination, autonomy, and participation, an older person’s status before justice
institutions, protection from violence and abuse, social protection, employment, and
various aspects of care (including consent to medical care, palliative care, residen-
tial care, and institutional care). The Committee of Ministers recommends that
member states ensure the implementation of the Recommendation’s principles
within national legislation and practice, that they consider providing examples of
good practices, and that they evaluate the effectiveness of the measures taken.
Aimed at raising awareness of the human rights and fundamental freedom of older
persons, the Committee advises the wide dissemination of this document by the
states among the relevant authorities and other stakeholders. The Recommendation
provides that the Committee of Ministers will examine the implementation of its
provisions within 5 years of its adoption. So, despite its non-binding character, the
Recommendation is equipped with a follow-up mechanism, which might improve
its chance of achieving long-term effects.
Surprisingly, the term “ageism” was not used in the text of the Recommendation.
According to the Explanatory Memorandum interpreting this Recommendation, it
merely “aims at promoting older persons’ protection in societies where the ageism
is rising or in situations where they may be vulnerable” (Council of Europe 2014,
para. 30). The Memorandum does not explain the meaning of ageism, but it refers
to the concept of ageism contained in Parliamentary Assembly Resolution 1793
(2011), Promoting Active Ageing—Capitalising on Older People’s Working
Potential.
Although the Recommendation does not use the term ageism, it tackles the prin-
ciple of ageism directly and indirectly, through related issues such as age discrimi-
nation and awareness, by raising campaigns on older persons’ rights, including the
protection of whistle-blowers. The interpretation of the anti-discrimination clauses
provided in the Memorandum to the Recommendation should be recognized as par-
ticularly important, because it may affect the future case law of the European Court
of Human Rights and the European Committee of Social Rights. The Memorandum
explains that the Recommendation reaffirms the principle of the full enjoyment of
all human rights and freedoms of older persons without any discrimination in the
meaning of Article 14 of the European Convention on Human Rights and Article E

of the Revised European Social Charter. As mentioned above, “age” is not indicated
among the premises stipulated in these anti-discrimination clauses, which, until the
adoption of the Memorandum, created various controversies and ambiguities.
Therefore, it is significant that the Memorandum provides extensive interpretation
of these clauses by including age as a premise of “other status” (Council of Europe
2014, para. 31).
In the area of raising awareness, the Committee invites the member states to take
appropriate measures to protect older persons from financial abuse, deception, and
fraud. As to the situation of older persons who require assistance and care, the
Committee places special attention on the implementation of sufficient measures
aimed at raising awareness among medical staff, care workers, informal carers, and
other individuals who provide services to older persons. The appendix to the
Recommendation indicates German, Greek, Austrian, and Finnish good practices in
this area as models to be followed by other member states. It also mentions the
European project “Breaking the Taboo” (co-financed by the European Commission)
aiming at drawing up a strategy for recognizing and counteracting violence against
older women within families. At the same time, the Memorandum, referring to the
European Court of Human Rights judgement in the Heinisch case, explains that one
of the Recommendation’s goals is to encourage member states to take legislative or
other measures to protect anyone reporting abuse of older adults from dismissal or
other reprisals. All such initiatives, if they are adopted by the states, might also
contribute to the elimination of ageism, as the background of ill-treatment of older
people.
20.5 Conclusions
Taking into account almost seven decades of the Council of Europe’s activity in the
field of human rights, addressing the rights of older persons is relatively new in this
forum. Ageism has scarcely appeared in documents adopted in the last decade. It
might also be stated that the threat of ageism and the need to take steps against it
have only slowly been breaking through, with difficulties, in the agendas of the
Council of Europe bodies, and have been introduced into very few Council of
Europe official documents. However, it should be remembered that the Council of
Europe is created by its member states and it reflects those member states’ attitudes
towards ageism and their political will to identify and eliminate it. Each document
adopted by the Parliamentary Assembly and the Committee of Ministers is a result
of a consensus achieved by the member states, which are not always aware of the
existing problem, or are not interested in taking steps that require financial outlay,
such as financing media campaigns or training caregivers and officials.
Currently, ageism is more often indicated in explanations to soft law documents,
where it is understood as prejudice or stereotypes serving as grounds for discrimina-
tion, elder abuse, and other violations of older persons’ human rights. It is confirmed
336 B. Mikołajczyk
that ageism is inextricably intertwined with discrimination, but both concepts are not
used interchangeably. Only once has ageism been described as a special or unique
form of discrimination and not as its source.
On the other hand, although ageism does not appear on the Council of Europe’s
agenda as often as sexism, racism, or homophobia, the Council of Europe has tan-
gible tools at hand to take action against it. Potentially, each of the Council of
Europe organs indicated at the beginning of this chapter is or might be competent to
contribute to the elimination of ageism. This aim might be achieved thanks to the
proper interpretation of the presently binding treaties, through calling on member
states to take relevant measures and monitoring the implementation of these mea-
sures, and finally, through pointing out good and bad practices towards older per-
sons. Certainly, the European Court of Human Rights, as a “hard” controlling
mechanism, plays an extremely important role in this area. If it takes a position on
ageism, or simply refers to relevant soft law documents, in its jurisprudence, it will
be a quantum leap forward in the protection of older persons in Europe. If the fight
against ageism is to be effective, other tools at the Council of Europe’s disposal,
such as monitoring and warning on violations of human rights, must also be mobi-
lized. However, it seems that, at the present time, the Council of Europe is just at the
beginning of this fight.
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Chapter 21
The European Union’s Approach towards
Ageism
Nena Georgantzi
21.1 Introduction
Τhe European Union (EU) provides legal guidance and policy coordination for its
member states and represents an additional layer in the political, economic, and
social reality faced by older people. What started as a purely economic union has
been transformed into an enhanced inter-state collaboration on an increasing num-
ber of policy areas. The EU is now expected to act not only in several fields that
impact older people’s lives, including non-discrimination and human rights, gender
equality, patient safety, consumer protection, and passengers’ rights, but also to
engage in “soft cooperation” on aspects of social security, notably in the fields of
pensions and healthcare. Studying ageism at the EU level can, therefore, help to
unravel whether the multilateral legal, policy, and economic processes serve to dis-
able or foster the various barriers and discrimination in old age.
This chapter does not discuss the case law of the Court of Justice of the European
Union (CJEU), which is presented in another Chap. 19 Doron et al., 2018 of this
volume, but instead makes a critique of the scope of the EU’s agenda to tackle age-
ism. Focusing on the end of the life spectrum and based largely on experiential
knowledge of the EU arena, I do not look into ageism as a theoretical construct but
instead am interested in its policy application by the Union’s bodies.
Under these considerations I critique the EU’s narrow agenda, which fails to
adequately address equality in old age. I also argue that the Union’s conceptualization
N. Georgantzi (*)
National University of Ireland Galway, Galway, Ireland
AGE Platform Europe, Brussels, Belgium

https://doi.org/10.1007/978-3-319-73820-8_21
342 N. Georgantzi
of ageing and older people is susceptible to prejudice. To do this, the chapter first
presents the sense of equality that guides the assessment of the EU’s performance in
tackling ageism (Part 21.2). Second, it discusses the EU’s main achievements in the
area of non-discrimination and ageing, as well as its shortcomings (Part 21.3).
Third, it exposes examples of ageist discourse that create discrepancies between EU
rhetoric and practice to promote equality for all ages (Part 21.4). And finally, it sug-
gests how EU laws and policies can move towards a more substantive form of equal-
ity through a human rights-based approach (Part 21.5).
21.2 T
owards a Substantive Understanding of Equality
in Old Age
Ageism is not the same as discrimination as the latter involves a manifestation of

ageist prejudice in the form of behaviour or treatment (Herring 2009, p. 12).
According to its treaties, the EU has a duty to combat discrimination (Article 3§3,
Treaty on the European Union 2012), but there is no language explicitly stipulating
the need to fight ageism in all its forms or to address comprehensively the social
construct of old age that is entrenched in European society. For this reason, in this
chapter I understand the EU’s efforts in the area of non-discrimination as contribut-
ing generally to an anti-ageist agenda. However, the lack of the use of the term and
concept of ageism in EU discourse probably reveals a narrow understanding of
structural inequalities in old age.
Equality and non-discrimination are not uncontroversial terms; they are attrib-
uted diverse meanings and goals (Fredman 2011, p. 40). Not all forms of unequal
treatment qualify as wrongful discrimination, even more on the grounds of age
where—according to international and European law—even direct discrimination,
such as age limits, can be justified in the context of labour market policies, pension
systems, and the allocation of scarce resources.
This chapter goes beyond a formal understanding of equality according to which
likes should be treated alike. It adopts Fredman’s (2003) definition of equality as
“the facilitation of choice or autonomy, the protection of dignity and the enhance-
ment of participative democracy or social inclusion” (p. 38). Accepting that struc-
tural barriers, such as ageist norms, may create disadvantages for older people, it
asserts that positive action might be necessary to achieve equality of opportunities
and prevent undignified treatment and marginalization of this population.
This broad understanding of equality is not merely theoretical but builds on the
aspirations of the EU treaties and the Charter of Fundamental Rights (known as the
Charter or the EU Charter). Thanks to Article 19 (previously Article 13) of the
Treaty on the Functioning of the European Union (TFEU), the EU can take positive
action, such as adopting dedicated legislative measures, to preclude discrimination.
Moreover, Article 21 of the Charter of Fundamental Rights (European Union 2016),
which became part of the EU’s primary law after the Treaty of Lisbon in 2009
21 The European Union’s Approach towards Ageism 343
(European Union 2007), prohibits discrimination on the grounds of age. This provi-
sion represents a novelty in human rights law, which lacks an explicit and clear
protection from age discrimination. Nevertheless, the EU’s primary law merely
gives the possibility for the EU to take anti-discrimination measures, without impos-
ing a duty to do so. In addition, positive action is possible only upon the unanimous
agreement of all the member states of the European Council (Article 19§1 TFEU),
in compliance with the EU’s existing array of competences and the principle of
subsidiarity,1 as well as only within the remits of EU law (Article 51 of the EU
Charter of Fundmantal Rights). These limitations give broad discretion to EU bod-
ies and member states to decide whether and what type of positive action might be
needed to tackle discrimination.
In the legal tradition older people are consistently problematized as subjects of
social security and economic and social rights (Dabove 2015, p. 141). Legislative
instruments preceding the EU Charter of Fundamental Rights, including the EU’s
1989 Community Charter of Fundamental Social Rights of Workers (European
Community 1989), which enshrined the right to adequate income in retirement, and
the Revised European Social Charter of the Council of Europe (1996), which intro-
duced the first legally binding reference to the “right of the elderly to social protec-
tion” under Article 23, only attributed social rights in old age, discounting aspects
of equal treatment. Failing to enshrine a vision of equality in old age can send a
discriminatory message and further reinforce stereotypes of older people as recipi-
ents of welfare and individuals with needs instead of rights.
The EU Charter of Fundamental Rights includes “the most reliable and definitive
confirmation of the rights of the elderly … within the EU” (Meenan 2007, p. 65). It
recognizes in Article 25 “the rights of the elderly to lead a life of dignity and inde-
pendence and to participate in social and cultural life.” Unlike previous instruments,
this provision is introduced in the Equality Chapter of the Charter and represents
another remarkable legal innovation (EU Network of Independent Experts on
Fundamental Rights 2006). Article 25 should be read as giving guidance on how
equality in old age needs to be interpreted so that it becomes effective. What this
Article tells us is that—as with other discrimination grounds—the EU aspires to an
application of substantive equality that needs to be understood as an obligation not
only to refrain from action that treats people less well because of their age but also
to take into account the particular needs of older people through positive action
(Duncan 2008; McLachlin 2013; Nikolaidis 2015). As a matter of fact, the EU leg-
islature provides us with a clear benchmark on the basis of which we can measure
the Union’s performance in the pursuit of equality in old age. Dignity, indepen-
dence, and participation are the bedrock of a human rights-based approach to
equality in old age. These notions mirror Fredman’s (2003) definition of substantive
equality, which refers to dignity, choice, autonomy, participative democracy, and
social inclusion (p. 38).
1
According to the principle of subsidiarity, in areas where the EU does not have exclusive compe-
tence (including non-discrimination), action is in principle at the discretion of member states, and
the EU can only take action if the objectives cannot be sufficiently achieved at the national level.
344 N. Georgantzi
Placing dignity at the centre of equality means that the EU should not diminish
older people or perpetuate ageist treatment. Lumping people together in age catego-
ries can be a risk to their inherent dignity as it attributes certain characteristics (such
as loss of ability, contribution, or value) to the individual and accepts stereotypical
views of old age. In practice, a conception of equality that respects the dignity of the
person should not result in undermining the moral and social status of older people.
At the same time, equal respect for the dignity of people of different ages will on
occasion require treating age groups differently (Duncan 2008). In addition, the
distinct experiences of age discrimination faced by older persons justify tailored
measures that take into account the specific challenges of old age (Mégret 2011;
Seanad Public Consultation Committee 2012). For example, more needs to be done
to cater for groups particularly at risk of discrimination, such as older women, who,
in addition to suffering from gender and age discrimination in the labour market, are
now struggling with increased difficulties to reconcile work and family care duties
as a result of the reduction in social services to older persons.
When independence underpins equality agendas, policies are directed towards
giving people of all ages choices to live independently. To reach this objective, not
only are older people to be offered the same array of opportunities as everyone else,
but they are also to be enabled to fulfil their choices (Fredman 2003, p. 44). This
understanding implies going beyond an obligation to abstain from limiting older
people’s autonomy to taking steps, such as promoting adapted housing, adequate
income, access to flexible working, care, and support so that older people can con-
tinue to live independently.
The notion of participation is broad, encompassing social and cultural life
(which are included in the letter of Article 25) but also—according to the explana-
tions to the Charter (Fundamental Rights Agency n.d.)—all other spheres of life.
Age discrimination and age stereotyping underpin social exclusion, whether in rela-
tion to employment, health care, or the fair distribution of assets and resources
(Stuckelberger et al. 2012). Including participation in the conceptualization of
equality is not merely about avoiding interference but also about facilitating mean-
ingful involvement, strengthening consultation, and combating social exclusion, for
example through non-discrimination legislation, accessibility standards, and affir-
mative action for the integration of those in vulnerable situations, such as migrants
and people with functional limitations. A substantive equality approach is not exclu-
sionary, in that it aims to ensure equal participation in society and build the capacity
of individuals to understand and claim their intrinsic rights.
In sum, the EU Charter aspires to more than consistent treatment to achieve
equality across all ages. Yet the absence of a legal duty for the EU to adopt non-
discrimination legislation and promote equality, which applies to all grounds of
discrimination based on Article 19§1 TFEU, is one of the reasons why, to date, “the
scope of legal protection on grounds of age hardly goes beyond the employment
sector” (Lassen et al. 2014, p. 106). Whilst acknowledging this normative restric-
tion, this chapter investigates the potential for the EU to become a driver for a
“society for all ages”. It critically analyses EU law, policy, and discourse based on
the three criteria set out in the Charter of Fundamental Rights—dignity, indepen-
dence, and participation—to discuss the EU’s record on promoting equality for
older people and to suggest how future EU action can be framed so that it effectively
meets the Charter’s objectives.
21.3 Key EU Milestones and Their Limitations
21.3.1 EU Anti-discrimination Legislation
Arguably one of the key achievements in the EU’s fight against ageism is the 2000
directive establishing a framework for equal treatment in employment and occupa-
tion, also known as the Employment Framework Directive (Council of the European
Union 2000). This law has provided minimum standards throughout Europe and has
led to positive reforms at the national level (Tymowski 2016). It has moreover
helped to challenge structural inequalities in the labour market, such as upper age
limits in job advertisements (European Commission 2014).
However, as explained in a previous chapter (2018; Chap. 20), Article 6 of the
Employment Framework Directive allows member states to apply a wide range of
exceptions to the rule of age equality in order to fulfil their social and employment
objectives. For example, it is legitimate to offer professorships to younger people as
a means of encouraging recruitment in higher education (see, for example, Vasil
Ivanov Georgiev v. Tehnicheski universitet—Sofia, filial Plovdiv. Joined cases
C-250/09 and C-268/09, 2010). For O’Dempsey and Beale (2011), direct discrimi-
nation on the basis of age does not appear to be exceptional, which “creates an
inherent vulnerability at the heart of the prohibition of age discrimination, and
means that a careful balance has to be struck in order to ensure that the prohibition
is meaningful” (p. 5). This broad discretion afforded to national jurisdictions to set
aside equal treatment in old age has led to diverging national practices and levels of
protection against age discrimination across the EU (Tymowski 2016).
Another shortcoming of this legislation is that it fails to extend reasonable
accommodation to older workers. The concept of reasonable accommodation cre-
ates a duty to make necessary adjustments so that individuals can gain access or
perform tasks, which otherwise they would be unable to. This right, which, accord-
ing to Nikolaidis (2015), is inextricably linked with equality, at the moment only
exists for people with disabilities. Yet giving older people a right to flexible work-
ing, adjustment of the work environment, and arrangements to support informal
care provision makes economic sense and also increases equality of opportunities
for senior workers. However, to date, there is limited discussion on extending
reasonable accommodation beyond disability and what discussion there is is only at
346 N. Georgantzi
a theoretical level.2 To move from theory to practice the EU would need to revise its
legislation and should also ensure that future initiatives on work-life balance take
due account of the interdependencies between the working population and retired
people, with both sides occasionally providing financial support and care for the
other age group.
Moreover, the EU law does not extend protection from age discrimination out-
side the field of employment. In 2008, the European Commission prepared a pro-
posal for a Council Directive on implementing the principle of equal treatment
between persons irrespective of religion or belief, disability, age, or sexual orienta-
tion (European Commission 2008b). If adopted, this piece of law would complete
the EU framework by affording to the above discrimination grounds a similar level
of protection as currently exists for race and gender under EU law (European
Commission 2008a). However, 8 years after the initial proposal, the directive is still
stuck in negotiations, due to strong resistance from a few member states and despite
the promise of the current Commission that the so-called “horizontal directive”
would be passed within a year of its election. Due to this lack of coverage of other
areas it can be argued that there exists a “hierarchy of grounds”, whereby EU law
protects more comprehensively against discrimination on some grounds than on
others (Fundamental Rights Agency 2012).
With regard to age discrimination, the draft directive includes an exception for
financial services, for which age can be used as a proxy when it is a determining
factor for the product or service in question (Article 2§7, European Commission
2008b). In addition, there is a general clause allowing public and private actors to
apply measures which discriminate on the ground of age as long as they can be justi-
fied by a legitimate aim. This draft provision (Article 2§6), which is similar to
Article 6 of the Employment Directive, allows for a broad range of measures to be
objectively justified as non-discriminatory. Such measures include situations where
appropriate age differences might be needed, as for instance children’s toilets, chil-
dren’s airfares, or age limits for selling alcohol.
In 2015, the Latvian EU Presidency included a new exemption for preferential
pricing in respect of specific age groups in the draft directive (Article 2§6c, Council
of the European Union 2015b). The proposed new text by the Latvian Presidency
allows any preferential charges, fees, or rates in respect of persons in a specific age
group not to constitute discrimination. This new clause creates open-ended oppor-
tunities for commercial actors to apply different prices for specific age groups.
Although intended as a means for seniors or young people to benefit from special
tariffs and services, it does not exclude purely commercially driven risk assess-
ments. In the point of view of AGE Platform Europe, the representative network of
older people at the EU level, this addition weakens the principle of age equality and
practically excludes older people from the scope of the directive (AGE Platform
Europe 2015a).
For a notable exception, see Bribosia and Rorive (2013).

2
At the very least, this long list of exceptions seems to be telling us more about
when discrimination is acceptable than when it is not. Not only do these exceptions
complicate the negotiations of the draft directive, but they also enhance the view
that old age disadvantages are unavoidable and therefore acceptable (Calasanti et al.
2006). Failing to enshrine a universal protection from age discrimination, old age is
perceived as a relevant criterion of social structures rather than as a source of sys-
tematic inequalities. In its report on the implementation of the Employment
Directive, the European Commission underlined that concerted efforts are needed to
remove prejudices and “clarify the circumstances in which difference of treatment
based on age may be justified” (European Commission—Research and Innovation
2014, p. 49). Undoubtedly, the even more complex set of exemptions foreseen under
the horizontal directive makes it even more difficult to clearly demarcate which
treatment is justified and which is discriminatory.
In this section I have argued that the provisions of both the Employment
Framework Directive and the draft horizontal directive are susceptible to abuse.
They can be used to limit the opportunities of older people to access employment,
goods, and services and therefore breach the principle of independence. By consid-
ering age limits and proxies as valid and widely acceptable they therefore reinforce
stereotypes of older people as different from the rest of the population and disregard
their individual capacities, which offends their human dignity and may lead to
degrading treatment. They do not distinguish between policies that enable participa-
tion and measures that lead to exclusion of certain groups and therefore they also
fail to promote equal participation.
Instead of endorsing and justifying blunt age limits, in order to comply with the
Charter’s objectives, EU legislation and its interpretation by the CJEU should build
on the benchmarks of Article 25 to define whether a treatment is discriminatory or
not. Article 25 requires us to ask whether differential treatment—be it in the form of
“justified discrimination” or positive action—facilitates the participation of older
people in public, economic, social, and cultural life or rather impedes their dignity
and independence and therefore breaches their rights. This is a simple test but also
a fundamental change in mindset that is necessary to deliver the promise of age
equality and to challenge ageism with the same rigorousness as with other forms of
discrimination. Indeed, it is not so long ago that distinctions on the basis of one’s
sex were also considered to be “objectively justified”. For example, a 1961 case of
the Italian Constitutional Court considered female adultery as more serious than
male adultery and therefore approved the differential treatment of men and women
on this matter (de Witte 2010). EU law has been instrumental in levying gender-
based stereotypes and breaking down the barriers to the equal participation of
women. To tackle injustice and prejudices based on age, the EU needs to abandon
its conservative outlook on age-based distinctions and inspire an anti-ageist vision
across its legal and policy framework.
348 N. Georgantzi
21.3.2 EU Policy
Policy action complements the Union’s legislative competence and can provide use-
ful guidance on how to address systemic forms of ageism. The EU addressed ageing
for the first time in 1982 in the European Parliament Resolution “on the situation
and the problems of the aged in the European Community” (European Parliament
1982). Seizing the momentum of the first World Assembly on Ageing that took
place in the same year, this resolution underlined the EU’s responsibility to take
measures, including reallocating the budget, to help older citizens. It moreover reaf-
firmed older people as citizens with equal and full rights. Several age-related policy
proposals followed. Notably, in 1990, the European Council adopted a Decision on
“Community Actions for the Elderly” (Council of the European Communities
1990), which prescribed priority actions aiming at their integration and declared
1993 as the European Year of the Elderly and Solidarity Between Generations.
These early policy directions provide a relatively comprehensive roadmap for pro-
moting older people’s participation and independence and view seniors as citizens
with full rights.
Since then, EU legislation, funding, research, and policy coordination in the field
of ageing has been well developed (European Commission 2012b). These activities
range from adopting senior employment strategies and addressing the risk of elder
abuse to promoting lifelong learning and funding research on new technologies that
can, among other things, support older people’s stay at home (AGE Platform Europe
2012). For example, the EU has set up a platform for exchange among private actors
that have signed onto “diversity charters”—voluntary commitments to fight dis-
crimination, including on the grounds of age—in the workplace (European
Commission 2015d). These policy tools have a potential to promote the three
aspects of substantive equality, but they also entail some gaps.
The last time the Commission made explicit its commitment to fight against
discrimination on age was in a communication that provided the baseline for the
2008 legislative proposal for a horizontal directive (European Commission 2008a).
Moreover, the European Commission has not paid attention to the widespread age
limits that exist across the region in access to health services; neither has it addressed
age discrimination against older people with disabilities, despite the fact that it is
bound by the UN Convention on the Rights of Persons with Disabilities (UN CRPD)
(United Nations General Assembly 2007) and complements member states’ efforts
to materialize the rights therein (AGE Platform Europe 2016).
Even without the adoption of the draft horizontal directive, the Commission has
the possibility to address the (in)validity of age-related criteria in soft policy mea-
sures and in the implementation of existing mechanisms, such as its “Disability
Strategy” (European Commission 2010). Tolerating age-based distinctions, failing
to provide guidance for member states on how to apply equal treatment in all ages,
and lacking a cohesive approach to the fight against age discrimination gives a mes-
sage of older people as potentially being less deserving of health care, support in
case of disability, and overall equal treatment.
On the other hand, the European Commission financially supports NGOs, such
as AGE Platform Europe, which brings together older people’s associations from
across the EU. Through its funding, the Commission indirectly empowers older
people and facilitates their participation in decision-making. It also promotes a posi-
tive image of old age and supports older people to become active citizens.
Nevertheless, the Commission does not consistently consult representatives of older
people in dossiers of direct relevance to them, thus failing to attain their equal par-
ticipation. For example, AGE Platform Europe has deplored the lack of involvement
of older people in the implementation of the UN Convention on the Rights of
Persons with Disabilities, despite the EU’s rhetoric about the relevance and direct
application of this treaty for a large part of the older population (AGE Platform
Europe 2015b). The NGO has also stressed that older people are rarely consulted by
the Council when the rights of older people are discussed.
EU-funded research can help to understand discrimination in old age and provide
the evidence necessary for adopting or adjusting policy action. While EU research
in the field of ageing is relatively developed,3 one still comes across age limits in
data collection and/or the use of age categories that are too broad, such as “the 65+
population”. For example the Fundamental Rights Agency (FRA), an EU advisory
body, included age limits in a recent study on violence against women and failed to
include older people in the sample of a project on the rights of people with disabili-
ties (Fundamental Rights Agency 2014a, b). These generalizations treat older peo-
ple as a homogeneous group and do not reflect the living realities and challenges in
different stages of the lifespan. Associating “the old” with a fixed set of characteris-
tics is demeaning and a violation of their human dignity.
On a positive note, in 2015, age discrimination and the rights of older people
were included for the first time in the EU’s Action Plan for Human Rights, which is
a roadmap for the Union’s relations with third countries (Council of the European
Union 2015a). Under priority 16 the Action Plan mentions, “Increase awareness of
the human rights and specific needs of older persons paying particular attention to
age based discrimination.” Unfortunately, this commitment is not mirrored in the
EU’s internal affairs, where “there is a lack of a coherent policy and legal frame-
work to enhance the enjoyment of the rights of the elderly” (Lassen et al. 2014,
p. 107).
To justify its inaction, the European Commission has argued that the primary
duty to deliver age equality and fulfil the rights of older people falls within the com-
petences of member states and limits its obligation to respecting the rights of older
people—that is, to refrain from action that deliberately impacts the enjoyment of
these rights (European Commission 2016c, p. 89). Although the same claim can be
3
The creation of the European Equality Law Network, a group of legal experts on non-discrimina-
tion, which provides analysis on issues of equality across European states, is a positive example.
Other examples include the funding of the Survey of Health, Ageing and Retirement in Europe
(SHARE), the Active Ageing Index, and several studies on experiences of discrimination
(Eurobarometer). Eurofound, the European Foundation for the Improvement of Living and
Working Conditions, has compiled an impressive set of research on ageing, with a focus on work,
retirement, and care.
350 N. Georgantzi
made for the rights of other groups at risk of discrimination, the EU has only used
this argument for older people. As a matter of fact, the Union has an extensive pol-
icy framework for the protection of women: in 2010 the EU launched a “Strategy for
the Equality Between Women and Men,” which was recently extended to 2019
(European Commission 2015e). The European Commission also enshrined its pri-
orities in the field of disability in the “Disability Strategy” (European Commission
2010) and adopted an “EU Agenda on the Rights of the Child” (European
Commission 2011). Other equality initiatives include the “EU Framework for
National Roma Integration Strategies” (Council of the European Union 2011), the
“List of Actions by the Commission to Advance LGBTI4 Equality” (European
Commission 2015c), and several soft and legal measures to promote the rights of
children, racial, ethnic, religious, and linguistic minorities as well as to tackle intol-
erance (European Commission 2016c).
Overall, EU bodies prefer an ad hoc and opportunistic approach to ageing; while
this can help to promote independence and participation in the labour market, at the
same time it does not reflect the broad aspirations inscribed in the EU’s early texts,
which were based on equality and rights. Ageing policies are nowadays primarily
driven by economic arguments and as a result the policy framework on active age-
ing and the silver economy5 is a lot more developed than actions to combat poverty,
exclusion, elder abuse, and discrimination. References to the rights of older people
in human rights reporting by the European Commission, the European Parliament,
and the European Council are scarce and unsystematic (AGE Platform Europe
2013). At the same time, ageing and older people are not “mainstreamed” in other
areas, such as disability, in the same way that, for instance, gender is.
Compared to other discrimination grounds, the EU has deprioritized age dis-
crimination and older people’s issues (AGE Platform Europe 2014b). This results in
soft, incoherent policies, which fail to establish age discrimination as wrongful and
to politicize the fight against ageism. To achieve the threefold objectives of substan-
tive equality, the EU needs to open up a dialogue on how to extend and scale up its
activities to fight age discrimination and how to ensure consistency and avoid gaps
in its existing array of work.
21.3.3 The Legacy of the European Year 2012
An exception to the residual concern of the EU for older people was the European
Year on Active Ageing and Solidarity Between Generations (EY2012). During this
year, the Union put a spotlight on older people and aimed at, among other things,
promoting activities “which will help to combat age discrimination, to overcome
4
Lesbian, Gay, Bisexual, Transexual and Intersex.
5
According to Eatock (2015), “The “Silver Economy” can be defined as the economic opportuni-
ties arising from the public and consumer expenditure related to population ageing and the specific
needs of the population over 50” (Eatock 2015, p. 2).
age-related stereotypes and to remove barriers” (European Parliament & European

Council 2011, art. 2). However, the expectations set out for the year were relatively
low: EY2012 was intended as a framework for the mobilization of stakeholders to
foster awareness raising, exchange good practices, and convey a more positive
image of population ageing and did not aim at extending the scope of age discrimi-
nation at EU and national levels. Despite lacking a real potential for measurable
impact on the ground, EY2012 offered funding opportunities for national authori-
ties to develop comprehensive strategies on active ageing, which “are about chang-
ing attitudes and developing a more positive approach to tackling the challenges of
ageing” (Zaidi 2015, p. 2). While it is out of the scope of this chapter to explore how
EY2012 influenced action at a national level, it is certain that follow-up initiatives
are needed to translate the political momentum into a “strong political legacy that
delivers concrete results” in the long term (Council of the European Union 2012).
However, some tools developed during EY2012 may serve as building blocks for
anti-ageist policies. “Guiding Principles on Active Ageing and Solidarity Between
Generations” (Council of the European Union 2012) provides a roadmap for such
action. This document, which was adopted by the Council in December 2012,
makes specific reference to age discrimination, but only focuses on the labour mar-
ket. Moreover, at the EU level, following EY2012, the active ageing agenda has
been integrated into existing EU frameworks, in particular in “Europe 2020”, which
is the EU’s strategy for “smart, sustainable and inclusive growth” and includes the
“European Innovation Partnership on Active and Healthy Ageing” (European
Commission 2012a). These initiatives have a strong focus on increasing the partici-
pation of older people in the labour market and ensuring the sustainability of health
and social care systems through innovative mechanisms. Whilst these actions have
the potential to support independent living in old age, they lag behind in effectively
promoting dignity and participation beyond the economic sphere.
Almost 5 years after EY2012 we are witnessing the deficiency of EU policies in
living up to the commitments made during the European Year. Despite its focus on
active ageing, age discrimination in the labour market has not waned; older workers
are still penalized despite research that shows that their productivity and expertise
increase in old age (European Commission 2014, p. 49). Negotiations on the hori-
zontal directive have not advanced, and the European Commission has not included
older people’s rights or age discrimination in its work priorities and “is concentrat-
ing its action on the rights of children, women, persons with disabilities” (Parent
2015, p. 3). In fact, the portfolio of the Commissioner for Justice, Consumers and
Gender Equality does not include any reference to age discrimination, with the
exception of the horizontal equal treatment directive (Juncker 2014a). EU policy
initiatives on ageing thus seem to be consistently downgraded into actions that view
older people as service users or consumers, and the actual impact of EY2012
remains questionable. As a result, the recently announced “European Pillar of Social
Rights” will concentrate on work-related rights (European Commission 2016a).
Drawing attention to the older workforce and to financial gains reflects the hier-
archy of the economic over the social in EU policymaking. The EU action on old
age is characterized by an à la carte approach, which does not encompass all forms
352 N. Georgantzi
of exclusion and fails to recognize the multiple roles played by older people in soci-
ety. Looking at old age only through the lens of employment and social protection
assumes that older people are either active in the labour market or in need of care
and protection. The following section explores whether the EU’s discourse on age-
ing reflects the diversity of the group or rather ignores older people’s equal rights as
citizens and human beings.
21.4 Ageist Discourse and the Diversity of Older People
21.4.1 The Elder Burden Narrative
Although age-inclusive laws and policies can considerably improve the lives of
older people, when institutions, structures, and behaviours are underpinned by age-
ist assumptions, older people face significant disadvantages in their participation in
society. EU policy action aims at “confronting demographic change” (European
Commission 2005), “dealing with the impact of an ageing population” (European
Commission 2009) and the “dramatic changes in the age structure in the EU”
(European Commission—Economic and Financial Affairs 2015, p. 1). It highlights
the financial implications of demographic ageing, engaging in a discourse on depen-
dency, and the so-called “elder burden”. Yet it has been argued that this narrative of
the burden of older people creates a new form of ageism, imposes various forms of
societal barriers, and nourishes intergenerational conflict (Walker 2015).
An illustrative example of this prejudiced approach is the 2015 Ageing Report,
which presents a mere macroeconomic analysis of the costs of ageing and consis-
tently uses old age as a proxy for declining abilities and increasing needs (European
Commission—Economic and Financial Affairs 2015). By contrast, the 2015 Youth
Report presents a comprehensive account of the situation of young people, how the
economic crisis influenced them, and what actions the EU should take to address
them (European Commission—Youth 2015). The choice of authors of the two docu-
ments is indicative of the different lenses through which EU institutions view age-
ing and youth: the former is drafted by the European Commission’s financial service
unit, the latter by the Directorate General for Education and Culture, which is in
charge of youth policies. Thus, ageing is considered at the macro level and in rela-
tion to the financial implications it brings, without considering aspects of individual
ageing and older person’s rights. On the other hand, youth benefits from a compre-
hensive approach that reflects on societal barriers to their active inclusion, as well as
EU initiatives to promote it.
Certainly economic concerns linked with demographic ageing are not only inevi-
table but also to a large extent legitimate. However, the pursuit of socioeconomic
objectives, such as ensuring the sustainability of social protection systems, promot-
ing youth employment, and improving the capitalist function of the market, needs
to be accompanied by a reflection of how older people can be empowered as citizens
with full rights and responsibilities to participate in employment and education and
contribute to social, political, cultural, and economic life.
Besides, the presentation of ageing as a profound social challenge resembling
acute financial and economic crises is per se ageist, as it fosters a view of old age as
a life stage of unmet needs rather than as a period of productivity, growth, and equal
opportunities (Huenchuan and Rodríguez-Piñero 2011, p. 20; Thompson 2005).
Framing ageing policies based on dependency ratios assumes that everyone 65 and
over is not working or contributing in another capacity to the economy and to soci-
ety. Not only are working lives across the EU gradually extending beyond this
threshold, but also a large number of older people contribute in the informal sector,
in particular, as volunteers and caregivers (Ehlers et al. 2011). In addition, the older
generation represents unexploited social capital as mentors and socio-political
actors in their communities. Sustaining a view of old age through a dependency lens
diminishes older people’s role, ignores their multiple contributions to society, and
equates ageing with unproductivity, impairment, and leisure. It thus legitimizes and
reinforces older people’s marginalization, including by providing them with fewer
and lower quality services (Fredvang and Biggs 2012).
Instead of merely focusing on old age as a bounty, policies need to equally
address investments in ageing as an opportunity. The previous part of this chapter
provided evidence of an asymmetric response to an ageing society. This policy
thinking is worrisome from a social justice perspective, as it does not empower
older people to use their accumulated knowledge and life experience for the benefit
of society. This approach moreover, ignores how structural ageism, which is inher-
ent in legal, social, and economic institutions, diminishes older people’s life chances
(Scrutton 1990, p.21, as cited in Duncan 2008; Macnicol 2006).
21.4.2 Ageing as a Disability
The EU shares the viewpoint that there is an important overlap between age and
disability-related issues and suggests viewing older people’s vulnerability from a
disability angle (European Union 2011). This approach ignores the idea that “grow-
ing older should not be a disability in itself” (Morgan and David 2002, p. 436). It
moreover disregards the diversity of the older age group, since although the preva-
lence of disability increases with age, approximately half of the 65 + generation
across the EU does not encounter disabilities (Grammenos 2013). It also impedes a
due consideration of the distinct challenges of old age and the social factors that
impact older people’s lives.
Ageism is not the same as “disablism,” although older people may be victims of
both (Thompson 2005, p. 72). Old age is a period of systematic inequalities in dis-
tributions of power, roles, and resources, which unless acknowledged are likely to
be seen as natural, and thus beyond dispute (Calasanti et al. 2006, pp. 17–18). It is
these structural disadvantages and stereotypes that, in association with disability
and other characteristics and experiences, such as gender and race, may lead to
354 N. Georgantzi
multiple discrimination. Using the disability legal and policy framework to provide
adequate responses to specific issues that affect older people, such as access to for-
mal and informal services, accessibility, and others, is an important tool for ageing
advocates. However, equating old age with disability is an unwelcome stereotype,
since it narrows the scope of old age needs, challenges, and contributions solely to
those related to impairment.
21.4.3 The Active Ageing Trap
The “active ageing” paradigm has potential as an alternative to the idea of older
people as dependent, disabled, or vulnerable. Drawing on the work of the World
Health Organization (WHO) (World Health Organization 2002), for the EU “active
ageing” involves releasing older people’s potential by helping them “stay in charge
of their own lives for as long as possible as they age and, where possible, to contrib-
ute to the economy and society” (European Commission—Employment Social
Affairs and Inclusion n.d.).
According to Moulaert and Biggs (2012), however, the originally holistic active
ageing narrative has been restricted through EU practice to a notion intrinsically
linked with economic productivity. Although the EU framework has evolved since
Moulaert and Biggs made the above remark—as shown in the previous part of this
chapter—the EU maintains a utilitarian ageing agenda which largely focuses on
people of good health who can contribute to its economic growth: its threefold
approach includes increasing “senior employment”; investing in the silver econ-
omy; and improving the sustainability of social protection systems (European
Commission 2015b; European Commission—Research and Innovation 2014).
Anti-ageist agendas that are driven by concerns about the economy and not about
older people are likely to undermine their interests (Duncan 2008). In particular, the
Silver Economy initiative (European Commission 2015b) adopts a consumerist
approach targeting mainly older people with a secure income but also indirectly the
families of those who need support and care and might benefit from innovative
market-based solutions. Not only does this frame see older people merely as con-
sumers and not as citizens with full rights and responsibilities, but it also risks forc-
ing out of its remit all those who do not consume. As former UN Secretary-General,
Kofi Annan, once said, “A society for all ages is one that does not caricature older
persons as patients and pensioners. Instead, it sees them as both agents and benefi-
ciaries of development … it seeks a balance between supporting dependency and
investing in lifelong development” (Annan 1998).
In addition, despite being at least to a certain extent helpful in providing an
image of ageing which is powerful, positive, and dependency-free, active ageing
strategies may exclude people who are very old, isolated, or suffering from severe
impairments (Priestley 2003). Although extremely relevant as a preventive concept,
this approach has its limits in addressing older people who may already be in a vul-
nerable situation. Just like consumerism, active ageing policies encourage individ-
ual responsibility to cope with the challenges of ageing and alleviate the societal
burden. They are more concerned with what older people can do to avoid the col-
lapse of the health and social security systems, rather than with what the state can
do to serve older people and proactively confront demeaning attitudes about old
age, as well as the intersection of old age with race, disability, and gender, among
other factors. These intragenerational inequalities are often more widespread and
pervasive than intergenerational inequities (Duncan 2008). Unless active ageing is
understood to be more than economic participation or consumerism, policies cannot
avoid the damaging and diminishing effects of social constructions of old age.
Regardless of the intention to empower older people, active ageing strategies prob-
ably have little impact on those older people who assume different roles or purposes
in later life, such as those oriented towards the community or self-growth, and those
who struggle to live independently and be included in their communities.
Our societies tend not to make a distinction between active and inactive child-
hood, motherhood, or adulthood. However, active ageing is seen as the standard that
older people need to achieve in order to benefit from state protection as full citizens.
As long as active ageing agendas dictate what older people should and should not
be doing, they may be perceived as patronizing but also as excluding those who
deviate from the norm. Moulaert and Biggs (2012) suggest moving instead toward
agendas of “desired ageing,” which are flexible and respectful of older people’s
autonomy to live their lives as they wish.
On the one hand, active ageing and silver economy initiatives can help disen-
tangle old age from the stigma of inevitable decline, burden, and worthlessness and
thus may have a strong anti-ageist effect. On the other hand, by overstressing older
people’s economic contribution and individual responsibility, they fail to reflect the
diverse experiences and wishes of older people and the societal disadvantages that
they may face, such as poverty, social isolation, loneliness, role loss, discrimination,
and abuse. Positive stereotypes of ageing can, therefore, also be ageist insofar as
they “deny and downgrade their distinctive needs and actual and potential contribu-
tions, and question the legitimacy of old age per se, and they especially denigrate
those who cannot conform” (Duncan 2008, p. 1152). Instead of normative labelling,
we need a holistic approach to ageing, which includes all the good and bad things
associated with old age, just like with all other parts of life. This is why active age-
ing strategies need to be accompanied by a rights-based political agenda outlining
public responsibility to respect the autonomy of older people and support them in
their diverse roles and expectations of old age.
356 N. Georgantzi
21.5 T
he Potential of a Rights-Based Approach to Fight
Ageism
The two previous sections of this chapter argued (a) that the consistent downplay of
older people’s rights within the EU framework is emblematic of the injustice faced
by this group, and (b) that current conceptions of older people by the EU—whether
as burdensome, disabled, or active—have failed to address the diversity of the older
population and inspire a society for all ages. Even outside times of economic and
refugee crises older people have attracted little, if any, attention as subjects of rights.
Discrimination against older people, although prevalent across all EU countries and
extremely pervasive in its manifestation and effects on older people’s personhood,
autonomy, and security, has neither induced public outrage nor a body of standards
to confront it. This last section explores how a human rights-based approach
(HRBA) can be operationalized as the EU’s antidote to ageism.
The HRBA is gaining traction worldwide as an effective way to address in a
systematic and comprehensive manner the disadvantages and prejudices linked with
old age (Bras Gomes 2011; Chung 2010; UN Department of Economic and Social
Affairs 2009; Doron and Apter 2010; Duncan 2008; Fredvang and Biggs 2012;
Hammarberg 2011; Mégret 2011; Pillay 2014; Quinn 2013; Stuckelberger et al.
2012; Tang and Lee 2006; Townsend 2006). An HRBA shifts the focus towards state
obligations to remove social injustices faced by individuals in their jurisdiction. It
creates a duty to promote equality and emphasizes seeing older people as holders of
rights. The added value of this approach compared to the welfare or neoliberal mod-
els often reflected in EU policies is that, whereas the realization of human rights
requires the organization of socio-economic policies, the HRBA goes beyond eco-
nomic arguments as the raison d’être of such policies. It does not target only those
who are privileged, healthy, or have money, nor does it aim only at action that is
cost-efficient, but focuses on the full and equal realization of human rights for all.
Hence, it has the potential to make the most positively impactful policy changes for
older people and for society as a whole.
Counter arguments to this approach will necessarily reflect the economic costs of
a comprehensive rights agenda. Although it is outside the scope of this paper to do
a cost-benefit analysis, its thesis is that the current status quo is not only bad for
older people, but for society as a whole, as ageism impedes older people from
becoming full agents in their communities. Lifting age barriers in preventive screen-
ing can enhance the health and therefore the employability of older workers.
Providing reasonable accommodation to informal caregivers will allow older people
to stay longer in the labour market, while relieving the state from the obligation of
formal assistance to those in need. Providing training without age limits breaks the
cycle of long-term unemployment as older people can more easily re-enter the
labour market. Better transport and services will not only improve older people’s
independence and participation but it will also allow them to travel, consume, and
volunteer. Investments in health and accessibility lead to savings for the funding of
long-term care. Economic objectives can only be partially achieved unless wider
societal issues are tackled. As Fredman and Spencer (2003) suggest, “The real ques-
tion then becomes not what is the cost of age equality, but how should the cost be
equitably distributed among the three main possible cost bearers: employer, the
state and the individual or the family” (p. 4).
The EU’s current approach to ageing is full of paradoxes: on the one hand, it
reproduces stereotypes of older people as burdensome and useless; on the other
hand, its concentration on labour market participation assumes exactly the opposite.
The tolerance of age limits across EU countries results in situations where people
65+ in the same country are considered capable of working but too old to drive and
to receive preventive treatment. Upper age limits in travel insurance also create bar-
riers to intra-EU freedom of movement, damaging the targets of “senior tourism”
and the silver economy. The EU promotes longer working lives while at the same
time maintaining mandatory retirement ages. Obviously many of these cases do not
make economic sense. As Blaikie (cited in Macnicol 2006) observed, “the reasons
behind discrimination are frequently economic, but the capacity to maintain oppres-
sion is primarily psychological” (p. 11).
These considerations should encourage us not to jump to conclusions about the
cost of an HRBA, at least not before considering the cost of the alternative. Instead
of only proposing ambitious special measures for older people, an HRBA focuses
on tangible actions, which require a shift in the mindset and some procedural aspects
of EU institutions. Its premise is that while progress will be gradual and lengthy, as
an immediate next step a lot can be accomplished just by equally factoring older
people into EU decision-making.
The new Commission has appointed its first Vice-President in charge of “ensur-
ing that every Commission proposal or initiative complies with the Charter of
Fundamental Rights” (Juncker 2014b, p. 4). Vice-President Timmermans is expected
to mainstream fundamental rights across all EU actions. The proposal for an inte-
gration of an HRBA across all EU policies is, therefore, timely and consistent with
the EU’s aspirations.
The following paragraphs explore how EU action can be reframed to comply
with an HRBA, based on the framework developed by Amnesty International and
the International Human Rights Network (2006). Their methodology embraces the
following five principles: express application of the human rights framework,
empowerment, participation, non-discrimination, and accountability (Amnesty
International & International Human Rights Network 2006). Each of these methods
is analysed below, with suggestions for concrete ways in which they can be opera-
tionalized by the EU.
358 N. Georgantzi
21.5.1 Express Application of the Human Rights Framework
This chapter has provided anecdotal evidence of EU policy being driven by the
needs of an older population. Using this criterion, instead of the fulfilment of rights
that the EU adheres to in its founding treaties, makes the obligation to respect and
promote these rights appear contingent and reversible.
Applying the first principle of the HRBA in EU policies on ageing and older
people would entail first and foremost looking at how Articles 21 and 25 of the EU
Charter of Fundamental Rights has shaped EU action, translating intentions into
means. Secondly, an HRBA would rebalance the EU’s action on ageing by covering
areas unrelated to economic or utilitarian concerns. Thirdly, EU officials would be
trained and encouraged to consistently consider the impact of their decisions and
budget allocation in making assessments of the rights of older people.
Expressly referring to the rights of older people would tear down the barriers
between different policy sectors and give visibility to older people as rights-holders.
Without necessarily creating a branch of human rights specific to older people, this
could act as a comprehensive and coordinated approach to older people’s funda-
mental rights, which would ensure uniformity, policy coherence, and synergies
between initiatives taken at different levels and by various services. It would strike
a balance between the competing paradigms of dependency and active ageing that
prevail across EU policy, based on the vision set forward by the EU Charter of
Fundamental Rights, its founding treaties, and international human rights conven-
tions ratified by the EU—in particular, the UN Convention on the Rights of Persons
with Disabilities (UN CRPD) (United Nations General Assembly 2007).
“Mainstreaming” would become an obligation for all EU bodies, who would have
to look at old age through a human rights lens. As a result, the rights of this group
would not be ignored or set aside but would be placed “at the heart of its activities”
(European Union 2016, Preamble).
21.5.2 Empowerment
Empowerment means ensuring that policies allow older people to participate equally
in society, not to be considered as “charity”. The EU has a long history of social
policies for older people, but it treats them as beneficiaries and not as rights holders
(Martin et al. 2015). Applying this principle, the EU should move away from the
dependency and burden paradigm. It should abandon the stereotypical portrayal of
older people as senile, unproductive, and frail. Nor should it dictate to older people
what they ought to do to remain active, but rather support them in making autono-
mous choices for their lives. It could also reject the dependency ratio as a measure
of older people’s value in order to reflect both the extended working lives of older
people and their economic contribution as volunteers, informal carers,
grandparents, and so on.6 It should engage in an empowering discourse that does not
adopt old-age biases and perceptions of ageing as something negative that is to be
avoided and fought against. This narrative needs to be reflected across all of the
EU’s action and funding, by scrutinizing new initiatives and research projects. For
example, although the majority of EU-funded projects promote positive images of
old age, the IMI SPRINTT project, which aims to prevent physical disability, claims
that “the real challenge is to fight ageing” (AGE Platform Europe 2014a; SPRINTT
Project 2014). Rather than seeing ageing as something to be fought against, old age
should be acknowledged as a period full of resources and opportunities.
Moreover, efforts are to be made to ensure a common understanding of age
equality and the rights of older people. By encouraging a welfare approach to old
age, the EU puts an emphasis on servicing older people’s needs rather than building
their capacity to understand and claim their rights. Older people should be made
aware of the existing legal framework and how it relates to their everyday lives and
the policy developments at the national and EU level. They need to know their rights
and responsibilities, the duties of state and private actors to respect, protect, and
fulfil them, as well as the processes that are available for them to claim their rights
and bring about positive reforms. This could be achieved through EU-wide
awareness-raising campaigns and funding initiatives at local and national levels that
aim at empowering older people to take up various roles in their communities.
Overall policies should give older people the power and capacities to improve their
lives, allow them to raise their voices, to contribute and to be heard by decision-
makers, without making them passive subjects.
21.5.3 Participation
The principle of participation is a call for policies that allow for a genuine participa-
tion of older people, including the most marginalized and minority groups.
Participation in policy and legal processes can take the form of involvement of rep-
resentative civil society organizations with anchors at grass-roots level. It presup-
poses timely and accessible information so that participation is constructive and
meaningful.
AGE Platform Europe has deplored the inconsistent consultation of older people
across EU policies and called for the inclusion of older people in all policies that
concern them (AGE Platform Europe 2015b). There is certainly room for improve-
ment by systematically including old age advocates in related bodies (such as the
High Level Group on Disability and High Level Group on Non-Discrimination),
processes (such as the European Innovation Partnership on Active and Healthy
Ageing and the European Semester), and also by ensuring regular dialogues with
institutions, such as the Directorate-General (DG) for Justice, Consumers and
For an alternative, see Farrel 2016.

6
360 N. Georgantzi
Gender Equality (DG JUST) and the DG for Employment, Social Affairs and
Inclusion (DG EMPL), as well as formations of the Council, including the Council
Working Parties on Human Rights (COHOM), Fundamental Rights, Citizens’
Rights and Free Movement of Persons (FREMP), and Social Questions. The EU
could also consider setting up an inter-service group on old age—such as the one
that exists on disability—that would inform and guide EU action, exchange infor-
mation, and improve understanding of old age challenges and the EU’s role to tackle
them. Participation and inclusion of persons at risk of discrimination, such as older
people, must also be supported by the EU Structural and Investment Funds. Such
actions would ensure that involvement at the EU, national, regional, and local levels
is accessible, transparent, and timely.
21.5.4 Non-discrimination
The HRBA seeks to end discrimination, paying due attention to causes and situa-
tions of accumulated disadvantages that may lead to multiple discrimination. Non-
discrimination on the grounds of age is considered to be a general principle of EU
law but EU institutions have not applied it directly to guide policy, case law, or to
combat ageism. As explained earlier in the chapter, in practice, EU law is narrowly
focused on employment and on a formal definition of equality that includes a nega-
tive obligation not to interfere.
Non-discrimination on the grounds of age needs to become a matter of priority
in all EU policies. The EU should establish where age limits and proxies are appro-
priate and which are the factors that accentuate discrimination also beyond the
workplace. Mainstreaming non-discrimination includes a comprehensive and con-
nected consideration of older people across all EU actions, in a similar way that the
EU has taken gender into account in every policy decision (Fredman and Spencer
2003).
The EU should also gather data so that difference in opportunities can be
assessed. Data should be disaggregated by age and gender, avoiding large age
cohorts (for example, 50+), and as far as possible avoiding age limits. Age discrimi-
nation needs to be consistently addressed in surveys, such as the Survey of Health,
Ageing and Retirement in Europe (SHARE), which to date does not include specific
questions on age discrimination. Moreover, resources should be allocated for empir-
ical studies on old age inequalities, including those at the intersection of racial,
religious, gender, disability, and other forms of discrimination. The Fundamental
Rights Agency, in particular, should initiate and foster projects that put a spotlight
on the social injustices faced by the older group.
21.5.5 Accountability
The allocation of equal rights to people of all ages represents an important element
of fulfilling the EU’s commitments (Economic Commission for Europe 2008). As
we have seen in the first part of this chapter, the EU Charter does not provide for
legally enforceable rights that individuals can claim from their governments and EU
institutions. However, human rights are stripped of meaning unless they are accom-
panied by social and economic policies to support them. The principle of account-
ability is about identifying positive and negative obligations—for state and private
actors and by extension for the EU—in order to move from commitments to tangi-
ble outcomes.
In concrete terms, the application of the principle of accountability requires a
threefold effort. First, it calls for human rights impact assessments to identify the
potential positive and negative impact of plans, budgets, and reform programmes, as
well as the necessary policies to address it. However, the EU has not included the
rights of older people in its country-specific recommendations in the area of equal-
ity (European Commission 2016b). Neither has the European Commission addressed
the adverse impact of social reforms on healthy life expectancy, whereas there is
evidence that while people are living longer, they live more years in ill health (AGE
Platform Europe 2015c). In the future, austerity measures promoted by the EU
should not disregard existing human rights standards but instead ensure that the
structural disadvantages faced by older adults are taken into account in budgetary
and macroeconomic reforms. Impact assessments are necessary to allow for planned
reforms to address sustainability and deficit problems, without undermining the
enjoyment of human rights.
Second, to respect the principle of accountability a set of specific, enforceable
targets that can be used to measure the EU’s performance internally and as a global
actor in promoting age equality and confronting ageism could also be developed. To
do so, the EU could take stock of existing international instruments, such as the
Madrid International Plan of Action on Ageing (MIPAA) (United Nations 2002),
which, although it is neither a bill of rights nor legally enforceable, includes a set of
commonly agreed upon policy objectives. The EU could also promote the use of
human rights indicators in order to monitor the progressive realization of economic
and social rights under the ongoing reforms. In practical terms, this would mean that
reforms should take into account the human rights implications of measures, as well
as principles such as transparency, accountability, participation, and attention to the
most vulnerable groups, including older persons.
Third, monitoring over time would ensure that there is a gradual improvement
rather than deterioration of rights. However, the EU lacks an enforcement mecha-
nism that reviews progress in mainstreaming age equality and the rights of older
people. A service or dedicated body, including the Commission, civil society
organizations, and representatives of the member states, might be needed to ensure
362 N. Georgantzi
policy integration and “to link ageing to other frameworks for social and economic
development and human rights” (Annan 2002, p. 1). A consistent application of the
principle of accountability along the above lines will ensure that older people are
factored into laws, policies, and institutions, allowing for a prompt response to
threats or violations of rights.
21.6 Conclusion
The EU has an impressive legal and policy framework in place when it comes to
other grounds of discrimination, but it misses the mark for old age (Lassen et al.
2014). This chapter outlines the EU’s narrow interpretation of its obligation to com-
bat age discrimination and shows how it has not afforded ageism the visibility it
deserves, bearing in mind that it is the most commonly experienced form of dis-
crimination (European Commission 2015a). In fact, the EU’s ongoing austerity
measures inadvertently increase the risk of inequality and exclusion (Parent 2015).
Despite some remarkable achievements, including the Employment Framework
Directive and EY2012, the EU has generally had a patchy approach to ageism.
Efforts to enshrine anti-ageist objectives in active ageing and social policy agendas
are to be encouraged, without ignoring their limits in terms of scope and impact,
both because they have not been part of a well-developed set of mainstreaming
actions and because they fall into the trap of “essentializing” older people either as
vulnerable or active. Active ageing strategies are certainly useful elements in an
effective approach towards non-discrimination and equal opportunities; but, “for
anti-ageist policies and practices to be taken seriously in their own right, they have
to be given the profile they deserve” (Thompson 2005, p. 59).
Moreover, policy action will be deficient if ageism persists in beliefs and policy
thinking (Herring 2009, p. 13). This chapter shows that the EU is deeply conscious
of population ageing but is less concerned with individual ageing and the human
rights challenges related to ageing. The Union’s legal and policy framework have
attributed social characteristics to chronological age, in particular, consolidating
expectations about the relationship between work, retirement, and economic contri-
bution. Old age has been defined as an indicator of incapacity, unproductivity,
dependency, impairment, and burden. This vision of ageing not only sustains age-
based stereotypes and categories but also legitimizes age discrimination and mar-
ginalization. The EU needs to set up more cohesive and effective mechanisms to
rectify the structural inequalities and prejudicial disadvantages that serve to exclude
older people. A human rights-based approach is particularly well suited to promot-
ing equality and dignity in old age. It advances a vision of older people as rights-
holders and guarantees an in-depth analysis of how EU law and policies affect the
rights of older people and what further action is needed to materialize them, taking
into account both individual and public responsibility.
Acknowledgments Many thanks to Professor Eamon O’Shea from NUI Galway who reviewed
an earlier draft of this chapter and helped me improve its overall structure. In addition, I would like
to thank my colleagues at AGE Platform Europe, in particular Julia Wadoux and Ilenia Gheno, who
provided comments and ideas for elaboration. I also acknowledge the contribution of Ann Leahy,
PhD Candidate, Department of Sociology, Maynooth University, Kildare, who gave me the idea of
discussing in detail how to apply a human rights-based approach to EU action, based on her work
on how to apply HRBA to ageing policies in Ireland.
The opinions presented in this chapter are those of the author and do not necessarily reflect the
official opinion of AGE Platform Europe or the National University of Ireland in Galway.
Responsibility for the information and views set out in this chapter lies entirely with the author.
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Chapter 22
Ageism and the Rights of Older People
Annika Taghizadeh Larsson and Håkan Jönson
22.1 Introduction
Internationally, engagement in critical thinking on disability is still rare in official

discussions on ageing policies as well as in gerontological research. Rather than
focusing on environmental and societal failures to remove barriers to inclusion,
activity restrictions and related problems encountered by people in later life are, in
ageing discourse, even today, frequently viewed through the medical model lens.
Ageing discourse largely continues to stress the incapacities and helplessness of
older persons with care needs and impairments and tends to overlook the environ-
mental and societal limitations that diminish a disabled person’s opportunities to
fully participate in society and enjoy life. Furthermore, attempts to counter ageism
have tended to put healthy ageing and healthy seniors to the fore, and might there-
fore inadvertently contribute to further exclusion and discrimination of the less
healthy and vital part of the older population. On the other hand, in actions against
disability discrimination and in disability studies, there are few references to older
people (Kennedy and Minkler 1998; Priestley 2003). Consequently, the scope for
knowledge transfer from disability activism and research to the field of gerontology
that could counter discrimination of older people with impairments and lead to
changes and improvements in current systems of long-term care have so far largely
been rendered invisible.
This chapter examines how, and if, the situation of older people in need of long-
term care could be targeted by learning from disability policies. We base our
A. T. Larsson (*)
Division Ageing and Social Change, Linkoping University, Norrkoping, Sweden
H. Jönson (*)
School of Social Work, Lund University, Lund, Sweden

https://doi.org/10.1007/978-3-319-73820-8_22
370 A. T. Larsson and H. Jönson
e laboration on this issue on a number of works that we published between 2009 and
2016 (Jönson and Harnett 2016; Jönson and Taghizadeh Larsson 2009; Taghizadeh
Larsson 2013, 2011), the most recent of which was co-authored with our colleague
Tove Harnett. The chapter starts with a critical analysis of established attempts to
counter ageism, highlighting how these attempts have failed to include the so-called
fourth age, and might instead contribute to further stigmatization of older people
with care needs. Drawing upon models from disability policies, we then introduce
an equal rights framework and show how it could be used to combat discrimination
and improve everyday conditions of older people in need of care. In the third section
of the chapter, we use the equal rights framework to question existing cases of
“institutional ageism” whereby older people with disabilities are excluded from
government programs benefiting younger people. Cases where the support system
of Sweden enables older people with impairments and need for support in tasks
such as eating, dressing, and going to the toilet to participate in so-called third age
activities (cf. Laslett 1989) are included to illustrate this possibility. We conclude
with recommendations on how improvements in long-term care could be accom-
plished by learning from disability policies and critical thinking on disability.
In this chapter, we frequently refer to Sweden and, in particular, to Swedish dis-
ability policy. Given differences between welfare states, our argument is not that the
Swedish model should be exported and used internationally. Instead, we consider
Swedish policies and arguments presented in Swedish policy documents as useful
in order to rethink and reframe long-term care.
22.2 A
dvantages and Disadvantages of Countering Ageism
Through the Concept of “Healthy Ageing”
The most prevalent way to counter ageism so far can be summarized as dissociation
between old age on the one hand and illness, impairment, and dependency on the
other hand. As part of this approach, discourses and concepts of healthy ageing,
third age, and successful ageing have helped to dispel myths about older people as
a frail and dependent population. This approach has helped disseminate more accu-
rate information about the fact that today most people over the age of 65 live healthy,
active, and independent lives. This resonates with the tripartite model of attitudes
that has been prominent in research on ageism, consisting of cognitive, emotional,
and behavioural components, and draws upon theories on lagging images of old age
that appear in the writings of scholars like Mathilda Riley and Erdman B. Palmore.
In an article published in the Journal of Ageing Studies (Jönson and Taghizadeh
Larsson 2009), we analysed this upgrading approach to ageism by referring to cam-
paigns aimed at increasing participation in working life during the 1950s and 1960s,
where activists claimed that older people had the same capacity to work as their
younger workmates. What older workers lacked in speed and adaptability, they
22 Ageism and the Rights of Older People 371
gained in experience, patience, and thoroughness (Wohlin 1960). Older people

should therefore be valued and encouraged to keep working. Upgrading of older
people by bringing healthy ageing and healthy seniors to the fore is also embedded
in current campaigns in Europe to promote intergenerational solidarity. While
enhanced solidarity between different age groups is launched as a strategy in itself
to counter age discrimination on the AGE Platform Europe (2016) website, it is also
described as a way to “help achieve the EU’s goal of promoting active and healthy
ageing.” Furthermore, a short movie that “encapsulates the achievements of the
European Year 2012 for active ageing and solidarity between generations” that can
be downloaded on the website is crowded with seniors dancing, singing, laughing,
demonstrating, working, and golfing in groups or together with children of all ages.
In the movie, there is no sign of wheelchairs, sticks, or walkers, and no sign of nurs-
ing homes or other forms of long-term care.
Though obviously excluding older people with impairments and illnesses, it is
easy to understand the occurrence of this upgrading approach from a historical per-
spective. Every new generation of seniors has become increasingly more vital and
healthy, and the development of welfare states has enabled a larger proportion of
older people to keep a decent standard of living, but images have lagged behind.
Laslett’s (1989) reference to a third age reflects these changes and was, unsurpris-
ingly, introduced as an attempt to upgrade images of ageing on the basis of func-
tional ability among third age seniors. For a long time, functional comparisons have
been a trump card of anti-ageism, in the sense that “the truth” has proven that older
people are more capable and similar to non-old people than is generally believed.
For example, Wigdor (1995) wrote, “People confuse the 90% of older people who
are able with the 10% that are not” (p. 103). Whereas the upgrading approach has
great advantages, it is also “ableist” in its character as it communicates the message
that societal status is gained through health and functional ability. This problem has
been highlighted in critical gerontology, in relation to divisions between a third and
fourth age and attempts to launch models of successful and healthy ageing by
acknowledging that this might contribute to further stigmatization of older people
with impairments and care needs.
Another, yet related, established attempt to counter ageism could be summarized
as the age irrelevance approach. Critical gerontologists such as Bytheway (1995)
have argued that the construction of old age as a distinct category acts to justify age
discrimination. Using a similar argument, a Swedish government investigation of
older people (SOU 2002:29, 2003:91) ten years ago suggested that “age” and
“older” should become less relevant concepts. People would thus be freed from
roles and limiting expectations that accompany the traditional division of the life
course into separate stages, and working life could contain several careers and span
well beyond the age of 65. However, because our present society is not only ori-
ented toward age but also toward function, attempts to de-age policies could result
in problematic consequences for people with illnesses and impairments. Even if
such attempts aim at replacing age grading with individual needs among all equal
citizens, functional ability enters as a key factor when age becomes less important.
This is what happened in Sweden during the 1950s and 1960s, when researchers
hoped to arrange for a more flexible working life. The plan was to let company
doctors decide when older workers were no longer fit to belong in the workforce
rather than imposing a fixed retirement age (Jönson 2001). A suggestion made by
Sweden’s Committee on Older People also highlights the tendency to replace age
with function: “Our claim is that political action must be directed towards the pos-
sibility of enabling new and more flexible patterns of the life course without further
age divisions in society. Instead of dividing the life course further into chronologi-
cally defined blocks, possibilities must be increased to sandwich work, education,
societal involvement, family life and free time from early youth until this is impos-
sible due to illness or failing functional ability” (SOU 2003:91, p. 194). A chrono-
logically graded life course with accompanying norms may be ageist, but it has the
capacity to replace functional ability as a way of labelling citizens.
Upgrading and age irrelevance approaches have been developed as part of a laud-
able project to dissociate old age from a paradigm of decline and loss. However, the
character or consequences of these prominent attempts to counter ageism tend to be
ableist and to further stigmatize and marginalize older people with impairments and
care needs by conveying and consolidating the message that high status and success
in old age is related to health and functional ability. In both cases, and alongside the
discrimination of older people, ableism is to some extent present in the very struggle
against ageist norms. Thus, in order to combat discrimination and to improve every-
day conditions of older people in long-term care there is a need for other approaches.
22.3 Lessons from Disability Policies and Disability Research
Already in 1980, Levin and Levin (1980) argued that a prominent feature of ageism
is to regard problems of older people as caused by ageing. Following this line of
thought, common strategies within anti-ageism have been to question age as an
explanatory factor and organizing principle and to downplay physical, bodily con-
sequences of the ageing process. This was also the logic followed by the Swedish
Committee on Older People referred to above. Quite different approaches to func-
tion as well as to age have been launched by disability activists, policy makers, and
researchers as part of an endeavour to improve the situation for (non-old) people
with disabilities.
In Sweden, public care and support services for older people and people with
disabilities are handled and discussed within two policy areas: policy for older peo-
ple and disability policy. Although the objectives of these areas are in many ways
similar, there are also obvious differences between the two (Erlandsson 2014),
entailing government investigations and other documents within the realm of dis-
ability policy—an area with a strong connection to the disability movement—to
display more of a clear-cut citizenship perspective. Consequently, there is a stronger

emphasis on equal value and equal rights and on the need to close the gap between
people with and without disabilities. Within disability policies, researchers and offi-
cial policy makers have frequently taken a protagonist stance and emphasized the
need to make people with disabilities equal citizens. Prominent members of the
disability movement have also been key players in the process—most notably,
Bengt Lindqvist, who was the minister responsible for disability policies in the
Social Democratic government from 1985–1991, had previously been president of
the Swedish Association of the Visually Impaired (1975–1985), and was one of the
founders of the socialist association, Disabled People’s International.
Below we present a model developed in disability policies that could be used to
argue for improvements of long-term care for older people. The model refers to a
recent paper published in The Gerontologist (Jönson and Harnett 2016). The strat-
egy we suggest differs from both the upgrading and the age irrelevance approaches
that have been adopted internationally within anti-ageism as well as within Swedish
Policy for older people (SOU 2002:29, 2003:91). It aims to acknowledge age, while
also looking past bodily shortcomings in later life, and focuses on the way society
disables and discriminates older persons with care needs and impairments. In this
model, we refer to the Scandinavian normalization principle that has been promi-
nent in disability policies of the Nordic countries. In the Gerontologist paper, this
principle is developed into an equal rights framework that may be used to identify
discriminating practices and claim “equal rights” for older persons with long-term
care needs.
The first outlines of the Scandinavian normalization principle appeared in
Denmark and Sweden in the 1950s. A characteristic of the principle was that it used
people in general— referred to as “ordinary citizens”—as the comparative refer-
ence group and identified persons with impairments as deprived relative to other
members of society. The principle suggests that society should make available for
persons with impairments living conditions that are the same as or similar to those
of citizens in general. People with disabilities should be able to live like “others.”
In 1970, the originator of this principle, Bengt Nirje, suggested eight normaliz-
ing rights for young people with developmental impairments (Nirje 1970):
1 . A normal rhythm of the day
2. A normal weekly rhythm
3. A normal rhythm of the year
4. A normal development experience of the life cycle
5. Have choices, wishes, and desires respected
6. Live in a bisexual world (not in unisexual groups)
7. Apply normal economic standards
8. Access to physical facilities such as (apartment-like) housing, schools, work-
places, and hospitals that are the same as or similar to those provided for ordi-
nary citizens
Nirje (1970) formed his principle as a critique of contemporary disability policies at

a time when large institutions were the dominant form of housing for persons with
intellectual disabilities. Normality and justice for people with disabilities living in
institutions was at the time based on comparisons to others living in institutions or
having similar disabilities.
To question institutionalization and categorization according to medical models,
Nirje (1970) used a number of references to comparative categories external to the
institution and to the entire context of care and bodily and intellectual shortcomings.
In accordance with the right to access physical facilities similar to those provided
for ordinary citizens, Swedish disability policy has emphasized that housing for
people with intellectual disabilities should be the same as or similar to ordinary
housing. Daily activities should take place in arenas that are external to the context
of care; that is, that schools and workplaces should be separate from housing
(Tideman 2000).
In his original work, Nirje particularly commented on normal conditions in rela-
tion to life phases: childhood, youth (school age), adulthood, and old age. This
construction of normality with reference to age has become central to Swedish dis-
ability policies and activism. Age-based activities have guided comparisons of life-
styles and rights, with the former being used to argue for the latter. For example, in
the early 1990s, policy makers and disability activists argued with reference to age
in a comprehensive government investigation (SOU 1990:19, 1991:46, 1992:52)
preceding the introduction of a system of personal assistance that significantly
improved conditions for younger people with disabilities. In the investigation, the
Swedish Disability Committee (SOU 1991:46) explained how key concepts like
accessibility, participation, influence, and equality should be measured: “We have
seen it as important to present proposals which mean that people with significant
impairments (children, youth and adults) have equal conditions as others of similar
ages” (p. 143). In this perspective, it is in relation to their age peers that the condi-
tions of people with disabilities should be compared. This is clearly expressed in
writings about younger people with disabilities, where normalization is defined as a
right to participate in activities typical of young people. A reference to the age
norms of youth may be phrased like this: “He who is young should be able to live a
life like other youngsters, to travel on an Interrail pass, take a language course, study
abroad, party, and so on” (Peterson 2003, p. 217). The Disability Committee also
mentioned specific roles, norms, and activities associated with childhood and youth,
and discussed parenthood and participation in working life as roles for adults (SOU
1991:46). The possibility to compare ages may be regarded as the trump card of the
disability movement, since such comparisons have the potential to identify welfare
arrangements without focusing on diagnosis or characteristics associated with
impairments.
22.4 The Equal Rights Framework and Institutional Ageism
Is it possible to transfer the ideas of the normalization principle adopted by disabil-

ity activists to long-term care for older people? Can society make available for older
persons with impairments and illnesses living conditions that are as close as possi-
ble to those of “others of the same age”? Who are those “others of the same age”
who could serve as comparative reference groups in demands for justice? What kind
of comparable living conditions should policies aim to achieve?
Building on the Scandinavian normalization principle, Jönson and Harnett
(2016) have developed an equal rights framework (Fig. 22.1) that could be used to
analyse and propose changes in care for older persons. A typical internal reference
is to argue that justice is achieved when residents at a care facility are treated equally,
for instance having the possibility to go for a walk or having a shower twice every
week like others at the facility. An external reference group for comparison might
include people in general: for example, other men or women; other Muslims; other
vegetarians; or other couples. Should older couples be deprived of possibilities to
live together like other couples, just because they have support needs? If not, society
should provide solutions that allow them to keep living together. Following the dis-
ability movement, a general aim should be to increase external comparisons when
discussing the rights of older people who receive long-term care.
In order to explain the strengths of the equal rights framework to improve long-
term care and living conditions for older people in the fourth age, we use the frame-
work to question existing cases of “institutional ageism” whereby older people with
impairments are excluded from government programs benefiting younger people
with disabilities. The strategy proposed could also be used in attempts to improve
Type of references Internally oriented – Externally oriented –
care and impairment society in general
Context-centred The contexts of care or Other contexts invoked
impairment as comparison
Category-centred Other care users or Other categories
categories relating to invoked as comparison
care or impairment
Personhood-centred The unique person in Other aspects of the
relation to care or unique person invoked
impairment as comparison
Fig. 22.1 An equal rights framework for persons in need of support and care (First published in
The Gerontologist, Jönson and Harnett 2016; Reproduced from Jönson and Harnett 2016)
long-term care in cases, and countries, where the situation in need of improvement
is not as clearly and explicitly related to ageism.
Instead of acting as a normative reference group, as the ideal or individually cor-
rect standard that older persons may fail or manage to live up to, we suggest that it
is possible, and relevant, to use the third age and older people without impairments
and care needs as a comparative reference group. Furthermore, we argue that soci-
ety should make available for older persons with impairments living conditions that
are typical for members of this group of active, healthy seniors. Our point of depar-
ture is a qualitative interview study with people ageing with extensive physical
disabilities that was conducted in Sweden some years ago. The study was previ-
ously published in English as an article in the Journal of Human Development,
Disability, and Social Change (Taghizadeh Larsson 2011) and as a chapter in the
book, Ageing With Disability: A Life Course Perspective (Taghizadeh Larsson
2013).
In disability policy, a prominent idea is that the right of people with extensive
disabilities to live like others and to be self-determinant and autonomous can be
realized through personal assistants that serve as the so-called assistance user’s
“arms and legs,” while the user determines what should be done, and how. In
Sweden, this idea was materialized in 1994 by the introduction of the system of
personal assistance. This reform improved conditions for people below the age of
65 with lasting, long-term support requirements, in the sense that their opportunities
to take control over their own lives were significantly improved (Szebehely and
Trydegård 2007). In 2001, the right to keep assistance after 65 was introduced.
However, the conditions still are that personal assistance has to have been granted
before the age of 65, and the amount of assistance accorded may not be increased
after the 65th birthday. This “institutional ageism” can be understood partly as the
result of the above described and successful endeavour to provide disabled people
of younger ages with rights that are typical of non-disabled citizens. In this struggle,
what is just and equal has been defined in relation to citizens of similar ages: chil-
dren, youth, and adults of “active ages”. To some extent the exclusion of older peo-
ple can then be understood as the inadvertent result of a struggle against other forms
of prejudice; that is, as a struggle against ableism. It can also be seen as a struggle
against the traditional inclusion of all people with needs into one group (Jönson and
Taghizadeh Larsson 2009). For older people, there has been a lack of comparative
reference groups and, as a result, comparisons in long-term care have tended to
depart from the left-hand column of the framework: as internal to care and
impairment.
How do we move comparisons to the right-hand column in the framework? We
have already mentioned a number of categories that could be used creatively when
claiming rights to live like “others”. Our suggestion then is that the third age, associ-
ated with a number of activities and lifestyles—studies, travel, leisure, involvement
in the family, and volunteer work—could be used as a comparative reference group
for older persons in need of care. In other words, and building on lessons from dis-
ability policies and research, we suggest that it could be claimed that an older per-
son who has aged into impairments should be able to live a life like others who are
older, visiting relatives, traveling, studying, and participating in volunteer work.

These activities should not be regarded as normative—they should not be standards
to live up to—but as typical, and thus possible to refer to when defining social
rights.
Third Agers with Extensive Impairments The idea of using the third age as a
comparative reference group for older persons with impairments does not depart
from an imagined situation; it is empirically anchored in the life of some people
who have aged with impairments. Based on qualitative interviews with 12 persons
aged 65–72 with extensive physical disabilities belonging to the first, and small,
cohort of Swedish citizens with the legal right to keep their personal assistance after
65 years of age, we illustrate the potential of the third age to become an important
reference group for people with impairments and long-term care needs.
All 12 interviewees were dependent upon some form of mobility support (cane,
walker, or wheelchair) more or less all the time; nine primarily used a wheelchair.
The diagnoses reported were the following: polio (three); multiple sclerosis (MS)
(five had at one time been diagnosed with MS, but two of these presented the diag-
nosis as uncertain or ambiguous); cerebral palsy (two); spinal injuries (one); stom-
ach and intestinal diseases (one). What is of interest is that members of the population
of older people who had impairments and extensive support needs before they
turned 65 are provided with a type of help that other members of the category of
older people are not entitled to have. Having had their impairments for a long time,
they have to some extent also encountered and in some cases embraced the ideology
and models that have been developed by the disability movement and as part of
official policy.
When the 12 individuals talked about what they had been doing lately, what they
were planning to do in the near future, and when they were asked to talk about an
ordinary week and a normal day, an image of recreationally active, committed indi-
viduals emerged. The women and men in question described how they went to the
theatre and concerts, were involved in artistic activities, took part in language stud-
ies, sports and gymnastics, and travelled both within and outside Sweden. Several
took an active part in society through volunteer work at various levels (international,
national, and municipal) and within various associations aimed at improving the
living conditions of disabled people. Some were active in providing supervision for
their personal assistants and in handling elements of the administration connected
with their assistance. They appeared, in other words, as continually engaged in life
in a way typical of a “third ager” (see Laslett 1989).
The current lifestyle of the participants largely seemed to be a matter of devoting
their free time to activities that they to some extent had been previously engaged in,
when they were still on early retirement pension or were working. As Margareta
(aged 66), who left work when she was in her 50s, put it: “Much of what I thought
was kind of hobby stuff before, I pursue in a somewhat different way now.” Some
commented that the activities that they were engaged in today were the kind that
they probably would have devoted their careers to if the possibility had existed.
Among those was Inger (aged 67), who was diagnosed with polio as a child. Inger
had applied and been accepted to an art college when she was a young woman. At
that time, however, the educational institution was located on the fourth floor of a
building without a lift, which made it impossible for her, as a wheelchair user, to
begin her studies. Today Inger, with the support of her personal assistants, devotes
a good portion of her time to artistic activities of various forms. Likewise, other
participants described how developments in technical aids had created an opportu-
nity for them, despite increased impairment, to engage in sports in ways that were
impossible when they were younger. Hence, the dimension of self-fulfilment that is
characteristic of the third age (Laslett 1989) can also be part of being a senior with
extensive impairments.
For those participants who had personal assistance, this support stood out as a
critical element in effectively achieving an active, third-age-like lifestyle. They
talked about personal assistance as “the best thing that ever happened” to them and
as “heaven-sent”. When life with personal assistance was compared to previous
experiences of eldercare in the form of municipal home help services, participants
highlighted flexibility, the possibility to influence the choice of assistants, and
greater control over one’s everyday life among the benefits. In line with arguments
from disability scholars and activists that it is possible to be highly dependent on
other people, yet perceive oneself as autonomous, some said that personal assis-
tance makes it possible to “manage oneself.”
A striking example of this is the story of Ann-Marie, aged 65, and diagnosed
with MS at the age of 20. Ann-Marie was an active member of an international art
association. Through a monthly scholarship, a more established artist supported her
in her artistic development for a few hours every Wednesday. As Ann-Marie had lost
the ability to move her arms and legs, she used her mouth when she painted. Aside
from being one of the participants engaged in artistic activities and in gymnastics,
she was an experienced traveller. At the time of the interview, she had recently vis-
ited Denmark, Spain, and Iceland. During the interview, Ann-Marie described her
future travel plans:
On the topic of travelling, I probably won’t travel abroad anymore. I’ve had enough of that.
Although, sometimes I think I haven’t explored all of Iceland yet. I should go to the north-
ern part, too. But, no, I probably won’t. I’ll keep myself to Sweden from now on. And you
know what? Recently I had this idea to adjust Lennart’s car so we can adjust one of the seats
to fit my wheelchair in there. That way we can go on shorter trips alone. So that’s our small
project right now.
Lennart, who is referred to in the interview extract, is one of Ann-Marie’s personal

assistants and has for many years assisted her with tasks from brushing away strands
of hair from her face to personal hygiene, meals, and dressing. However, it is Ann-
Marie herself, through a specially designed computer, who administers the assis-
tance and plans the assistants’ schedules.
The participants in the study mentioned above managed to do something that
both anti-ageists and disability activists so far have largely failed to do. Through
their stories, they provided “updated” images of older people with extensive impair-
ments living third-age-like lifestyles. By doing so, they also indicated that activity
restrictions and problems that people encounter in later life could be countered in
similar ways as in younger ages; that is, they indicated that they should have the
right to live like others in the same (third) age—like older people without impair-
ments and long-term care or support needs.
Adding to our argument that the third age could be considered as a relevant refer-
ence group for older people with long-term care needs, two recent case studies
exploring the phenomenon of living with dementia with support from personal
assistants (Hellström and Taghizadeh Larsson 2017) showed that older people who
have acquired cognitive impairments as older adults may also live active lives “like
others in the third age.” The two persons who participated in the case studies both
received their dementia diagnosis at a relatively young age and had extensive care
needs when they reached the age of 65. One of the case studies involved a 72-year-
old man, diagnosed with frontotemporal dementia 13 years previously, his wife, and
personal assistants. The other involved a woman aged 66, diagnosed with
Alzheimer’s disease 11 years previously, her husband, and personal assistants. Both
the man and woman had lost their abilities to use spoken language and to walk.
Their daily lives with dementia and personal assistance were studied by participant
observations inside and outside the home of the participant, video recordings, and
audio-recorded interviews with spouses and assistants. The study illustrates that an
active and relatively independent life inside one’s own home and in the local com-
munity, including for example daily trips with an adapted car to various destina-
tions, such as cafés and tourist sights, may be an option even for people with late
stage dementia if access to flexible and personalized support, such as personal assis-
tance, is provided.
How should we respond to ageism? This question is at the heart of the chapters in
this book that deal with interventions to reduce ageism. Our conclusion, based on
the Swedish case, is that older people in need of long-term care/support are victims
of institutionalized ageism in the sense that they receive less help than people of
younger ages. The justifying idea behind this discrimination is that because the
process of ageing is generally linked to more diseases, impairments, and ultimately
results in death, it can be considered appropriate to regard impairments among
members of the category of older people as normal, and hence a matter to adjust to
and cope with. This ageist rationale is internalized in the form of low expectations
among older people themselves. Kane and Kane (2005) suggested that part of the
discrepancy between long-term care for young and old can be traced to differences
in the goals and expectations held by these age cohorts. Whereas younger people
with disabilities see themselves as prevented by circumstances from participating
fully in life’s activities and thus seek (or demand) services that will permit full par-
ticipation, older people seem to be willing to settle for much less: “They seem to
view decline as an inevitable consequence of aging that must be borne with equa-
nimity. This propensity to accept less, and hence to demand less, is associated with
greater life satisfaction—interpreted as some form of coping, but the propensity

really reflects ageism” (Kane and Kane 2005, p. 52). People are educated to expect
that impairments after the age of 65 are the result of normal ageing and that shrink-
ing possibilities are consequences of the normal ageing process.
In relation to the equal rights framework, attempts to fight institutionalization
have been expressed in claims that the person in long-term care should be able to
keep preferred habits and appearances. However, as shown by Harnett and Jönson
(2017) in a recent study of Swedish nursing homes, external comparisons to
personhood were found to be difficult to uphold when the ageing process was per-
ceived to change the needs of the person. As a result, references to personhood are
moved to the left in the framework; normality and justice are then defined as the
possibility to live like one usually lives within the context of care. The persons who
are cited in this chapter as members of a category that have aged with impairments
and with the type of support that older persons are usually not entitled to, show us
that these “truths” may be challenged.
Responding to ageism as a general phenomenon, anti-ageist campaigners have
attempted to establish differences and divisions within the category of older people
that are based on the presence and absence of disease and impairments. A major
approach has been to claim that a majority of older people are healthy and able and,
for this reason, ageist images of older people as frail should be replaced by updated
descriptions. Our argument is that ableism has become embedded in and/or might
be the consequence of some of the most prominent approaches that are used to
counter ageism. Our recommendation is to shift focus from the performance and
capability of ageing individuals to the performance and capability of society, and
investigate how society enables or disables older persons with impairments. Our
main argument is that policies relating to long-term care for older people could be
improved by learning from disability policy and critical thinking on disability pro-
moted by scholars aiming to improve the living conditions for, particularly, younger
people with impairments. The approach that has been suggested in this chapter
means that the third age, which so far has been a normative reference group for
older people, could serve as a comparative reference group when older persons with
impairments and care needs, as well as researchers and activists, argue for improve-
ments in long-term care.
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Handikapputredning. [Swedish official government reports].
SOU. (1992:52). Ett samhälle för alla [A society for everybody] Handikapputredningens slutbetän-
kande. Betänkande av 1989 års Handikapputredning. [Swedish official government reports].
SOU. (2002:29). Riv ålderstrappan! Livslopp i förändring [Down with the age ladder! Changing
views of the life course]. Diskussionsbetänkande av den parlamentariska Äldreberedningen
Senior 2005. [Swedish official government reports].
SOU. (2003:91). Äldrepolitik för framtiden. 100 steg till trygghet och utveckling med en åldrande
befolkning [Future Policy for the Elderly in Sweden.100 steps to security and development for
an aging population] Slutbetänkande av den parlamentariska Äldreberedningen Senior 2005.
[Swedish official government reports].
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skilda villkor, skilda trender? Socialvetenskaplig tidskrift, 14(2–3), 197–220.
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physical impairments. Journal of Human Development, Disability, and Social Change, 19(2),
127–140.
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ments? In E. Jeppsson Grassman & A. Whitaker (Eds.), Ageing with disability: A life course
perspective (pp. 55–71). Bristol: Policy Press.
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tik i teori och praktik för personer med utvecklingsstörning. Lund: Studentlitteratur.
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ference, Sierre, Centre for Interdisciplinary Gerontology. Geneva: University of Geneva.
Wohlin, M. (1960). Hela folket i arbete! Arbetsförmedling och arbetsanskaffning för äldre [The
entire population at work! Distributing and providing work for older people]. Stockholm:
Möllerkommitten för åldringsfrågor.
Chapter 23
Educational Methods Using
Intergenerational Interaction to Fight
Ageism
María del Carmen Requena, Hannah J. Swift, Laura Naegele,

Marc Zwamborn, Susan Metz, Wilco P. H. Bosems, and Joost van Hoof
23.1 Introduction
The social phenomenon of ageing has deeply modified contemporary societies,

making it possible that three or more generations live together within the same
chronological environment. Even though this development can be viewed as a great
achievement, it does not mean that societies have changed their often negative con-
cept of older generations. This holds particularly true for younger generations, as
they, for example, often view older persons as conservative, petulant and pessimistic
(Requena and Gonzalez 2008). Studies that explain ageist behaviour tend to focus
on the micro level (linking ageist attitudes with individual characteristics) or on the
macro level, where ageist behaviour is attributed to shared cultural norms and atti-
tudes that shape individual, organisational and societal behaviour regarding certain
age cohorts (Shiu et al. 2015). As multigenerational societies become the norm,
M. del Carmen Requena (*)

Department of Psychology, Universidad de León, León, Spain
H. J. Swift
Centre for the Study of Group Processes, School of Psychology, Keynes College, University
of Kent, Canterbury, UK
L. Naegele
Institute of Gerontology (IfG), University of Vechta, Vechta, Germany
M. Zwamborn · S. Metz
Summa College, Summa Healthcare, Eindhoven, The Netherlands
W. P. H. Bosems · J. van Hoof
Centre for Healthcare and Technology, Fontys University of Applied Sciences,
Eindhoven, The Netherlands

https://doi.org/10.1007/978-3-319-73820-8_23
384 M. Carmen Requena et al.
rather than the exception in Europe, the question of how existing prejudices and age
cohort related discrimination could be tackled arises.
Within this context education plays an important role. The sector of higher edu-
cation, in particular, aims to form professionals in this new multigenerational land-
scape and it must be aware of its double role as a tool to combat demeaning
stereotypes based on ageing and prevent ageist beliefs and attitudes. Ideally, higher
education incorporates learning social competences and interpersonal abilities, and
this perspective faces implicit stereotypes because it removes social conventional-
isms and shared expectancies where ageist stereotypes are grounded.
Theoretical frames based on intergroup theories (Stephan and Mealy 2011) lay
out how coexistence and participation in a common space favours personal knowl-
edge and avoids explicit ageism (Hagestad and Uhlenberg 2005). Intergroup theo-
ries propose that positive intergenerational relations, which require personal
involvement beyond the mere coexistence, can reduce implicit ageist attitudes and
values. Intergenerational relations presuppose a double bond between persons: one
is affective and another one is based on specific interaction rules within the com-
munity. Research has shown that affective bonds promoted by personal relationships
are significantly related to the lack of implicit ageist stereotypes (Jost et al. 2004).
This kind of intergenerational relations is present in family or labour contexts, but is
underrepresented in formal educative environments, which are typically homoge-
neous regarding age. It is not usual to find older persons sharing the classroom with
younger students, unless when intentionally prepared. It is also not usual to find
young and older persons sharing leisure places unless some kind of emotional bond
is present. Therefore, higher education institutions have the responsibility to pro-
mote educative intergenerational experiences both within the formal academic envi-
ronment and beyond it in real life contexts. Students find the chance to put into
practice not only the technical knowledges acquired in their studies, but develop
affective bonds and prosocial abilities by means of intergenerational encounters.
A myriad of concrete examples illustrate these ideas. Consider how young
European nursing students prefer not to work in the ageing sector, even if it is a
major source of employment. For example, studies on the professional preferences
among students of degrees such as medicine, social work or education show that
they begin their studies preferring to work with children or young persons, while the
practice with older persons is generally neglected to the last ordinal preference
(Kalisch et al. 2013). This lack of interest is not only related to the emergence of
negative memories and experiences but also to erroneous beliefs and myths about
age and ageing (Requena and Gonzalez 2008). Such tenets are based on outdated
socio-cultural patterns of interaction between generations especially among young
persons and first year university students. In contrast, it has been confirmed that
intergenerational groups linked by commercial or ephemeral bonds are less efficient
in terms of prosocial interaction than affectively loaded intergenerational relations
(Chonody and Wang 2014).
This chapter presents theoretical models, methodologies and a case-study, which
exemplify and lay the foundation for an applied educative model based on the
combination of scientific knowledge delivered in classrooms with experiential
23 Educational Methods Using Intergenerational Interaction to Fight Ageism 385
methodologies. In particular, the proposed approach combines technical instruction

with person-centred education as a successful formula to fight implicit ageist stereo-
types in higher education. The chapter starts out with outlining three theoretical
frameworks (Intergroup Contact Theory, Intergenerational Contact Theory and the
Concept of Generational Intelligence) and aims to explain in educational contexts
how intergenerational contact can help to prevent discrimination based on age.
Subsequently the illustration of concrete experiential methodologies in higher edu-
cation that facilitate intergenerational contact are outlined, the chapter ends with the
presentation of the case study “Senior in Class”, conducted in the Netherlands, that
can be considered as a ‘good practice’ example of intergenerational contact inter-
vention to preventing ageism.
23.2 Theoretical Frames
23.2.1 Intergroup Contact Theory
Intergroup contact theory (Allport 1954) is a social psychological theory, which

suggests that, under the right conditions, contact or interactions between members
of opposing groups may improve attitudes and bring about a reduction in intergroup
prejudice and stereotypes. The optimal conditions specified by Allport include equal
status between group members, working towards a common aim or goal, providing
an opportunity for intergroup cooperation and institutional support or support from
an authority figure. Research has identified further conditions that facilitate the ben-
eficial effects of intergroup contact. For instance, Cook (1962) highlighted the
importance of intimacy within the interaction and suggests this underpins the poten-
tial to see the interaction partner as more than an ‘acquaintance’, which is likely to
facilitate the development of a cross-group friendships (i.e., friendships between
people who belong to different social groups). Indeed, cross-group friendships are a
direct form of intergroup contact. Pettigrew’s (1998) review found that individuals
with friends from different social groups had significantly lower levels of in-group
bias, and it is the most likely type of contact to result in positive outcomes, includ-
ing, a reduction of prejudice and increase in sympathy towards, and admiration of,
outgroup members (Pettigrew 1997; Davies et al. 2011).
Since Allport introduced intergroup contact theory as a means of prejudice reduc-
tion, there have been many studies exploring its effects, in various contexts, with a
range of outgroup targets (predominately race and ethnicity, followed my mental or
physical disability and sexual orientation). In 2006, Pettigrew and Tropp conducted
an extensive review and meta-analysis of 515 of these studies, conducted between
1940 and 2000, that included more than 250,000 participants. The results showed
that studies adhering to Allport’s optimal conditions of contact tend to produce
larger effects and are therefore, generally seen as more successful in reducing preju-
dice. However, studies that didn’t adhere to these conditions tend to produce smaller
effects, but were also considered successful at reducing prejudice. Therefore, the
authors concluded that these conditions should be seen as facilitating factors, rather
than essential conditions for prejudice reduction. In addition, research has shown
that the prejudice reduction effects of intergroup contact are generalizable beyond
the original contact partner (Pettigrew and Tropp 2006). In other words, contact
interactions between people who belong to different social groups can reduce preju-
dice towards the contact partner’s entire outgroup (as well as to the contact partner),
resulting in changes in attitudes towards groups of people. The findings of the meta-
analysis, in which 10% of the studies explored contact interactions between differ-
ent age groups, has significant implications for intergenerational contact (i.e.,
contact between members of different age groups or generations), suggesting that it
is viable prejudice reduction technique capable of reducing ageist attitudes towards
contact partners, as well as prejudice towards older adults in general.
23.2.2 Intergenerational Contact Theory
The majority of intergenerational contact research tends to focus on the effects of

intergenerational interactions that take place during day-to-day life, and reveals that
positive intergroup contact is related to more positive outcomes, including a decrease
in explicit and implicit negative attitudes towards older adults (see Drury et al. in
press for review) and tend to lead to more positive behavioural intentions, such as
intentions to donate to charities that support older people, and agreeing to spend
more time with older adults (Bousfield and Hutchison 2010; Hutchison et al. 2010).
This is particularly the case when young people’s experiences were frequent and of
good quality, in other words, considered to be positive interactions (Hutchison et al.
2010).
However, just like intergroup contact, there are different types of intergenera-
tional contact, which can occur in a range of settings. For instance, cross-group
friendships are a direct form of contact, but contact can also be indirect, such as
extended contact and imagined contact. Extended contact works on the basis that
a-friend-of-yours-is-a-friend-of-mine (Wright et al. 1997). For example, the knowl-
edge that a same aged friend has a friend, who is an older adult, can reduce ageism.
Imagined contact works simply by asking people to imagine having a positive
encounter or interaction with someone (usually asked to imagine a stranger) from
another social group. For example, in two studies, undergraduate students who
imagined a positive interaction with an older adult stranger reported less prejudice
and bias toward older adults compared to students, who imagined an outdoor scene
(Turner et al. 2007). However, unfortunately it seems that opportunities for mean-
ingful interactions between generations and opportunities to from cross-generational
friendships between generations are rare. Evidence from the European Social
Survey shows that 80% of respondents aged 15–24 have no friends aged 70 and over
(Abrams et al. 2011). There are often significant barriers and obstacles to the
formation of cross-group friendships, particularly between people from different
age groups. Therefore, intergenerational contact programmes, are often used to fill
this void and provide opportunities to bring generations together with the aim of
improving intergenerational relationships.
23.2.3 Generational Intelligence
The emerging model called “generational intelligence” offers a conceptual frame to

interpret the complex and multidimensional issue of intergenerational relations.
Against the backdrop of constantly shifting socio-demographics, the model takes
the dual challenges of being placed in the situation of another generation, while
simultaneously negotiating sustainable relationships amongst members of different
generations (Biggs et al. 2011). Generational intelligence is defined as the capacity
to reflect and act towards the comprehension of oneself and others as members of an
age group, of a cohort, and of a family living in a present social and cultural context.
Young and old coordinate common chronological time with roles, which can differ
between generations. For example, in the past, the older persons were the holders of
wisdom while currently young persons have a better access to knowledge. In the
past, the social role determined by the pair education-work was significantly less
dependent on chronological age. For example, work was distributed in terms of
family needs, not in chronological terms when children had to leave school to work
and help at home. Moreover, in contemporary societies there are manifold temporal
contexts occupied by several generations sharing the same chronological time. An
essential feature of generational intelligence is using education to encourage people
to understand the temporal context of others. This model does not search for a neu-
tral age and does not presuppose that age is irrelevant. Rather, the model focuses on
creating spaces where age is distinctive from several generational points of view,
and suggests this must be taken into account within a pragmatic negotiation process.
The social classification of people according to age influences the expectations of
the roles played by citizens at different ages: children play, young people study,
adults work and the elderly rest. However, the real plurality of significant roles
played by older persons (such as support for the family, caring for their grandchil-
dren and support for the community through volunteering) goes beyond the tripar-
tite social structure education-work-pension. There are severe discursive limitations
on the expectancies of older persons because their identity and responsibility are
impoverished (Biggs and Lowenstein 2013).
The National Council on Aging of the U.S.A. (Ventura-Merkel and Lidoff 1983),
for instance, proposes the development of generational intelligence through activi-
ties that increase cooperation, interaction or exchange between two generations.
The exchange is more than the mere fact of bringing together young and old, since
it aims at the organised achievement of benefits for both generations. The co-
presence of older and young people should promote generational know-how
together with the ability to use it as a key and non-decorative element of g enerational
interventions. Decisions about the content of these programmes are made taking
into account as a priority objective the generational educational exchange that, pre-
cisely because they are different from each other, can create a space for communica-
tion, dialogue, encounter and learning (McClusky 1990).
The presented frameworks stress the potential of reducing existing age-related
stereotypes through direct interaction between different generations. Establishing
ties between different generations is essential in order for members of different age
cohorts to discuss differences between them as well as to express their need for each
other (Manheimer 1997). Such ties include interactions that happen through the
exchange of knowledge, such as young people introducing older people to the use
of technologies, while older people contribute their vital life and work experience to
younger generations. The idea of intergenerational knowledge exchange is rather
common in the social sphere of work, for example, as part of mixed-age groups in
general. However, this chapter aims to look at the higher educational sector and its
potential for reducing ageism through intergenerational contact. It should be men-
tioned that programmes, aimed at fostering this intergenerational contact, are not
exempt of unexpected results that can end in failure and therefore, careful planning
and constant supervision are required (Sánchez and Kaplan 2014). The following
chapter (2018; Chap. 24) introduces the method of “Experiential Service-Learning”
as a vehicle for facilitating interaction amongst different cohort members and pro-
vides the methodical background for the case study presented in the closing of this
chapter.
23.3 Experiential Service-Learning
Educational practices in ageing societies are constantly exploring new inclusive

educational methodologies for all ages. According to the theoretical models previ-
ously proposed, it is necessary to balance the current curriculum based on the acqui-
sition of an extensive body of theoretical knowledge with new experiential learning
methodologies that favour not exclusively academic formation, but also community-
based learning. John Dewey (1916–1995) is acknowledged as the creator of the
theoretical rationale for contemporary academic Service-Learning: “Experience is
better than a ton of theory because it is only in experience that any theory has vital
and verifiable experience” This author argued for the advantages of offering signifi-
cant experiences with which students can acquire knowledge and develop abilities
to solve real world problems. Dewey’s proposal is to incorporate concrete experi-
ences into the learning process with an ulterior critical reflection on the experience
(Conway et al. 2009). The success of Service-Learning as a powerful strategy able
to improve learning and foster an engaged citizenship against ageism is well docu-
mented (Basran et al. 2012). In fact, research showed that students taking part in
Service-Learning Programmes obtain better academic records, increase their
self-efficacy, enrich their personal identity, their social conscience and self-confi-
dence and are more aware of their civic and ethical responsibilities towards the
sociocultural context where they live.
The Service-Learning planning methodology requisites, established by the
National Service-Learning Clearinghouse (NSLC) (Gallagher 2007), are the
following:
• The production of knowledge departs from problems rather than from
disciplines;
• Problems faced by Service-Learning strategies and their solutions are handled
with academic tools and scientific rigour. The activities should foster social links
to articulate Service-Learning within and without the classroom;
• Active participation of students in all phases of the Service-Learning field work,
including diagnostic, planning, management, results, evaluation and reflection
(see the project “Seniors in Class” below);
• The evaluation of solidary attitudes amongst different generations has the same
weight as academic learning;
• Reflection on results. To achieve this requirement it is appropriate to use evalua-
tion tools such as discussion groups and portfolio, described in the case study in
the following section.
23.3.1 Service-Learning in Higher Education
Within the context of higher education (universities and colleges) Service-Learning

methodology begins with the American Compact Campus in the 1990s. This cam-
pus is currently shared by more than 959 colleges, universities, public and private
educational institutions in more than 30 states throughout the United States of
America. The mission of these centres is to promote civic responsibility through
knowledge transmission and community-based research. Europe also was influ-
enced by Service-Learning methods. Among the first initiatives stands out the 2003
created European Service-Learning Association and the EU project CIVICUS, pro-
moted by the Vytautas Magnus University in Lithuania, in which forms of coopera-
tion between universities and companies were explored (Natalija and Deivida 2011).
The Netherlands Centre for Social Development (Movisie) is one of the main enti-
ties disseminating Service-Learning (Lub et al. 2009), including special attention to
older persons. The drop of voluntary work in society forced the government to rule
that all students must work between 48 and 72 h in Service-Learning activities from
September 2010 onwards. Service-Learning was introduced in the curriculum in
2007 and obtained compulsory status in 2011. Similar centres are created in Sweden
and Switzerland.1 In the United Kingdom, Service-Learning practices are under-
stood as citizenship education and they are organized by civic extra-academic
www.servicelearning.ch
1
institutions such as Community Service Volunteers. For example, outstanding inter-

generational programmes incorporate old persons as mentors of difficult school
children (Jerome 2012). Germany founded the network Lernen durch Engagement,2
which includes excellence and cooperative centres and is active in the publication of
materials. In Spain, the network Red Estatal de Aprendizaje-servicio and in
Barcelona the Red ApS-U organise Service-Learning activities promoted by a group
of older persons and retired professionals, like the iaioflautas.3
23.3.2 R
easons for the Service Learning Model in University
Settings
The university as an institution must articulate educational programmes, lines of

research and civic missions that together reflect the key elements of the curriculum
of students as future professionals. In particular, service learning methodologies in
higher education settings: (1) are not a panacea (or new magic recipe) but an educa-
tional approach consistent with the intention to achieve meaningful learning experi-
ences and create genuine theory/praxis interfaces, (2) mobilises teaching resources
for new realities. The rejection and avoidance of patterns of social discrimination
and stereotyped behaviour such as ageism are realistic curricular objectives of expe-
riential methodologies (Brown et al. 2013). The European Higher Education Area
has reformulated the concept of higher education with the incorporation of ethical
education including values and attitude education, However, no curricular space
have been granted to these aspects. Therefore, these learnings are to be acquired by
extracurricular activities and a transversal approach to the curriculum (see the
example offered in the “Seniors in Class” project case study). The difference
between practical curricular activities and service learning is the compulsory char-
acter of the former. Curricular activities are obligatory in order to obtain an aca-
demic title, while service learning experiences must be conceived in a less rigid
way, not as a bureaucratic requirement but as an experiential methodology valued
beyond the academia. The following section describes the project of the third age
class, cross-curricular approach based on the service learning methodology.
23.4 Seniors in Class Project: A Case Study
This section describes the different phases of an ongoing service learning experi-
ence, which follows the National Service-Learning Clearinghouse methodology
(Fig. 23.1). The project ‘Seniors in Class” (Dutch: ‘Senioren in de Klas DOEN!’) is
www.servicelearning.de
2
http://www.iaioflautas.org
3
Fig. 23.1 Phases of the

service-learning field work Phases of the Service-Learning field
work
Diagnostic
Planning
Management
Results
Evaluation
Reflection
a project which concerns the improvement of the educational programme, involving

the active participation of seniors in lectures and workshops, in this case, in the
domain of healthcare and technology. This project is a joint project of Fontys
University of Applied Sciences and Summa College in Eindhoven, The Netherlands
(van Hoof et al. 2015b). Besides fostering the academic learning of the student-
participants, this project also puts a focus on facilitating intergenerational contact
and developing generational intelligence through inviting seniors to actively partici-
pate in class.
23.4.1 Phases of the Service-Learning Field Work
In the Netherlands, the provision of healthcare and welfare services for the older
population is a topical subject in politics at national and local levels, and features
heavily in the media. Older people are expected to age-in-place, thresholds for
admission to long-term care facilities are growing ever higher, and existing nursing
home capacity is being re-evaluated in terms of quantity and quality. Health care
schemes that were once provided by the state are now being substituted by solutions
and services at the local level, some of which include a wide array of healthcare and
welfare technologies. The education programmes of universities of applied sciences
and vocational colleges in the domains of healthcare and welfare are, therefore,
continuously updated in terms of the inclusion of societal themes and new develop-
ments (van Hoof et al. 2015a). One of the projects which concerned the improve-
ment of educational programmes involves the active participation of seniors in
lectures and workshops, in this case, in the domain of healthcare and technology.
23.4.2 Planning
The project aims to involve older adults (explicitly referred to as ‘seniors’ as

requested by the participants of the project) with students in education related to the
design and application of technology in healthcare in order to combat age stereo-
types and ageism. In order to achieve this general objective, three goals were placed
central in the project, which directly relate to some of the facilitating conditions for
intergroup contact:
• First, the project wanted to present seniors as societal role models. A role model
is not per se a successful businessman or a famous person. In this project, a role
model is someone who is right in the middle of a certain societal problem or
challenge, such as a senior who actively uses numerous means and solutions to
keep functioning independently and maintain a social life. It is this group explic-
itly, that we wish to involve in our educational programme as ‘old and gold’, with
a differentiation in terms of needs and interests for a certain type of educational
method.
• Second, seniors work together during educational activities with students and
lecturers (co-creation) in the field of design and evaluation of living environ-
ments and technologies. There is a mutual exchange of knowledge and skills, and
design prototypes of students are being optimised.
• Third, by involving seniors in education, they indirectly receive didactical educa-
tion and they participate more intensively in society. By giving attention in class
to the topics that seniors are experts of, seniors have to prepare themselves in the
context of a certain problem and the way the related knowledge can be trans-
ferred as optimally as possible. A lecturer has the task to support the senior in
transferring this knowledge to the students.
In this project, the young participants were third and fourth year students of dif-
ferent educational programmes and a group of approximately 30 seniors between
the age of 60 and 90 years old, who are no longer actively part of the work force.
These seniors were willing to involve in the development and execution of new
types of educational activities and methods in Summa College (educational pro-
gramme of nursing and welfare) and Fontys University of Applied Sciences (educa-
tional programme of the minor healthcare and technology). The recruitment of the
participants started out by contacting existing networks, such as organisations and
associations for older people, and new networks to come into existence during the
project itself. Some of the seniors knew of friends, acquaintances and other inter-
ested persons who joined the group of volunteers. Summa College had a large net-
work of participating seniors who had an active engagement in the activities
organised in the Lokaal+ initiative. Recruitment through a mailing to the associa-
tion for retired workers of both educational organisations yielded more volunteers.
The majority of participating seniors had higher education, had experience with
educational methods, management, coaching of young persons and students, and
presenting to groups. Only a few had a strong basis in the domain of healthcare and
Fig. 23.2 Intergenerational cooperation during design classes, lectures and iPad instructions
gatherings
technology. There were also some limitations that impacted the involvement of
seniors, such as chronic back problems and impaired hearing.
23.4.3 Management
The project of the senior class was carried out at the Summa College and Fontys
University of Applied Sciences worked together to arrange creative workshops for
the project Nursing Home of the Future (van Hoof et al. 2014a, b, c, 2015c) and in
the project Lokaal+ of Summa College.4 This project was financially supported by
the Municipality of Eindhoven (Programma Leren in Eindhoven 2030).
In the first project, seniors were involved as active co-designers of technological
solutions for bed-ridden residents of nursing homes (Fig. 23.2) (van Hoof et al.
2015c). Seniors, even those with mild dementia, can be excellent spokespersons for
their own subgroup and contribute to design projects when receiving the right levels
of support and instruction (Kort and van Hoof 2014). Together with students, seniors
write scenarios for the interior design of nursing home rooms and improvements to
http://www.summacollege.nl/over-summa-college/leuk-en-lekker/lokaal.html
4
the direct surroundings of the bed itself, in order to support the self-care abilities of
bed-ridden nursing home residents. In the second project, seniors learn how to use
homecare technologies during training sessions by students from the nursing depart-
ment. Lokaal+ is a meeting space, shaped as a small home, within the faculty build-
ing of Summa College, which is run by students who are supervised by lecturers.
The Lokaal + initiative aims on community dwelling seniors, who live in the adja-
cent neighbourhoods, and who are welcome for a talk or activities, or to get a help-
ing hand for small household tasks or societal support which is no longer provided
for by the State of municipality. In a corner of the Lokaal+ facility, seniors can get
acquainted in the VieDome Experience Centre with the possibilities of modern tech-
nologies (home automation systems) in the domain of smart homes and e-health.
Students can provide assistance and instructions to seniors in the field of modern
technologies, including the use of tablet computers and internet banking (Fig. 23.2),
exploring the digital world which can pose problems in terms of accessibility and be
ageist in its own way (Sourbati 2015). Both projects showed that the people involved
(students, seniors and lecturers) gained insights from the interaction with each
other, and that further research was needed as to how seniors could be involved in
the educational programme in the most fitting and beneficial way.
23.4.4 Procedure
The seniors were informed that participating in the project provides a quality stimu-
lus to the educational programmes. During their involvement, experiences and
knowledge become available to the students. Through the project, seniors can
exploit their value as life experts in an educational setting, and introduce students to
the realm of aged care and implementation of technology to support the facilitation
of care. Moreover, seniors serve as coaches and can share some of their life experi-
ences. In the project, the participation of seniors means that they have again a tan-
gible societal importance (as educators), have a chance to combat possible social
isolation, gain new knowledge of technology and build a new social and semi-
professional network. The educational programmes, in turn, are being enriched by
life experiences of seniors and expertise from outside of the universities and col-
leges. The involvement of seniors also provides opportunities to add a layer of depth
in the curriculum, for instance, in relation to themes which require a certain degree
of life experience, such as illness and pain, loss and mourning, euthanasia, and
death. In addition, the seniors also made an appearance as simulation patients in
practicing telecare (screen-to-screen e-health). With the students, the stereotyped
image of a “grandmother or grandfather” was previously worked in front of the
image of “old gold” that fine-tuned into a more subtle image that is a better presen-
tation of a modern-day senior. The actual knowledge, skills and attitudes of the
students become more realistic. This is an asset when making personas or fictional
characters in design projects.
The participation of seniors calls for creativity among the lecturers, as they have
to come up with new ways to involve seniors in their educational programmes and
methods. Seniors need to acquire a certain position in these lectures and workshops,
in which their knowledge and skills can be exploited to the benefit of all. The large
advantage of the involvement of seniors lies in the fact that students have direct
access to the end-users of healthcare technology, whether these seniors are ‘patients’
using these technologies themselves, or as informal carers assisting a loved-one in
need. The basis for the project is the creation of a win-win-situation.
Although the majority of seniors have skills to share with students, it does not
automatically mean they wish to engage in the role of a lecturer and actively teach
students. There was a general consensus in the project that the senior should not
take over tasks from a lecturer and actually be a cheaper substitute for an existing
lecturer on the pay roll of the school.
23.4.5 Evaluation Tool
The activities will be carried out through two cooperative methodologies: discus-
sion groups and portfolio to be complicated as part of the evaluation, both during the
process and at the end of it. The training sessions were conducted through the dis-
cussion group led by the project promoters in which the members of the project
participated: seniors, students and teachers. As mentioned earlier, the discussion
group not only provides information on the contents of an activity but also provides
a space for interpersonal knowledge and offers opportunities to overcome emotional
upheavals caused by erroneous beliefs about age stereotypes (Ferguson et al. 2013).
In addition, the mutual support provided by the group improves the performance of
activities (Wilson 1992). The portfolio is a collection of evidence that is considered
pertinent, relevant and useful for the project: documents, cartoons, articles, public-
ity, stories, anecdotes, sound files and photographs. The portfolio is coordinated by
the project leaders and built by the seniors, students and lectures participating in the
project. The final part of the portfolio is a final reflection of the strengths, weak-
nesses and possible improvements.
23.4.6 Results
The majority of seniors said the instructions to participate in the project were clear
and they indicated that they knew what was expected from them as a contribution to
the achievement of the educational goals. Without any exception, seniors felt that
they were treated with respect and that they had sufficient space and freedom for
their own opinions and ideas. The participation turned out to be meaningful to the
seniors, partly because of the valuable ideas they heard during discussions with
students. Seniors stated that they learnt practical new things by participating in
classes, such as getting acquainted with new technologies (tablet computers,
e-health systems).
It became evident that seniors liked the fact that students were willing to share
their own life experiences concerning illnesses and losses in open-hearted group
discussions. During the sessions, seniors broke the ice and students soon followed.
Because of the interaction a mutual understanding is developed, and insights are
provided into each other’s lives. The seniors and students learn to tune their com-
munication skills to one another. This is another asset for students who pursue a
career in the healthcare and welfare sectors. Seniors expressed a unanimous sense
of joy from participating in the activities, and words as “collaboration”, “listening”,
“mutual learning” were mentioned. Students were described by the seniors as “sin-
cerely interested and involved.”
Lectures and students valued the participation of seniors in the health and tech-
nology education programme as a “valuable contribution” because they acted as
sounding board for the student, t as an experts who can help the student to sharpen
ideas or to improve a design. In the words of one of the students, who was involved
in the design of an interactive closet for dressing challenges in dementia:
Brainstorming about our project together with seniors certainly gave use new insights. The
seniors told us that it is important for care recipients to receive visual feedback. We started
working on this feedback the same week. We have made 3d prints of the handles in the
shape of clothes. (student participate in the project)
Finally, the participation of seniors in the project made it easier for them to see
the friendly side of technologies. This fact contributes to alleviate the digital divide
between generations that is behind some of the ageist beliefs.
23.4.7 Evaluation
The evaluation conducted through the discussion groups revealed the need to con-
sider sociodemographic variability in future projects, in order to reflect the hetero-
geneity among seniors in Dutch society. Note that the group of major participants in
this project belong to a group with a good educational level and a certain manage-
ment of technologies. Considering the different typologies of seniors will not only
have a greater efficiency in the resolution of technological projects, but also a
greater respect and less ageist attitudes on the part of the majors, teachers and stu-
dents. From a more content-based perspective, seniors valued working together
with young people, for instance, having fruitful discussions with one another. Some
of the reflections of the students make it clear:
It was great fun to engage with actual seniors.
I though the lecture was nice and interesting, much nicer than the standard lectures because
you can put theory into practice. I would like to have many more of such lessons.
I believe that these conversations and interactions make a deep impression on all students,
and therefore stick to the collective mind. In addition, the seniors give us new insights
because they were raised in a different time and also because they have more life experi-
ence. In short, I like to see more of it!
Finally, based on the information obtained in the discussion groups and portfo-
lio, a large number of manuals were made for the interactive educational methods
that are used for embedding the activities in the existing curricula. By doing so, the
results become embedded in the routines of the educational programmes instead of
an occasional activity. Currently, these manuals are being implemented in educa-
tional activities of other degrees such as the orthopaedic technology and applied
gerontology classes.
23.4.8 Reflection
For future generational projects, prior training in intergenerational communication

skills should be considered. One of the critical points identified in both discussion
groups and in the portfolio were the difficulties in managing emotions and commu-
nication between participants. Regarding the turn of the word among the seniors, it
was more complicated to solve because some seniors take on a more dominant role
than others and this caused some irritation between them. On the other hand, the
conversation between the students and seniors was overprotective or secondary talk
of the baby, reflecting stereotypes attributed to seniors. Often, stereotyped behav-
iours are generally unconscious and accommodate the stereotype that is formed
over the group with which it has to interact.
23.5 Limitations of Educational Methodologies on Ageism
There is still much to learn in higher education about potentially successful method-
ologies against ageism. Educational techniques such as experiential learning meth-
odologies such as Service-Learning at a local, regional or international levels,
concentrate in answering the how and the what for questions but lack a ripe theoreti-
cal body of knowledge sustaining them. Moreover, in this kind of educational expe-
rience several distinct institutions and entities are obliged to cooperate and share
objectives, organisation and deployment of spaces, schedules, budgets and resources.
Despite scattered academic university efforts to implement those programmes, such
ventures often lack rigor or an ability to systematically measure their educational
outcomes. Furthermore, professional education programmes in the scientific fields

that may hold many of the solutions such as engineering, natural, social and health
sciences find that their curricular schedules are too intensive to allow students to
combine technical learning with programmes that serve the community. However,
advanced societies require academic curricula that incorporate educative pro-
grammes contributing to generational and cultural coexistence in an increasingly
aged and mobile world.
Faculty and institutions often find difficulties when it comes to the application of
learning methodologies in the classroom. Students usually find that these method-
ologies require from them an additional work charge in their course. Sometimes
they have problems with their own classmates and other team members, or consider
they receive little help from their tutors. Also lecturers signal some difficulties
regarding the amount of time they need to set up and manage their teaching out of
classrooms. It is important to bear in mind that lecturers normally do not receive any
support in the heavy administrative and organisational tasks derived from launching
this type of programmes (Blakey et al. 2015). The institutions and entities fostering
learning initiatives in the academic realm also face problems regarding the technical
and personal inexperience of students in professional environments. Therefore, the
new methodological initiatives require time investment in the adequate formation
and supervision of students. Despite all these difficulties, methodologies such as
story-telling and Service-Learning local, regional and international are steadily
growing in all educative fields and the success in their application in general com-
pensates the difficulties encountered (Blakey et al. 2015).
Regarding research designs and characteristics, experiential methodologies usu-
ally present specific limitations due to their educational origin. For example, studies
are usually transversal and based on qualitative inquiries, diary data from students
and self-evaluations. Samples are small and often not aleatory, comparison groups
are not always present and participants are often self-selected. Answers are stan-
dardly recorded in the presence of the concerned professionals, and therefore stu-
dent’s answers can be systematically biased.
Not all experiential methodologies are successful, because some experiences
may reinforce stereotypes or reflect a charitable conception of volunteering (doing
for instead of doing with) (Egger 2008). Educating the next generation of profes-
sionals requires broad perspectives in the areas of social responsibility and global
citizenship. Additionally, experiential methodologies rely on praxis-oriented theo-
ries which try to improve the participation and responsibility of students with
respect to social life and global citizenship. Interdisciplinary methodologies out of
the classrooms require from the docents high amounts of motivation and engage-
ment. Experiential methodologies need not only an adequate academic niche, but
also the support from financial and political decisions, in order to favour educational
models based on generational intelligence and sensibility towards age
idiosyncrasies.
23.6 Proposal for the Future
Ageing brings unknown sceneries in which several generations and life styles meet
during prolonged periods. We need to promote a theoretical model as “having an
open mind while actively seeking to understand generational norms and expecta-
tions of others, and leveraging this gained knowledge to interact, communicate and
work effectively in diverse environments” (Hunter et al. 2004).
The interconnected and accessible flat world in which we live gives us the chance
to appreciate how all human cultures share a common interest in fostering inclusive
societies for all ages. In order to develop generational intelligence, it is necessary to
educate specific knowledge, skills, and attitudes, including maintaining openness to
other generations and other cultures, withholding judgment, respecting and valuing
differences and tolerating ambiguity (Songer and Breitkreuz 2014). Learners build
on these attitudes by gaining knowledge of cultures, customs, beliefs, and by becom-
ing generationally self-aware (Deardorff 2006). People with generational intelli-
gence are able to observe, evaluate, analyse, interpret, and, finally, relate to others in
variable generational and cultural keys (Deardorff 2006; Breitkreuz and Songer
2015).
Author Contributions Mª del Carmen and J. van Hoof jointly planned and conceived the chap-
ter. J. van Hoof, M. Zwamborn, S. Metz, W.P.H. Bosems contributed to the chapter through their
case study of the Seniors in Class project. Hannah Swift wrote the theoretical frame and Laura
Naegele brought together the different sections of the chapter.
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Chapter 24
Introduction to the Section: Researching
Ageism
Research is critical to assess the prevalence, origins, and consequences of ageism as

well as the potential effectiveness of various interventions to fight ageism. A major
challenge associated with the assessment of ageism is the fact that being seen as age-
ist is generally considered to be negative. Most people do not wish to be seen as age-
ist (Cherry et al. 2015) and so will respond to questions about ageism with caution.
Moreover, ageism is highly prevalent and often unnoticed, because it is so ingrained
in our lives (Perdue and Gurtman 1990). This is why implicit measures of ageism are
recommended to supplement explicit measures (Shiovitz-Ezra et al. 2016).
Another challenge associated with the assessment of ageism concerns its subjec-
tive nature (Ayalon 2016; Voss et al. 2017). In order to acknowledge an event as
ageist, one has to notice the event, interpret it as ageist, and then cite ageism as the
cause of the event. Any of these three processes can impact one’s willingness to
acknowledge ageism. The social context plays an important role, as society clearly
defines events as ageist or non-ageist based on current norms and expectations. For
instance, whereas asking a job applicant his or her age is the norm in some coun-
tries, in other countries asking such a question is not considered acceptable. Hence,
the subjective nature of ageism should be acknowledged (Ayalon 2016; Kornadt
et al. 2015).
In the first chapter of this section (2018; Chap. 25), Snellman argues that most
research on ageism to date has focused on empirical data. Less attention has been
paid to aspects such as the normative value applied to ageism and theoretical or
L. Ayalon (*)
C. Tesch-Römer

https://doi.org/10.1007/978-3-319-73820-8_24
interpretive considerations. Snellman argues that the research training of the inves-
tigators, rather than the research questions, often guides the selection of the
approach. He further suggests that more attention to the selection of a particular
research approach would be beneficial and enriching for research in general and for
research in the field of ageism in particular.
As international researchers, Wilińska, de Hontheim, and Anbäcken (2018;
Chap. 26) give a reflexive personal account of conducting research on ageism in
different countries and cultures. They argue that being physically away from your
own culture is an opportunity to re-examine common assumptions about age and
ageing and develop a more critical understanding of these issues in light of their
varied manifestations in different cultures. To some degree, this chapter corresponds
with Snellman’s chapter (2018; Chap. 25), as it indicates ways to broaden normative
understandings of ageism through exposure to views and perspectives that do not
represent the majority view in one’s own culture.
The chapter by Swift et al. (2018; Chap. 27) is an empirical account of ageism in
Europe as assessed via the European Social Survey (ESS). The chapter highlights
the ESS data as a means to understand ageism. It draws from social psychology
theories to demonstrate the contribution of the findings to theory and empirical
knowledge. In addition, the authors discuss the importance of multi-level analysis
to account for the individual and country levels simultaneously. Given the fact that
ageism has both micro- and macro-level origins and manifestations, the ESS pro-
vides a unique opportunity to enhance understanding of the intersections between
the two levels.
Buttigieg, Ilinca, Sao Jose, and Taghizadeh Larsson (2018; Chap. 29) present a
comprehensive overview of how ageism is defined and measured in health and long-
term care. Like Snellman, these authors call for a division between empirical
research and theoretical research, as most research in the field of health and long-
term care is empirical and atheoretical in nature. The authors further call for the use
of mixed research methods and perspectives in order to provide a more complete
account of ageism in health and long-term care.
Abuladze and Perek-Bialas (2018; Chap. 28) similarly encourage the use of pub-
licly available datasets to measure ageism. Their chapter focuses on the use of mea-
sures to assess ageism in the workforce. They use an empiricist approach (as defined
by Snellman in this section) to classify measures according to five possible aspects
of ageism in the labour market: recruitment/retention, performance, training, inter-
action with older colleagues, and structural ageism. This chapter, as well as the
chapter by Swift et al. (2018; Chap. 27), provides an excellent resource for readers
who wish to become familiar with the use of publicly available datasets.
Also in this section, Mendonça, Marques, and Abrams (2018; Chap. 30) outline
the results of a review of measures to assess ageism in children. Research has con-
sistently shown that ageism is common among young children and youth and not
only among older adults. This supports claims about the automaticity of age catego-
rization (Perdue and Gurtman 1990) and potentially about the evolutionary nature
of ageism (Burnstein et al. 1994). Nevertheless, children have different language
and test-taking skills that may require somewhat different measures. The authors
24 Introduction to the Section: Researching Ageism 405
suggest a classification of measures according to the tripartite model of attitudes

(behavioural, cognitive, emotional) and their placement along a continuum of
explicit versus implicit measures.
The last chapter in this section is by Phelan (2018; Chap. 31), who uses discourse
analysis to demonstrate how ageism is constructed and deconstructed in everyday
life. The chapter demonstrates how individuals can position and construct older
people in an ageist or non-ageist framework. Using Snellman’s definitions, this
chapter takes an interpretive approach, as it examines ageism from a more philo-
sophical/theoretical stand.
These chapters provide potentially useful tools to assess ageism. The chapters by
Snellman (2018; Chap. 25), Wilińska et al. (2018; Chap. 26), and Phelan (2018;
Chap. 31) are more theoretical in nature. They suggest new ways to think about the
phenomenon of ageism, which could potentially affect the ways we study it. The
chapters by Swift et al. (2018; Chap. 27), Buttigieg et al. (2018; Chap. 29), Abuladze
and Perek-Bialas (2018; Chap. 28), and Mendonça et al. (2018; Chap. 30), on the
other hand, provide practical tools for the assessment of ageism in various settings
(general society, health and long-term care, and the labour force) and among differ-
ent target populations (older adults, professionals, adult children, family members,
and young children). Swift et al. (2018), Abuladze and Perek-Bialas (2018), and
Mendonça et al. (2018) take into account cross-cultural and national considerations.
This is particularly important given the fact that ageism is a social phenomenon that
does not only occur at the individual level, but rather is affected by socio-cultural
aspects (Cuddy et al. 2005; Vauclair et al. 2016).
Although it is not specifically focused on in the chapters of this section, an addi-
tional aspect of ageism research is the assessment of ageism at the macro-level
(Ayalon and Rothermund 2017). There are multiple macro-level indicators of
inequality, such as the Gini coefficient and the coefficient of variation (Allison
1978). With regard to specific characteristics, there are measures of gender inequal-
ity such as the Gender Inequality Index and the Gender-Related Development Index
(Dijkstra and Hanmer 2000; Gaye et al. 2010) that could potentially be applied to
ageism. Consistently, the Active Ageing Index and the Age Watch Index both repre-
sent attempts to assess the conditions of older adults in society (AgeWatch 2015;
Zaidi et al. 2013). Although informative, these studies evaluate the absolute status
of older adults in society and do not provide a comparative analysis of the status of
old versus young people in society, as was recently proposed by Ayalon and
Rothermund (2017). Nonetheless, these studies indicate a macro-level direction,
which is much needed given the manifestation of ageism at the individual level as
well as at the social/structural/institutional level.
There has been great progress in researching ageism and there are multiple pos-
sibilities for future research. Research should take into account not only ageism at
the individual level but also at societal and institutional levels, as ageism often co-
occurs at both levels. The availability of public datasets on ageism provides a sub-
stantial resource for researchers wishing to explore the topic and develop
cross-national comparisons. The limited theoretical grounding of a substantial
portion of the research on ageism should be seen as an opportunity for researchers,
who could potentially contribute to an emerging and growing field not only through
the production of empirical data, but also through the construction and development
of theoretical understandings of the phenomenon of ageism.
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Chapter 25
Normative, Empiricist, and Interpretive
Considerations in the Ageism Research
Process
Fredrik Snellman
25.1 Introduction
This chapter reflects on the normative, empiricist, and interpretive considerations

researchers are facing in the process of researching ageism. The starting point of
this study was a doctoral dissertation that, by triangulating data, methods, and the-
ory, explored how ageism is manifested in the lives of older people (Snellman
2009). Such a research endeavour is warranted by system justification theory, argu-
ing that support for an ageist structure of society is sometimes strongest among
individuals who are most harmed by it (Jost et al. 2004). A large and increasing
number of ageism studies report on empirical data; however, these studies are rarely
explicitly related to epistemological and ontological questions. Little attention has
previously been devoted to the philosophy of science aspects of ageism and there-
fore there is a gap in what we know about the wider scope of challenges in research-
ing ageism and how we view and understand ageism in our world.
One way to devote attention to the philosophy of science aspects of ageism is to
focus on the normative, empiricist, and interpretive (Howarth 2000) considerations
and choices we as researchers are forced to make during the research process. In
short, these considerations enable researchers to (a) take a standpoint against and
strive to change negative ageist consequences in society (normative); (b) observe
accurately and show how ageist elements are related in a narrow context (empiri-
cist); and (c) observe, show, understand, and reflect critically on how ageist ele-
ments are related in a wider context (interpretive).
Among the myriad of choices to be made is the choice of what definition of age-
ism to use in any given case. This chapter demonstrates different types of ageism
definitions. These are influenced by normative, empiricist, and interpretive
F. Snellman (*)
Department of Social Work, Umeå University, Umeå, Sweden

https://doi.org/10.1007/978-3-319-73820-8_25
410 F. Snellman
c onsiderations, each of which is crucial to how the research process will play out
and what claims will be able to be made, and not made, about ageism. To make one
choice of definition automatically prevents the analytical possibilities coupled to the
choice of other alternatives. The chapter provides examples of ageism studies,
which are influenced by normative, empiricist, or interpretive considerations. These
examples should not be understood as strict representations of normative, empiri-
cist, or interpretive types of study. Rather, these types of considerations have led to
specific outcomes, and reveal the choices made during the research process. It is not
reasonable to claim that any study on ageism is strictly coupled only to one of these
considerations and simultaneously uncoupled from all of the others. Fragments of
all considerations, to a varying degree, are present in any ageism research process
and in any definition of ageism. Inspired by Howarth’s (2000) reasoning on dis-
course theory and normative, empiricist, and interpretive types of science, I draw
here on the experiences made in trying to triangulate data, methods, and theory to
show how ageism is manifested and sustained in older people (Snellman 2009).
25.2 T
riangulating Data, Methods, and Theory to Explore
Ageism in Older People
My starting point for this discussion of ageism research process considerations was
my doctoral dissertation, “Old Folks” [gammfolket]. On Life Experiences and
Everyday Ageism (Snellman 2009). The dissertation consisted of three empirical
studies and an analytical summary that investigated the connections between them.
Gammfolket is a dialect form commonly used in the northern inland of Sweden,
roughly translating to “old folks”. It has positive connotations inasmuch as it signals
a group of people we should in some way admire, treasure, and protect. It can also
have negative connotations: it can be used ironically to describe older people who
are no longer able to do something or are lagging behind in current trends or knowl-
edge, such as new communication technologies. These meanings are not exhaus-
tive—others could be added—but, in essence, the word gammfolket captures
different nuances of how we use often ambiguous, ageist language in society.
The research process leading to Gammfolket started with an interest in older
people’s experiences of age discrimination, which eventually led me to something
quite different. The first study (Snellman 2005) demonstrated that there were simi-
larities in narrative elements in the ways the older people sampled in the study
talked about their lives—for instance, that there were clear boundaries between dif-
ferent life stages (childhood, war-time experiences, working life, and retired life)
and similar types of narrated experiences within those life stages. When the older
people in the study summarized their lives it tended to be done in a meaning-making
manner that ended in a rich and positive view of life. This rich view of life emerged
independently of how many traumas the informants had experienced during their
lives, and how severe those traumas were. Deeply unsettling life experiences and
25 Normative, Empiricist, and Interpretive Considerations in the Ageism Research… 411
traumas (of which encounters with discriminatory practices were not even a small
part) were woven into a meaningful narrative of life.
The design of the first study included two significant challenges. First, it was not
appropriate to ask people directly about age discrimination, because people often do
not eagerly admit to being a member of a disadvantaged group in society. Second,
in 2002, when the study was conducted, Butlers’ (1969) definition of ageism did not
turn out to be useful for analysing how ageism was manifested and sustained in the
life stories of older people. Ageism, as well as its Swedish equivalent ålderism, was
not a familiar word to Finno-Swedish older people living in the Western coastal
regions of Finland. Consequently, empirical questions containing “ageism” were
not possible to use. General theories in social gerontology that were available at the
time (Bengtson et al. 1999) also did not provide explicit guidance on how to research
age discrimination in older people. An alternative study design was decided upon,
which was considered novel at the time. The choice was made to collect life stories
from 16 people (9 women and 7 men in their late 70s and early 80s), with the expec-
tation that this would allow people to freely share their lifetime experiences of age
discrimination. This expectation turned out to be naïve. Despite my sense that the
informants did talk about age discrimination during the interviews, it was disap-
pointing and frustrating to listen to the recordings and read the transcribed text,
because not once during the many hours of life story interviewing did the infor-
mants mention the word “discrimination”. Additionally, the word “age” was explic-
itly mentioned by only one informant on one occasion. The word “age” was
ostensibly not used at all in the narration of these life stories.
When the life-story study was being finalized, an opportunity emerged to design
and include survey questions within Interreg’s Gerontological Regional Database
(GERDA) project funded by the European Regional Development Fund. Coming on
the heels of the difficulties I had demonstrating how age discrimination is mani-
fested and sustained in older people by using life stories, explicit survey questions
on age discrimination and attitudes towards older people within different domains
of society were included in the GERDA survey in 2005. This study found a high
proportion of individuals who reported negative attitudes towards older people
within the labour market (70.1%), and a smaller number of people who reported
negative attitudes towards older people when visiting shops or banks (12.3%) as a
customer. A theoretically informed structural equation model suggested that the
reported attitudes were latent factors of structural, cultural, and individual levels of
ageism in society (Snellman 2009). As opposed to not being able to make any
explicit claims about age discrimination by utilizing life-story data, the GERDA
survey data allowed for making explicit conclusions about both age discrimination
and ageism.
In this second study, however, there was uncertainty as to whether the designed
items were valid and reliable. During the research process there was a lot of discus-
sion on aspects of language and about what the informants actually had in mind
when they responded to the questions. In addition, even though I had intended this
empirical study to deliver the data that would finalize the dissertation, there was no
obvious way to relate the outcomes to the first study that used life stories. The two
412 F. Snellman
simply did not add up. They seemed to be of two totally separate scientific worlds,
and, frankly, did not contribute as much as I had hoped to exploring how ageism is
manifested and sustained in older people.
A third empirical study (Snellman et al. 2012) and research process was there-
fore designed in parallel. This study design returned to the advantages of having the
informants speak freely about their experiences. When I thought about my role as a
researcher I realized the importance of how to introduce the topic in the first instance
and that the way questions are posed to informants is crucial. This led to a focus
group design. Six focus groups (three in Sweden and three in Finland) were carried
out with the novel idea of allowing different types of birthday cards to guide the
participants’ discussion of age and ageing. Six cards in total were presented to par-
ticipants: one was a humorous card on the topic of sexual activity, another merely
had the number 75 printed on it, and so on. This design required extremely little
involvement from me as a researcher. The focus group interviews more or less
guided themselves and the informants participated very eagerly in the discussion,
asking and answering questions amongst themselves. The focus group design cre-
ated a sort of miniature version of society and allowed for a kind of demonstration
of how ageism is negotiated. It enabled us to see the complexity of meaning that was
triggered by the birthday cards, and it highlighted the infeasibility of providing a
simple explanation of ageism. For instance, it was made obvious that the positive
views some respondents had of one type of birthday card did not hold true for other
respondents. This was also the case for cards that were initially judged as conveying
negative views.
By listening to the recordings and reading the transcripts it became apparent that
silence and changing the subject were tactics used to negotiate ageism. The infor-
mants talked about age discrimination. For example, when one of the informants
said, “I think he wants us to talk about discrimination,” they did talk about discrimi-
nation for a short while (the role of age and gender among women active in munici-
pal politics), but eventually changed the subject and continued discussing age-related
aspects of life that they were more interested in. Although previous research has
suggested that birthday cards convey negative views of older people, none of the six
focus groups was in unanimous agreement that the cards they were shown were
negative or inappropriate and should be prohibited. The focus group design made it
evident that older people themselves are co-creators of ageist language and
culture.
After having completed the three empirical studies of ageism in older people, I
returned my attention to the overarching aspects of what connected the different
studies. During the process it became clear that the focus group study and the study
that drew on survey data were explicitly related to ageism. The study that drew on
life stories, however, was still a loose end: it did not seem to relate to ageism or age
discrimination in any explicit way. Guided by discourse theory and by themes that
were identified in the focus group study, the life stories were revisited. With a modi-
fied understanding of ageism as much more complex and as something continu-
ously negotiated, a pattern that had not been evident before revealed itself in the life
stories, perhaps because it was too simple and familiar. The life-story data contained
a very high number of words such as “old,” “older,” “young,” “younger,” “time,”
“year,” “month,” and so on. The number of these signifiers of everyday ageism
(Snellman 2009) suggested that they held meaning for the narrators of the life sto-
ries. These signifiers, and the meanings coupled to them, seemed both to mask and
to mark ageism in society.
To summarize, identifying how ageism is manifested and sustained in older peo-
ple, in a societal context in which there was no linguistic awareness of ageism,
posed a significant ontological challenge. This challenge was addressed by triangu-
lating different types of data, methods, and theories. An inductive starting point in
older people’s life stories utilized deconstruction and theories of social gerontology;
descriptive statistics, structural equation modelling, and explicit ageism theories
were applied to survey data; and focus group interview data analysed with thematic
content analysis and informed by discourse theory and the theory of age coding
enabled the discovery of ageism signifiers such as “older” and “younger”. In other
words, there was no easy answer to the question of how ageism is manifested and
sustained in the lives of older people. It was a long process: the findings did not
appear overnight, and the process required multiple data sets, methods, and theories.
Researching ageism in older people required its own theoretical and conceptual
customization, which was derived from normative, empiricist, and interpretive con-
siderations and decisions during the research process.
25.3 Normative Considerations
Taking into account normative considerations in the ageism research process mainly
implies two things. First, normative considerations require taking a standpoint
(without necessarily making theoretically informed interpretations) that ageism per
se is negative. Second, the phenomenon of ageism concerns a certain target group
of people, commonly referred to as “older people” or “the elderly”. Normative con-
siderations are often accompanied by an automatic and unquestioned assumption
that the problem, whatever it might be, is a problem of discrimination—that is, that
it is negative by definition. Ageist discrimination or negative treatment is invoked
instead of analysed (Cruikshank 2003), without a substantial understanding of what
is behind a certain kind of behaviour or practice.
Normative considerations imply reactiveness against things that are perceived as
inappropriate in society. These considerations are commonly brought to the fore
when we are observing troubling issues for the very first time or at an early stage of
acquaintance. For instance, this was my un-reflected position when I was first
attempting to demonstrate how ageism is manifested and sustained in older people
by collecting and analysing life-story data. In my own case, the drive to use life
stories was inspired by my own previous discriminatory actions toward my paternal
grandmother, who suffered a period of severe mental illness and who attempted
suicide twice. I felt that I had not respected my grandmother’s fullness as a person
when, for example, I went with her to a doctor’s appointment and accused her of
414 F. Snellman
lying. As a result of my actions, I considered it important to allow older people to

speak their minds freely about what matters to them, without allowing anyone else
to define their reality. I was doing normative consideration, which, according to
Howarth (2000), “seek[s] to advocate and justify the key principles around which
society [should be] structured” (p. 130). Awareness and the observation of unjust
age-related phenomena can be imperative for an early stage conceptualization of
ageism and more generally how society should be structured, by allowing us to
consider more insightfully our common sense views of what is acceptable and not
acceptable in an age-friendly society.
Normative considerations are evident in the way ageism was first defined by
psychiatrist and gerontologist Robert Butler (1969) as
the systematic stereotyping of and discrimination against people because they are old, just
as racism and sexism accomplish this with skin color and gender. Old people are catego-
rized as senile, rigid in thought and manner, old fashioned in morality and skills … [A]
geism allows the younger generation to see older people as different from themselves; thus
they subtly cease to identify with their elders as human beings. (p. 243)
Considering that this was the first definition of ageism it is not surprising that it is
normative, as it arose in reaction to something perceived as unjust. As a definition it
categorizes older people as a group; it is difficult to view as anything other than
targeting the negative; and it arose reactively from Butler’s identification of issues
with unsatisfactory housing for older people. Several years later, Butler continued
the conceptualization process by adding other considerations to what he had first
discovered and defined. In his article, “Dispelling Ageism: The Cross-Cutting
Intervention”, Butler (1989) added that he was just as concerned with older people’s
negativism towards younger people. Butler’s work shows the importance of renewed
and continued consideration and reasoning that goes beyond the normative by prac-
tising bold self-criticism. Butler’s 1969 article is very often cited in publications
focusing on ageism, whereas the article from 1989 is hardly ever mentioned. This
alone calls for critical reflection on the homogenizing normative power that early
conceptions and definitions can have. It also highlights the need to question habitual
categories initially created during research training and to continue training the
“capacity to break old mental habits and create new ones” (Swedberg 2012, p. 19).
Normative considerations are justifiable as long as they are understood not to be
the only possible approach to studying ageism, and as long as they are not allowed
to define and delimit the broader field. In fact, normative considerations can be
viewed as critical in the first stages of a research process or as a first step in chang-
ing society. For instance, legislation is needed to secure fair treatment of older and
younger workers within the labour market; but legislation would not be needed
unless it addressed something we collectively agree is unjust. Regardless of what
has been scientifically demonstrated, we have agreed, as a society, that something is
needed to prevent discrimination within the labour market. Legislation on age dis-
crimination has been introduced across all European countries partly as a result of
the EU council directive on equal treatment in employment and occupation
(2000/78/EC). The directive forced EU member states to introduce legislation
against age discrimination and is an example of an applied supranational, reactive,

normative consideration, that indicates how societies should be structured, viewed
from an EU perspective. However, previous research has shown that the directive
was received differently in member states (Nygård and Snellman 2014). Legislation
on age discrimination was quite automatically adopted in Finland, whereas there
was more debate, resistance, and negotiated exceptions in Sweden. This shows how
early normative initiatives are interpreted in different ways and that these initiatives
might not automatically fit all societies, unless they are adapted in order to corre-
spond better with the norms and values that already exist in a specific societal
context.
It is not explicitly stated in scientific publications that normativity is applied,
which in itself is not surprising. We tend to avoid the idea of applied normativity
because we think science should not be affected by mores. Smith (1995), however,
writes “all self-images [of disciplines] reflect normative concerns” (p. 30), which
begs the question whether any of the considerations used in studying ageism or in
published studies on ageism can be considered non-normative.
The use of normative considerations is key in intervention studies when research-
ers set out to demonstrate whether it is possible to improve an unjust or negative
outcome. The starting point of any intervention study must be that some aspect in a
group of people’s lives is negative and that it can possibly be improved by interven-
ing in an appropriate way. An example of using normative considerations within a
randomized controlled trial context is a study by Jacobson (2006) entitled,
“Overcoming ‘Ageism’ Bias in the Treatment of Hypercholesterolaemia”. The term
ageism is mentioned four times in the article, but the inclusion of it in the title puts
ageism in the spotlight and discloses its significance. Ageism in the title has been
assigned quotation marks, which signals something that is not explicitly communi-
cated. The review article showed that statins are more often prescribed to younger
patients than to older patients, who are thereby denied the benefits of the interven-
tion. The clinical findings demonstrated that statins are safe and well tolerated when
prescribed to older patients, and that there is no obvious reason not to prescribe
statins to those with the highest cardiovascular risk. The article shows that, even
when appropriate methodological rigour is used, there can be a glide into applying
normative arguments, without including scholarly sources on ageism research. The
argument against ageist practice is accomplished without an explicit theoretical
foundation at any stage of the research process. In some cases this makes sense, for
instance when all other alternative explanations have been overthrown. It is, in other
words, possible to invoke ageism in a reactive manner, even though it has not been
empirically analysed. This conveys a normative message about how society should
be organized.
Another example of a study that addresses negative views of older people is
Kane’s (2004) “Ageism and Intervention: What Social Work Students Believe About
Treating People Differently Because of Age”. Kane investigated whether social
work students’ perceptions, needs assessments, and recommendations varied as a
function of the age of people diagnosed with severe cancer as described in a vignette.
This study found that social work students were more likely to think that older
416 F. Snellman
people should be allowed to commit suicide (which was ethically problematic) and
that younger people had a greater chance of recovery (which was not true). The find-
ings have obvious relevance for social work practice, but did not provide evidence
on how social workers would actually make decisions in practice. This study pin-
points a pattern of reasoning that people might not necessarily be aware of. Like
Jacobson’s study (2006), Kane’s study (2004) examined the normative foundation
the work of a certain group relies on and how and why this foundation should be
changed. In other words, it showed that there are other key principles around which
professions and society should be structured.
Other studies within the field of social work have shown that substance users’
age affects professionals’ perceptions of substance use severity (Samuelsson and
Wallander 2014) and treatment recommendations (Wallander and Blomqvist 2009).
These studies, however, did not explicitly use the term ageism, but nonetheless
serve as examples of applying normative considerations and attempting to raise
awareness of age-related perceptions in social work practice. There are a large num-
ber of scientific publications, on a range of topics, that demonstrate the significance
of age, but that are not explicitly coupled to theories of ageism.
25.4 Empiricist Considerations
Traditional forms of (logical) empiricism emphasize the utmost accuracy in making

empirical observations and represents a nomothetic (generalizing) notion of an ideal
form of knowledge. As a starting point for knowledge, empiricism generally opposes
speculation, intuition, feelings, and other sources that are difficult, if not impossi-
ble, to quantify (Andersen 2001). It is not possible to categorically avoid empiricist
considerations in any given research process. However, there can be some variation
in the degree to which empiricist considerations find their way into the actual prac-
tice of collecting data. The goal for social sciences is to explain social phenomena
(Elster 2007). The explanation needs to be grounded in reality, and on observations
and empirical data about this reality. So we have to decide how to observe reality
based on ontological views we have about how ageism exists. Whether or not we
consider ourselves to be empiricist researchers, we always struggle to identify the
most appropriate methods for obtaining data at some point in the research process.
In every single research process, we strive to design our investigation in a way that
enables us to observe ageist reality in the most accurate manner. Observations we
make of the ageist reality are theory-dependent (Føllesdal et al. 2001), and the
emphasis on accurate observations which characterizes empiricism presumes a the-
oretical foundation at an earlier stage in the research process. This simultaneously
sets constraints on what observation-based interpretations it is possible to make.
Collecting data with surveys, carrying out experiments, and using existing data
registers are examples of methods that at the design stage are more clearly influ-
enced by empiricist considerations. However, it would not be accurate to think that
quantitative data is the only type of data that is influenced by empiricist

considerations. Qualitative data collection is also influenced by empiricist consider-
ations. Empiricist decisions can be seen to be made when we arrive at a point in the
research process where we know with greater certainty what we want to assess and
how. For instance, the focus group study collecting qualitative data on ageism in
birthday cards can be seen as more influenced by empiricist considerations than the
survey that collected quantitative data by asking direct questions about age dis-
crimination. When I asked direct questions in survey form, I had only a vague notion
of what I wanted to observe. But in the focus group study, I had a much clearer sense
of how and what I wanted to observe, based on an empiricist understanding.
Empiricist considerations are also evident in definitions of ageism as a prejudice,
a method of stereotyping, and discrimination (e.g., Wilkinson and Ferraro 2002;
Iversen et al. 2009). Empiricist considerations in the ageism research process can be
seen in efforts to accurately assess individual-level components of ageism (stereo-
type, prejudice, discrimination) (Thompson 2006; Palmore 1999, 2005) using
explicit and implicit measures of ageism (for an overview of such measures, see
Lassonde et al. 2012, pp. 175–176). Lassonde et al. (2012) developed an implicit
way of assessing ageism using the so-called contradiction paradigm “to measure
age-related stereotypes in passages describing older adults” (p. 174). They found
that people read sentences more slowly when the content portrayed behaviours that
were inconsistent with age-related stereotypes as compared to content that was con-
sistent with age-related stereotypes. Their results were not related to explicit ways
of assessing ageism, which, according to the authors, confirmed that the contradic-
tion paradigm can be used to assess age-related stereotypes. The researchers
acknowledged that the scale is not an alternative for assessing affective (prejudice)
and behavioural (discrimination) components of ageism. Lassonde et al.’s method
of assessing stereotypes is an important theoretical contribution, and a result of
systematic empiricist consideration. Their study demonstrates robust empirical
results, a transparent description of the study design and decisions made during the
research process, and a highly effective way of instantiating what prejudice, stereo-
typing, and discrimination corresponds to in real life situations.
North and Fiske’s (2013) development of an intergenerational-tension ageism
scale illustrates an explicit way of assessing ageism in an empirical study. In this
study, North and Fiske did not depart from a definition of ageism, but from existing
ageism scales, which they felt focused mainly on descriptive stereotypes and what
older people are. Instead, they empirically tested a three-factor model of prescrip-
tive ageism. These factors were described as “active, envied resource succession,
symbolic identity avoidance, and passive, shared resource consumption (SIC)”
(North and Fiske 2013, p. 706). The SIC-scale fulfilled the requirements for internal
validity, i.e., statistical explanations of the data were identified that qualified the
results as a scale.
Lassonde et al. (2012) and North and Fiske (2013) focused on stereotypes and
prejudice and did not engage in discussion about what the scales are linked to in
terms of outcomes. Both contributions end in a suggestion that the scales can be
418 F. Snellman
used for purposes of investigating how ageism relates to behaviour, which is a very
challenging task. Tornstam (2006), in a study of age-related attitudes and
discrimination, demonstrated that even if we are predisposed to behave in a certain
way (for example, by embodying negative attitudes), we do not necessarily do so.
Other studies using empiricist considerations have, however, investigated ageism
and beliefs related to different outcomes.
Becca Levy has made significant contributions to empirical studies of ageism.
She proposes that ageism and self-stereotypes have an effect on memory perfor-
mance in old age (Levy 1996), on handwriting (Levy 2000), on the will to live (Levy
et al. 1999), hearing decline (Levy et al. 2006a), myocardial infarction (Levy et al.
2006b), cardiovascular events in later life (Levy et al. 2009), and longevity (Levy
et al. 2002). These studies make important contributions because they provide sta-
tistical explanations related to outcomes most people can comprehend. Many peo-
ple would agree that ageism—even if they do not necessarily recognize the term—at
least in principle is important. It is not, however, until we start linking it with poten-
tial challenges in our own bodies that people really understand its impact on life and
society. Measuring ageism accurately and demonstrating its relation to outcomes
requires empiricist considerations at an early, theory dependent, stage of the research
process.
25.5 Interpretive Considerations
Interpretive considerations in the ageism research process concern designing stud-

ies for activities of interpretation, understanding, and meaning-making of a com-
plex ageist reality. Interpretive considerations originated with scholars such as
Wilhelm Dilthey, Max Weber, and Hans-Georg Gadamer. Interpretive design con-
siderations are brought to the fore in the research process when we want to explore
the uniqueness of situations in an ageist reality and when the study focus is of a type
that does not repeat itself in a regular manner (i.e., when ageism is considered too
complicated to explain by making generalizations). These occasions require that
ideographic notions—notions that describe the uniqueness of individual situa-
tions—are utilized. The dependency on interpretive theory (Føllesdal et al. 2001) is
more present in later stages of the research process.
Interpretation is viewed as necessary in situations in which we do not understand
the complexity of what is being studied (Føllesdal et al. 2001). This type of dilemma
presents itself in unique, previously unexplored cases in which we do not have a
clear idea of how to accurately observe ageism. Without interpretation in these
cases, there is no way of understanding ageism, no way of making sense of or iden-
tifying the meaning of how and why ageism takes place in our world. For instance,
the unintentional discovery of and labelling of ageism signifiers in the life stories
study (Snellman 2009) was the result of an extensive process of triangulating empir-
ical data, analytical methods, and a variety of theories to interpret and understand
the unique and challenging phenomenon of how ageism is manifested and sustained
in older people. This discovery was enabled by critically scrutinizing empirical data
collected at different points in time during the research process. In the process,
words such as “older” and “younger” were observed, but, without combining differ-
ent types of data, methods, and theories, I would not have been able to label those
words signifiers of ageism. The fragments of a complex ageist reality that surfaced
in the later stages of the research process required interpretive considerations to
bring them to the fore.
There are other distinctive features to interpretive considerations. One feature is
the two-way direction between the overall structure of society on the one hand and
individuals living and making choices in society on the other. This has been called
the “dialectical confluence of ageism” (Wilkinson and Ferraro 2002), and is perhaps
the main reason why empirical data needs to be interpreted with the use of theory in
the later stages of the research process. A second feature is that actors in the role of
researchers are co-creators (meaning makers) of society’s ageist structure (Bytheway
and Johnson 1990; Føllesdal et al. 2001; Snellman 2016). A third feature is aware-
ness, which is needed to understand, among other things, (a) the uniqueness of situ-
ations and the broader consequences of ageism, (b) what comprises the ageist
structure of society, and (c) how the ageist structure is sustained.
Interpretive considerations can be identified in definitions describing ageism in
terms of practices (Bytheway et al. 2007; Snellman 2016). There are other useful
conceptualizations of (ageist) practices that use other terms than ageism, such as
“age-relations” (Calasanti 2003) and “age coding” (Krekula 2009). Elsewhere I
have suggested an interpretive (constitutive) working definition of ageism as
constitutive practices which are permeated with our experiences of the chronological,
social, biological and psychological life course. We utilize age—or some other adjacent
terminology that signifies age—in a myriad of different ways to organize our own and other
people’s lives and to make our social worlds intelligible. (Snellman 2016, p. 149)
This working definition of ageism was enabled by the triangulation of empirical

data, methods, and theory that I arrived at during an extended research process. In
addition to the word “practices”, the word “constitutive” in the working definition
has important implications for continued interpretive considerations. Constitutive is
generically described as “having the power to enact or establish” (Merriam-Webster
n.d.). Constitutive means that structure—in the meaning of established societal
practices—influences (not determines) individual behaviour (is constituted by) and
individual behaviour establishes (constitutes) the structure in the meaning-making
practices of society. In other words, this is the “dialectical confluence of ageism” as
described by Wilkinson and Ferraro (2002). This, in turn, implies that if structure is
not complete, decisively finished, it can potentially be changed. So, interpretive
considerations in the research process are sometimes more about reflecting on who
has the power to define and label an ageist reality. Interpretive considerations allow
for an understanding of how people themselves can become aware of and master
420 F. Snellman
their life-world (Freire 1996). Higher levels of awareness spill over into enhanced
possibilities of exercising power over one’s own situation. Departing from defini-
tions of ageism as practices enables a more open form of investigation that allows
for the discovery of aspects that could not even be anticipated in the early stages of
the research process. Interpretive considerations in the ageism research process also
bring us closer to exploring the intersectional complexity of situations and society
(Wilińska et al. 2018; Chap. 26, in this volume). In simple terms, intersectionality
means that we try to observe and analyse several uniquely socially organizing prin-
ciples simultaneously; for example, how aspects of age, gender, ethnicity, and class
overlap in a given situation.
Interpretive considerations in the ageism research process include other ways of
collecting data than carrying out experiments, collecting survey data, and using
existing registers. For instance, Bytheway et al. (2007) used diaries to examine peo-
ple’s accounts of discrimination, exclusion, and rejection. They were able to show
that everyday events, such as going to the hairdresser, were perceived as discrimi-
nating when individuals were not given the haircut they wanted. This type of study
design was needed to capture unique, ageist events that often occur in everyday life
but still in some countries are considered too trivial to qualify as discrimination in,
for example, a legal sense.
25.6 Discussion
In this chapter, I reflect on how normative, empiricist, and interpretive consider-

ations have influenced the ageism research process and definitions of ageism.
Normative considerations in the research process are characterized by taking a stand
against something perceived as immoral or negative in society and wanting to
change something which is viewed as problematic. A normative research process is
not dependent on ageism theory or theorizing at any stage of the process. Rather, it
is characterized by taking a stand, making a claim, and invoking ageism (Cruikshank
2003) as a means to explain practices when other explanations have been precluded.
Reliance on normative considerations can be depicted as the initial step in theoriz-
ing ageism and as a way to suggest new testable hypotheses and novel research
questions. Normativity on the structural level of society enables common sense
decision making about what the morally correct thing to do is in a variety of situa-
tions. As human beings, we are quite often, but not always, good at common sense
decision making. However, acting on normativity, always to some degree, leads us
into a biased dead-end. Normative characteristics in ageism definitions show most
evidently in the description of the phenomenon as something negative and as a way
to distinguish older people (for example) as a target for intervention. Normative
considerations guide us towards designing research (perhaps even without inten-
tion) in a way that allows us to express opinions about and strive to change negative
consequences of ageism for a variety of target groups in society.
Empiricist considerations in the ageism research process are characterized by

making as accurate as possible assessments of ageism. This requires having a clear
idea of what and how to assess, which, in turn, presupposes a foundation in theory
at an early stage in the research process. Empiricist considerations are theory depen-
dent at early stages of the research process. This is for instance accomplished by
assessing prejudice, stereotypes, and discrimination. These three elements are the
most obvious empiricist characteristics in ageism definitions. Accuracy resulting
from empiricist considerations has provided the research field with validated scales
to assess ageism (e.g., Lassonde et al. 2012; North and Fiske 2013) and demon-
strated how stereotypes affect a range of different outcomes. Empiricist consider-
ations allow us to assess ageism in as valid, reliable, and accurate a manner as
possible. Empiricist considerations in early stages of the research process help
guide research towards accurate observation and allow us to show how ageist ele-
ments are manifested in specific contexts.
Interpretive considerations in the research process are brought to the fore when
the phenomena being studied are unique and extensively complex, that is, when
complexity surpasses the possibilities of accurate assessment. In this chapter, for
example, the discussion involves the complex challenge of demonstrating how age-
ism is manifested in and sustained among older people. Our notions of a complex
ageist reality are often present in a variety of ways, but uncertainties about how to
make sense of a complex reality often prevents us from proceeding. Addressing
situations of great complexity regarding ageism requires a process in which we
observe reality, collect rich data about age-related aspects of everyday life, and link
those data to more abstract types of theories in later stages of the research process.
Interpretive considerations in the research process are distinctively characterized by
theory dependency in its later stages. In order to make sense of complex situations,
it is of the essence that the choice of ageism definition is of a type that allows an
interpretive kind of process. Such definitions of ageism include those that identify it
in terms of practices. Unique, complex situations can be explored by using a defini-
tion of ageism that includes “practices”, as this enables a wider contextual concep-
tualization not circumscribed by narrower alternatives, such as stereotypes.
Interpretive considerations in later stages of the research process guide our investi-
gation towards meaning making and understanding of a complex ageist reality, and
towards reflecting critically on how ageist elements are related in a wider context.
Normative, empiricist, and interpretive considerations can be seen as being
active in different stages of the research process, and are differently theory depen-
dent. The purely normative is not theory dependent at any stage; the empiricist is
theory dependent at an early stage; and the interpretive is theory dependent at a later
stage of the research process. Depending on the degree of complexity and what we
hope to accomplish in researching ageism, normative, empiricist, and interpretive
considerations guide our choices and influence our notions of what the most useful
forms of knowledge are. As researchers, we are often inclined to make one-sided
choices about whether a normative, empiricist, or interpretive design is the most
422 F. Snellman
appropriate solution. This depends largely on what kind of research training we

have. Research training, rather than the research problem, tends to guide what we
eventually use. In this chapter, I have argued that a customization of normative,
empiricist, and interpretive considerations—in other words, a triangulation of data,
methods, and theories in an extended research process—can be a fruitful and cre-
ative way to pursue ageism research. Hopefully, the merits of customized triangula-
tion have been demonstrated in a way that will inspire creative identification of
novel research questions that will continue to help raise awareness of ageism and
identify ways to intervene against the elements of ageist reality that we do not want
and retain the elements of ageist reality that we still need.
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Chapter 26
Ageism in a Cross-Cultural Perspective:
Reflections from the Research Field
Monika Wilińska, Astrid de Hontheim, and Els-Marie Anbäcken
26.1 Introduction
There has been a long-standing interest in researching ageing from a cross-cultural

perspective. The recognition of the societal and cultural dimensions of ageing has
spurred interest in research that explicitly focuses on highlighting the meaning of
context for the process and experience of ageing. Moreover, the acknowledgment of
previously limited views of ageing has opened new directions in ageing research. In
1986, when the Journal of Cross-Cultural Gerontology was established, its editors
stipulated that research on non-Western settings would be favoured in the journal,
which corresponded with “a need for a scholarly journal devoted to worldwide vari-
ation in the aging experience” (Beall et al. 1986).
This trend has also been visible in studies that aim to define and measure ageism
in objective ways in different parts of the world. For example, in North America,
measurement scales that assess the scope and prevalence of ageism in everyday life
include the Ageism Survey (see McGuire et al. 2008; Palmore 2004) and the
Relating to Older People Evaluation questionnaire (see Allen et al. 2008; Cherry
and Palmore 2008). In Europe, the European Social Survey (ESS) has been widely
applied to investigate ageist attitudes, the prevalence of age discrimination at
national levels, and to offer cross-country comparisons (see Swift et al. 2018;
M. Wilińska (*)
Jönköping University, Jönköping, Sweden
A. de Hontheim
Université libre de Bruxelles, Brussels, Belgium
E.-M. Anbäcken
Mälardalen University, Västerås, Sweden

https://doi.org/10.1007/978-3-319-73820-8_26
426 M. Wilińska et al.
Chap. 27, in this volume). Accordingly, there is growing recognition that ageism

needs to be understood in relation to the various spaces in which it occurs (McHugh
2003). For example, different welfare and cultural norms tend to affect the ways in
which people relate to this phenomenon (Radl 2012; Trusinová 2014; van den
Heuvel and van Santvoort 2011).
Schoenberg and Lewis (2005) discussed the phenomenon of cross-cultural age-
ism to emphasize that a cross-national perspective in the study of ageism makes an
important contribution to understanding the ways in which local contexts shape and
influence ageism. Such a perspective, however, does not need to entail an essential-
ist view of culture; rather, it encourages reflection upon various norms, practices,
and meaning-making processes embedded in particular socio-cultural settings and
their influence on ageism and ageist practices. In this chapter, we follow this line of
argument and develop it further by discussing the complexity of exploring diverse
ageist practices as performed in different parts of the world and reflecting at the
same time upon the researchers’ socio-cultural backgrounds, through which their
experiences of fieldwork and research on various enactments of ageism are filtered.
The key tenet of our argument is that these two dimensions interact during the field-
work to create unique frameworks that researchers apply in their studies and which
in effect lead to various understandings of ageism.
26.2 Ageism—From Global to Local Phenomena and Back
“Every age is problematic, or rather, having an age is a danger” (Gullette 2004,

p. 181). This statement, made by renowned cultural critic Margaret Gullette, accen-
tuates the prevalence of age ideology in current socio-economic and cultural con-
texts. Ageism is a multidimensional phenomenon that goes beyond discriminatory
practices or events. It is predicated upon the understanding of age as an important
signifier of classes of people (Bytheway 1995) that effectively creates ranks of more
and less desired ages. It is a form of social oppression and inequality that often goes
unnoticed when people are involved in their business as usual. As emphasized in the
chapter on gendered ageism, ageism is also a form of social practice that is used to
achieve not only age-specific goals, such as favouring some age groups at the
expense of other groups, but also to accomplish other important objectives, such as
fulfilling organizational visions or work-related tasks (Llewellyn 2015; Wilińska
and Henning 2011). Because of this, ageism becomes a difficult phenomenon to
research. Like any other form of social inequality, ageism not only exists in direct
discriminatory and exclusionary actions, but, more often, it can be found in numer-
ous taken for granted meanings and practices that are ordinarily considered natural.
The popularity and social acceptance of widely used anti-ageing products (Vincent
2006, 2007) and age-related jokes on birthday cards (Ellis and Morrison 2005) are
only two examples of practices that very often receive little if any recognition as
harmful and demeaning to particular age groups.
26 Ageism in a Cross-Cultural Perspective: Reflections from the Research Field 427
26.3 Ageism in West and East
Ageism as a societal structure that is enacted in social relationships and practices

has been mainly associated with Western cultures that have been extensively criti-
cized for their overarching focus on and desire for everlasting youth which devalues
ageing and old age (Gullette 2004). Studies that explicitly aim at comparing enact-
ments of ageism in Western and Eastern cultures usually employ either attitudes
surveys or media analysis.
In an overview of quantitative studies examining differences in attitudes towards
older people in Western and Eastern countries, North and Fiske (2015) demon-
strated that their results contradict many common assumptions about East and West.
For example, the most commonly held assumption about those differences is that
Eastern countries and cultures are more respectful of older people. North and Fiske
(2015) challenged this claim by establishing a link between level of ageism and
population ageing rate and suggesting that many Eastern countries experience high
rates of population ageing and, therefore, increasing levels of ageism. They empha-
sized a need for more context-sensitive research that is also conducted within simi-
lar cultures and geographical regions.
Ageism may be a worldwide phenomenon but its particularities attest to the
importance of recognizing the interaction between situational contexts and ageist
practices. For example, methodological reflections on the ways in which the ESS is
used in Europe to study ageism confirms that levels of sensitivity to the experience
of ageism vary from country to country making it difficult to reach rigorous conclu-
sions (Trusinová 2014). There seems to be a clear difference in the experience of
direct age discrimination between Northwest and Southeast Europe, which, among
other things, can be related to the differences in social arrangement systems follow-
ing diverse welfare state traditions (van den Heuvel and van Santvoort 2011).
Research results from studies examining ageism in the media also confirm the
importance of context when discussing this phenomenon. For example, a compara-
tive study of TV advertisements in Taiwan and the UK has shown that although
ageism is widely spread in both countries, its forms and contents differ due to vari-
ous cultural and traditional norms (Chen 2015). Whereas in the UK ageism is mostly
visible in unrealistic images of active and healthy older people, in Taiwan the same
phenomenon is reflected in advertisements that mainly focus on ill health and the
vulnerability of older people. Lien et al. (2009) and Raman et al. (2008) further
demonstrated that, although the underrepresentation of older people in the media is
widely spread around the world, the particularities of marginalization and stigmati-
zation of older people in the media need to be contextualized.
26.4 Cross-Cultural Research Approaches to Ageism
Very often, cross-cultural comparisons of ageism are conducted from the perspec-
tive of difference (idiographic) and it is difference that is actively searched for. In
contrast, Anbäcken and Nitta (2008) discussed the position of “similarities in differ-
ences and differences in similarities” (p. 172) as a more fruitful response to the
challenges posed by cross-country comparisons. This position rejects the static view
of culture and instead brings to the fore sensitivity to the context and the interlinked
relations between particularities and universalities. It is a position that, for example,
has enabled researchers to demonstrate that the perception of daily life among older
people whose spouses were institutionalized in the Japanese and the Swedish con-
texts are similar. Moreover, it might be useful to highlight in-group varieties rather
than only to delineate differences between countries (Anbäcken and Nitta 2008;
Johansson et al. 2008). Such a position has the potential to creatively combine a
search for differences and unique characteristics (idiographic perspective) with a
search for similarities and discovering overarching patterns (nomothetic perspec-
tive) by demonstrating that differences and similarities can co-exist.
Not only does the perspective used to compare various contexts make a differ-
ence, but researchers themselves matter. Japanese gerontologist Koyano (1989)
contended that many myths regarding ageing in Japan had been constructed by
Western scholars who entered the country without fully understanding the particu-
larities of everyday life and the ways in which older people would and would not
interact with foreign researchers. For example, he found that rituals of respect which
were praised by Western scholars very often concealed negative attitudes towards
old age that were very difficult to discern, even by natives (Koyano 1989). This only
strengthens the point about the complexity of revealing ageist practices, which,
enmeshed in everyday doings, often go unnoticed. This difficulty not only exposes
the conflict between insider (emic) and outsider (etic) perspectives that may sub-
stantially impinge on comparative research efforts in the field of ageing (Tesch-
Römer and von Kondratowitz 2006), but also highlights the fact that regardless of
the perspective, knowledge is hardly objective. On the contrary, it reveals its inter-
dependency on the social reality in which it is produced (McCarthy 1996; Longino
1990).
Research on ageism conducted in unfamiliar socio-cultural settings is also chal-
lenging simply from the practical perspective of researchers travelling, living, and
working abroad. The prospect of encountering new, unexpected scenes typical of all
research fieldwork can be much higher in such situations. Furthermore, the process
of negotiating one’s own position in the field can be very demanding because even
off-field negotiations are conducted outside the familiar context (Ortbals and
Rincker 2009). These, combined with a range of theoretical and methodological
perspectives, may be perceived as diverse “voices” pulling the researcher in differ-
ent directions (Mallozzi 2009). This hidden or “shadow” side of fieldwork (Corin
2008) simultaneously influences our perception and is contingent upon our own
stories and experiences in the fieldwork.
26.5 Researchers Entering the Field of Ageism
In this chapter, we reflect upon examples of qualitative studies to highlight an

important but often neglected dimension of research on ageism: the researchers
themselves. We work from the perspective of knowledge as culture, where culture
does not only entail a system of shared meanings, but rather emphasizes a range of
cultural practices that form our reality (McCarthy 1996). We explore the position of
researchers who, on the one hand, apply the privileged perspective of strangers to
their fieldwork, and on the other hand, are deeply embedded in their own socio-
cultural backgrounds, which affect their way of approaching later life and ageism
(e.g., Anbäcken 2004; Anbäcken and Kinoshita 2008; Wilińska 2014).
The fieldwork situations analysed in the subsequent parts of this chapter are
based on the three distinct voices of the researchers who authored this chapter. All
excerpts are based on fieldnotes the authors took while conducting thier studies. We
discuss the presented fieldwork situations to highlight two issues: first, the complex-
ity and variety of ageist practices; second, the active role researchers have in making
sense of the social world. This means that in addition to analysing the empirical
material, we critically look at the ways in which we approached that material in the
past and the ways in which we could approach it currently. Following Mason’s
(2013) reasoning about “re-using” qualitative data, we reflexively engage with the
empirical material from both a close and a far away perspective. In this way, we
contextualize and recontexualize our data and ourselves to apply perspectives of
time and space not only to ageism as a social phenomenon but also to research on
ageism.
The three authors are women of different ages. We were born and brought up in
different countries: Astrid is from Belgium; Els-Marie is from Sweden and Japan;
and Monika is from Poland. We embarked on our academic journey researching
ageism in different ways, although we all have an academic connection with Asia;
Els-Marie also has a private connection to Japan. All three of us are qualitative
researchers, although from different disciplinary positions. Our thinking and writ-
ing about ageism is affected by the various “voices” we hear during periods of
fieldwork and while conducting interviews. We combined our experiences to offer a
shared reflection on conducting cross-cultural research on ageism. The situations
presented below attest to how our various backgrounds impacted our work, and
emphasize the need to understand ageism as a socially, culturally, and politically
embedded phenomenon that reveals itself variously, depending on the context.
26.6 The Pervasiveness of Ageism
Monika I see myself as an inequality researcher. The focus on ageism is important

in my work, but I also work on wider issues to understand patterns of inequality and
their persistence over time and space. My own life is also an important site of such
inquiries mainly due to my status as an Eastern European immigrant woman living

in Western Europe. My thinking about inequalities always begins with a simple yet
profound principle of sociological imagination as outlined by Mills (1959/2000),
which aims at linking individual biographies with societal histories. As challenging
as it is, this statement gains a whole new meaning in the context of cross-cultural
research.
A few years after migrating to Sweden from Poland, I travelled back to my home
country to conduct fieldwork at one of the many Universities of the Third Age (U3A).
I was rather excited about the visit and its purpose. I recalled times when I was a
student and could see U3A students coming for their afternoon sessions, which
started just after our sessions ended. We not only shared the building but also the
teaching staff. I had thought of the visit as a possibility to shed a positive light on
old age and to demonstrate an example of activist initiative that goes against widely
accepted ageist stereotypes.
During my visits, I was always treated in a very positive and friendly manner and
I could feel that my visit and prospective study were welcome. I was also excited
about conducting research in a familiar setting, in a well-known country. I was,
however, considered a kind of hybrid person who was “one of us” in some sense and
yet also “the other.” People often said to me, “You know how it is here,” but I also
felt I was approached with caution and that little was revealed about the organiza-
tion. It was within this context that I was told that if I wanted to learn more about
old age, I should “walk the streets” rather than spend my time with the U3A,
“because, although ageing does happen, it does not happen here.”
26.7 The Easiness of Ageism
Els-Marie My studies on ageing and care in Japan began in the early 1990s but did
not specifically focus on ageism. To look at previous studies in the rear-view mirror
through an ageism lens is not only a thrilling task, but it also provides methodologi-
cally unorthodox ways of studying a phenomenon that originally was not intended
to be studied. The text below serves as a good example of both ageism and how the
researcher as a tool is influenced by perhaps hidden ageist preconceptions.
After a few days of participant observations at a Japanese municipal “home for
the aged,” which at that time were for older persons with social rather than health
care needs, I attended a meeting of the karaoke club. I was seated at the large rect-
angular table with ladies and gentlemen mostly dressed in brown and grey, with
solemn faces, singing love songs: “You and I are Osaka sparrows... how far will we
fly tonight?” It not only shook my image of older people, but evoked in me a strong
feeling of existential closeness. I realized that they had once been my age, and the
places they were singing of were “my” places too, as I was born in Japan and in the
Osaka region (Anbäcken 1997, p. 1).
While my focus had been on the residents as a category of older people with
certain care needs in a specific socio-cultural setting, they revealed themselves
behind their institutional identity as individuals of a particular time in Japanese

history and with their own history. Those love songs were part of their life course.
In retrospect, I feel that, with my preconceptions about ageing in Japan, I was the
one with unconscious ageist views. My preconceptions, formed by an image of filial
duty, had made me see older people as a category of care recipients, where care
needs and care relations defined their life. Moreover, I risked making simplified
“culturalist” assumptions in my field of study. This could possibly have blurred my
views, colouring my analysis with unquestioned ageist views hidden within cultural
explanations.
26.8 Ageism as Inequality Practices—Analytical Reflections
When Monika visited the University of the Third Age (U3A), she was in her early
30s. She assumed that the U3A members, people in their 60s, 70s, and 80s, would
be sharing their stories of ageing and old age with her. It took time for her to under-
stand that the U3A was, in fact, used by its members as a shield to protect them from
negative images of old age and older people. The phrase, “There is no ageing here,”
was, on the one hand, an enactment of ageism; on the other, it offered protection
from the socio-cultural context that associated ageing with a time of decline, and
withdrawal from public and social spaces. Els-Marie similarly began her studies
with a search for differences. Her surprise at discovering similarities instead revealed
to her that she had been seeing older people as a “category” with defined features,
rather than as individuals.
When conducting research on ageism, we need to start hearing stories about
researchers’ preconceived ideas about older people and ageing and how they might
lead to discrimination. The examples above demonstrate that inequalities are per-
petuated by every one of us. We as researchers might also be contributing to fuelling
the inequality systems. Inequalities are not only about direct and obvious discrimi-
natory acts, but also about “small things” that we do daily without thinking
(Schwalbe 2008). In this context, it is possible to see how tempting and comfortable
it can be to think about oneself as an exception, as one who can move beyond ste-
reotypes and draw on the privileged position of a stranger. Neither researchers nor
people in later life are immune to preconceptions. Cross-cultural studies only mag-
nify this process.
Unfamiliar settings and people can help reveal hidden stereotypes and images
that we use to make sense of situations, events, and processes. These stereotypes
and images become anchors that we easily drop but struggle to pull up due to the
comfort of illusory understanding they create. For example, it is much easier to
accept that an older person of American origin living in Japan does not like sushi
because she or he is not Japanese rather than to actively look for alternative explana-
tions, such as that the person has a food allergy or is a vegetarian. In the field of
ageing, this form of cultural determinism is often built on the understanding of
cultures as static and older people as mere victims of their national cultures (Wilińska
and Anbäcken 2013).
26.9 Ageism and Socio-political Structures
Els-Marie “What generates changes in policies for older people, and what con-
serves them?” was a question I posed in an attempt to write a policy ethnography
study on how policies and institutional care pamphlets constructed the image of
older persons and their families in Japan and Sweden (Anbäcken 2013, p. 256).
With regard to policies, it was clear (albeit from a very small sample) that both
Japanese and Swedish texts from the early 21th century showed similar patterns of
belittling older people in need of care and describing them as a social problem. This
problematic view of old age is related to an image of older people ceasing to be
productive—in both cases in industrialized countries where experience and wisdom
are not much valued anymore. Even the traditional image of wisdom in older age in
Japan was challenged after WWII when the welfare regime adopted a productivist
view, emphasizing economic development over social distribution (Makita 2010,
p. 82).
By the mid-20th century, Sweden had already developed a pension system, and
old age homes were gradually being transformed in the direction of “home-like care
and care at home” (Anbäcken 2013). The social democratic view slowly changed
ageist views of “old people’s homes,” but the view that “those who have built our
nation should be cared for” continued to bear hidden ageist views, as the message
was that they (the elderly) were to be taken care of. The Japanese old-age care pam-
phlets depicted “cute,” smiling, animation-style grannies, often in three-generation
settings. The Swedish pamphlets had realistic drawings of an elderly couple fol-
lowed by a text describing care options. Could the Swedish pamphlet be described
as less ageist than the Japanese, because it simply provided information on avail-
able services and how to obtain them? The Japanese brochures seemed to put for-
ward a consumerist perspective by providing information about room sizes, number
of staff, and frequency of baths. In contrast, the Swedish brochures tended to empha-
size the care relation between older people and staff members; they were filled with
images of affection and communication between the care home residents and care
home staff.
Looking back, I made a new discovery: that what I had earlier found to be posi-
tive about the kindness described in the Swedish brochures and negative about the
seemingly materialistic view in the Japanese ones could itself be problematic. While
the former used an idealized image of benevolent staff, the latter offered a more
concrete description of the physical environment and daily routines that one could
expect. The process of re-reading the empirical material through the lens of ageism
led not only to new understandings but also to a greater awareness of my own
assumptions.
26.10 S
ocio-political Embeddedness of Ageism—Analytical
Reflections
Welfare and social policy discourses have been identified as important sites of age-
ism (Biggs 2001), clearly contributing to, if not shaping, intergenerational conflicts
(Estes and Phillipson 2002), and invoking irrational fear of the ageing population
(Vincent 1996). However, the reading of such policies and interpreting them in a
cross-cultural context is far from easy. The example above demonstrates the way in
which researchers’ own backgrounds and socio-cultural reference points can inter-
act with the analysed material, leading to interpretations that may be biased.
The use of animation in the eyes of Western culture is often perceived as childish,
and, when applied to other than child-like situations, is read as patronizing and dis-
criminatory. However, in Japan, with its long-standing tradition of manga, the read-
ing of animation is different and does not always imply childish content. On the
contrary, the art of manga has been used for centuries to narrate complex stories by
engaging multimodal reading skills, and it remains one of the key hallmarks of
Japanese culture (Ito 2005). Els-Marie’s reflections on her interpretation of policy
texts from two different countries demonstrate the continual homage we pay to our
own socio-cultural background when researching ageism. In fact, on many occa-
sions, we wish we could go beyond our socio-cultural background in order to be
able to transcend taken for granted understandings that continually affect our
research results and the concepts we selectively use to justify them.
The socio-political context gives meaning to social practices and it is via this
context that some practices can be interpreted as ageist. For example, the use of
manga itself cannot be seen as a sign of ageism in the example described above, but
the focus on material aspects of care could be, as it indirectly implies that the mate-
rial is what older people are interested in. Such an image reduces the view of care to
the provision of goods rather than social relations—a reduction that is made more
problematic by occurring in an environment that values the collective self over the
individual self. Similarly, at the outset, the Swedish brochures seemed far from age-
ist. Yet given the cultural focus on the individual that characterizes the welfare state
in Sweden, the predominance of staff in the images of care homes can also be seen
as potentially ageist. In Sweden, a direct relationship between the individual and the
state has traditionally been a unique characteristic of the welfare contract (Bergren
and Trägårdh 2006), and by emphasizing the role of a mediator (care staff), the
brochure imagery can be seen as implying a weakened position of older people.
26.11 Ageism Across the Life-Course
Astrid My interest in ageism began when I was working on a book I dedicated to

my older students, which aimed to strengthen their confidence in the success of their
studies and help them overcome stereotypes related to ageism (de Hontheim 2014).
In addition to that, several of my research topics have focused on radical socio-
cultural changes, such as pioneer evangelization in West Papua. When traditions are
profoundly shaken, society seeks ways to mobilize creativity to build new refer-
ences with the help of those who are considered knowledgeable and culturally wise.
In West Papua, older people are traditionally designated to lead communities
through times of change.
26.12 H
onouring Older People and Discriminating
Against Younger People
In West Papua, population movements are mostly caused by massive transmigration

from overcrowded Indonesian islands such as Java and Sumatra, pushing the Asmat
to the edge of their former territories. The Indonesian administration has been
struggling with this cultural group, which they classify as “the least economically
active in the country.” The majority of the 70,000 Asmat are hunter-gatherers and
tradition constitutes the core of their daily life.
In the ritual house (jeuw), the centre for the community and political decision
making, the only people authorized to speak are the elders, who are considered to
be the tradition-holders or cultural specialists. They have the right to sit in the
physical centre of the house, where the ancestors are thought to dwell. Guided or
inspired by the ancestors, these cultural specialist elders protect the traditions and
ensure that norms are respected, with an emphasis on appropriate social and ritual
relationships.
A major part of traditional knowledge is transmitted through initiation, which is
still intimately connected to headhunting, although it is symbolic nowadays. The
elders’ responsibilities are of paramount importance, from training the young to
giving gifts that signify young people’s entry into the community. In a society that
imposes silence on the younger generation, control by older adults is the norm.
Young people are considered to be foolish and are deprived of the right to speak. In
this culture, young people are at the service of others. They always follow behind
older people, for example during meal times or when strolling through the village.
Older people have the right to use physical force in the teaching of the young.
In this context, human sciences researchers must manage deeply ingrained ageist
structures directed against younger people. In this culture, young people are not
considered to deserve the right to participate in research or to express their
opinions.
26.13 Ageism as a Total Social Fact—Analytical Reflections
Although ageism may refer to any age group, the most common understanding is
that it mainly affects older people. Astrid’s example reemphasizes the point that the
direction of ageism is context-bound. For the Asmat, it is old age that is privileged
and carries numerous benefits in social position and status. Consequently, European
researchers may find themselves reproducing Asmat adults’ deeply ingrained age-
ism that affects young people in that society. Ageism as a social practice based on
the differentiation of people according to their age may not only be expressed in a
variety of ways, but may also refer to different age groups. To study ageism in
diverse societies requires attentive observation of various age practices and their
consequences for different groups within each society rather than for just one age
group.
Astrid’s fieldwork example demonstrates some of the most direct and visible
forms of discrimination that can affect different age groups. Lack of a voice, lack of
respect, and lack of one’s own place are typical among the underprivileged in struc-
tures that privilege some groups over others and effectively discriminate to the point
of symbolic and physical abuse. What is more, such practices are seen as necessary
to maintaining and reproducing the social reality. Ageism could thus be considered
a total social fact (Mauss 1923)—an expression of social mechanisms most essen-
tial to the perpetuation and reproduction of society. The division of society into age
classes not only determines the social positions of people belonging to different age
groups, but importantly it creates age-based systems of rights, obligations, and
moral conduct.
26.14 Ageism in the Eye of the Beholder?
Monika I travelled to Japan with the aim of researching care and the everyday life
of older people in several Japanese towns and cities. It was an amazing journey that
allowed me to get a glimpse into the social and cultural norms guiding everyday life
in Japan. I lived and worked with Japanese colleagues, I read books written by
Japanese authors, and I learned the basics of the Japanese language. This helped
me make sense of what I observed and heard about old age. A number of study visits
helped me learn about the various ways in which older people lived and were cared
for. I had the privilege of speaking with several older women and learning about
their everyday lives.
I began to understand the significant role of technology in people’s lives and
learned about a number of innovative solutions that were designed with the purpose
of increasing the safety and security of older people. During one of the visits in an
assisted living facility for older people, I was introduced to a woman who proudly
walked me through her apartment showing off her life story through pictures,
objects, and various certificates. Prompted by the visit organizer, she also
d emonstrated a number of safety alarms and technological devices that the apart-
ment was equipped with. While we were taking another tour of the apartment, the
visit organizer noticed an unopened box with a wearable alarm device that was to
be used by residents at all times for the purpose of alerting staff to sudden weakness,
illness, and so on. When asked why she was not using it, the woman said that she
was not that old yet.
26.15 Is It Ageism or Not?—Analytical Reflections
Initially, the situation above seems far from exemplifying ageism. In Els-Marie’s
view, the alarm system was a sign of safety, a service from the welfare system that
at a minimum level allowed this seemingly independent older woman to keep her
autonomy and control when to call for help. Els-Marie interpreted the woman’s
choice as a sign of being autonomous and exercising the right to decide about her
own life. Els-Marie situated that understanding of the situation in a research context
which was rooted in the continuous study of change processes regarding ageing,
care, and the welfare system in Japan (Anbäcken 1997, 2004, 2008).
According to Monika, with her understanding of social inequalities as accom-
plishments—as something that “doesn’t just happen … it happens because of how
people think and act” (Schwalbe 2008, p. 38; see also Tilly 1999)—the situation
revealed several dimensions that are relevant for researching ageism. First, there is
the context of social policy, with its focus on improving the wellbeing of older
people, which produces a certain image of the needs and wishes that an older person
may have. Second, there is the reaction of an older person to a supposedly helpful
device that in her eyes symbolizes old age—something negative that she does not
want to identify herself with. Third, there is a researcher born in the early 1980s in
Poland and brought up in the context of a deeply ingrained mistrust in things that
come from the state, who interprets the situation as a clash between the overpower-
ing state and a vulnerable individual.
Haraway (1991, p. 190) argued that “only partial perspective promises objective
vision,” suggesting that the situated nature of our knowledge rather than being limit-
ing is liberating. In their highly informative argument about the value of and need
for comparative research on ageism, Tesch-Römer and von Kondratowitz (2006)
privilege the role of theory in assuring a high quality of endeavours that could effec-
tively push the field of ageing studies forward. However, to use a theory is to look
at a phenomenon from a certain position, and that position has been developed in a
certain context. There is a risk of transposing theories and concepts born in one set-
ting to another. In the context of North-South power relations, this aspect of cross-
cultural research on ageism becomes even more pronounced. As discussed above,
Els-Marie and Monika each looked at the same situation and offered two different
interpretations that were grounded in their personal histories as well as in the theo-
retical frames they chose.
26.16 D
iscussion: Establishing a “Sense of Touch”
with the Field
Ageism is a global, socio-cultural practice that is deeply embedded in local contexts

that not only filter its meaning but also give rise to unique enactments of ageism. In
this chapter, our objective was to spotlight the active role of researchers, who
become tools for transporting various meanings and enactments of ageism. This
chapter is an attempt to tease out various entanglements of ageism, context, and
researcher to accentuate the role of researchers in cross-cultural studies of ageism
and to offer some “how to” recommendations in studies that research ageism from
a cross-cultural perspective.
We began this chapter with a reference to the opening statement of the Journal of
Cross-Cultural Gerontology. We agree with the importance of demonstrating
“worldwide variation in the aging experience” (Beall et al. 1986). Ageism is a
diverse phenomenon including a large variety of practices that are deeply embedded
in socio-cultural and political contexts. This means that cross-cultural research on
ageism should aim at broadening and complicating our perspective on ageism rather
than arriving at a unified picture. Longino (1990) contends that “[s]cientific inquiry
is unlike portrait painting in two very important ways: it is social and it is complex,
consisting of many activities carried out by different persons” (p. 19). The examples
used in this chapter are not straightforward and are prone to a variety of interpreta-
tions. We purposefully selected them to demonstrate the complexity and sociality
involved in researching ageism from a cross-cultural perspective. In many respects,
what we propose here is a type of reflexive methodology (Alvesson and Sköldberg
2009) that is needed in research on ageism to constantly remind ourselves of the
relationship between the knower, the (un)known, and the context of knowing. This,
in turn, may help us to rethink various theories and concepts that we apply in our
studies. Globally practiced ageing research is often based on standards and theories
born in Western countries (Aboderin and Hoffman 2015). The example of the Asmat
and their understanding of old age as a time of increased social and political engage-
ment reveals the extent to which such theories are ill-fitted to account for worldwide
variations of ageing experiences and, by extension, ageism.
Our discussion is based on examples from qualitative studies that by their nature
focus on situated meaning making. We find this dimension important not only for
revealing the various enactments of ageism in everyday life, but also for highlight-
ing the voices of people who confront ageism by interpreting and acting upon its
meaning. However, the points we raise in the chapter are not limited to qualitative
research. The active role of researchers who colour their research with their own
understanding of age and ageism is visible in all types of studies. Further, as Jylhä
(2007) contends, ethnographic comparisons may fruitfully inspire larger quantita-
tive studies of ageing and ageism. For example, the idea that ageism is not only
perpetrated against older people is just one such inspiration. This means that rather
than locating our studies within specific age groups, we can move beyond
c hronologically oriented studies to explore the ways in which a variety of age norms
affect and/or are enacted among various groups (Bytheway 2005; Gullette 2004).
In the context of their discussion of a “joint participation model,” Kinoshita
(Anbäcken and Kinoshita 2008, p. 8) emphasizes the necessity of establishing “a
sense of touch in the field” that involves researchers visiting each other’s empirical
fields and learning about the research contexts to create a common ground for forth-
coming interpretations. Acknowledging the importance of such exchanges that
merge emic and etic perspectives, in this chapter we extend the discussion by claim-
ing that the “sense of touch” in cross-cultural research on ageism should not only be
established within the socio-cultural context, but also in researchers’ own precon-
ceptions and reasons for selecting certain concepts, theories, and methodologies.
This constant dialogue is necessary to fully appreciate and benefit from the great
privilege of participating in cross-cultural studies of ageing and ageism. Importantly,
this dialogue needs to be firmly based on spatial and temporal considerations. It is
not only about the question of where but also about the question of when. It is the
socially, spatially, and temporally created contexts that make a difference to ageist
practices and the research that examines them.
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Chapter 27
Agisem in the European Region: Finding
from the European Social Survey
Hannah J. Swift, Dominic Abrams, Sibila Marques,

Christin-Melanie Vauclair, Christopher Bratt, and Maria-Luisa Lima
27.1 Introduction
It’s been almost 50 years since the term ‘ageism’ was first introduced in recognition
of prejudicial attitudes held towards people because of their age. Since then, research
in Europe has consistently shown that more people report experiencing age preju-
dice and discrimination followed by prejudice based on gender, and then race or
ethnic background (Abrams et al. 2011a; Abrams and Houston 2006). This trend is
found in most countries in the European region with the exception of Israel and
Latvia (Ayalon 2014). On average 35% of people who took part in the European
Social Survey (ESS) said they had experienced ‘unfair’ treatment because of their
age, but these experiences of ageism differ across Europe, from 54% in the Czech
Republic to 17% in Portugal and Cyrus (Abrams et al. 2011a). Despite its relatively
high prevalence, ageism is still under researched (Abrams et al. 2015) and remains
a relatively accepted form of prejudice, deemed to be an inevitable part of the age-
ing process (Nelson 2005; Nelson 2017). Differences between countries in the prev-
alence of experienced ageism could be related to various contextual differences that
exist for these countries. Across Europe rates of population ageing, fertility, immi-
gration and emigration differ and are leading to changing patterns of demography
(Creighton 2014). Although Europe as a whole must adapt to population ageing,
changing demographic patterns across Europe, coupled with substantial socio-
economic, cultural and political differences, are likely to impact on people’s experi-
ences of ageing, and could also explain why people in some countries are more or
H. J. Swift (*) · D. Abrams · C. Bratt

Centre for the Study of Group Processes, School of Psychology, Keynes College, University
of Kent, Canterbury, UK
S. Marques · C.-M. Vauclair · M.-L. Lima
Instituto Universitário de Lisboa (ISCTE-IUL), CIS-IUL, Lisbon, Portugal

https://doi.org/10.1007/978-3-319-73820-8_27
442 H. J. Swift et al.
less likely to experience ageism. Cross-national data, such as the ESS, have allowed
researchers to identify some of the psychological and sociological factors associ-
ated with people’s experiences of ageism.
In this chapter, we review the existing social psychological framework used to
explore ageism which informed the design of the Experiences and Expressions of
Ageism Module fielded in the 2008/2009 ESS. We also review the subsequent pub-
lished findings and studies that have utilized the ESS data to explore how the avail-
ability of cross-national data has advanced theory and understanding of ageism
across Europe. Much of this evidence uses a multilevel approach. Thus, we also
explore the benefits and limitations of such an approach for understanding ageism
across Europe.
27.2 The European Social Survey
The European Social Survey (ESS) is an academically driven cross-national survey

conducted every 2 years across the European region since 2001. The survey measures
attitudes, beliefs and behavior patterns in (up to) 30 nations. Each survey consists of a
fixed module and two or three rotating modules. Round 4 of the survey fielded in 2008
and 2009 included a rotating module on Experiences and Expressions of Ageism
(herein referred to as the Ageism Module). The module was designed by members of
the EURAGE group (European Research group on Attitudes to Age) lead by Prof.
Dominic Abrams (University of Kent), Prof. Luisa Lima (CIS-IUL at ISCTE-IUL)
and Prof. Genevieve Coudin (University of Paris). It contains 55 items which were
developed and pilot tested extensively within a framework that was subject to detailed
scrutiny, peer review and evaluation by experts in the ESS Central Coordinating Team.
The Ageism module provides representative samples from 29 countries and over
55,000 individuals. It uses computer-based personal interviews with national samples
between 1215 and 2576 people aged 15 and over. The questions in the module reflect
seven key domains including how age boundaries are defined, age identification, the
content of age-based stereotypes, perceived social status, perceived threat, experi-
ences of discrimination and the extent of intergenerational relations. The items within
these domains are guided by theoretical models from social psychology theories of
prejudice, including social identity and self-categorisation theory (Tajfel 1981), ste-
reotype content model (Fiske et al. 2002), intergroup threat theory (Stephan and
Stephan 2000) and intergroup contact theory (Pettigrew 1998).
This chapter introduces each of these domains and reviews key findings from
published research that has used the Ageism module. The search for published
research was conducted using Google Scholar in 2017. First, key search terms
‘Ageism’ and ‘European Social Survey’ were entered. The search, which was
restricted to publications after 2008, resulted in 391 hits. Each article (conference
proceedings, presentations were excluded) was read to make an initial judgement
about its relevance. We were only interested in academic or grey literature (i.e.
research published in academic journals or by government or non-government
27 Agisem in the European Region: Finding from the European Social Survey 443
o rganizations) that used, analyzed or reported findings from the Ageism Module.
We stopped the search at the point when all of the articles listed were irrelevant
(page 20 of Google Scholar search). This resulted in 36 articles for review which
were then categorized according to the primary or most relevant domain. Before we
review the findings it important to note that many of the publications adopt a multi-
level approach to analyzing ESS data.
27.2.1 Multilevel Modelling
The ESS data constitute individual responses that are grouped or clustered by the
country they are from. This hierarchical structure (i.e. individuals grouped within
countries) is conducive to multilevel modelling. Multilevel modelling is a statistical
regression approach that accommodates the context in which individuals are living
(Raudenbush and Bryk 2002), thus allowing for the simultaneous examination of
phenomenon at both the societal (e.g. country)- and individual-level. In order to
explain differences between countries, country-level (also known as macro-level)
variables are used as predictors of individuals’ attitudes and experiences. These can
be socio-cultural, but also socio-structural contexts. The first refers to collective
social phenomena such as widely shared social representations, for example, about
older people’s social status in society, or societal meta-perceptions (see Vauclair
et al. 2016). The latter refers to structural aspects of society such as economic and
political systems of the country, for instance a country’s gross domestic product
(GDP), level of inequality (as indicated by the GINI index) or a country’s average
retirement age. All of which can have an effect on different aspects of expression of
prejudice and experiences of ageing.
The benefit of the multilevel approach is the examination of psychological phe-
nomena of expressions of ageism (e.g. age stereotypes, perceived threat, perceived
social status of older people) which do not emerge in social vacuum. It is known that
groups and whole societies recognize and tend to share similar stereotypes and prej-
udices (Schaller et al. 2002) which constitute a collective reality that has an impact
on older people in terms of their ageing experiences. Thus, the ESS allows for
research to be conducted at two levels of analysis and therefore can independently
explore effects at the individual and country-level, as well as provide insight into
what kind of the combination of these factors are most likely to ameliorate or exac-
erbate ageism. Some of the factors might be difficult to change (e.g., a country’s
affluence), however, other factors might be more malleable. For instance, employ-
ment of older people may be raised through ‘age quotas’. Cultural beliefs may also
(slowly) change through targeted information, because culture is after all dynamic.
Interventions can be targeted by taking into account the different layers of effects
that produce negative age stereotyping. Furthermore, country-level findings (e.g.,
the effect of unemployment rates or the age ratio) can be translated to the regional-
level within countries which will be of great interest for policy-makers within
c ountries in Europe. The following sections summarise the empirical studies that
were identified as relevant in our review.
27.3 Ageism in Europe
27.3.1 Age Categorisation
In order to understand who is vulnerable to age discrimination it is important to

understand how people define age groups. Age categorisation is the process of clas-
sifying people as belonging to a certain age group, and by implication, not belong-
ing to other age groups. Age categorisation is highly relevant to the issue of
age-based discrimination because ageism can arise in relation to specific age points,
for example, the age of retirement or particular age ranges (e.g. the over 50’s), but
also in terms of general category labels such as ‘young’ or ‘old’ (Bytheway 2005).
Once categorisation has occurred, stereotypes associated with the category label
might then be erroneously applied to the individual. This can result in discrimina-
tion, but also put individuals (particularly older adults) in a situation where they fear
being ‘judged’ negatively in terms of their age (cf. stereotype threat, Lamont et al.
2015). Socially and psychologically the use of age categorisation can be highly
problematic because it may cause people to restrict what is deemed acceptable for
particular age groups based on their own or others’ ageist assumptions. For exam-
ple, people may be judged or they may see themselves as ‘too young’ or ‘too old’ to
pursue particular activities or roles. For this reason, the very act of categorising
others into different age groups and the way people define those groups has signifi-
cant implications for people’s choices and actions (see The Risks of Ageism Model,
Swift et al. 2017).
However, understanding the process of age categorisation can be tricky. Unlike
other forms of prejudice, such as racism and sexism, which are directed at fixed
social categories, the boundaries that define ‘old’ and ‘young’ age groups are fluid
(Bytheway 2005). In the Ageism module respondents were asked to estimate the age
at which people stop being described as ‘young’ and to estimate the age at which
people start being described as ‘old’. On average, across the 29 countries, respon-
dents perceived youth to end at 40 years and old age to begin at 62, this may mean
that people below 40 years and over 62 years are more vulnerable to age prejudice
and discrimination due to their perceived ‘young’ or ‘old’ age, respectively.
However, the placement of these age boundaries varies by respondent’s own age,
the self-categorization of their age, gender and the country in which they live
(Abrams et al. 2011a; Ayalon et al. 2014; Basleven 2010), such that both percep-
tions of the end of youth and onset of old age increase with respondents’ age. In
addition, respondents who self-categorized themselves as belonging to a younger
age group (relative to those who are the same chronological age) also perceived old
age to start later (Basleven 2010). Women perceived the end of youth and onset of
old age to be later than did men, and the end of youth was viewed as early as 34 in
Portugal 34 66
Norway 34 63
Sweden 36 63
Russian Federation 39 64
Denmark 39 64
Finland 37 62
Switzerland 42 66
France 41 64
Great Britain 37 60
Poland 43 65
Hungary 40 62
Netherlands 42 64
Israel 45 67
Croatia 40 61
Estonia 41 62
Bulgaria 43 63
Belgium 46 66
Spain 44 63
Ukraine 45 64
Turkey 37 56
Czech Republic 42 61
Latvia 45 63
Slovenia 46 65
Slovakia 44 62
Germany 44 62
Greece 53 69
Cyprus 52 67
Romania 48 63
0 10 20 30 40 50 60 70 80
Age people start being old Age people stop being young
Fig. 27.1 Estimated end of youth and onset of old age
Norway, but as late as 52 in Greece, while old age was viewed as starting at 65 in
Greece, but 55 in Turkey (Abrams et al. 2011a) (Fig. 27.1).
Analysis by Ayalon et al. (2014) using the full ESS data confirmed that 14% of
the total variance in the perceived end of youth was associated with differences
between countries, while only 5.7% of the total variance in the perceived onset of
old age was associated with differences between countries. In addition to the previ-
ous study, the authors found that having better subjective health and living with a
spouse or partner was also associated with perceiving the end of youth to be later,
while higher levels of education, better subjective health, higher life satisfaction and
sharing a residence with a spouse or partner were all associated with perceiving old
age to be later. Taking a multilevel approach, Ayalon et al. (2014) also examined
how contextual factors, such as country-level differences in life expectancy or

inequality, are associated with each age-boundary. The study revealed that respon-
dents in countries with a higher life expectancy, higher levels of inequality and a
higher percentage of individuals between the ages of 15–64 were more likely to
perceive the end of youth to be later. Whereas, respondents in countries with higher
education and higher levels of inequality, were more likely to perceive old age to be
later. However, official retirement age and fertility rates were not associated with
either age boundary.
Together, this research suggests that people have different constructions of age
depending on their vantage point, depending on personal, shared and interdepen-
dent social contexts of the individual, but also on some culturally shared social
contexts (e.g. education, life expectancy and inequality). Understanding how age
boundaries are socially constructed within societies is important because they can
shape individual’s social construction of what age is, and what it means to belong to
a particular age group. In this way, age categorisations can impact on individuals via
their own behaviours and life choices, but also by constructing attitudes towards
various age groups (Swift et al. 2017).
27.3.2 Age Identification
One factor that is likely to influence the salience of age in social contexts, and there-
fore the likelihood of age categorisation processes and the subsequent application of
stereotypes is age identification. Age identification is the extent to which people
identify with an age category and can be an important measure of the extent to
which age, and belonging to an age group informs social identity and who we are
(Tajfel and Turner 1979; Tajfel 1981). Social Identity Theory states that individuals
are motivated to gain positive distinctiveness for their ingroups by comparing them
favourably with other groups, which can result in holding prejudice views against
outgroup members. Shared age identity is assumed to denote an awareness of simi-
larities, a feeling of solidarity towards others in the same position but this, by impli-
cation can also be a potential antagonist against those who are different. Therefore,
age identity could also be an important factor in shaping generational conflict, for
instance, over the distribution of resources.
The meaning of age identification can be ambiguous unless it clarifies what age
people identify with. For instance, research conducted with individuals aged 65 and
over revealed that those with more positive perceptions of ageing (measured by self-
ratings of cognitive and physical functioning tasks) typically have a more youthful
age identity, i.e. participants felt younger. These individuals also had a higher level
of satisfaction with their current age, perceived the onset of old-age to be later and
showed more willingness to live to 100 years of age (Uotinen et al. 2003). Therefore,
it cannot be assumed that age identification measures identification to chronological
age, as this research demonstrates individuals can identify with their subjective
age – the age they feel, which might be different from their chronological age.
Accordingly, in the ESS, respondents were first asked to ‘self-categorize’ them-

selves by picking a box from a card with nine possible options laid out horizontally.
The first three boxes (A, B and C) were described as ‘young’, the next three (D, E
and F) as ‘middle’ and the final three (G, H, and J) as ‘old’. Respondents were asked
‘which box best describes the age group you see yourself as belonging to? If you see
yourself as very young, pick the first box. If you see yourself as very old, pick the
last box. Otherwise pick one of the boxes in between. Fitzgerald et al. (2010) analy-
sis of this item (for UK only) revealed that the oldest ‘young’ category and the two
younger ‘middle-aged’ categories were most popular accounting for half of the
responses from respondents aged 18 to 59. Interestingly, around half of those in
their 40s (49%) and 50s (52%) chose the mid-point of the “middle” category on the
scale (E). Perhaps this reflects a desire to be perceived as precisely in mid-life,
aware that ‘young’ is no longer an option but not ready yet to accept being labelled
‘old’. Most notably, 25% of respondents aged 70 and over defined themselves as
‘middle aged’ and only a small minority (14%) choose the highest “old” label (J).
Importantly, the analysis by Fitzgerald et al. (2010) suggests two things; (1) people
of the same age do not necessarily identity with the same age group, and (2) many
people chose to identify with an age group that is ‘younger’ than what might be
assigned according to chronological age.
In the ESS, respondents were then asked whether they had a weak or strong sense
of belonging to the age group they had chosen, using a scale from 0 (‘very weak
sense of belonging’) to 10 (‘very strong sense of belonging’). Analysis of this item,
has tended to find the relationship between age, self-categorized age and age iden-
tification to be a curvilinear ‘U’ shape, with younger and older age groups showing
stronger identification to their respective age groups (Abrams et al. 2011a, b;
Fitzgerald et al. 2010; Marques et al. 2014a). This suggests that age identification is
more important for younger and older age groups, or that age identity is more salient
for these age groups, perhaps due to transitional changes occurring around them
(e.g. becoming a young adult or moving into retirement). It could also suggest that
these age groups are more likely to be motivated to maintain a positive distinction
and therefore, more likely to hold ageist attitudes against one another, which in turn
means people belonging to these age-groups may be more vulnerable to age-
discrimination from other age groups.
However, social identity also can have important positive consequences for self-
esteem, health and wellbeing (Whitbourne and Sneed 2002; Marques et al. 2014a)
and the literature thus far, has mostly been concerned with exploring how older
adults are able to maintain a high level of age identification, self-esteem and wellbe-
ing in later life, despite the existence of ageism and other negative perceptions asso-
ciated with ageing (e.g. paradox of wellbeing, Swift et al. 2013; Whitbourne and
Sneed 2002). Research suggests a positive age-identity is one mechanism by which
older adults are able to maintain positive self-esteem, sense of self and wellbeing.
The other mechanisms include having a developed set of coping mechanisms, hav-
ing the ability to select emotionally rewarding social partners (see socio-emotional
selectivity theory, Carstensen 1992) and being able to shift goals and standards to
what is achievable in later life (e.g. accommodation; Whitbourne and Sneed 2002).
Research exploring the associations of age identity on older people has been
mixed. For instance, older individuals who perceived themselves as “old” also rated
their health as poorer than older individuals who perceived themselves as younger
(Stephan et al. 2012). But, in a study of 60 people aged 64 and over, Garstka et al.
(2004) showed that when older people are faced with age discrimination, increasing
their identification with their age group may be an important “fighting” strategy to
increase well-being. However, the impact of social identification on self-esteem,
health and wellbeing is dependent particularly on the perception of the social status
associated with the group (Ellemers 1993; Ellemers et al. 1988; Tajfel and Turner
1979). In line with this, research using the ESS data suggests that these mixed
effects of age identification are because age identity can confer a positive or nega-
tive image of ageing, depending on the perceived social status of older people
(Marques et al. 2014a).
27.3.3 Social Status
The status of a group is determined by its relative place or position in society

(Parsons 1951). In the ESS, social status refers to prestige, social standing or posi-
tion ascribed to individuals that mark their position in a given social system.
Evidence form the ESS demonstrates that people in their 40s are perceived to have
the highest status, followed by people in their 20s and people over 70 are perceived
to have the lowest status (Abrams et al. 2011a). Understanding social status is
important because ageism is partly driven by societal representations of older peo-
ple as being inferior to middle-aged people in terms of power and social status,
wealth, respect and influence (Garstka et al. 2004). These perceptions determine
how we deal and interact with members of these groups, and how we feel and iden-
tify with our own social groups.
In our recent paper, we argue that in order to understand the impact of age iden-
tification on older people’s self-reported health, we have to understand the role
played by the perceived social status of old age group in society (Tajfel and Turner
1986; Marques et al. 2014a). For instance, older people’s subjective evaluation of
their social status is negatively associated with their self-rated health, depression
and long-standing illness (Demakakos et al. 2008; cf. Hu et al. 2005). According to
Wilkinson (1996) the perceptions of one’s place in the social hierarchy are linked
with negative emotions (i.e., feeling of shame) and may influence fundamental
health outcomes via neuroendocrine mechanisms. Belonging to a subordinate cate-
gory potentially confers a negative social identity which can have negative conse-
quences for self-esteem and well-being. On the other hand, belonging to a high-status
category creates feelings of pride and positive outcomes for one’s self-esteem.
Therefore, the effects of age identity on self-esteem and subjective-health (i.e. self-
rated perception of health) are very much dependent on the social standing or posi-
tion of that group in society. Our analysis of a subsample of respondents aged 70

and over revealed that perceived status moderates the negative effect of age
identification on older people’s subjective health. Firstly, if age identification is
high, there is a greater impact of social status on subjective health. Secondly, age
identification is negatively related to subjective health in countries where older peo-
ple are perceived to have lower status (Marques et al. 2014a). In countries where old
age is perceived as signifying low status, just acknowledging that one is old is likely
to present real risks to one’s health, a possibility that is rarely considered in health
policy but should be considered by public policy addressing health issues (WHO
2002). The research provides an important theoretical contribution by demonstrat-
ing that the perceived social status of people over 70 is an important determinant of
the extent to which age identification has negative consequences on older people’s
subjective health and clarifies some previously mixed evidence concerning the
effects of age identification.
Although, across ESS countries there is a general consensus that people aged 70
and over are considered to have lower social status, there are considerable differ-
ences depending upon the perceivers’ age and also between European countries. For
instance, the perceived social status of people aged 70 and over increases with
respondents age (Abrams et al. 2011b; Marques et al. 2014a), which is likely to be
due to increasing motivation to gain positive distinctiveness for the next age group
they will belong to. There are also considerable cross-country differences in the
amount of status afforded to older people. For instance, in the ESS 16.27% of the
total variance in the perceived social status of people over 70 was associated with
differences between countries (Vauclair et al. 2014b). Our research findings also
show that societal perceptions of older people’s status are positively related to cross-
country differences in Gross Domestic Product (GDP), state pension age, the soci-
etal emphasis on autonomy values and levels of social inequality indicated by the
GINI index (Abrams et al. 2011b). Furthermore, a separate analysis revealed that
both societal modernisation (a sociological construct referring to profound eco-
nomic, social and cultural transition from ‘pre-modern’, ‘traditional’ societies to
‘modern’ societies, indicated by the Human Development Index) and levels of
employment of people aged 65 and over are positively associated to the perceived
status of people over 70. However, these two factors also interact with each other.
The perception of older people’s status is boosted in less modern societies if there is
a relatively high employment rate of people aged 65 and over indicating that their
active contribution to the economy is credited with more positive representations
(Vauclair et al. 2014b). The finding suggests that maintaining the employment of
older people may be an important factor determining their personal living standards
and providing more positive representations of the status of older people across
society. Moreover, low social status of people over 70 can be particularly problem-
atic for older people who identify with their age, as this can have a stronger negative
effect on health.
27.3.4 Age Stereotypes
Research suggests that there are multiple representations and stereotypes of ageing,
which vary in the extent to which they are negative and positive. For instance,
research from the US, UK and across Europe has continued to suggest that older
people are stereotyped as frail, ill, dependent and incompetent (Levy 2009; Marques
et al. 2014b, Coudin and Alexopoulos 2010), but also wise, experienced and more
moral than younger adults (Levy 1996; Swift et al. 2013; Abrams et al. 2011a).
Several studies have explored age-related stereotypes across age and cultural
groups. Many of the negative and positive representations of ageing can be captured
within the stereotype content model, which has been supported by over 10 years of
national and international research. It proposes that younger and older age groups
can be evaluated along two basic dimensions of competence and warmth (otherwise
referred to as friendliness; Fiske et al. 2002; Cuddy et al. 2005). Work conducted in
the UK and across Europe, (e.g., Abrams et al. 2009, 2011a; Vauclair et al. 2010)
has shown repeatedly that older people are stereotyped with a mixed representation
of high warmth (positive), but low competence (negative). This mixed representa-
tion results in feeling pity for older people, thus society holds ‘benevolent’ or
patronising ‘doddery but dear’ views of older people (Cuddy et al. 2005) –older
people are liked but often patronised and not given power or voice because of their
perceived low status and declining competence. In contrast, younger targets are
characterised by high competence, but relatively low warmth. This is also a mixed
perception, but results in feelings of envy and underpins a more hostile form of
prejudice (Fiske et al. 2002). Thus, the stereotype content model does provide a
framework that proposes that different societal representations of younger and older
adults informs the expressions of prejudices and types of discrimination they are
likely to experience. In the ESS, the stereotype content items were presented as
meta-perceptions, i.e. they asked ‘to what extent do you think other people think
people over 70 are viewed as…competent, friendly’. Therefore, they represent a
view and perspective that is thought to be widely shared by others.
The literature search found three papers that explored the role of stereotypes. The
first described here, explored the extent to which competence and warmth moderate
determinants of job satisfaction. Using data from Round 4 and 5 of the ESS, the
research conducted by Shiu et al. (2015) was primarily interested in exploring how
extrinsic rewards (e.g. job security and opportunity for career advancement) and
intrinsic rewards (e.g. task discretion and work pressure) relate to job satisfaction. It
also hypothesized that each of these relationships should be moderated by societal
views of older people’s competence, such that in countries where there is a shared
meta-perception that older adults are less competent, there would be a stronger
effect of job security on job satisfaction, a stronger negative effect of work pressure
on job satisfaction and a weaker effect of opportunity for advancement on job satis-
faction. It also hypothesized that societal views of older people as warm and friendly
should moderate the relationship between work pressure and job satisfaction, such
that the negative relationship between work pressure and job satisfaction should be
stronger for older workers in countries where people over 70 are perceived as more
warm and friendly. Based on Gouldner’s (1960) norm of reciprocity, the authors
suggest meta-perceptions of older people to be warm and friendly places expecta-
tions and work pressures on older workers to be more sociable, leading to lower job
satisfaction. The multilevel analysis revealed that country-level competence and
warmth (aggregated ESS data from Round 4) moderated the effect of work pressure
on job satisfaction in the predicted direction, but also found that the relationship
between opportunity for advancement and job satisfaction is stronger in countries
where older people are perceived as less warm. No other hypotheses were con-
firmed and there was no support for moderating effects of competence on job secu-
rity, opportunity for advancement or task discretion.
However, relatedly, the second paper found that perceptions of people aged 70
and over as competent are significantly predicted by participation of older people in
paid and volunteer work (Bowen and Skirbekk 2013). The final paper explored the
extent to which personal meta-perceptions predict experiences of ageism, using data
from respondents aged 70 and over. It revealed that personal meta-perceptions of
negative age stereotypes and specific intergroup emotions (pity, envy, contempt) are
associated with higher perceived age discrimination. However, at the country-level,
only paternalistic meta-perceptions (i.e. warmth and pity) were consistently associ-
ated with greater perceived age discrimination (Vauclair et al. 2016).
In sum, given the theoretical connection between stereotypes, prejudice and dis-
crimination, it is important to establish the role of personal and societal meta-
perceptions (i.e. those perceptions and views held by individuals and those
aggregated to the country-level). The research reveals the importance of countering
age-stereotypes at each of these levels, thus effective counter-ageism strategies need
to be directed towards and change individual’s perceptions but also collective soci-
etal perceptions (Vauclair et al. 2016).
27.3.5 Feelings of Prejudice
The ESS includes both direct and indirect measures of prejudice. Two direct mea-
sures ask respondents to rank on a 0–10 scale “how negative or positive you feel
towards people in their 20s / 70s”. In general, respondents reported positive feelings
towards older and younger age groups, however, these feelings do vary across
Europe, with respondents in Turkey reporting the most negative feelings towards
people in their 70s and respondents from Latvia and Finland reporting the most
positive feelings. A difference score created by Ayalon (2013) indicated in general
more positive feelings towards older than younger adults, with only three countries
reporting more positive feelings towards younger (Turkey, Greece and Croatia), but
an intraclass correlation coefficient of 2.3% revealed little cross-country variability.
On the surface, this finding is inconsistent with the common assumption in the lit-
erature that older people are the foremost targets of ageism (see Nelson 2017).
Usefully, the ESS data allows us to make comparisons between the degree to
which people hold age-prejudices with the reported experiences of discrimination
(i.e. the degree to which people are targeted by discriminatory behaviors or prac-
tices because of age), and reveals a discrepancy; despite widely shared positive
feelings towards younger and older people, there is a relatively high prevalence of
age discrimination. However, direct measures of prejudice should be interpreted
with some caution as people may not be willing to admit having feelings of preju-
dice towards older or younger people (Abrams 2010). To overcome this, the ESS
also included two indirect measures of prejudice by assessing the extent to which
people are internally and externally motivated to be unprejudiced (Plant and Devine
1998).
In an extensive exploration of how individual meta-perceptions, societal meta-
perceptions and norms of intolerance predict older people’s experiences of ageism,
Vauclair et al. (2016) revealed that in countries in which people think that it is
important to be unprejudiced towards other age groups, older people reported expe-
riencing less age discrimination. Moreover, social norms of intolerance of age prej-
udice had a larger statistical effect on perceptions of age discrimination compared
to other societal meta-perceptions, including the perceived status, warmth and com-
petence of people aged 70 and over. The analysis suggests that social norms that
promote intolerance to prejudice are an important factor to improve older people’s
experiences of ageing.
27.3.6 Experiences of Discrimination
In order to understand the extant and prevalence of ageism it is important to ask

people whether they have experienced age discrimination. The Ageism module con-
tains three items to explore this issue, one of these measures can be compared to
reported experiences based on gender or ethnicity. The other two items allow us to
understand experiences of specific forms of discrimination, such as blatant discrim-
inatory acts (e.g. bad treatment) and more subtle behaviours (e.g. patronizing behav-
iour or neglect). Importantly, these items coupled with advances in statistical
analysis, allow us to explore experienced of age discrimination across countries
(Trusinova 2014) and age (Bratt et al. 2018). A recent study used these three items
to (1) investigate measurement invariance for perceived age discrimination across
countries and across age and (2) to investigate levels of perceived age discrimina-
tion across age (Bratt et al. 2018). The study concluded that the three items have
sufficient measurement invariance across countries and across age to merit conclu-
sions about levels of perceived age discrimination. The analysis uncovered substan-
tial perceived age discrimination not only among older people, but even more so
among younger people. The consistency and international scope of the evidence
from the ESS strongly challenges the conventional wisdom that ageism is primarily
a problem for the old. Rather, it affects all ages and the relationship between them.
The study concluded that more research is required to understand ageism toward
younger people and to consider developmental differences and changes over the
lifespan.
Using a stepwise linear regression approach Van den Heuvel and van Santvoort
(2011) revealed that gender, education, income, belonging to an ethnic minority, life
satisfaction, subjective health status, trust in other people and the perceived serious-
ness of age discrimination in the country, are all related to experiences of age dis-
crimination in a subsample of ESS respondents aged 62 years and over. Interestingly,
using ESS data from Round 4, Meeusen and Kern (2016) investigated the generaliz-
ability of five types of prejudice (prejudice directed towards immigrants, homo-
sexuality, age-groups, unemployed, and gender) and revealed they were positively
related, such that if an individual holds negative attitudes towards one target group,
they are also likely to hold prejudicial attitudes towards other target groups as well.
This could indicate that any counter-prejudice and discrimination interventions are
likely to have spill-over effects for reducing prejudicial attitudes towards other
social groups not specifically targeted by an intervention.
27.3.7 Perceived Threat
Some theories of prejudice also contend that negative attitudes towards social
groups are associated with the perception that these groups pose various types of
threat (e.g. Intergroup Threat Theory, ITT Stephan and Stephan 2000; Riek et al.
2006). These include symbolic threat, the threat to people’s values, culture and way
of life and economic threat, the extent to which economic outcomes of one group
might be burdened or dependent on those of a different group. Evidence from the
ESS demonstrates that older age groups pose greater threats to the economy by
being a burden on health care and welfare resources by being perceived to contrib-
ute little to the economy (Abrams et al. 2009, 2011a).
Perceptions of threat change with age. Younger people are more likely to per-
ceive older adults as being a threat to the economy (Abrams et al. 2011a, b).
However, older people themselves perceive other older people as being a burden on
health care resources. Perceptions of threat also depend on the cultural context.
Higher state pension age is associated with lower perceived threat to health care
resources, GDP, autonomy values and inequality are associated with reduced per-
ception of economic threat (Abrams et al. 2011b).
Perceived threat in the form of the economic contribution of older people has
been associated with older people’s participation in entrepreneurship and innova-
tion. Using a subsample of the Eurobarometer of respondents aged between 50 and
74, Kautonen (2012) found that the perceived economic contribution of people over
70 (a macro-level contextual variable derived by aggregating the ESS data) was
significantly, negatively related to the probability of an individual thinking about
becoming an entrepreneur. In other words, people over 50 seem to be inclined
towards considering entrepreneurship in countries where older people are perceived
to contribute less to the economy. Kautonen (2012) suggests that a positive
p erception of the economic contribution of people aged 70 and over in a country

may lead to reduced ageism in the workplace and, therefore, a higher demand of the
services of older workers in the labour market, both of which decrease the relative
attraction of starting a business.
27.3.8 Intergenerational Relations
An important indicator of social inequality and prejudice is the degree to which

social groups share the same goals and values and the degree to which they under-
stand each other. The ‘Common ingroup identity’ model (Gaertner and Dovidio
2000) shows that prejudice can be reduced when people perceive they belong to one
common group, or belong to different groups that share an overarching community.
ESS respondents were asked how they saw people in their 20s and people over 70.
On average, across the European Region, respondents were more likely to view
people in their 20s and 70s as two separate groups within the same community
(49%), 29% thought that people in their 20s and 70s should be seen as individuals,
10% though they belonged to one group, while 12% thought people in their 20s and
70s belonged to two separate groups who were not part of the same community.
A large number of studies in social psychology (see Pettigrew 1998) have shown
that experiences of positive contact between members of different groups lead to
positive inter-group attitudes and relations. Specifically, the theories about inter-
group contact suggest that positive personal relationships, especially friendship
with members of other groups, are important determinants for reducing prejudice
between different groups. Thus, the degree and type of contact are relevant indica-
tors of exclusion and discrimination of different age groups in a given society (c.f.
Schneider 2004). To get a sense of whether respondents have meaningful voluntary
interactions with people from different age groups, ESS respondents were asked
how many friends, other than family members, they had under the age of 30 and
over the age of 70 – age boundaries which most people would regard as clearly
distinguishing between young and old. Across the ESS 52% of respondents said
they did not have a friend over the age of 70, compared to 31% who said they did
not have a friend under the age of 30. The number of respondents who reported hav-
ing friendships with people under 30 and people over 70 varied by respondents’ age
group. Those aged between 15 and 24 were more likely to have other friends under
30, 80% stated they had no friends over the age of 70. People over the age of 70
were more likely to have friendships with those also over the age of 70, but over half
of these respondents (70%) said they had no friends under the age of 30 (Abrams
et al. 2011a).
Dykstra and Fleischmann (2016a) explored predictors of cross-age friendships.
As predicted by the ‘meeting principle’, individuals who operate in settings where
there are opportunities for meaningful interactions with people belonging to a differ-
ent age group, (e.g. age-diverse work places, religious communities and having close
ties with different generational family members) are more likely to have cross-age
friendships. In addition, individuals with more favourable attitudes towards other age
groups are more likely to have cross-age friendships, which supports intergroup con-
tact theory. In a separate analysis Dykstra and Fleischmann (2016b) contend that
having greater capacity to ‘actively age’ i.e. greater independence, health, security,
might create greater opportunities for meaningful intergenerational interactions.
However, the active ageing index, developed by Zaidi et al. (2013) which assesses
experiences and potential for active ageing across four domains of employment,
social participations, independent living and capacity for active ageing (as a country-
level predictor) was not found to be associated with the development of intergenera-
tional friendships (Dykstra and Fleischmann 2016a). This suggests that to improve
contact between generations interventions should focus on proving opportunities to
interact within people’s immediate environments.
27.4 Conclusions
The ESS data on ageism provide a framework for understanding people’s attitudes
to age, and their experiences of age discrimination. The data provide evidence based
indicators that can inform policy on issues surrounding age equality and anti-
discriminatory legislation for individual countries but also at the European region
level. They also provide an insight into avenues for tackling some of the issues that
affect older people and all of us as we age, such as negative attitudes to age, isola-
tion and exclusion. There is great value in cross-national data such as the ESS. Thus
far, the ESS data have been important for (a) understanding people’s experiences of
growing older, (b) understanding processes that contribute to age discrimination,
such as how age groups are perceived throughout the life course and (c) understand-
ing how people’s experiences influence their perceptions of age, or how their per-
ceptions of age influence their experiences. Moreover, multilevel approaches to the
analysis of ESS data have made significant theoretical and practical contributions to
disciplines concerned about ageism and issues associated with ageing, such as,
social psychology, sociology, social gerontology, social policy and business
studies.
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Chapter 28
Measures of Ageism in the Labour Market
in International Social Studies
Liili Abuladze and Jolanta Perek-Białas
28.1 Introduction
Because the population is ageing, the workforce is also ageing, and ageism in the
workplace has become increasingly evident. Measuring and analysing ageist atti-
tudes, values, and perceptions among the general population is a more common
practice than researching ageism in the workplace or in the labour market (e.g.,
Ayalon 2013). However, there are some good examples of research on ageism in
the labour market (for some general studies see Phillipson 2004; Taylor and
Walker 1998).
It is important to acknowledge that the lives of older adults and their ageing
experiences are not fixed but fluid, dialectical, contextual, and changeable through
human actions (Calasanti 1996). This is especially important in the labour market
context, because of the tendency of ascribing fixed or inherent characteristics to
older working people that may hinder working. A more detailed picture of older
workers and retirement will help lead to a better understanding of many facets of
ageism. Combining research on ageism in general and research on ageism in the
labour market could help inspire new theoretical frameworks on these issues.
In the current chapter, ageism is firstly seen in prejudiced attitudes towards older
people and their participation in the labour force. Ageism can be encountered in job
seeking and hiring practices (Karpińska et al. 2011), in the workplace (Duncan
2003), in retention of workforce (Perek-Białas and Turek 2012), and in retirement
L. Abuladze (*)
Estonian Institute for Population Studies, Tallinn University, Tallinn, Estonia
J. Perek-Białas
Jagiellonian University, Krakow, Poland
Warsaw School of Economics, Warsaw, Poland

https://doi.org/10.1007/978-3-319-73820-8_28
462 L. Abuladze and J. Perek-Białas
practices (McNair 2006). Ageism in the labour market participation phase can man-
ifest in cases when older people are not re-trained for or considered for jobs that
require new types of skill sets in specific economic sectors, such as the high-tech or
IT industries.
Much of the debate about older people in the labour market context centres on
their productivity decline (Skirbekk 2004). Employers usually value the loyalty and
experience of older workers, but often have doubts about their adaptability and
learning capability (Solem 2015; Turek and Perek-Białas 2013). Specifically, man-
agers often see older workers as resistant to innovation (Conen et al. 2011a; Henkens
2005). Such prejudices become even more of a concern given the technological
advancements and emergence of the digital market in Europe, and may hold older
adults back from acquiring new skills and knowledge necessary for new types of
tasks. In addition to hindering renewal of skills at current workplaces or making
training opportunities less accessible for older people, this could also result in dif-
ficulties to find a job (which is related to hiring practices). More communication and
frequent contact with older workers, especially at the leadership or managerial level
of the workplace, have been shown to help dissolve managers’ negative stereotypes
of older workers (Henkens 2005; Solem 2015).
Another form of ageism in the labour market, which may be country-specific, is
structural ageism, stemming from fixed or in some cases even mandatory1 retire-
ment ages that prohibit or make it difficult for people to continue working after a
certain age (O’Dempsey and Beale 2011). These are situations where statutory
retirement age is coupled with mandatory retirement—that is, a country’s policies
or legislations do not allow a person to work and receive a pension at the same time
(OECD 2013; Sonnet et al. 2014). Some tax and benefit arrangements were identi-
fied previously as incentives for early retirement in most of the so-called industri-
alised countries – these operated as a way to allow younger generations to enter the
labour market (Duval 2003; Blöndal and Scarpetta 1997). However, several coun-
tries have declared these incentives and practices unsustainable, and are reviewing
and reforming these arrangements, for example by rising retirement ages. Although
retirement age should usually correspond to population health developments and
availability of national resources, it can be considered a form of ageism when it cre-
ates a barrier to employment. Moreover, such retirement age limits might be partly
creating ageist attitudes in people, reinforcing the view of older people as fragile
and non-capable after a certain age.
Ageism in the labour market can be intertwined with other discriminatory atti-
tudes towards gender, ethnicity or race, and class (Crenshaw 1991; Jyrkinen and
Mckie 2012). Additionally, differences in countries’ workplace ageism depend on
contextual and historical backgrounds that impact people’s attitudes and values, and
consequently the results of surveys that are taken in those countries. We explore
1
Mandatory retirement age is a specific age at which the employee must retire. Several EU coun-
tries have mandatory retirement ages for specific sectors (O’Dempsey and Beale 2011). Fixed
retirement age is defined for the purpose of this paper as simply being fixed at some level in a
country as opposed to having a flexible retirement age system, such as in Sweden.
28 Measures of Ageism in the Labour Market in International Social Studies 463
international surveys that could be used for studying ageism in the labour market,
and discuss their main attributes in the evaluation of measures, keeping in mind the
target population, definition of old age, and a variety of country contexts. An inter-
national comparison of measures allows for a detailed evaluation of the performance
of indicators across cultures, and international comparisons of measures of ageism
in the labour market may provide insights into whether a country’s position is an
outlier or part of a regional pattern.
The following section gives an overview of the surveys chosen for our chapter.
The third section presents descriptive results of country positions on five aspects of
ageism in the labour market. This is followed by a discussion of the findings. Finally,
the last section provides recommendations for researching ageism in the labour
market using existing tools (measures as well as surveys).
28.2 Comparative Surveys
We look at how ageism in the labour market as a stereotype, attitude, or experience

has been measured in international (mostly European) cross-country social surveys
in order to evaluate available research tools. We searched all measures that reflected
aspects of job seeking or hiring, workplace experiences or attitudes, retention of
workers, retirement practices, skill renewal, and the qualities or characteristics
ascribed to older workers.
The surveys were chosen based on the following criteria:
• They had information on individuals’ (in some cases employers’ or managers’)
self-reported experiences or attitudes regarding age in labour-market related
issues;
• They were international/European cross-country surveys of the general
population;
• Or they were international/European surveys that focused on the labour market
or workplace context.
We examined the following surveys:
• The European Social Survey
• The World Values Survey
• Eurobarometer
• The Generations and Gender Survey
• The Survey of Health, Ageing and Retirement in Europe
• The European Union Labour Force Survey
• The European Company Survey
• The European Working Conditions Survey
• The Activating Senior Potential in Ageing Europe
These surveys were targeted at individuals or employers. All of the surveys were
carried out in several countries which makes international comparisons and
measures of ageism in the labour market possible. Also, most of these surveys have
been established as regular data collecting infrastructures, and some of them spe-
cialise in studying the labour market context. These surveys are usually representa-
tive of the total population, thus making it possible to compare different population
group experiences with ageism. More information on the sampling procedures and
questionnaire methodologies of each survey can be found on their websites or in
relevant publications.
Two surveys—the European Social Survey and the World Values Survey—are
specifically aimed at charting the development of attitudes and values.
Correspondingly, we found a large number of indicators in these surveys that mea-
sure ageist attitudes in the labour market. These indicators were mapped in special
ageism modules: in round 4 of the European Social Survey (2008) and in round 6 of
the World Values Survey (2010–2014). Similarly, Eurobarometer maps public opin-
ion on various issues, including age-related attitudes in working environments.
Discrimination-related questions were asked in 2006, 2009, 2012, and 2015. This
survey regularly asks the opinion of around 1000 people aged 15 and above in each
EU member state and EU candidate country.
The Generations and Gender Survey aims to study family relations and dynam-
ics by interviewing people aged 18–79. It contained two indicators of ageism in
the labour market that could be included in the analysis (from waves 1 and 2).
Overall, 18 European countries and Australia have been part of the Generations
and Gender Survey, a panel study that is carried out every 3 years in most of the
participating countries. The fieldwork in different countries was carried out
between 2002 and 2013.
The Survey of Health, Ageing and Retirement in Europe is a longitudinal survey
of European countries interviewing people aged 50 and older every 2 years since
2004 on a wide range of topics, including work and retirement. The number of
countries has varied, but steadily increased over the years, and the whole European
Union is covered from the seventh survey round (since 2017). This survey is an
offspring of the Health and Retirement Study that was started in the US.
The European Union Labour Force Survey is an annual survey of the European
Union working-age population (15–74 year olds) carried out in all European Union
countries. We mention this survey because we found one question from the ques-
tionnaire of the Estonian Labour Force Survey (2009–2014) that addressed ageist
hiring practices.2
There are also a number of surveys mapping employers’ perspectives or employ-
ees’ working environments, such as the European Company Survey, the European
Working Conditions Survey (both carried out by Eurofound), and Activating Senior
Potential in Ageing Europe, funded under the Seventh EU Framework Programme
(Conen et al. 2011a).
2
Unfortunately, we did not find similar questions in the surveys of other countries. Therefore, at the
time of writing this paper, it was not possible to make a comparative analysis based on this
indicator.
The first European Company Survey was carried out in 2004–2005 and included
21 countries: 15 ‘old’ European Union Member States, as well as Cyprus, the Czech
Republic, Hungary, Latvia, Poland, and Slovenia. The second European Company
Survey was carried out in 2009 and included 30 countries: the 27 EU member states,
Croatia, the Former Yugoslav Republic of Macedonia, and Turkey. The third time
the survey was carried out was in 2013 and it included companies from 32 coun-
tries – the 27 European Union member states and Croatia, the former Yugoslav
Republic of Macedonia, Iceland, Montenegro, and Turkey. The European Working
Conditions Survey, which has been running since 1991, maps the working condi-
tions and work environments of employees and self-employed people in Europe.
The sixth wave was conducted in 2015 and included the 28 European Union coun-
tries, as well as Norway, Switzerland, Albania, the former Yugoslav Republic of
Macedonia, Montenegro, Serbia, and Turkey.
The Activating Senior Potential in Ageing Europe project aimed at mapping
employers’ views and practices regarding older workers (ages 50–70) in ageing
societies, and whether employers’ views and organisational policies correspond to
governments’ policies (Conen et al. 2011a), providing a valuable source of studying
ageism in the labour market. In total, more than 6800 employers were interviewed
in Denmark, Germany, France, Italy, Poland, the Netherlands, the United Kingdom,
and Sweden in this survey. We selected two questions from Activating Senior
Potential in Ageing Europe to present here. These questions can be used as exam-
ples of measuring direct ageist attitudes of employers.
We calculated the prevalence of ageism per measure for each country and the
mean of each indicator. The choice for a cut-off point indicating when a relatively
large proportion of people could be identified as engaging in ageist behaviour or
having ageist attitudes according to a specific measure in each country was based on
the standard deviation of the mean. The results indicate ageism towards older peo-
ple. Other potential indicators for which we could not present findings, but which
could be valuable for research on ageism in the labour market are discussed in a
separate section (Sect. 28.3.6). The overview and list of measures in Sect. 28.3 is
followed by an evaluation of the observed measures (Sect. 28.4) and recommenda-
tions for researching ageism in the labour market (Sect. 28.5). The evaluation of
findings led us to develop a taxonomy of measures, which we follow in outlining
our recommendations for future research of ageism in the labour market.
28.3 Measures of Ageism in the Labour Market
We identified 18 of the most relevant measures from seven international (mostly

European) large-scale population surveys and from one employers’ survey that
included eight European countries. All measures were self-reported. Seventeen
indicators measured ageist attitudes and perceptions in the labour market (either
from the employees’ or the employers’ perspective) or attitudes and perceptions
about ageism in the labour market. One indicator measured the experience of
structural ageism in the labour market (see Table 28.1). We chose these measures
based on their explicit mention of an age-related word in the question in relation to
any aspect of the labour market (contribution to the economy in general, labour
market entry or exit, retaining workforce, workplace, colleagues, etc.). The most
common age-related word was either a specific age number (e.g., 30, 70, 20s, 40s)
or a relative indication of age, such as “young” or “old.” The measures were grouped
into five broad categories based on their focus:
• Workforce recruitment and/or retention,
• Performance,
• Training,
• Interaction with older colleagues,
• Structural ageism.
Most of the measures fell into the first two categories.
This chapter presents the results of international descriptive comparisons of the
18 measures grouped into five themes. Countries that had ageist attitudes or prac-
tices were chosen based on their results reaching above or below the standard devia-
tion of the mean. This was true with the exception of one indicator from the
Activating Senior Potential in Ageing Europe survey (“At what age would you say
a person is too old to be working 20 h or more per week?”), as well as for the
Eurobarometer indicator (“Regardless of whether you are actually working or not,
please tell me, using a scale from 1 to 10, how comfortable you would feel if one of
your colleagues at work belonged to each of the following groups: a person over
60 years; a person under 25 years”). In case of the Activating Senior Potential in
Ageing Europe indicator, the cut-off point was chosen to be age 65. In the case of
the Eurobarometer indicator, the difference between responses regarding younger
and older age groups was calculated. We focus on ageism towards older age groups,
hence, even if some questions were asking about younger age groups, we present
the results that indicate ageism towards older adults.
28.3.1 Recruitment and/or Retention of the Workforce
One question from the European Social Survey used a specific age range to ask
about people’s concerns about employers’ age-related preferences (“How worried
are you that employers prefer people in 20s rather than in their 40s or above?”), and
could be used as an indicator of perceived ageism of employers when recruiting or
retaining workforce. A question from the Generations and Gender Survey that also
specifically contrasted younger and older members of the workforce could also be
used as a measure of general views of the employability of older people and is thus
grouped under the category of recruitment and/or retention of workforce (“When
jobs are scarce, younger people should have more right to a job than older people”).
An important distinction between these two questions is that the latter reflects ageist
views of the respondents themselves, not their experience or perception of ageist
Table 28.1 Indicators and results of ageism in the labour market
Countries Cut-off point
Age and most ageist of defining a
Survey number of Countries towards older country being
Indicator Answer categories Measuring Survey year respondents included people “ageist”
Recruitment/ Contribution 11-point scale from Perception of European 2008 15+ FI, EL, PT,LV, PL, RU, 50.7–37.4%
retention of people in 1-“contribute very little younger Social Survey (n = 54,705) BG, PL, SI,IL, IE say they
their 20s to economically” to people’s ES, BE, LV, contribute a
the economy 11-“contribute a great economic NO, HR, great deal
these days deal” contribution CH, SE, CZ, (7–11 points)
CY, NL, SK,
DK, EE,
HU, UK,
FR, RO,
DE, IE, UA,
TY, RU, IL
Contribution 11-point scale from Perception of European 2008 15+ FI, EL, PT, SK, BG, RU, 73.5–65.1%
of people over 1-“contribute very little older people’s Social Survey (n = 54,707) BG, PL, SI, CZ, UA, HU, say they
70 to the economically” to economic ES, BE, LV, LV, HR contribute
economy 11-“contribute a great contribution NO, HR, little (0–3
these days deal” CH, SE, CZ, points)
CY, NL, SK,
28 Measures of Ageism in the Labour Market in International Social Studies
DK, EE,
HU, UK,
FR, RO,
DE, IE, UA,
TY, RU, IL
467
(continued)
468

How worried 11-point scale from Perception of European 2008 15+ FI, EL, PT,FI, EL, PT 56.4–50.1%
that 1-“not at all worried” to ageism Social Survey (n = 52,534) BG, PL, SI, say they are
employers 11-“extremely worried” towards ES, BE, LV, worried to a
prefer people recruiting/ NO, HR, high level
in their 20s retaining older CH, SE, CZ, (7–11 points)
rather than 40 people CY, NL, SK,
or older? DK, EE,
HU, UK,
FR, RO,
DE, IE, UA,
TY, RU, IL
When jobs are 5–point scale: 1- Perception of Generation 2002– 18–79 BG, RU, GE, BG, RU 77.7–58.7%
scarce, “strongly agree”, 2 – ageism and Gender 2013, (n = 167,207) GE, DE, say they
younger “agree”, 3 – “neither towards Survey depending FR, HU, strongly agree
people should agree nor disagree”, recruiting/ on the (IT), (NL),
have more 4- “disagree”, 5 – retaining older country RO, AT, EE,
right to a job “strongly disagree” people BE, LT, PL,
than older CZ, SE
people
L. Abuladze and J. Perek-Białas
When a 11 answer categories, Perception of Eurobarometer 2015 15+ 34 countries NL, FI, CY 78.1–69.6%
company including “The ageism in (n = 27,718) (28 EU mention the
wants to hire candidate’s age, if he or recruiting member answer
someone and she is over 55 years older people states, 5 category (“the
has the choice old” candidate candidate’s
between two countries age, if he or
candidates and the she is over
with equal Turkish 55 years old”)
skills and Cypriot
qualifications, community
which of the in the part
following of the
criteria may, country that
in your is not
opinion, put controlled
one candidate by the
at a government
disadvantage? of the
Republic of
Cyprus)
Performance Companies 4-point scale: Performance World Values 2012– 18+ 59 countries TY, AZ, KG, 68.1–53.5%
that employ 1-“strongly agree”, (of companies Survey 2014 (n = 84,755) of the world CY say they
young people 2- “agree”, with younger agree or
perform better 3-“disagree”, workers) strongly agree
than those 4-“strongly disagree”
that employ
people of
different ages
(continued)
469
470

How 11-point scale from Performance European 2008 15+ FI, EL, PT, SK, BG, HU, 57.1–47.7%
acceptable is 1-“completely (of boss) Social Survey (n = 55,601) BG, PL, SI, UA, RU say
it for most unacceptable” to ES, BE, LV, unacceptable
people if a 11-“completely NO, HR, (0–3 points)
qualified acceptable” + “it CH, SE, CZ,
70 year old is depends” CY, NL, SK,
appointed as DK, EE,
their boss? HU, UK,
FR, RO,
DE, IE, UA,
TY, RU, IL
Is a 30-year 10-point scale: 1- Performance World Values 2012– 18+ 59 countries AZ, KZ, UA, 78.8–71.1%
old boss “completely (of boss) Survey 2014 (n = 86,274) of the world UZ, EE say
acceptable? unacceptable”, to acceptable
10- “completely (7–10 points)
acceptable”
Is a 70-year 10-point scale: 1- Performance World Values 2012– 18+ 59 countries RO, AM, BY, 51.5–32.8%
old boss “completely (of boss) Survey 2014 (n = 86,274) of the world PL, RU, SI, say not
acceptable? unacceptable”, to UA acceptable
10- “completely (0–3 points)
acceptable”
At what age Age in years Performance Activating 2011 n = 6260 PL, SE, NL, PL, FR Less than
would you (of workers): Senior (employers) DE, DK, 65 years
say a person productivity Potential in UK, FR, IL
is too old to Ageing
be working Europe
20 h or more
per week?
To what 4-point scale: 1- “no/ Performance Activating 2011 n = 6260 PL, SE, NL, IT: 38.3%,
extent do you low extent”, 2-“some (of workers): Senior (employers) DE, DK, Flexibility, 37.9%, 36.7%
think the extent”, 3- “high characteristics Potential in FR, IL creativity, say no/low
following extent”, 4- “very high Ageing willingness extent,
characteristics extent” Europe to learn,
apply to DK: 30.4%, 52.5%
workers aged Willingness say no/low
50 years and to learn, new extent
older: technological
Flexibility, skills
social skills, PL: 25.6% say
loyalty, Willingness no/low extent
productivity, to learn
creativity,
management
skills,
reliability,
willingness to
learn, physical
health and
stamina,
ability to cope
with stress,
new
technology
471
skills
(continued)
472

Training Have you had Yes/no Retaining European 2015 15+ (total n = AT, BE, BG, PT, CY, BG, 18.2%–4.6%
training paid measures: Working 35765 for EU CY, CZ, DE, RO, EL say they had
for by your training Conditions countries) DK, EE, training
employer in Survey here results EL,ES, FI, provided
the past year? only for 50+ FR, HR,
HU, IE, IT,
LT, LU, LV,
MT, NL,
PL, PT, RO,
SE, SI, SK,
UK
Have you had Yes/no Retaining European 2015 15+ (total n = AT, BE, BG, ES, BG, IT, 15.7%–7.9%
on-the-job measures: Working 35765), here CY, CZ, DE, PT, EL say they had
training in the training Conditions results only DK, EE, on-the-job
past 12 Survey for 50+ EL,ES, FI, training
months? FR, HR,
HU, IE, IT,
LT, LU, LV,
MT, NL,
PL, PT, RO,
SE, SI,
SK,UK
Have −2 – “refusal”, Retaining Survey of 2004– 50+ (n = AT, DE, SE, ES, EL 44% and 45%
opportunities −1- “don't know”, 1- measures: Health, Ageing 2005 9070 – wave NL, ES, IT, (W1), ES, PL (W1), 49%
to develop “strongly agree”, 2-“ investment in and (wave 1), 1, 10512 – FR, DK, (W2), PL, and 55%
new skills in agree”, 3- “disagree”, new skills Retirement in 2006-7 wave 2, GR, CH, HU, IT (W4) (W2), 42%,
(main) job 4- “strongly disagree” Europe (wave 2), 15744 – wave BE, IL, CZ 43% and 48%
2011 4) (W2 & 4), say they
(wave 4) PL (W2 & disagree or
4), IE (W2), strongly
HU (W4), disagree
PT (W4), SI about having
(W4), EE opportunities
(W4) to develop
new skills
Interaction Time spent 4 -point scale: 1 –“none Contact European 2008 15+ FI, EL, PT, FI, EL, PT, 87.3–84.3%
with older working with of the time”, 2- “some frequency Social Survey (n = 30,986) BG, PL, SI, BG, PL, SI say none of
colleagues colleagues of the time”, 3-“most of (with older ES, BE, LV, the time
aged over 70 the time”, 4- “all/almost colleagues) NO, HR,
last month all of the time” + “No CH, SE, CZ,
work with other people CY, NL, SK,
in last month” DK, EE,
HU, UK,
FR, RO,
DE, IE, UA,
TY, RU, IL
(continued)
473
474

Do you think Answer categories: Perception of Eurobarometer 2015 15+ 34 countries PT, IT, CZ, 30–25% say
that enough is 1-“Yes, definitely”, encouraging (n = 27,718) (28 EU GR, CY, AT “no, not
being done to 2-“Yes, to some extent”, contact with member really” and
promote 3-“o, not really”, 4 – older states, 5 “no,
diversity in “No, definitely not”, colleagues candidate definitely
your work 5-“There is no need to countries not”
place as far as promote diversity”, and the
each of the 6-“Not applicable”, Turkish
following is 7-“Don’t know” Cypriot
concerned? community
Age, for in the part
people over of the
55 years old. country that
is not
controlled
by the
government
of the
Republic of
Cyprus)
Regardless of 10-point scale: 1 - Readiness/ Eurobarometer 2015 15+ 34 countries SK, LT, CZ, The
whether you feeling “not at all willingness to (n = 27,718) (28 EU HR, MT, LV, difference in
are actually comfortable” and work together member RO means to the
working or 10- feeling “totally with older states, 5 benefit of
not, please tell comfortable” people (vs. candidate younger
me, using a younger countries people is
scale from 1 people) and the largest in
to 10, how Turkish these
comfortable Cypriot countries
you would community
feel if one of in the part
your of the
colleagues at country that
work is not
belonged to controlled
each of the by the
following government
groups? a of the
person over Republic of
60 years; a Cyprus)
person under
25 years
Structural Why did you One of the answer Structural Generations 2002– 18–79 BG, RU, RO 24.4% say
ageism stop working categories: “mandatory ageism (exit and Gender 2013, (n = 1858 out GE, DE, mandatory
in your retirement” from labour Survey depending of 167,207) FR, HU, IT, retirement
previous job market) on the NL, RO, AT,
or business? country EE, BE, LT,

PL, CZ, SE
Source: Authors’ preparation based on different surveys and calculations of average values
475
behaviour or attitudes in others. Hence, differences in the results might partly be

related to this nuance. In the question that asked about people’s perceptions of
employers’ ageist behaviours, Finland, Greece, and Portugal were shown to be the
countries that were most concerned about employers preferring people in their 20s
over people in their 40s. The question that asked about a person’s own ageist views
showed that Georgia, Bulgaria, and Russia were the most ageist.
The indicator that we used from Eurobarometer (“In ([name of country], when a
company wants to hire someone and has the choice between two candidates with
equal skills and qualifications, which of the following criteria may, in your opinion,
put one candidate at a disadvantage? The candidate’s age, if he or she is over 55
years old?”—which was one of the possible answer categories) can be used as a
measure of attitudes towards hiring older people. The highest percentage of people
reporting this criterion was found in the Netherlands, Finland, and Cyprus. On the
other end were Great Britain, Italy, Croatia, Poland, and Ireland. This indicator may
have measured awareness of disadvantage by age rather than actual perceptions,
attitudes, or experiences of ageism in the labour market.
Two questions from the European Social Survey that are categorised under
recruitment/retention can be indicators of how people of different generations are
perceived from an economic perspective. These questions ask about the contribu-
tion of younger (20s) and older (70s) people to the economy, but in two separate
questions, thus not explicitly opposing young and old within a single indicator.
However, when we compared the results from the two questions, we were able to
identify countries in which respondents demonstrated ageist attitudes as those that
had a high percentage of people who thought that people in their 20s contribute to
the economy a great deal and a high percentage of people who thought that people
in their 70s contribute little. The countries that scored high on both indicators were
Russia and Latvia.
28.3.2 Performance
One question in the European Social Survey and one question in the World Values
Survey asked about the acceptability of having a 70-year-old boss. The World
Values Survey question was accompanied by a note indicating that countries may
change the wording from “70” to “over 60” if the 70+ population is small. (The list
of countries that changed the wording can be found from additional survey method-
ology or metadata documentation). The results of both surveys show that Slovakia,
Bulgaria, Hungary, Ukraine, Russia, Slovenia, Romania, and Armenia were the
least accepting of this situation. Finland also scored quite high in terms of being less
accepting of having an older boss, although they remained within the margins of the
standard deviation of the mean. In the Finnish case, it is possible that the fixed
retirement age of 68 and mandatory retirement age of 67 for some public service
occupations (O’Dempsey and Beale 2011) have some influence on the answers.
Azerbaijan and Ukraine (followed by Kazakhstan, Uzbekistan, Estonia, Belarus,
Romania, Russia, and Georgia within the standard deviation margin) showed cor-
respondingly the highest proportions of people accepting a 30-year-old boss. Some
non-European countries, such as Colombia, Egypt, Mexico, Qatar, Brazil, and Peru
have reported values of the same magnitude.
One question from the World Values Survey measured attitudes about people’s
performance (“Companies that employ young people perform better than those that
employ people of different ages”), and can be used as one of the measures of pro-
ductivity expectations or prejudice. It is important to bear in mind that this question,
similar to the Eurobarometer question about age being a potential disadvantage in
recruitment/retention, addressed the ageist views of the respondents themselves, not
their experiences or perceptions of ageism in others. Respondents from Azerbaijan,
Kyrgyzstan, and Cyprus reported the most ageist attitudes in this indicator, follow-
ing, on a global level, Ghana, Egypt, India, Turkey, and South Korea. Also, this was
the only indicator among performance measures that opposes “young people” and
“people of different ages.” However, due to its ambiguous wording the question
might measure attitudes of opposing performance of “young people” and “people of
all ages”, and not so distinctively “young people” and “old people”.
Two questions from the Activating Senior Potential in Ageing Europe survey
(Conen et al. 2011b) measured employers’ ageist perceptions or attitudes. One of
them was an indicator of attitudes about older adults’ productivity or work ability
(“At what age is a person too old to be working 20 h or more per week?”). This
question was different from other indicators as it did not pre-define an age, but
rather let the respondent (employer) define it. Polish and French employers reported
the most ageist attitudes according to this indicator, as the mean value of answers
was the lowest for respondents in these countries, i.e., below 65. The second item
mapped a number of characteristics that are attributed to older workers (aged 50 or
above): “To what extent do you think the following characteristics apply to workers
aged 50 years and older (1 – “ no/low extent”, 2 – “some extent”, 3 – “high extent”,
4 – “very high extent”): flexibility, social skills, loyalty, productivity, creativity,
management skills, reliability, willingness to learn, physical health and stamina,
ability to cope with stress, new technology skills”. Employers in Italy reported the
most ageist attitudes: a larger share of these employers thought that flexibility, cre-
ativity, and willingness to learn did not apply to workers aged 50+. In Denmark and
Poland more employers felt that older workers have no motivation to learn, and that
they lack new technological skills.
28.3.3 Training
A number of questions addressed the workplace training of older adults. These

questions can be used as sub-indicators for both retention and performance.
Investing in older workers’ training and skill renewal can improve their perfor-
mance, which is especially important in societies where the general population as
well as the workforce is ageing. These indicators could be used as measures of
ageism regarding older people’s performance enhancement at work. However, they

could also be used as indicators of retaining practices. Through training that
improves the performance of the existing workforce in an organisation, the retention
of the workforce should also improve.
Two questions targeting employees and self-employed people from the European
Working Conditions Survey showed that in Cyprus, Bulgaria, Romania, Bulgaria,
Spain, Greece, Italy, and Portugal, a fairly small number (approximately 15%) of
workers aged 50 and above reported having received paid or on-the-job training.
The Survey of Health, Ageing and Retirement in Europe3 included a self-reported
indicator of opportunities of training on the job of currently employed people. This
was identified as a measure of investing in older workers’(aged 50+) performance
as well as of workforce retention. According to this indicator, over 40% of employed
people above the age 50 in Spain (in 2004 and 2006), Greece (in 2004), Poland and
Hungary (both in 2011), and over 50% in Poland in 2006 reported not having had
training opportunities.
28.3.4 Interaction with Older Colleagues
Three indicators were classified as measures of interaction with older colleagues.

The Eurobarometer survey (2015) asked the following question: “Do you think that
enough is being done to promote diversity in your work place as far as each of the
following is concerned?” Options included, “Age, for people over 55 years old”.
Portugal, Italy, the Czech Republic, Greece, Cyprus, and Austria had the highest
percentage of people reporting that diversity was not being promoted in terms of
having people 55 and older in the workplace. The option, “There is no need to pro-
mote diversity,” was not included in the calculation of these outcomes, because the
interpretation of this option includes ambiguity, and might therefore go beyond age-
ism towards older people only. However, we see that it could be considered as an
answer category indicating ageism as well. If that option was to be taken into
account, the countries with the highest percentage indicating ageism in that measure
would include Bulgaria, Italy, Portugal, Poland, Greece, and the Czech Republic. In
addition to interaction with older colleagues, this indicator might be used as a mea-
sure of ageism in hiring practices, but more specific information is needed to com-
plement this.
We included a second question from the Eurobarometer survey: “Regardless of
whether you are actually working or not, please tell me, using a scale from 1 to 10,
how comfortable you would feel if one of your colleagues at work belonged to each
of the following groups: a person over 60 years; a person under 25 years.” This
question can be used as an indicator of readiness or willingness to work with older
3
Data from wave 1 (2004–5), 2 (2006–7) and 4 (2011) were included in this overview. Data from
the most recently available wave 5 (2013) yielded numbers of cases that were too low to be anal-
ysed by each country.
people (vs. younger people). In general, the means for both age groups were quite
high, but some countries indicated a lower mean of comfort for working with people
aged below 25 years. We decided to calculate the difference in means between these
indicators of different age groups to get a better idea of which countries had the
largest split in acceptance of older and younger colleagues. The following countries
showed the largest difference, indicating a greater comfort with younger than with
older colleagues: Slovakia, Lithuania, the Czech Republic, Croatia, Malta, Latvia,
and Romania. Interestingly, the means for being comfortable with younger and
older colleagues were the same both in Denmark and Spain, indicating that egalitar-
ian attitudes are more common in these two countries.
The European Social Survey asked how much time respondents had spent work-
ing with someone over 70 in the month prior to the interview. This indicator is a
good measure of contact frequency between different age groups. Contact with
older colleagues is an important factor in improving attitudes towards older people
(Henkens 2005). Most people in all the countries surveyed did not have contact with
colleagues over 70 in the workplace, probably as a result of most people retiring
before that age. The largest proportion of people not having spent any time with
colleagues over 70 were found in Finland, Greece, Portugal, Bulgaria, Poland, and
Slovenia. The highest proportion of people having spent at least some time with
colleagues over 70 were in Israel, Ireland, and France. Israel actually had the largest
proportion of respondents saying they had spent most of their time (6.7%) or all/
almost all of their time (5%) working with colleagues aged 70 and over. In addition
to ageist attitudes, the results are probably related to other factors, such as state
policy (fixed retirement age), distribution of the population by fields of economic
activity within countries, and life expectancy. Further analysis could deconstruct the
exact conditions and causes shaping interaction with older colleagues: how much
can be attributed to the ageist attitudes of employees, employers, and policymakers,
and how much can be attributed to other factors, such as policies of mandatory
retirement.
28.3.5 Structural Ageism
The mandatory retirement indicator is an explicit measure of structural ageism that

might be a barrier for people to continue working. According to this self-reported
measure from the Generations and Gender Survey, Romania has a large proportion
(24.4%) of people leaving their job due to mandatory retirement. It would be useful
in future surveys to ask whether people would have continued working if mandatory
retirement did not exist or if they had the chance to work past retirement age. Hence,
a combination of willingness to continue working and the actual exit age would give
a more informative idea of the extent of ageism. Otherwise, the single self-reported
measure in its current form might just reflect the existence of an official retirement
age, where causality might in fact run the other way, with the official retirement age
impacting people’s attitudes.
Table 28.1 presents the most relevant survey questions. We decided to group the
measures by the topic or theme they cover, for a total of five groups. Many of the
questions capture attitudes, opinions, and perceptions with a scale measurement,
such as a 4-point or 11-point Likert scale. However, even variations in the wording
of similar measurements can lead to variations in output in terms of the countries’
ranking on ageism in the labour market. Thus, results may reflect cultural differ-
ences in understanding and interpreting ageism. The importance of cultural contexts
is discussed below.
28.3.6 O
ther Potential Indicators of Ageism in the Labour
Market
The Survey of Health, Ageing and Retirement in Europe has several indicators that
could be used as measures of ageism in the labour market (e.g., having a short-term
or permanent contract, opportunities to develop new skills, and evaluation of pros-
pects for job development). However, the most recently available wave of this sur-
vey (wave 5, 2013) had a low number of cases for most of these indicators. Coupled
with a longitudinal methodology that maps each individual’s various spheres of life
events and characteristics every 2 years, the survey could potentially be a valuable
source for studying ageist attitudes and experiences at the individual level. However,
the ageing and attrition of the sample in longitudinal surveys often leads to a
decrease in the number of cases (in this case employed older adults) available for
analysis after a few waves.
In the European Union Labour Force Survey, one indicator was spotted that
could be used as a measure of ageism in recruitment. The question, “Why did you
not take the job when offered?”, was followed by a number of options, including,
“The employer wanted someone younger.” This question was in the Estonian LFS
questionnaires from 2009–2014 (question H24).
The European Company Survey included two potential indicators, one of which
is an indicator of ageism in hiring practices: “Could you please tell me, for this
establishment, the number or percentage of employees who… are older than
50 years of age?” The second question, which could be used as an indicator of atti-
tudes regarding older employees’ training practices or of an ageist behaviour
(“Please tell me for each of the following groups of employees whether or not their
needs for further training are systematically checked at regular intervals”), included
“Older employees” as one of the potential answers (question MM562, Management
Questionnaire, 2009).
The European Working Conditions Survey had indicators of potential ageist
experiences at the workplace, such as: “Over the past 12 months at work, have you
been subjected to any of the following?”, followed by a number of options, includ-
ing “Age discrimination” (Q65/72 in the 2010 and 2015 questionnaires); and “Since
you started your main paid job, have you been subjected at work to any of the
following?” (Q72 in the 2010 questionnaire only), also followed by a range of

options, including “Age discrimination”.
Activating Senior Potential in Ageing Europe had a number of potential indica-
tors of ageism in the labour market, two of which we mention here: “At what age
would you say a person is generally too young to retire permanently?”, as an indica-
tor of ageism towards younger ages; and “To what extent do you think the following
characteristics apply to workers aged less than 35 years: flexibility, social skills,
loyalty, productivity, creativity, management skills, reliability, willingness to learn,
physical health and stamina, ability to cope with stress, new technology skills?”,
which could be used as an indirect indicator or as a validation of ageism towards
older people because it does not use a specific term for older people in the
wording.
28.4 Evaluation of the Findings
This paper identified measures of ageism in the labour market and tested their per-
formance in cross-country comparisons. The comparative analysis was done with
descriptive methods only, so the conclusions on country differences should be tested
in the future with more rigorous analyses. Our discussion in the current section
focuses on the topics or themes of measures, the target population of indicators and
surveys, the wording of questions (especially with regard to the definition of old
age), and each survey’s usefulness for researching ageism in the labour market.
The measures identified in international cross-country surveys cover a broad
scope of aspects of ageism in the labour market. Some measures indicated accep-
tance of older people as colleagues or as bosses, asking about frequency or avail-
ability of contact with older colleagues, about perceptions of employers’ preferences
in recruitment or performance of older adults, about qualities attributed to older
people, and also about practices to improve older people’s performance, training,
and retention. There was also one indicator addressing the experience of structural
ageism. In general, we divided the indicators into five broad groups based on which
aspect of ageism in the labour market they measured:
• Recruitment and/or retention of older people,
• Performance of older workers,
• Training,
• Interaction with older colleagues,
• Structural ageism.
The recruitment/retention and performance indicators were the most widespread.
The target populations of the indicators and surveys examined in this chapter are
generally defined by the survey sampling, not by a specific question. However, it is
possible that some survey questions targeted specific respondents through routing.
One question in the Eurobarometer survey specified that all survey respondents
should reply regardless of the employment situation of the respondent. The
Eurobarometer survey, the European Social Survey, the World Values Survey and
the Generations and Gender Survey target the general adult population, with only
the Generations and Gender Survey having an upper age limit (79). Some surveys
specifically focus on older people (50+ in the Survey of Health, Ageing and
Retirement in Europe), and some more generally on the working age population or
working environment of employees and self-employed people (Labour Force
Survey, European Working Conditions Survey). Company and employer surveys
(European Company Survey, Activating Senior Potential in Ageing Europe) can be
very valuable sources for studying employers’ perspectives, attitudes, and practices
because these are positions where ageist practices are often implemented.
There are variations in how “old age” is defined in the measures. Some use spe-
cific age indicators (e.g., 20s, 30s, 40s, 50 or above, 70) whereas other indicators are
more general (e.g., “young,” “old,” “different ages”). However, most of these mea-
sures do not give information about what the respondents themselves consider
“old,” and therefore the results may be a reflection of a combination of factors. Only
one question in the Activating Senior Potential in Ageing Europe survey asked
employers to define the age at which an employee would be considered too old to
work 20 h or more per week. In some cases, for example in the World Values Survey,
differences in demographic structure are taken into account and countries have the
option to change the wording of the question (from “70” to “over 60”) if there are
too few people in the older age groups. This is a good example of taking into account
demographic trends and country context in measuring age discrimination, as well as
of the perception of when old age starts (possibly often associated with eligible
retirement age). This is also something for researchers to take into account when
comparing different countries. In some cases, such as in the Eurobarometer interac-
tion indicator, it is possible to combine different age groups for comparison.
It is not clear to what extent questions that specify a certain age or age group
measure purely ageist attitudes. The results may reflect various aspects of the labour
market, such as participation levels, qualification requirements, economic circum-
stances, health and life expectancy, and so on. In general, based on our descriptive
overview, several Eastern and Central European countries emerge as most ageist
based on the studied indicators—especially Russia, Poland, and Slovenia, followed
by Bulgaria, Romania, and Ukraine. Some of these countries had a relatively low
retirement age (60 for men and 55 for women) in the 1990s and in some cases even
into the early twenty-first century (De Castello 1998; Puur 2000). Rapid population
ageing and the transition from a planned economy to a market economy have
occurred in these societies within a relatively short period. The economic restructur-
ing during the transition period resulted in job losses that particularly impacted the
older population, as new types of knowledge and experience were suddenly required
(Puur 2000; Nugin et al. 2016). Therefore, several Eastern and Central European
countries might have had less time to develop positive age-related attitudes, or in
some cases might have placed a higher value on young people in the workforce that
still holds today. Consequently, older people’s potential, including in terms of loy-
alty, reliability, and experience, in the labour market may not yet be valued in a
similar way as in some Nordic or Western countries. When comparing countries,

contextual and historical backgrounds play an important role, especially the signifi-
cant societal transformations that have occurred in several Eastern European coun-
tries since the 1990s.
Western and Northern European societies also have some ageist manifestations.
Finland in particular emerged as a somewhat ageist country. This might indicate
structural problems in the labour market, but it can also signify a high awareness of
ageism in this country. Israel seems to be a competitive country where older people
need to or want to work beyond the retirement age (or a very heterogeneous country
with different attitudes and practices regarding older workers in different communi-
ties), but did not appear necessarily to be ageist based on our findings. A large pro-
portion of people in Israel were concerned that people in their 20s were preferred by
employers over those in their 40s. At the same time, a large proportion of people
said that young people actually contribute to the country’s economy a great deal.
Also, Israel had the largest proportion of people who said they had spent time work-
ing with colleagues aged 70 or over, indicating a high frequency of contact between
different age groups in the workplace. Israel’s retirement age of 67 is relatively high
compared to most other countries, which might influence the possibility of spending
time with older colleagues in the workplace.
The Activating Senior Potential in Ageing Europe survey proved to be very use-
ful in our study of ageist attitudes in that it pointed to potential problems with
employers’ attitudes in some Western and Nordic countries. We found that Italy had
the largest proportion of employers who hold negative views about the characteris-
tics of older adults. However, the Activating Senior Potential in Ageing Europe
survey only included eight European countries, one of which was in Eastern Europe
(Poland). Also, this survey was only carried out once, which does not allow for the
assessment of changes in attitude over time. The results from the European Working
Conditions Survey showed that a fairly small number of workers aged 50 and older
have received training in Southern European countries such Portugal, Cyprus and
Greece, but also including Bulgaria and Romania.
Questions in which the wording opposed different age groups in a single ques-
tion—for example, “How worried that employers prefer people in their 20s rather
than 40 or older?” seemed to work in a similar way to separate questions that asked
about different age groups (for example, “Is a 30-year old boss acceptable?” and “Is
a 70-year old boss acceptable?”). However, from the indicators observed in this
paper, the questions that asked specifically about respondents’ preferences of one
age group over another seemed to create an explicit outcome of ageism. This might
be because the wording of these questions presented an inevitable opposition that
was necessarily reflected in the answer. Respondents’ perceptions of their employ-
ers’ attitudes might also lead to some confusion in the results because the answers
may be dependent on overall satisfaction with the working environment (García-
Mainar et al. 2015) or overall satisfaction with colleagues (Hombrados-Mendieta
and Cosano-Rivas 2013). Therefore, it might be more accurate to rely on employ-
ers’ self-reports of their attitudes. One question’s wording can be understood or
interpreted ambiguously by respondents (“Companies that employ young people
perform better than those that employ people of different ages”). Therefore the
performance of this indicator as a measure of ageism specifically towards older
people requires additional validation.
The European Social Survey and the World Values Survey are both general atti-
tudinal surveys. Unfortunately, they have not included questions about ageist atti-
tudes in the labour market context on a regular basis. Data on ageist attitudes
gathered at one point in time do not give any information on the dynamics of the
attitudes, how they change, improve, or worsen over time. Ideally, these dynamics
could be measured longitudinally, as they are in the Generations and Gender Survey.
In the Generations and Gender Survey, the relevant measures were included in
waves 1 and 2. In a number of countries, many of the same people were interviewed
in both waves. Therefore, using longitudinal methodology would give the best pic-
ture of change in attitudes over time.
Even though we identified some possible indicators of ageism in the labour mar-
ket from the Survey of Health, Ageing and Retirement in Europe, most of these
indicators did not have enough cases per country for generalisation. This is because
some of the specific questions of the survey only targeted employed individuals,
which means that the number of employed people per country included in the
Survey of Health, Ageing and Retirement was too low to provide representative
information pertaining to ageism in the labour market (at least in wave 5). This may
be reflective of low labour force participation levels among the 50+ population in
several countries, and thus itself may be a manifestation of ageism in the labour
market. Alternatively, the problem may lie in attrition of people over time in panel
studies.
The Generations and Gender Survey could be a useful source for studying age-
ism in the labour market, especially as it had one indicator of structural ageism.
However, to be able to evaluate the effect of mandatory retirement as ageist, more
measures need to be added to the analysis, such as willingness to work above the
mandatory retirement age, which is highly dependent on job type, education, and
broader cultural values on the individual level. One of the downsides of using the
Generations and Gender Survey is that the fieldwork has been carried out over a
long period of time (2002–2013). Hence, period effects, such as changes in politi-
cal, legislative, and economic settings that may shape ageist attitudes or practices
in the labour market may not be captured well.
28.5 T
axonomy and Recommendations for Researching
Ageism in the Labour Market
This chapter examined indicators that asked about ageism-related beliefs, attitudes,
and perceptions regarding the labour market. We disregarded more general ageist
behaviours, attitudes, and feelings that were not related to the labour market. The
Table 28.2 Taxonomy of measures of ageism in the labour market

Target population of surveys or
Topic/theme Perspective Defining (old) age questions
Recruitment/retention View Opposing different age General population vs. targeted
groups population
Performance Value Specific age Age limit
Training Attitude Asking to define age
Interaction with Perception
colleagues
Structural ageism Experience
Source: Authors’ preparation based on the overview done for this chapter
purpose was to map indicators of ageism in the labour market from existing large-
scale social surveys that are representative of countries’ total populations, and that
were carried out using internationally comparable methodologies. Table 28.2 pres-
ents a taxonomy of the studied measures (see Table 28.2). The measures, the tax-
onomy, and the surveys included in this analysis should not be taken as an exhaustive
list. All of the surveys included here are carried out in several countries. Most of the
observed indicators were measured only at one point in time, so change over time
from an international perspective is not addressed in Table 28.2, but it is discussed
in the text.
28.6 Age: What Is Old?
The age limits included in some survey questions were very broad. As a general
rule, the definition of “old” depends on the country’s cultural, social, and historical
background. Some surveys or questions pre-defined “old”, for example by limiting
the age of the population that responds to the specific survey or question. Only one
question, from the Activating Senior Potential in Ageing Europe survey, asked
employers to specifically define old age (“At what age would you say a person is too
old to be working 20 hours or more per week? ”). Some outcomes of these measures
may have multiple interpretation options in addition to indicating ageism towards
older people in the labour market. For example, in the indicator that asked respon-
dents specifically about people in their 20s and people in their 40s, the outcome may
reflect a variety of situations, experiences, and policies relating to the educational
system, labour market rigidity, occupation, and economic sector specificities of
people from different age groups. To help mitigate this confusion, the definition of
“old” should be very transparent or should be made very specific when ageism mea-
sures are being developed as well as when data is analysed. In surveys that allow for
country-specific variations (as in the case of the World Values Survey), researchers
should use additional documentation to research country information and should
report such differences in measurements in their own research reports and articles.
When surveys include separate questions with different age groups specified in the
questions (for example: “Is a 30-year old boss acceptable?” and “Is a 70-year old
boss acceptable?”), such indicators should be both used and compared in analyses.
28.7 Target Population
It is important to differentiate between the perspective of employees and employers

when studying ageism in the labour market. When using surveys, the occupation of
the respondent and the sector in which he or she is employed should be among the
controlling factors. As employers are largely responsible for shaping organisational
cultures and practices through communication (Henkens 2005; Solem 2015), spe-
cific surveys that target employers and would be conducted regularly might be espe-
cially useful. Some indicators not specifying a target population may be more
suitable for assessing public opinion on ageism in the workplace.
28.8 Development over Time
All the indicators included in this study were measured only at one point in time.
Regular measurements are needed to assess changes in attitude over time, the influ-
ence on attitudes of younger people entering the labour force, and the impact of
policy or organisational reforms on attitudes. Longitudinal studies might provide
the best opportunity to assess changes in ageist attitudes at the individual level,
which might be influenced by personal or policy factors. The same might apply to
employers’ surveys.
28.9 Context Matters
Large international social surveys provide an opportunity to combine information

from different spheres in a person’s life; therefore, researchers of ageism indicators
should make maximum use of existing surveys and the rich information within
them. In addition to including indicators of overtly ageist attitudes, other more or
less related events and characteristics should be controlled for, such as occupation,
work history, and other related perceptions and attitudes. Specifically, satisfaction
with life, satisfaction with the work environment, and satisfaction with colleagues
can be seen as general proxies for subjective well-being (Muffels and Headey 2013),
as well as subjective well-being in the labour market context (Tay and Harter 2013).
Therefore, including these measures in research of ageism in the labour market may
help explain ageist experiences of employees to an important extent. Studies should
be able to address causality issues and to deconstruct the effects of attitudes, percep-
tions, organisational practices, employers’ financial resources, structural barriers,
and other factors influencing older adults’ labour force participation and
experiences.
Countries’ contextual and historical backgrounds should be elaborated on in
analyses of ageism in the labour market. As mentioned above, this may help to
supplement information on demographic development (for example, regarding pop-
ulation ageing), how older people are seen in general in society, the context for
developing certain attitudes, and how institutional settings have changed over time
to accommodate these developments. Our descriptive analysis is only the first step
in mapping ageism in the labour market on an international level. Future studies
could aim to disentangle the relationship between measures and country contexts
with regard to ageism in the labour market. With population ageing and transforma-
tions in the way work is done, ageism is an increasingly important topic for research-
ers and policymakers to address.
28.10 Limitations
This overview only mapped self-report measures that were mostly about attitudes,
perceptions, and experiences of ageism in the labour market from quantitative social
surveys. We acknowledge that some of the outcomes or country rankings might be
explained by other factors, such as occupation or economic sector, the working
environment, individual countries’ policies and legislation, countries’ historical and
social contexts, and so on. For example, the measure we list under structural ageism
(mandatory retirement as a reason for stopping work”) can be seen to measure sev-
eral things at the same time: the country’s mandatory retirement age, respondents’
willingness or unwillingness to work, and other factors. Therefore, future analysis
should not only examine a single indicator. In addition, it would be useful to map
“real-life data” or “hard data”—that is, measures of non-perception aspects of age-
ism in the labour market. These measures could include actual number of older
workers in an organisation, number of trainings provided for older workers in com-
parison to younger people and their correspondence to the needs of people, contract
and salary comparisons, and so on.
Another limitation of our study is that we have not included data with actual
companies as the unit of analysis, capturing their hiring practices and promotion
and retirement strategies. Including this data could give additional insights into the
behaviour of employers. Even though such data have been collected, they are not
currently publicly available. It was therefore not possible to include the results of
these datasets in this overview. Finally, we carried out a descriptive analysis of
available data, presenting an overview of measures from existing social surveys for
the first time. This paper focused on identifying quantitative measures of ageism in
the labour market and bringing out some basic descriptive results of country com-
parisons based on these measures. We recommend using these findings and mea-
sures from several surveys at the same time with more advanced statistical analyses
to draw in-depth conclusions about ageism in the labour market.
Additionally, qualitative studies on ageism can provide in-depth information on
the conceptualisation of age discrimination in employment (e.g., Roscigno et al.
2007) and the identification of practices that older individuals use, such as altering
resumes, physical appearance, and language in order to increase their chances of
being employed (Berger 2009). A number of studies offer insight into how to re-
examine the hiring practices of employers or the retention of older workers (see, for
example, Karpińska et al. 2011, 2013; Lazazzara et al. 2013). Data from qualitative
studies on ageism in the labour market could be used to improve measures and sur-
veys on this topic as well.
28.11 Outlook
There is an extensive collection of research tools for studying ageism in the labour
market. Having data infrastructures in the form of international large-scale surveys
makes it possible to conduct international comparative analyses of ageism in the
labour market. Despite differences in the target population and in the wording of the
questions, the existing surveys and measures provide a good opportunity to map
attitudes and perceptions of ageism in the labour market with regard to recruitment,
retention, performance, training of the workforce, and interaction with older col-
leagues. There are also ample opportunities for conducting rigorous internal validity
tests of the indicators mentioned in this chapter.
The surveys examined in this overview allow information to be combined on
several aspects of people’s lives and their characteristics, which is highly advanta-
geous. Cross-sectional analyses can be completed to assess change over time once
the corresponding data become available.
Appendix: List of Surveys
Estonian Labour Force Survey (2009). Personal questionnaire. http://www.gesis.org/missy/files/

documents/EU-LFS/EE%20LFS%202009%20Quest%20Ind%20Eng.pdf. Accessed 13 May
2016.
European Company Survey (2009). Management questionnaire. http://www.eurofound.europa.eu/
sites/default/files/ef_files/docs/surveys/ecs2009/questionnairemm.pdf. Accessed 13 May 2016.
European Social Survey (2008). Round 4 Questionnaire. http://www.europeansocialsurvey.org/

docs/round4/fieldwork/source/ESS4_source_main_questionnaire.pdf. Accessed 16 May 2016.
European Working Conditions Survey, 6th survey (2010). Questionnaire. http://www.eurofound.
europa.eu/sites/default/files/ef_files/surveys/ewcs/2010/documents/masterquestionnaire.pdf.
European Working Conditions Survey, 6th survey (2015). Questionnaire. http://www.eurofound.
europa.eu/sites/default/files/page/field_ef_documents/uk_questionnaire.pdf. Accessed 13 May
2016.
Generations and Gender Survey (2003). Generations and Gender Survey Core Questionnaire
for Wave 1. http://www.ggp-i.org/sites/default/files/questionnaires/GGP_QuestW1Core.pdf.
Generations and Gender Survey (2012). Generations and Gender Survey Core Questionnaire
for Wave 2. http://www.ggp-i.org/sites/default/files/questionnaires/GGS_Wave2_
Questionnaire_V.2.0.pdf. Accessed 16 May 2016.
SHARE (2013). Wave 5 English generic main questionnaire. http://www.share-project.org/fil-
eadmin/pdf_questionnaire_wave_5/SHARE_paperversion_5_4_10_en_GB.pdf. Accessed 16
May 2016.
World Values Survey (2012). Round 6 Questionnaire. http://www.worldvaluessurvey.org/
WVSDocumentationWV6.jsp. Accessed 16 May 2016.
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Chapter 29
Researching Ageism in Health-Care
and Long Term Care
Sandra C. Buttigieg, Stefania Ilinca, José M. S. de Sao Jose,

and Annika Taghizadeh Larsson
29.1 Introduction
Even as the literature documenting the numerous negative consequences of ageism

for the experiences of older people is constantly growing (Minichiello et al. 2000;
Dionigi 2015; Chrisler et al. 2016), ageism remains an elusive concept, interchange-
ably used to cover a wide range of phenomena. Research on ageism across contexts
reveals the equivocal manner in which it is defined. Existing definitions of ageism
cover intolerant knowledge, values, attitudes and behaviors towards older people or
more generally, people of a certain age. Commonly, ageism is distinguished from
age discrimination, the latter often defined as only one of many possible manifesta-
tions of ageism, and used in the context of labor market research to describe the
manifest preference for younger employees. It is important to recognize that there is
a spectrum of concepts related to ageism depending more often than not on the
context in which it is studied. In this chapter, we aim to provide an overview of how
S. C. Buttigieg (*)
Department of Health Services Management, Faculty of Health Sciences, University of
Malta, Msida, Malta
S. Ilinca
European Centre for Social Welfare Policy and Research, Vienna, Austria
J. M. S. de Sao Jose
Faculty of Economics, University of Algarve, Faro, Portugal
A. T. Larsson
Division Ageing and Social Change, Linkoping University, Norrkoping, Sweden

https://doi.org/10.1007/978-3-319-73820-8_29
494 S. C. Buttigieg et al.
ageism is defined, measured and assessed in research on healthcare and long-term

care, and use some of the emerging research evidence for the existence of ageism in
these two contexts in order to exemplify. Focusing on ageism (focusing, for the
purpose of this chapter on its relation to old age) we aim to critically analyze the
conceptualization and measurement/assessment of ageism in existing empirical lit-
erature covering the wide spectrum of care from emergency and acute care to
chronic and long-term care of older adults in order to make recommendations for
future research. In so doing, we aim to provide insights into the various theoretical/
conceptual and methodological approaches that researchers can employ for measur-
ing and assessing ageism. As part of the Memorandum of Understanding for the
implementation of a European Concerted Research Action, designated as ‘COST
Action IS1402: Ageism – a multi-national, interdisciplinary perspective’, of which
the authors form part, five methodological aspects related to ageism were selected
as relevant. These are assessment; spatial design; prevalence, antecedents and con-
sequences; intervention; conceptualization and theory.
In this chapter, we focus on two of the aforementioned aspects, namely ‘assess-
ment’ and ‘conceptualization and theory’ and aim to answer the following
questions:
(i). Why is it important to know how ageism in healthcare and long-term care has
been empirically studied? (Sect. 29.1)
(ii). What evidence for the existence of ageism among key stakeholders (e.g.
health care professionals and long-term care workers, family members and
older adults) is reported in empirical research covering these two contexts?
(Sect. 29.2)
(iii). Which are the conceptual and methodological approaches used to measure
and assess ageism involving these key stakeholders in the two contexts?
(Sects. 29.3 and 29.4)
29.2 W
hy Is It Important to Know How Ageism
in Healthcare and Long-Term Care Has Been
Empirically Studied?
Health and long-term care represent important settings in relation to old age and
ageism as they cover the full pathway of delivery of care related to health and illness
that older adults often need to access. As populations are ageing, in particular in
developed countries, increasing numbers of older adults pass through the wide
spectrum of care from emergency and acute care to chronic and long-term care on
a daily basis. The spectrum of care includes community and public health, primary
care, emergency medicine, acute care, care of chronic illness and long term
care – both institutionalized, as well as home/community-based. Health care and
long-term care are complimentary yet diverse in the services offered, acuity of care,
characteristics of health care professionals caring for older people, as well as in
29 Researching Ageism in Health-Care and Long Term Care 495
terms of proportion and age of older persons cared for. In particular, long-term care
tends to have a higher percentage of vulnerable oldest old. Additionally, length of
stay is longer in these settings, thereby potentially increasing the possibilities for
discriminatory situations to arise. Furthermore, the level of education and training
of care-workers in long-term settings may be very different from that of health care
professionals in acute settings.
Our focus on ageism in health and long-term care is further motivated by huge
gaps in the literature with regard to the real needs of care for this age group, a situa-
tion that may be interpreted as ageist and specifically deficient in focus when it
comes to delivery of care for older people. This is most probably due to the fact that
the younger age groups have more often than not attracted attention from health
policy makers, as well as from hospital and primary care administrators and provid-
ers (Robb et al. 2003; American Diabetes Association 2015). Gatz and Pearson
(1988) labeled the attitudes shown toward older adults, namely the specific treatment
biases that are based on negative misconceptions, as a problem and defined it as
“professional ageism.” Specifically, Hunold et al. (2016) remarked that emergency
departments (ED) are progressively becoming a critical site of care for older adults,
but there is still minimal knowledge regarding the priorities of care delivery for this
population. The same authors identified accuracy and efficiency of the medical eval-
uation as the most common but lacking priorities among older adults in the
ED. Similarly, Aminzadeh and Dalziel (2002) argued that the currently practiced
disease-oriented and discontinuous models of emergency care are not sufficient to
match the multidimensional needs of frail older patients, who have divergent patterns
in terms of care needs, as well as service use (Scott et al. 2007). This situation calls
for further research to assess the effectiveness of triage and intervention strategies
pursuing vulnerable older ED patients. With regard to acute care, particularly inpa-
tient services, the major users are older people – a contribution of the ageing popula-
tion but also a reflection of the evolving patterns of disease, i.e. chronic with acute
complications, multiple comorbidities and functional consequences (Koch et al.
2009). Indeed, most health care systems are adapting to this change in users/patients
age groups by redesigning and shifting care for younger adults to the community,
primary care and day care where possible (Koch et al. 2009). However, one still ques-
tions the persistently reported fragmented care of older adults and urgently calls for
an older patient priority-directed and holistic decision-making process that addresses
the needs of older adults with multiple chronic conditions (Tinetti et al. 2016).
Fried and Ferrucci (2016) highlight the fact that the contribution of aging to
chronic diseases can no longer be toned down. Geriatricians and gerontologists have
approached this problem through the conceptualization of frailty as a diagnosable
clinical syndrome characterized by marked susceptibility to stress, underlying loss
of resiliency and diminished functional reserve. In health services, which cater for
the care of chronic diseases, as well as in long-term settings, there is the tendency
for professionals who may have internalized ageist attitudes during their formative
years to use patronizing talk to older people, which Nelson (2005) considers as
self-fulfilling prophecies that can translate ageist stereotypes into actual behavior
and eventually into lower levels of older persons’ empowerment of their care.
Furthermore, Coleman (2003) and Boockvar et al. (2004) identify transitioning

of care from health to long-term care facilities as commonplace for older adults,
who are often somewhat ‘lost’ or ‘sidelined’ in terms of clinicians’ priorities par-
ticularly when long lengths of stay in acute settings are mainly due to lack of space
in long-term institutions. Indeed, older patients in acute settings are often consid-
ered a burden on the health system and are labelled as ‘social cases’ (Cohen et al.
2014) or ‘bed-blockers’ (Hawkes 2016). Perhaps more distressing is that at the far
end of the spectrum of care, Condelius and Andersson (2015) state that there are
gaps in the literature as to what care older people access throughout the last stages
of their life, as well as which factors enable access to care in this group.
Statistics from the United Nations predict that by 2030, older persons are
expected to account for more than 25% of the populations in Europe and in Northern
America, 20% in Oceania, 17% in Asia and in Latin America and the Caribbean,
and 6% in Africa (United Nations World Populations Ageing 2015). Therefore, it is
more likely that in the foreseeable future, the need for services in health and long-
term care will continue to increase as will the risk that older people are not looked
upon and treated as full citizens in these settings.
From such accounts it becomes evident that a structured analysis of ageism in
health and long-term care is both timely and pertinent. However, without a compre-
hensive conceptualization and operationalization of ageism efforts to measure and
assess the multiple manifestations of ageism in these two contexts are bound to fail.
Consequently, we are not able to fully tackle ageism in practice. It is therefore
important to evaluate the state of empirical research concerning ageism in both
health and long-term care in terms of, identifying the definitions used, and the con-
ceptual and methodological approaches applied. Only by so doing can we uncover
the strengths and weaknesses of research in this field and help guide future research
efforts towards the areas most in need of being addressed.
Finally, we hope that our results can contribute to the development of what we
consider that acceptable quality of care for older adults should embrace; that is, the
holistic bio-psychosocial model delivered by interdisciplinary teams of health care
professionals, who are competent in the care of older people and that steers away from
fragmented, chaotic and ageist delivery of care. This model of care is becoming even
more relevant in view of emerging evidence that the integration of attitudes, values,
standards and opinions referred to as internalization of ageist stereotypes is related
to memory failures, physical frailty and risk of cardiovascular events (Levy 2009).
29.3 E
vidence for the Existence of Ageism in Health
and Long-Term Care
This section is organized in two subsections, one focused on health care and the other
one on long-term care. In both sections we consider the evidence in relation to three
groups of research participants, namely care professionals, family members and
older people. In providing an overview of the evidence of ageism and ageist practices
in health and long-term care, we consider each sector separately. Our choice reflects
the clear separation in the specialized literature between analyses in health or in long-
term care settings, with virtually no overlap or joint consideration in extant studies.
It is also important to draw attention to the fact that each subsection considers evi-
dence of ageism in relation to three stakeholder groups, namely health and long-term
care professionals, family members and older people. This stands in recognition of
their separate but equally important roles in the process of care.
29.4 Ageism in Health Care
Existing empirical research on ageism in health care mainly involves health care
professionals across different disciplines (São José et al. 2017). Examples include
doctors in primary health care, where ageism is related to clinical decision-making
(Adams et al. 2006; Arber et al. 2006), physicians in hospital in their recommenda-
tions for physical activity among individuals with arthritis (Austin et al. 2013),
unfair judging by Florida physicians of older adults simply because of their advanced
age (Gunderson et al. 2005). Other examples are physicians deciding on access to
critical care that is influenced by age against older people (Hubbard et al. 2003), and
significant differences in access to treatment, depending on the patients’ chronologi-
cal age and prescribing chemotherapy less frequently as the patients’ chronological
age increase (Protiere et al. 2010).
There are also studies focusing on ageism in research in health care, involving
researchers in diabetes. Here, evidence of ageism is related to “the extent of
exclusion of older individuals from ongoing clinical trials regarding type 2 diabetes
mellitus” (Cruz-Jentoft et al. 2013; p. 734) and “(...)“whether exclusion of older
people was prevalent in research proposals submitted to Dublin teaching hospitals”
(Briggs et al. 2012, p.311).
Another group of health professionals involved in the body of research on ageism
in healthcare is nurses, such as nurses caring for individuals with spinal cord injury
(Furlan et al. 2009, p. 674). In one of these studies (Gething et al. 2002), evidence of
ageism is related to patterns of stereotyping among nurses in Australia and the United
Kingdom. Furthermore, Kydd et al. (2014) described attitudes of nurses and nursing
students in Scotland, Sweden and the US towards working with older people.
Moreover, Holroyd et al. (2009) reported that negative biases and ageist attitudes
among caregivers, and particularly nurses, toward older people in acute care settings,
are among the more notable expressions in the health care system.
Some studies report on evidence of ageism in distinct areas of specialization,
namely psychiatry (Bouman and Arcelus 2001) in the sense of taking a sexual history
far more frequently of middle-aged men and of neglecting to do so in older male
patients, and oncology (Kearney et al. 2000), whereby healthcare professionals
(physicians, nurses and radiographers) may discriminate against older people.
There are also studies that provide evidence of ageism involving older adults
themselves. Chambaere et al. (2012) reported that the level of involvement of
patients in decision making to intensify pain alleviation decreases with increasing
age. Additionally, Koch and Webb (1996) described the ‘conveyor belt’ way of
organizing care in wards, whereby patients dominated by the demands of the work
timetable, powerless to have any influence on their own care and unable to express
their individual needs. These authors also reported segregation in that providers
label older adults as “old”. Furthermore, Makris et al. (2015) reported that ageism
emerged as a result of dismissing or minimizing comments by providers that can
serve to inform or reinforce older adults’ beliefs that back pain is directly related to
old age, or perhaps, that providers have nothing more to offer.
29.5 Ageism in Long-Term Care
Existing empirical research on ageism in long-term care contrasts with that in

healthcare in that the studies more often involved older adults and family members
and less frequently care professionals as participants. This may be due to the fact
that the subjects are more easily accessible in long-term care.
Most studies on ageism in long-term care involve residents in long-term institu-
tions (Ayalon 2015; Bodner et al. 2011; Dobbs et al. 2008; Doyle 2014; Gamliel
2000; Lagace et al. 2011, 2012; Macdonald and Butler 2007; Roth et al. 2012, 2015;
Taverna et al. 2014; Zimmerman et al. 2014). Ayalon (2015) reported a prominent
general view of old age as a sign of decline and decay. This negative view of old age
was stated as prominent among adult children, as well as their older parents.
Zimmerman et al. (2014) also report evidence of ageism, namely physical environ-
ment (environmental press [ex.: not repairing a bathroom nearby because of budget
restrictions]; not using social space for engagement [ex.: sticking all the older
people in the front and leave them there]); using labels to describe different types
of residents; multi-level settings (not minimizing “us” versus “them” [ex.: older
people who are relatively autonomous and older people who are dependent]); inde-
pendence (not supporting autonomy [e.g.: discouraging older people from doing
certain tasks]); respect (not valuing the resident [ex.: feeling like a prisoner]); privacy
(not providing privacy); care provision (not taking the focus off of decline [e.g.:
reinforcing dependence and decay]; constant supervision).
Several studies on ageism in long-term care involved health care professionals,
care workers and administrators of long-term institutions (Band-Winterstein 2015;
Billings 2006; Dobbs et al. 2008; Dunworth and Kirwan 2012; Lagace et al. 2011;
Reyna et al. 2007; Roth et al. 2012, 2015; Taverna et al. 2014; Wells et al. 2004;
Zimmerman et al. 2014). For example, Band-Winterstein (2015) reported ageism as
neglect in the everyday routine of care with the following emerging themes (being
transparent; being invisible; being forgotten; perceiving older patients as no longer
human; being treated as an object, in an automated fashion; lack of accurate medical
diagnosis; using ageist language; using less expensive materials on older patients,
because money is not wisely spent on older persons; older persons lose their sexuality,
which justifies mixed communal and social participation of older people); and
avoidance (attitudes and behaviour regarding social contact with older people).
Billings (2006) reported evidence of ageism in professionals from health care and
social care in terms of insensitive treatment in relation to communication and atti-
tude; excluding older people from conversations, sensitive or otherwise; shouting at
older people; being patronising; little assessment of the preferred way that older
people like to be addressed; not giving an older person enough privacy when help-
ing them with activities such as toileting, washing or dressing; letting older people
have a limited choice in things such as when and what they eat, when they go to bed
or have a bath; older people are given too many tablets which are not reviewed often
enough; and that there are assumptions that older people are not sexually active.
There are also a few studies in this body of research that involved family mem-
bers as subjects (Ayalon 2015; Condelius and Andersson 2015; Dobbs et al. 2008;
Roth et al. 2012, 2015; Zimmerman et al. 2014). In particular, Condelius and
Andersson (2015) reported ageism among the next of kin, “in that they perceive
some conditions and complaints as a natural part of ageing with further examina-
tions or treatments being regarded as “pointless” or even “wasted” (p. 11).
To sum up, existing empirical research in the contexts of health and long-term
care provides an interesting continuum and diversity in terms of the evidence of
ageism provided and the stakeholder groups that are surveyed.
29.6 T
heoretical and Conceptual Approaches in the Study
of Ageism
On an overall level, what appear as most striking in relation to theoretical and con-
ceptual approaches in the empirical study of ageism in health and long-term care is
that most studies in both of these areas do not, at least explicitly, apply any theory,
and that very few studies use theories of ageism. Thus, the literature on ageism in
health and long-term care appears as under-theorized. Particularly striking is the
relative absence of theories of ageism. While the vast majority of the literature is
occupied with studying the causes, the consequences and possible preventive strate-
gies of ageism, scant attention has been paid to its conceptualization (Iversen et al.
2009). As many, non-harmonized definitions coexist in the field, the formulation of
a general theory on the causes and effects of ageism, which can help ground empiri-
cal research in a coherent fashion, is rendered impossible (Iversen et al. 2009). In
fact, our survey of the empirical literature on ageism in health and long-term care
yielded a majority of studies that altogether lack any references to a theoretical
framework and that are underpinned by definitions and conceptualizations of ageism,
often only implicitly defined.
Interestingly, even when established theoretical frameworks are included, they
are rarely theories specifically focused on ageism of ageism. The literature on ageism
in health care is affected by the disconnect between empirical work and theoretical
thinking on ageism. While a minority of studies is grounded in the conceptual works
of Butler (1969), Butler and Lewis (1973), Bytheway and Johnson (2001), Levy
et al. (2006), the vast majority fail to mention any theoretical framework or to inter-
pret their results within a broader theoretical context. Other theoretical frameworks
not specific to ageism, but employed in selected studies on ageism in health care
include psychological models of clinical decision-making, the Behavioral Model of
Health Services Utilization, The social ecological perspective (Moos 1979; Stokols
1992; Parke & Chappell, 2010) and Allport’s intergroup contact theory (Ajzen
2005). Theories that are normally used to study/discuss ageism in long-term care
(São José et al. 2017) are as diverse as Goffman’s perspectives on stigma and
depersonalization in institutions are applied, Age Stratification Theories, Foucault’s
perspectives on power, and Normative Ethical Theories are employed by authors,
while Terror Management Theory (Solomon et al. 1991) or Social Identity Theory
(Turner and Reynolds 2010), that explicitly refers to the concept and phenomenon
of ageism, if at all mentioned, are relegated to the discussion sections.
To date, the most comprehensive conceptualization attempt for ageism is offered
by Iversen et al. (2009) in their seminal paper on the conceptual analysis of ageism.
Starting from an in-depth review of existing definitions and theoretical works, they
structured the core aspects of ageism along four dimensions and proposed and
enriched, multi-dimensional conceptualization: “Ageism is defined as negative or
positive stereotypes, prejudice and/or discrimination against (or to the advantage of)
older people on the basis of their chronological age or on the basis of a perception
of them as being ‘old’ or ‘elderly’. Ageism can be implicit or explicit and can be
expressed on a micro-, meso- or macro-level”.
As identified by the authors, the key dimensions in the ageism concept are the
three classical components (cognitive-stereotypes, affective-prejudice, behavioural-
discrimination); the positive/negative aspect (positive ageism, negative ageism), the
conscious/unconscious aspect (explicit ageism, implicit ageism); and the levels at
which ageism can manifest (micro-level ageism, meso-level ageism, macro-level
ageism) (Iversen et al. 2009). To these dimensions, Sao Jose and Amado (2017) add
the self-directed/other-directed aspect of ageism, manifesting exclusively at the
micro-level, in recognition of the prevalence of negative stereotypes towards people
of one’s own age or towards oneself, a phenomenon aptly described by Bodner et al.
(2011) as ‘self-ageism’.
Mapping existing empirical literature on ageism in health and long term-care
over the main components of ageism, a spectrum of 32 possible variants of ageism
emerges at their intersection (see Table 29.1). Not surprisingly, no studies in the
empirical literature on ageism in health and long-term care recognize and account
for the complexity of the ageism concept along all five dimensions (see Table 29.1
for a visual depiction of the different variants of ageism and an overlayed mapping
of the empirical literature on ageism in the two settings). In fact, as numerous con-
tributions rely on Butler’s classical definition of ageism (1975) they recognize only
five of the 32 components, namely: cognitive, behavioural, other-directed, explicit
and negative ageism. Even more recent definitions of ageism that have been
Table 29.1 Variants of ageism and literature mapping

Micro-level Meso-level Macro-level
Cognitive Affective Behavioural Ageism in
corporate Ageism in
Non Non Non and
Self- Self- Self- institutional
self- self- self- categoric
directed directed directed systems
directed directed directed units
Explicit-
Negative
Explicit-
Positive
Implicit-
Negative
Implicit-
Positive
Legend The 32 variants of ageism

Variants covered frequently in the literature
Variants covered rarely in the literature
Variants lacking from the empirical literature
Source: Adapted from Iverson et al. (2009) and Sao Jose and Amado (2017)
employed in the empirical literature, as those proposed by Cuddy et al. (2005),
Greenberg et al. (2002), Levy and Banaji (2002) and others, while generally more
comprehensive in their scope, cover at most 10 components.
29.7 C
omparison of Research on Ageism in Health
and Long-Term Care
Concerning differences between the empirical literature on ageism in health and

long-term care, among the three classical components of ageism, discrimination
against people of a certain age, that is the behavioral components, is by a large mar-
gin most represented in the empirical literature on ageism in health care. The major-
ity of studies concern themselves with identifying forms of discrimination in
diagnosis (Adams et al. 2006, Arber et al. 2006, Rudd et al. 2007, Bond et al. 2003),
discrimination in treatment and management (Koch and Webb 1996; Chambaere
et al. 2012; Pedersen and Mehlsen 2011; Grant et al. 2000; Gnavi et al. 2007; Austin
et al. 2013), discrimination in access to research and clinical trials (Cruz-Jentoft
et al. 2013; Briggs et al. 2012) and differences in survival rates (Peake et al. 2003;
Grant et al. 2000). The cognitive component, mainly addressed in qualitative stud-
ies, is generally reflected in research on the stereotypes and assumption about older
patients not belonging in specific care institutions (Parke and Chappell 2010), about
symptoms that are “normal” at more advanced ages (Iliffe et al. 2005; Makris et al.
2015) and about expected responses to treatment (Skirbekk and Nortvedt 2014).
Finally, analyses of the affective component are all but absent in the literature on
health care, with only one, recent study discussing prejudice towards older people,
ageing and old age (Kydd et al. 2014) identified in our literature survey. The litera-
ture on ageism in long-term care, on the other hand, presents a more balanced divi-
sion of interest between the three components. Negative stereotypes about the
condition and abilities of older individuals (Band-Winterstein 2013; Billings 2006;
Condelius and Andersson 2015) and about old age in general (Ayalon 2015; Gamliel
2000; Petersen and Warburton 2012; Roth et al. 2012) as well as negative reactions
and prejudices towards older people (Dobbs et al. 2008; Roth et al. 2012; Natan
et al. 2013; Wells et al. 2004) are well mapped in empirical studies. Finally, studies
of discrimination against older adults in long-term care include such diverse topics
as controlling the interaction and using inappropriate and diminishing language
with older individuals (Band-Winterstein 2013; Lagacé et al. 2011; Doyle 2014),
limiting older individuals’ privacy (Billings 2006), providing sub-standard care
(Band-Winterstein 2013; Doyle 2014) and segregating residents in long-term care
facilities within age groups (Roth et al. 2012).
The representation of other ageism dimensions in the empirical literature is also
highly skewed. We were able to identify only one study focusing on ageism in
health care that explicitly considers positive stereotypes about ageing (Gunderson
et al. 2005). Research on long term care more often recognizes the positive aspect
of ageism (Lagacé et al. 2011; Natan et al. 2013; Wells et al. 2004) although it rarely
takes a central place in the analysis. A noteworthy exception is the study of Taverna
et al. (2014) who link the desire on the part of long-term care staff to respect resi-
dents’ independence and autonomy due to their age (positive discrimination) to
improper oral hygiene (a negative health outcome). This imbalance towards nega-
tive aspects of ageism is likely driven by a desire among researchers to identify
those attitudes and behaviors that are likely to harm older individuals and lower the
quality of the care they receive, in order to find ways to curtail them. However, the
study of Taverna et al. (2014) is a case in point that all ageist attitudes and discrimi-
nation, even positive ones, can have negative effects, albeit unintended ones, and
should therefore be considered in research more often.
Further differences between research on ageism in health and long-term care are
that empirical studies on ageism in health care exclusively address the non
self-directed aspect. This situation likely stems from the nature of interactions
between older patients and their health care professionals, characterized by large
information and control imbalances, shorter care spells and a focus on symptoms
and disease. In long-term care, however, where older individuals interact both with
caregivers and other residents for longer periods of time and with a more general
goal of addressing both physical and psychological wellbeing of the care recipients,
issues related to self-directed ageism are more salient. The empirical research on
ageism in long-term care includes studies on ageist attitudes among older individu-
als themselves (Ayalon 2015) and discriminatory behaviors towards other older
aged groups (Roth et al. 2012), as well as how these attitudes and behaviors are
shaped by the specificities of the community or residential care environment
(Gamliel 2000; Bodner et al. 2011).
Concerning similarities between research on ageism in health and long term

care, due to obvious difficulties in their systematic study, implicit stereotypes, prej-
udices and discrimination are rarely acknowledged in both bodies of the empirical
literature and are addressed almost exclusively in qualitative studies. They address
the existence of stereotypes and assumptions about older patients and residents that
care professional hold, without being consciously aware of their presence or harbor-
ing any ill intention. Nonetheless, such attitudes can lead to improper care (Skirbekk
and Nortvedt 2014) or delayed diagnosis, assessment (Pedersen and Mehlsen 2011)
and treatment (Iliffe et al. 2005; Makris et al. 2015) with clear risks for negative
health outcomes. Research on ageism in long-term care has also almost exclusively
focused on explicit ageism, although a series of recent studies carried out in Canada
(Lagace et al. 2011, 2012) on communication patterns between older adults and
their caregivers in residential environments had uncovered that ageist language and
attitudes are often employed by caregivers.
29.8 Methodological Approaches in the Study of Ageism
From our review of the literature, it is immediately apparent that ageism in health
care is prevalent but immensely vague as a concept. It is important to consider the
balance between older patients’ experiences demands, real needs and ethical con-
siderations when analyzing contexts, settings and case studies. This renders mea-
surement even more difficult to achieve. Similarly, in long-term care, Sao Jose and
Amado (2017) argue that despite the fact that ageism is “pervasive”, it is difficult to
define, identify, measure and most important of all to fight. Indeed, they call for
research strategies that are capable of detecting, measuring and understanding the
multidimensionality/complexity of ageism.
As should by now be apparent, the empirical literature on ageism in health and
long-term care addresses a wide variety of forms and manifestations of ageism in
these specific settings, which reflect into the diversity of study designs and tools
employed by authors. As measurement is both difficult and essential in this field of
research, in this section we turn our attention to methodological aspects. In very
broad terms, we can talk of two main categories of studies: (i) those attempting to
identify or capture ageism and that avail of qualitative methodological approaches
and (ii) those that strive to measure or quantify manifest ageism and that rely on
quantitative methodological approaches. Each is further described below, with a
view of comparing and contrasting the bodies of research in health and in long-term
care. In both fields, mixed methods studies are conspicuously rare. We identified
only a couple of studies on ageism in health care (Adams et al. 2006; Arber et al.
2006), and only two contributions in long-term care focused research (Lagace et al.
2011; Taverna et al. 2014). As a consequence, we do not treat them as a separate
category. This is an unfortunate gap in existing research, as mixed methods
approaches offer researchers the opportunity to triangulate and more convincingly
validate findings via different methodologies.
29.9 C
omparison of Research on Ageism in Health
and Long-Term Care
29.9.1 Qualitative Approaches
Qualitative studies of ageism in both health and long-term care rely predominantly
on interviews for data collection. Researchers generally choose a semi-structured
format for interviews, although structured, open and in-depth interviews are also
common, and often complement them with other data collection methods. Focus
groups and participant observation are also commonly employed methods, in
conjunction with interview based data collection (Makris et al. 2005; Skirbekk and
Nortvedt 2014; Billings 2006; Gamliel 2000; Lagace et al. 2011) but also as the
principle data collection method (Iliffe et al. 2005). Less prevalent in the empirical
literature is the use of document analysis (Petersen and Warburton 2012). While
many studies do not specifically identify the data analysis methods employed, thematic
analysis, content analysis, discourse analysis and ethnographic analysis are commonly
cited by authors.
While studies from both categories stated above have addressed ageism both in
health and in long-term care settings, imbalances between the frequencies of appli-
cation of qualitative versus quantitative approaches are apparent in both fields.
Namely, qualitative approaches predominate in research on ageism in long-term
care, whereas the vast majority of studies of ageism in health care belong to the
second category. A systematic review of the literature on ageism in long-term care
(Sao Jose and Amado 2017). reveals that qualitative studies are overrepresented in
this field and more than twice as numerous as a quantitative approach. Therefore,
the variety of qualitative methods employed is higher in the empirical long-term
care literature with respect to that focused on health care.
Interestingly, qualitative studies in long-term care seem to favour the selection of
older individuals themselves as study participants (Bodner et al. 2011; Doyle 2014;
Lagace et al. 2012), in the slight detriment of care professionals (Band-Winterstein
2013; Billings 2006) and family members (Ayalon 2015; Condelius and Andersson
2015). Conversely, in health care based studies, care professionals are relatively
more likely to be the subjects of qualitative studies (Skirbekk and Nortvedt 2014;
Iliffe et al. 2005), although older adults are also often interviewed with regard to
their in-patient and general care experiences (Koch and Webb 1996; Parke and
Chappell 2010). We stress that a majority of qualitative studies focus exclusively on
one participant group and fail to acknowledge the perspectives of other key actors.
As the results cannot be cross-checked and compared, this lack of triangulation in
participant selection can lead to one-sided accounts and paint only partial pictures
of the contexts the studies attempt to describe. It is however, worth noting that a lack
of diversity in participant selection is a problem that affects more severely the literature
on ageism in health care. By comparison, qualitative studies in long-term care more
routinely include two or all key stakeholders – i.e. older adults, family members and
care professional (Dobbs et al. 2008; Lagace et al. 2011; Roth et al. 2015).
Concerning similarities between the two fields of research, we note a dispropor-

tionate preference for studies based in residential care settings, both in the health
care and the long-term care literature. When studying the experience of older adults
in the health care system, researchers predominantly select in-patient settings and
only rarely interview older adults outside the hospital setting (Makris et al. 2015).
Similarly, ageism in long-term care is overwhelmingly studied in residential facili-
ties, be they nursing/care homes, assisted living facilities or retirement communi-
ties. Only one study selected participants living in their own homes to analyze their
experiences in receiving community based formal care (Doyle 2014). Equally rare
are research efforts that span care settings. Most noteworthy, Billings (2006) finds
evidence of ageist attitudes and discrimination against older people among profes-
sionals in health and social care services, working both in the community and in
residential and medical care settings. The lack of diversity in the selection of the
study setting is a significant shortcoming of empirical research on ageism in both
health and long term care, as it fails to reflect the experiences of a wide majority of
older individuals, who reside in the community and whose interaction with care
professionals is only episodic. While it is understandable that this bias arises as an
expression of convenience in participant selection and data collection, it constitutes
one of the most significant remaining gaps in qualitative research on ageism.
29.9.2 Quantitative Approaches
While outnumbered by qualitative studies in the literature on ageism in long-term

care, quantitative studies represent an overwhelming majority of research contribu-
tions on ageism in health care settings in our survey. The preferred data collection
method, by a wide margin, is the administration of questionnaire based surveys to a
selected population of interest. Common methods of survey administration include
telephone-based (Austin et al. 2013; Jerant et al. 2004), mail-based (Kearney et al.
2000; Protiere et al. 2010) and direct distribution to participants (Kydd et al. 2014).
Virtually all quantitative studies on ageism in long-term care rely on validated scales
of ageism for data collection, while in the literature focused on health care a mix of
ad-hoc survey instruments (Bouman and Arcelus 2001; Gunderson et al. 2005) and
validated instruments is used (please refer to the next section for an overview of the
main scales used to measure ageism). While sample sizes and response rates vary
widely, in relation to the specific participant population targeted, numerous studies
draw on small samples (less than 100 respondents), pointing to a necessity to repli-
cate and reconfirm these findings in other settings and on larger groups in order to
establish to what extent their results are generalizable.
While entirely absent from the long-term care literature, studies with random-
ized experimental designs eliciting the assessment of care professionals for patient/
case vignettes or video clips are not uncommon in health care focused research
(Adams et al. 2006; Arber et al. 2006). Similarly, in the health care setting, studies
of ageism are also based on registry data (Cruz-Jentoft et al. 2013), on analysis of
case documentation and files (Bond et al. 2003; Peake et al. 2003), on auditing of
clinical research proposals (Briggs et al. 2012), on the analysis of death certificates
(Chambaere et al. 2013) and of hospital and other regional medical databases (Gnavi
et al. 2007; Grant et al. 2000; Rudd et al. 2007). Due to the lack of coordinated data
collection efforts, among other constraints, such studies are rendered virtually
impossible and in fact, lack completely, from the empirical literature on ageism in
long-term care. Not surprisingly, the range of data analysis methods employed
parallels the diversity of methodological approaches to data collection. The most
prevalent forms of statistical analysis used include descriptive statistics, analysis
of variance and analysis of covariance techniques, factor analysis and regression
analysis, but other approaches, driven by the particularities of the collected data can
also be identified.
Quantitative studies of ageism using surveys for data collection are almost exclu-
sively directed at care professionals, rather than care users (i.e. older people) both in
health and in long-term care. Studies like Bodner et al.’ (2011), using self-completion
questionnaires to examine differences in ageist attitudes and perceived quality of
life among older persons living in residential facilities and in the community, are
exceedingly rare in the literature on long term care and, to the best of our knowl-
edge, no similar studies exist in the health care focused literature. Noticeable is also
the lack of quantitative studies on ageism that include family members among
participants, both in health and long-term care. It is therefore evident that quantita-
tive research has, to date, failed to recognize and appropriately map all relevant
actor groups, leaving the perspective and experiences of relatives and close family
circles covered exclusively by qualitative research efforts.
The problem of under-representation of diverse settings in studies of ageism in
long-term care described above carries fully to the quantitative research literature.
Virtually all studies collect data from only one care setting, overwhelmingly a resi-
dential care facility (Dunworth and Kirwan 2012). To the best of our knowledge,
only Bodner et al. (2011) use a multi-setting data collection approach including
individuals living in the community and in sheltered housing arrangements. In
studies focusing on ageism in health care a similar imbalance is evident with regard
to the over representation of specialist and high intensity care services, in the detri-
ment of primary care based studies (Adams et al. 2006; Arber et al. 2006; Gunderson
et al. 2005). Most commonly, the study focus is further narrowed with reference to
a specific disease or pathology: diabetes mellitus (Cruz-Jentoft et al. 2013), arthritis
(Austin et al. 2013), cardiovascular disease (Bond et al. 2003), spinal cord injury
(Furlan et al. 2009), ischemic heart disease (Gnavi et al. 2007), colorectal cancer
(Jerant et al. 2004), psychosis (Mitford et al. 2010), lung cancer (Peake et al. 2003),
brain injury (Pedersen and Mehlsen 2011), breast cancer (Protiere et al. 2010),
stroke (Rudd et al. 2007). This high degree of fragmentation of research results, by
clinical specialty and disease group, raises questions about their transferability and
generalizability and renders a comprehensive discussion about ageism in health
care extremely difficult.
29.10 Specific Measurement Tools: Scales of Ageism
As already hinted above, the majority of quantitative studies on ageism in health and
long term care rely on already established instruments, generally described as scales
of ageism. While the present review is not exhaustive, we briefly describe those
most widely accepted and most commonly used in the health and long-term care
literature, listed here in the chronological order of their development.
The Attitudes Towards Older People Scale proposed by Kogan (1961) is composed
by 34 statements in a Likert scale format, with item values ranging between 1 (dis-
agree strongly) to 7 (agree strongly) where higher scores indicate more positive
attitudes. An attitude index can be computed as the mean of all 34 items. The
Attitudes Towards Older People Scale is a uni-dimensional tool that does not recog-
nize any dimensions or factors. It covers the affective and cognitive, other-directed,
explicit, positive and negative components of ageism. This scale has been used both
in long-term care based (Natan et al. 2013) and in health care based (Furlan et al.
2009; Gallagher et al. 2006; Kearney et al. 2000; Lui and Wong 2009; Topaz and
Doron 2013) quantitative studies.
The Aging Semantic Differential Scale (Rosencranz and McNevin 1969) is a multi-
dimensional tool designed to measure attitudes towards older people. It is organized
along three factors: (i) level of effective goal orientation, adaptability and energy
output of older people, (ii) level of dependency upon others and personal autonomy
and (iii) level of social interaction. The tool consists of 32 polar adjectives (e.g.
exciting/dull, progressive/old-fashioned, independent/dependent) in a 7-point Likert
scale format, where lower values indicate more positive views. It covers the cogni-
tive, other-directed, explicit positive and negative components of ageism. The Aging
Semantic Differential Scale covers exclusively the cognitive component of ageism
and the explicit and non self-directed aspects. In the empirical literature on ageism
in health and long-term care it has been used, among others, by Gething et al. (2002)
and Reyna et al. (2007).
The Facts on Aging Quiz was designed and further developed by Palmore (1977,
1998) as a tool for measuring basic knowledge about old age and aging as well as
common misconceptions related to it. The proposed scale is uni-dimensional and
consists of 50 statements in a true-false format. While it recognizes both positive
and negative components of ageism, it covers only the cognitive, other-directed and
the explicit component. Applications to the study of ageism in health care include
works by Topaz and Doron (2013) and Gethering and colleagues (2002), while in
the long-term care settings it has been used by Wells et al. (2004).
Developed in 1990 by Maryann Fraboni and colleagues, the Fraboni Scale of
Ageism (Fraboni et al. 1990) was designed to measure attitudes and prejudices
towards older people via 29 statements in a Likert scale format. It recognizes three
distinct dimensions/factors: antilocution (referring mainly to stereotypes, positive
and negative, about older people), discrimination (referring to attitudes, positive

and negative, towards social rights and social participation of older people) and
avoidance (referring to affective attitudes and behavior, positive and negative, with
respect to social contact with older people). The scale covers all three classical
components and both the positive and negative aspects of ageism, but it focuses
exclusively on explicit and non self-direct variants of ageism. Examples of applica-
tions to the study of ageism in health and long-term care include Leung et al. (2011)
and respectively Bodner et al. (2011) and Lagace et al. (2011).
The Reactions on Ageing Questionnaire (Gething 1994) is an instrument devel-
oped to gauge attitudes toward personal aging, a measure that correlates highly with
attitudes towards other older people. The scale comprises 27 items in a 6-point
Likert scale format, each represented by a statement on expectations regarding old
age and is structured along three dimensions: fear of frailty, tedium in later life and
losses in later life. It covers the affective and cognitive, other-directed, explicit,
positive and negative components of ageism. Although the instrument was devel-
oped and primarily used in Australia, subsequent research confirmed its validity in
cross-country studies (Gething et al. 2004). Among the studies using the reactions
on Ageing Questionnaire, we note Gething et al. (2002), Wells et al. (2004) and
Williams et al. (2007).
It is worth noting that all the scales presented above are not specific to health and
long-term care research and are broad enough in their scope to be applicable to the
analysis of ageism in various other research fields. In fact, the classic scales of age-
ism have been applied widely in fields as diverse as marketing, media, educational
studies, business and organizational theory. This lack of context-specificity can be
seen as a limitation, as respondents are requested to think about older people in gen-
eral and not about older people receiving health and long-term care when answering
these scales. Results might differ if the instruments were contextualized.
29.11 C
urrent Advantages and Shortcomings in Research
on Ageism in Health and Long-Term Care
The empirical literature on ageism in health and long-term care, as it emerges from
our analysis of conceptualizations and methodological approaches, is very broad in
its scope and touches on a wide range of topics. Although not represented with the
same frequency, in depth analyses of ageist attitudes, prejudices and behaviors
have been carried out both in long-term care and in health care settings, in a variety
of contexts. We note however, a propensity for studies overwhelmingly representing
Western cultures. It is therefore, of great importance that the breadth of the field
continues to develop in future years, and that further studies are carried out in other
geographical areas and in more varied cultural contexts.
Such expectations do not appear overly optimistic, in light of the considerable

development of the field in the last decade. While ageism has been recognized and
discussed in the scientific literature for over 50 years, our review has uncovered a
proliferation of empirical studies of ageism in health and long-term care over the last
10 years. This is especially true for long-term care based research, where a system-
atic review of the literature on ageism (Sao Jose and Amado 2017) uncovered that all
selected studies were published after the year 2000, more than half of which had
appeared between 2011 and 2015. Increased research interest in ageism in health and
long-term care no doubt reflects growing awareness on the side of policy makers and
the general public of the relevance of the phenomenon in these specific settings. At
the same time as more research results become available and are disseminated issues
related to ageism are better and more widely understood and hopefully, more easily
addressed at the individual, organizational and institutional levels.
On the backdrop of this rapid and positive progression, a series of remaining
gaps need to be acknowledged. As a result of persistent theoretical fragmentation
and the co-existence of complementary but not entirely over-lapping definitions of
the ageism concept, the empirical literature does not reflect the complexities of
theoretical thinking on the topic. The mobilization of theories specifically focused
on ageism is rare. Furthermore, when mapped against the most comprehensive con-
ceptualization of ageism (Iversen et al. 2009; Sao Jose and Amado 2017), empirical
results cluster around few components while entirely failing to acknowledge more
refined aspects of ageism. The variants of ageism related to self-directed and to
implicit ageism are particularly under-covered.
In a similar vein, we argue the field must strive towards higher complexity and
flexibility in data collection and methodological approaches. Mixed methods stud-
ies that can integrate insights from both qualitative and quantitative data are all but
lacking in the literature.
Finally, while considerable progress is being made in the development of reliable
and validated measurement tools, we call attention to persistent shortcomings in the
available instruments. Studies often rely on overly general terms and imprecise
tools that use abstract terminology. A case in point is the pervasive use of the
syntagma “older people” without any qualification on what is to be considered old.
Reliance on such homogenizing expressions can mask the considerable diversity
characteristic of older populations, confounding the obtained results.
29.12 Recommendations for Future Research
Based on the evidence we surveyed in our analysis and building on the gaps and short-
comings identified above, we propose a series of recommendations for future research.
We believe development in these areas can help push the field forward and a coordi-
nated research effort to address them is timely and would prove most fruitful.
As our analysis uncovered a common weakness in underpinning empirical

research into theoretical thinking, we recommend that existing theories of ageism
should be mobilized more frequently. Such theories can prove extremely helpful for
the formulation of research questions but also for intervention and study design and
the interpretation of findings.
In fact, a stronger theoretical grounding, that recognizes the inherent complexi-
ties of the phenomenon of ageism should go hand in hand with the application of a
more comprehensive and ideally, unified definition of ageism that can reflect the
multiplicity and complexity of its manifestations. For example, by applying a com-
prehensive definition of ageism, we uncovered a gap in empirical research and
strongly recommend the development of tools and research strategies to measure
and assess self-directed ageism and implicit ageism. As long as this is not done, we
will continue to have an incomplete picture of the prevalence of ageism in health-
care and long-term care. Furthermore, a unified definition would allow for the
comparison of results between studies and across fields, enhancing the validity of
the evidence.
Turning to the methodological aspects of research on ageism, we believe future
studies should more frequently employ mixed research methods. By drawing on
both quantitative and qualitative methodologies, studies can gain both in breadth
and depth of understanding, while safeguarding against the shortcoming inherent in
using each approach in isolation. Triangulation between data sources and methods
can greatly improve the accuracy and reliability of research results and shed light on
the finer aspects of the phenomenon of ageism. Furthermore, researchers should
strive to enhance triangulation also with respect to participant selection (i.e. include
staff members, as well as older people and family members as study subjects) and
study setting (i.e. including non-residential settings in the research design) and
ensure that all relevant perspectives and the whole gamut of situations and living
conditions confronted by older people today are well represented in academic
research in health care and long term care.
The quality of available evidence is also likely to improve if future research
would rely on a combination of self-reporting techniques with non-self-reporting
techniques, such as, participant observation and experimental designs, by helping
minimize the impact of reporting biases. Similarly, the adaptation of an existing tool
to the specificities of the health and long-term care contexts could help to improve
accuracy. We recommend specifically that efforts should be directed to the develop-
ment of scales and tools that are designed for and sensitive to idiosyncrasies in the
care setting. A welcomed improvement on existing scales would also be the elimi-
nation of labels such as “old”, “elderly”, etc. As such scales should also be able to
capture “subtyping ageism”, a better strategy would be to formulate questions with
reference to specific age groups (e.g. 65–75) rather than homogenizing labels.
In conclusion, we wish to acknowledge the great strides that research on ageism
in health and long-term care has made over the last decades. This chapter aimed to
summarize the wealth of knowledge already existing in the field as well as to provide
more clarity into the conceptualization and measurement/assessment of ageism

in healthcare and long-term care. In so doing, we uncovered great achievements but
also “blind spots” in the literature and have, hopefully, charted the way ahead, in an
attempt to support researchers, policy makers and practitioners alike in their efforts
to address ageism in a variety of contexts.
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Chapter 30
Children’s Attitudes toward Older People:
Current and Future Directions
Joana Mendonça, Sibila Marques, and Dominic Abrams
30.1 Why and How Study Ageism in Children?
Being old is to lose memory, to have wrinkles and also white hair” (“Maria”, 6 years old).
“I think that when we became old we can and we know a lot of things to teach to the future
generation of the family (“Pedro”, 11 years old).
Age is a fundamental dimension along which children organize their perceptions

of people in their social world (Lewis and Brooks-Gunnn 1979). According to Levy
(2009), stereotypes about the ageing process and, more specifically, about older
people, become internalized across the life span in two fundamental ways: top-
down (from society to individuals) and over time (from childhood to old age). As
people age, stereotypes internalized during childhood and adulthood tend to eventu-
ally become self-stereotypes leading to often negative outcomes for older people
(Levy 1996, 2003). Four main stereotypes against older people seem to be prevalent
in society: (1) older people are generally depressed and lonely lacking family and
close friends and having mood disorders; (2) older people constitute a homoge-
neous group and ageing is perceived as a unidimensional and unidirectional pro-
cess; (3) older people are frail, sick and dependent on others; and (4) older people
are seen as having cognitive and psychological limitations (Whitbourne and Sneed
2002). Several studies have shown that the mere exposure to negative stereotypical
traits of old age (e.g., ill, dying, forgetful) has severe negative effects on older per-
sons in multiple domains such as memory performance, stress levels and the
J. Mendonça (*) · S. Marques

Instituto Universitário de Lisboa (ISCTE-IUL), CIS-IUL, Lisbon, Portugal
e-mail: [email protected]; [email protected]
D. Abrams
Centre for the Study of Group Processes, School of Psychology, Keynes College,
University of Kent, Canterbury, UK

https://doi.org/10.1007/978-3-319-73820-8_30
518 J. Mendonça et al.
will-to-live (e.g., Levy 1996, 2003; Marques et al. 2014a). These negative views are
both expressed at the individual and institutional levels because there is also much
evidence of negative treatment of older people across many areas such as the media,
healthcare and organizational settings (Marques 2011; Mendonça et al. 2016; Swift
et al. 2016; see similar chapters in this volume, e.g., Loos and Ivan (2018; Chap. 11),
Wyman, Shiovitz-Ezra, and Bengel (2018; Chap. 13), Stypinska and Nikander
(2018; Chap. 6)). Hence, understanding how representations of older people develop
from an early age is of crucial importance in order to better understand and inter-
vene in this domain.
At present, the literature in this field has still not yielded clear findings and it is
therefore inconclusive regarding children’s views of different age groups and, in
particular, of older people. In fact, the two quotes at the beginning of the present
chapter illustrate well the sort of contradictory evidence that currently exists regard-
ing the representations of older people among young children. On the one hand,
several studies show that children’s perceptions of older adults tend to be mostly
negative. For instance children as young as 3 years old (e.g. Middlecamp and Gross
2002), have been found to have negative ideas about older adults, children prefer
younger to older adults (Isaacs and Bearison 1986) and they may refer to older
people in a negative manner, associating this age group with traits such as helpless,
stubbornness and senility (Pinquart et al. 2000). On the other hand, there are other
studies that show no significant differences in attitudes regarding younger and older
targets and some even report positive perceptions of older people. For example, in a
study using the drawing test methodology, children expressed a generally positive
image of older people, depicting an older family member who was happy, healthy
and active (Robinson et al. 2014).
These contradictory sources of evidence suggest the need to explore this issue in
more detail. In this chapter, our goal is to explore and systematize the main evidence
gathered so far regarding children’s attitudes towards older people, in order to gain
a better understanding of how these attitudes develop in childhood. Therefore, the
goals of this chapter are: (1) to present a literature review of the main body of stud-
ies assessing children’s attitudes toward older people; (2) to classify the available
measures according to fundamental criteria of prejudice development in childhood:
their level of automaticity (explicit vs. implicit measures) and the dimensions cov-
ered (cognitive, affective or behavioral); and (3) to explore the pattern of develop-
ment of children’s attitudes toward older people in children. We believe that this
represents a very important and meaningful contribution to this literature.
In the present analysis, we adopt the definition of attitudes based on the tri-partite
model (Eagly and Chaiken 1993). According to this theory, an attitude is composed
of three dimensions: affective (represented by prejudicial feelings), cognitive (rep-
resented by beliefs and stereotypes) and behavioral (expressed through behavior or
behavioral intentions). These three dimensions of attitudes can express a positive or
negative evaluation regarding the object (Eagly and Chaiken 2007). Hence, we are
interested in exploring studies addressing these different dimensions of children’s
attitudes towards older people. In accordance with this definition, ageism represents
the specific case when there is a negative attitude towards older people (either in
affective, cognitive or behavioral terms).
30 Children’s Attitudes toward Older People: Current and Future Directions 519
30.2 W
hat Do We Know About the Development
of Prejudice in Childhood? Implications for the Study
of Ageism
There are numerous theories regarding the development of prejudice among chil-
dren. We follow Levy and Hughe’s (2009) suggested framework to organize the
main theoretical approaches. For example, the Social Learning Theory (Allport
1954) is based on the assumption that children learn prejudice through the observa-
tion and imitation of relevant role models, namely their parents or peers. According
to this theory, as children age and learn the expected behavior, their prejudice would
also tend to increase or match the levels of their parents.
A different approach is presented by the Cognitive-Developmental Theory origi-
nally developed by Piaget and Weil (1951) and applied to the prejudice field by
Aboud (1988), Bigler and Liben (2006) among others. According to this theory,
prejudice is derived from children’s limited cognitive abilities which undermines
their capacity to see people as individuals, leading to overgeneralizations. With age,
children’s cognitive abilities such as multiple classification ability become more
flexible, allowing them to recognize similarities across groups and differences
within the same group.
Along with this cognitive maturation, children’s expression of prejudice toward
out-group members varies across different stages in childhood. In this regard, almost
everything infants do is implicit in the sense that they are unlikely to be consciously
considering and controlling any of their attitudes (Olson and Dunham 2010).
Children’s attitudes become increasingly explicit as they grow older: as toddlers, as
preschoolers and, especially, as elementary school students. In this last develop-
mental stage, children (especially from the age of 8 – e.g., Rutland et al. 2005;
Abrams 2011) are able to manage the expression of their attitudes according to their
goals and social constraints. The gradual developmental of the “explicit system”
allows children to exert an increasing level of strategic control over previously auto-
matic processes (Olson and Dunham 2010).
Another set of theories known as Social-Cognitive Developmental Theories, are
based on both social and cognitive approaches, considering both personal factors
(e.g. age, cognitive skills) and also characteristics of the social environment. For
example, the Social Identity Development Theory (SIDT – Nesdale 1999), postu-
lates that intergroup bias can take different forms among both adults and children,
namely the preference for the in-group (in-group bias) and dislike for the outgroup
(e.g. race prejudice) (Rodrigues 2011). This theory is derived from the Social
Identity Theory (Tajfel and Turner 1979) which is based on the assumption that
individuals are highly motivated to achieve and maintain a positive self-esteem
within an intergroup context. Consequently, in-group favoritism reflects an indi-
vidual’s motivation to favor and positively distinguish the social groups he or she
identify with from other relevant out-groups.
The Social Identity Development Theory has been currently used as a framework
to explain the development of prejudice among children, mainly with regard to
r acism. According to this theory, racism is derived from a process, which involves
four sequential phases across childhood: (1) The Undifferentiated Phase: children
aged around 2–3 years old cannot categorize people based on their racial cues.
Consequently, they are not able to express any kind of intergroup bias; (2) The
Ethnic Awareness Phase: children of around 3–4 years old begin to be aware of the
existence of social categories that are most salient (e.g. age, gender and race). In this
phase, children develop the ability of self-identification and the sense of belonging
to social groups; (3) The Ethnic Preference Phase: children aged around 5–6 years
old, focus on positive in-group evaluation rather than on out-group derrogation. In
this phase, children begin to show an in-group preference (e.g. a preference for
people from their race); (4) The Ethnic Prejudice Phase: by the age of 7–8 years old
children intergroup evaluations are focused both on in-group and out-group.
Children hold negative out-group stereotypes and discriminate out-group members
when socially permissible.
In an elaboration of Cognitive Developmental Theory (CDT), Brown and Bigler
(2005) proposed a developmental framework for understanding children’s percep-
tions of discrimination directed toward themselves and others. This model is based
on the assumption that children’s perceptions of discrimination are influenced by
different factors: cognitive development (e.g. classification and social comparison
skills), situational contexts (e.g. salience of one’s group identity), and individual
differences. More specifically, this model proposed that by the age of six, children
acquire the basic cultural and social-cognitive skills required to perceive discrimi-
nation. Along with the cognitive maturation during the elementary school years,
children may become more skilled to make attributions to discrimination in differ-
ent contexts. At the end of elementary school (by age ten), children’s perceptions of
discrimination are more complex and similar to that of adults. However, at this age,
children may not be able to perceive societal or more complex forms of institutional
discrimination (e.g., subtle images portrayed in the media or hidden negative prac-
tices in some organizations). Finally, during adolescence, youth is expected to be
able to identify discrimination at both societal and institutional levels.
Rutland et al. (2010), proposed a new socio-cognitive developmental perspective
on prejudice that is drawn from two complementary theories: the social domain
theory (Turiel 1998) and the social identity theory (SIT; Tajfel and Turner 1986).
According to this perspective, the development of prejudice involves the interplay
between moral reasoning (beliefs about fairness and justice) and group identity
(influence of group norms). This means that children consider both moral beliefs
and group identity when reasoning and developing judgments about groups and
individuals. Overall, this perspective highlights the need to consider both social-
cognitive abilities (emergence of moral beliefs) and intergroup context variables
(social context and relationships with others).
Finally, in a further extension of the Social Identity Approach, the Developmental
Model of Subjective Group Dynamics (Abrams et al. 2007; Abrams et al. 2009)
holds that between the ages of 5 and 11 children develop a lay theory of group pro-
cesses, which enables them to calibrate their expression of bias according to which
groups are judged by the audience and by their own level of identity.
The evolutionary perspective, considers that prejudice and discrimination are

inevitable and, consequently, very difficult to change. For example, Fishbein (1996)
argues that humans are predisposed to prefer individuals who are more genetically
similar to themselves. The development of prejudice is therefore associated with the
development of a group identity at early ages (3/4 years old).
Beyond race, research on the development of prejudice has often focused on sex-
ism or gender-related prejudice – “prejudice attitudes (…) based on gender-related
categorization of people” (Glick and Hilt 2000, p.7). According to these authors,
gender-related prejudice develops and is expressed differently according to a devel-
opmental sequence – Between early childhood (2–3 years old) and puberty (around
the age of 11), children prefer to play with same-sex peers, showing hostile feelings
and beliefs toward out-group members. This hostile prejudice is expressed through
overall negative emotional evaluations of the other sex and is based on a simple
cognitive reasoning. A different pattern is found among adolescents whose greater
cognitive abilities, emotions and sexual attraction to other-sex individuals results in
a more ambivalent form of gender-related prejudice, which is characterized by
paternalistic beliefs: woman are viewed as romantic objects who are also weak and
need men’s protection. These two different kinds of prejudice – hostile and benevo-
lent – may coexist during adulthood, creating ambivalent attitudes and influencing
adult cross-sex interactions. The important point, however, is that prejudice should
become more multi-faceted with age.
Regarding the specific case of ageism, studies are scarcer but an important review
of this field (Montepare and Zebrowitz 2002) presented some evidence. Some stud-
ies (e.g. McCall and Kennedy 1980) suggest that children are influenced by salient
age cues at a very early age. In fact, children as young as 4 months differentially
look at pictorial representations of faces of people of different age groups. In this
chapter, Montepare and Zebrowitz (2002) advanced a hypothesis regarding the
expected development of ageist beliefs in children based on a social-developmental
perspective. According to this theory, children’s social perceptions require the cat-
egorization of people on the basis of their age-related physical characteristics
(height, face and voice cues) that are used to distinguish and classify people. Later
in development, children’s attitudes are reflected in three types of outcomes: preju-
dice (children’s feelings toward older adults), stereotypes (children’s beliefs and
knowledge about older persons) and discrimination (children’s intended or actual
behaviors toward older persons).These different dimensions may involve different
developmental paths. In early childhood, attitudes are mostly expressed through
(negative) affective reactions toward older people. Meanwhile, children develop
systematic behavioral stereotypes that become more complex as a function of their
cognitive development. In middle childhood, children’s attitudes toward older peo-
ple become more positive and differentiated and this continues throughout adoles-
cence and adulthood.
Montepare and Zebrowitz (2002) do not elaborate much on these initial proposi-
tions. Hence, much more attention needs to be devoted to evidence and theory. For
instance, although some insights may be gained from previous studies on racism
and sexism, we would be cautious about generalizing across domains. In fact,
e vidence so far, seems to suggest that different patterns of development and pro-
cesses occur in different types of prejudice. For example, there are different theories
specifically regarding the development of racism (e.g. Olson and Dunham 2010)
and sexism (e.g. Glick and Hilt 2000). In the case of racism, research has focused
on the role of the anti-racism norm and its influence on implicit and explicit preju-
dice in different stages of childhood. Studies suggest that the explicit expression of
racism decreases as children get older, mainly due to conformity to a strong social
anti-racism norm (Olson and Dunham 2010; Rutland et al. 2010). On the other
hand, theories about the development of sexism are based on the assumption that
gender-related prejudice exists throughout life assuming different forms according
to the developmental stages (hostile vs. benevolent sexism) (Abrams 1989; Glick
and Hilt 2000). These observations highlight the need to consider the distinctive
features of each type of prejudice. However, we also assume the existence of core
developmental processes. In this regard, Olson and Dunham (2010) suggest that the
distinction between more implicit or explicit forms of prejudice is fundamental to
understanding the patterns of development across childhood. Hence, similarly to
what had been done in the case of racism, it would be important to understand how
these two different modes of ageism operate across different age groups and to
address the role of social-environmental factors such as the anti-ageism norms.
Studies such as these would represent a very important contribute to this field of
research.
We therefore aim to progress the field by reviewing the existing literature and
providing a framework for systematic evidence from relevant studies in the litera-
ture. We present a classification of the main measures of ageism in children based
on two main criteria: (i) the dimensions covered – cognitive, affective and behav-
ioral (tripartite model of attitudes) and (ii) the four aspects of automaticity (con-
sciousness, controllability, intentionality and efficacy). Together these allowed
classifying measures into three categories: explicit/implicit and blend of explicit
and implicit measures. We hope that this classification contributes to our knowledge
regarding the development of attitudes towards older people.
30.3 Goals and Method of the Present Study
A literature review was undertaken using four databases (PsycARTICLES,

PsycINFO, ERIC and Psychology and Behavioral Sciences Collection) and a com-
bination of two groups of keywords – children AND ageism (n = 135); children
AND attitudes AND ageing (n = 1257). Studies were considered in this review if
they comply with the following inclusion criteria: (1) reported the use of measures
to assess children’s or adolescents’ (under 18 years old) attitudes toward older peo-
ple and/or the ageing process. (2) measured children’s attitudes without any previ-
ous manipulation. Our goal was to explore studies measuring attitudes in their
original form. Therefore, we excluded studies that employed interventions or exper-
imental manipulations.
Of the 1392 articles identified, 171 were duplicated and were therefore excluded.
This search allowed us to identify 10 articles that focused specifically on the assess-
ment of children’s attitudes regarding older people and that met the inclusion and
exclusion criteria. Subsequently, the reference lists from the identified studies were
also consulted allowing us to locate 6 additional articles. Therefore, a total of 16
articles were subjected to a deeper analysis. These included both quantitative, quali-
tative or mixed methods.
30.4 What Is Being Measured
30.4.1 Cognitive, Affective and Behavioral Measures
We analyzed the available measures to assess children’s attitudes based on the tri-
partite model (Eagly and Chaiken 2007), therefore considering their beliefs, feel-
ings and behavior regarding older people and/or the ageing process. The cognitive
dimension was mostly assessed through four scales: “Kogan’s Attitude Toward Old
People Scale” (Ivester and King 1977); “Social Attitude Scale of Ageist Prejudice”
(SASAP – Isaacs and Bearison 1986); “Tuckman-Lorge Old People Scale (OP –
Harris and Fiedler 1988); and the “Child Adolescent Facts in Ageing Quiz”
(CAFAQ – Haught et al. 1999). This quantitative approach is based on the assump-
tion that through the use of scales with different methodological characteristics (e.g.
Likert-type; dichotomous response) one can assess children’s knowledge, beliefs
and stereotypes associated with older people and the ageing process. For example,
the “Kogan’s Attitude Toward Old People Scale” (Ivester and King 1977) is a
Likert-type instrument (34 items) for assessing adolescent’s attitudes toward old
people with respect to both norms and individual differences (e.g. “Most old people
get set in their ways and are unable to change.”). Stereotypes and misconceptions
about different areas of older people’s lives (e.g. personality characteristics; social
adjustment) were also assessed through the use of the Tuckman-Lorge Old People
Scale (OP – Harris and Fiedler 1988), in which participants were asked to circle
“yes” or “no” for each of the 137 statements about old people (e.g. “They are unpro-
ductive.”). A very similar method was used in the “Child Adolescent Facts on
Ageing Quiz” (CAFAQ – Haught et al. 1999). However, in this case, children’s and
adolescent’s attitudes were assessed through 16 items using a true/false format (e.g.
“Most older workers do not work as well as younger workers”). All these instru-
ments have in common the idea that children’s attitudes are best assessed by asking
children about their representations regarding specific stereotypic traits of older
people.
A different approach was used in the “Social Attitude Scale of Ageist Prejudice”
(SASAP – Isaacs and Bearison 1986) in which the categories of young and old were
visually represented by photographs of a middle-aged person (35–50 years old) and
of an aged person (70–85 years old). Children were then asked to select the picture
of the person that they regard as the recipient of either positive (e.g. “One of these
people is always invited to all parties because everyone likes him. Which person
does everyone like?”) or negative social events (“These two men are arguing. One
of them is nasty and always yells at people. Which one is nasty?”) (46 items). Beliefs
and stereotypes regarding older people and the ageing process have also been
assessed using a sentence completion task (Lichtenstein et al. 2003), by asking chil-
dren to write responses to five prompts (e.g. “Old people…”; “When I am old I…”).
The affective dimension has been mostly assessed through indirect measures,
particularly the drawing test. This technique is based on the assumption that through
drawing, children share their internal world of experiences (Lichtenstein et al.
2005). In the studies using this approach, different methodologies have been
adopted. In some studies children were asked to draw a typical older person in a
setting (e.g. Lichtenstein et al. 2005). Other studies specified that the drawn person
should be an old person that children know from real life (Robinson et al. 2014),
making the task more self-relevant to the children. Still other studies asked children
to simply draw human figures of different ages (young/old from both genders) (e.g.
Villar and Fabà 2012).
In some of this research (e.g. Lichtenstein et al. 2005), interviews were used as a
complementary methodology in order to elicit oral or written responses to obtain
more detailed information regarding the pictures drawn (e.g. person’s age, activi-
ties, feelings, thoughts, possible relation to the child, person’s characteristics that
differ from those of the child). All the studies identified using this methodology
aimed to cover both the cognitive and affective dimensions of children’s attitudes
regarding older people based on the analysis of several dimensions: height of the
drawings, physical characteristics (e.g. wrinkles), activity level (e.g. wheelchairs),
health status (e.g. hearing aids), personality, roles, settings, facial expression, emo-
tions and also on children’s responses on the interview.
Children’s knowledge and feelings toward older people and the ageing process
were also assessed through the use of two qualitative methods: a word association
task (brainstorm about words associated with the concept of “young” and “old) and
an attitude toward-ageing interview (e.g. “What do most old people spend their time
doing?”) (Laney et al. 1999).
A very different approach has been used to assess the behavioral dimension of
children’s attitudes. We found two studies measuring children’s behavior toward
older people, both sharing similar methodology. These are based on personal inter-
actions between children and older people. For example, in order to explore whether
children as young as 4–8 years old already express negative stereotypes about older
people, Isaacs and Bearison (1986) developed a behavioral measure based on a
puzzle activity task (n = 144): in the experimental condition, each child worked
individually with an older person (approximately 75 years) and in the control group
the puzzle activity was performed by dyads of a child and a non-aged person
(approximately 35 years). Children’s attitudes regarding older people were assessed
based on the scores on behavioral measures: proxemics distance (the distance
between the confederate’s chair and the child’s placement of his or her chair); pro-
ductivity (number of puzzles pieces placed); eye-contact initiation (number of times
children directed their gaze toward the confederate); verbal interaction (e.g. number
of words spoken by the child). In the other study using a behavioral methodology
(Kwong See et al. 2012), the Piagetian number conservation task was modified to
assess young children’s age stereotyping. This was done by manipulating the per-
ceived age of the experimenter (younger and older) asking the second question. This
task was based on the assumption that children held different beliefs about the moti-
vations of the two experimenters for asking the second question.
Finally, very few studies have assessed all three dimensions of children’s atti-
tudes (cognitive, affective and behavioral). As far as we know, only two instruments
attempted to achieve this goal: “The Children’s Attitudes toward the Elderly Scale”
(CATE) (Jantz et al. 1977) and the “Children’s View on Aging” (CVOA) (Marks
et al. 1985). The CATE (Jantz et al. 1977) is composed by three sub-scales: (1) word
association questions regarding the affective (e.g. “How do you feel about getting
old?”), behavioral (e.g. “What do you do with that person?” – referred to the older
person the child knew) and knowledge (e.g. “What can you tell me about older
people?”) dimensions of attitudes; (2) semantic differential composed by ten items
on a five-point bipolar scale rating the two concepts “young people” and “old peo-
ple” (e.g. “friendly-unfriendly”); (3) picture series: four drawings representing men
at four stages of life were presented to children to elicit responses about their knowl-
edge and feelings regarding older people and the ageing process (e.g. “Can you put
these pictures in order from the youngest to the oldest?”).
The CVOA (Marks et al. 1985) includes four sections with open-ended ques-
tions: (1) children are asked to think about becoming an old person and to answer
nine open-ended questions covering the three dimensions of their perceptions of the
ageing process: cognitive (“How can you tell when people are growing old?”);
affective (“How will you feel when you are old?”) and behavioral (“What will you
do when you are old?”). These questions were followed by a close-ended question:
“Do you think this is: (a) a good thing to happen?; (b) a bad thing to happen?; (c)
neither a good or bad?”; (2) children are asked for information regarding the fre-
quency and quality of contact with their grandparents; (3) children are asked about
having an older person in the classroom (e.g. “Would you like having an old person
in your classroom as a helper?”); (4) using a semantic differential scale composed
by twelve bipolar word pairs children are asked to indicate what characteristics they
attribute to older people (e.g. “pleasant-unpleasant”).
Despite the useful effort to cover the three dimensions of children’s attitudes,
both scales (CATE and CVOA) share a common limitation – they represent an over-
lap of two different attitudinal objects: children’s attitudes about older people and
about the ageing process. The attempt to measure two different constructs simulta-
neously should be taken into consideration when analyzing the results obtained to
assess ageism among children. Moreover, both scales are also limited in their mea-
surement of the behavioral dimension of ageism in the sense that they only evaluate
the behavioral intentions of children regarding older people and not their actual
behaviors as it was done in other measures such as the puzzle (Isaacs and Bearison
1986) and the Piagetian adapted task (Kwong See et al. 2012). These aspects limit
the value of the results obtained by the use of these measures.
30.4.2 Explicit vs. Implicit Measures
In order to organize the literature regarding children’s attitudes towards older peo-
ple, we propose an alternative way to look at the measures and evidence. As far as
we know, this is the first time such a classification has been proposed in order to
classify children’s attitudes in the case of age. Based on the definition of measure as
an “outcome of a measurement procedure” (De Houwer 2006), and following previ-
ous approaches in other domains (Maass et al. 2000), we present a framework for
classifying children’s attitudes measures into three categories: explicit measures,
both explicit and implicit measures and implicit measures.
Intergroup attitudes have been mainly measured through self-report question-
naires to assess participant’s attitudes regarding their in-group and out-groups mem-
bers. However, there are some concerns regarding the validity of these measures
because people can easily control their explicit responses and act in order to comply
with social norms, making prejudice less likely. Consequently, implicit measures
have been increasingly used in order to reduce participant control over responses
(Maass et al. 2000). This is based on the assumption that participants cannot strate-
gically control the outcome of the implicit measurement procedure (De Houwer
2006).
The classification of the measures into the three categories mentioned above
(Fig. 30.1) was based on the following four automaticity features: (1) intentionality
Intentional Unintentional
Conscious Unconscious
Non efficient Efficient
Controlled Uncontrolled
Explicit Measures
Both Explicit and Implicit
Kogan´s Attitude Toward Measures Implicit Measures
Older People Scale (Ivester &
CVOA (Marks et al., 1977). Drawing Test (e.g. Falchikov,
King, 1977)
1990).
Tuckman-Lorge Old People CATE (Jantz et al., 1977).
Word association/Drawing
Scale (Harris and Fiedler, 1988)
Image identification Test/Interview (Laney et al.,
CAFAQ (Haught et al., 1999) (Seefeldt et al., 1977). 1999).
Sentence Completion SASAP (Isaacs and Behavioral measure (e.g.

(Lichtenstein et al., 2003) Bearison, 1986). Kwong See et al., 2012)
Fig. 30.1 Categorization of measures to assess children’s attitudes regarding older people accord-
ing to the automaticity features
(whether one is in control over the instigation or “start-up” of processes); (2) aware-
ness (one person can be aware of a stimulus event but also of its potential influence
on subsequent experience and judgments); (3) efficiency (effects that are relatively
effortless) and (4) controllability (one’s ability to stifle or stop a process once
started) (Bargh 1994). These automatic features do not necessarily occur together in
the sense that automatic processing is not unitary. In fact, they are independent
qualities that may appear in various combinations.
Explicit measures are more deliberative, mindful, and easily controlled (Maass
et al. 2000). An example of an explicit scale is the Tuckman-Lorge Old People Scale
(OP) (Harris and Fiedler 1988), in which participants were asked to circle “yes” or
“no” for each item regarding misconceptions and stereotypes about old people (e.g.
“They are unproductive”..”). In this case, the process is intentional because partici-
pants have the goal of engaging in a process, are aware of the stimulus (older per-
sons), the process itself is nonefficient (it requires attentional capacity and time to
answer the 137 items) and controllable in the sense that participants can stop the
process at any time.
By contrast, implicit measures are automatic because they are more uninten-
tional, efficient, non-conscious and uncontrolled (Bargh 1994). An example of an
implicit measure is the puzzle activity task described above (Isaacs and Bearison
1986). Behavioral measures aim to create experimental situations that parallel con-
texts of daily life and to observe participant’s interpersonal behavior (Maass et al.
2000). In the case of the puzzle activity, children in the experimental setting were
not aware of what was being measured (their behavior toward older confederates)
and, consequently, had little or no control of their own thoughts and behaviors.
Moreover, the process is efficient in the sense that it requires minimal attentional
capacity and is not time consuming.
The third category includes measures that are a blend of both explicit and implicit
questions. An example is the CATE scale (described above) which is constituted by
more explicit sub-scales (word association questions and semantic differential) and
more implicit ones (picture series based on drawings representing men at four stages
of life).
The classification of the measures into these three categories facilitates the inter-
pretation of the complex pattern of results that emerged from the use of different
instruments to measure children’s attitudes regarding older people.
30.5 Analyses of Children’s Attitudes Through Different

Measures and Across Different Stages of Childhood
30.5.1 Explicit and Mixed Measures
Studies using explicit measures or a combination of both explicit and implicit mea-
sures revealed more positive or mixed children’s views of older people in compari-
son with those adopting an implicit approach. Explicit measures have predominantly
assessed the cognitive dimension of children’s attitudes. Despite some variability,

the most positive results were found in studies assessing children’s attitudes in late
childhood (8–10 years old) (e.g. CVOA) and in the adolescence period (13–19 years
old) (e.g. Kogan’s Attitude toward Older People Scale; Ivester and King 1977). For
example, in a study using the “Child-Adolescent Facts on Ageing Quiz” (CAFAQ –
Haught et al. 1999), children’s knowledge and beliefs regarding older people were
assessed through sentences on basic physical, mental and social facts about ageing.
Adolescents (grade 12) showed positive attitudes whereas younger children (grade
3) showed a negative bias toward this age group. Younger children’s misconceptions
about older people were mainly focused on two dimensions: competence (not work-
ing as well as younger people) and social skills (being nice to other people).
The application of two scales that blended both explicit and implicit measures –
the “Children’s Attitudes Toward the Elderly Scale” (CATE – Jantz et al. 1977) and
the “Children’s View on Aging (CVOA – Marks et al. 1985) revealed a more com-
plex pattern of results. More specifically, the CATE was applied to children aged
between three and 11 years old and revealed that children’s attitudes toward older
people were mixed. In affective terms, their descriptions of older people tend to be
positive (e.g. “they are nice”; “friendly”; “wonderful”). However, the inverse pattern
was observed regarding attributes of older people’s physical (e.g. “ugly”) and
behavioral characteristics (e.g. “they can’t really walk very fast”). Moreover, chil-
dren’s attitudes regarding their own ageing process tended to be negative (e.g. “I
don’t want to get old”), ascribing negative feelings to old age (e.g. “sad”;
“depressed”). Nevertheless, older children (fifth and sixth graders) were the most
positive about their future as older persons.
Some of these results are in line with those obtained through the application of
the “Children’s Views of Ageing” (CVOA – Marks et al. 1985), namely the negative
perception children hold regarding their own ageing process (“you are sad”; nobody
cares”). Responses in the semantic differential scale highlighted the positivity
attributed to older people in the affective dimension, while young people were eval-
uated more positively based on the cognitive domain. In this study, children attrib-
uted negative characteristics to older people at both physical and psychological
levels (e.g “lonely”; “scary”; “people no longer care about you”). However, chil-
dren also showed positive behavioral intentions expressing motivation to interact
with old people in their classrooms. It is nevertheless important to emphasize that
children tested in this study were already 8–10 years old.
Taken together, these results suggest that, although some evidence shows that
views of ageing tend to become more positive as children grow older, at least based
on more explicit measures (e.g. Haught et al. 1999) a mixed and complex pattern of
results still occurs depending on the dimension being assessed. Overall, it seems
that children are more positive when we assess explicitly affective and behavioral
aspects instead of cognitive representations of older people. Children also seem to
be more negative when they are considering their own ageing process as opposed to
making judgments about older people. However, the most important finding to
emerge is the fact that these sort of explicit measures do not yield a significant and
consistent pattern of results. One possibility is that, similar to what happens in other
domains such as, for instance, racism, older children are able to control their answers
and show ageistic intentions in a more strategic manner depending on task domain,
thus limiting our ability to measure their more intrinsic attitudes (Olson and Dunham
2010). Given this complex pattern of results, attention to the type of procedure used
and the dimensions covered in the measurement of children’s attitudes should be
given wider attention than has been so far.
30.5.2 Implicit Measures
Ageism among children has been consistently found in studies using implicit mea-
sures. For example, in a puzzle activity task (Isaacs and Bearison 1986), four-, six-
and eight-year old participants distinguished aged from nonaged individuals and
responded differently to them. More specifically, participants in the experimental
condition (those working individually with an older person) initiated less eye con-
tact, spoke less to confederates, initiated less conversations with them and required
less appeals for assistance or verification. Interestingly, results showed an increase
in ageism between the ages of 4 to 6/8 years, with a decrease in the amount of eye
contact in the aged confederate experimental condition, thus contradicting the pat-
tern found with more explicit measures.
In another study, Kwong See et al. (2012) used a modified Piagetian number
conservation task in order to assess interpersonal relationships between children
and older people. In its original form, a child is asked if two aligned rows of
objects have the same number of objects or if one of the rows has more. After the
child agrees regarding the equality of the lines, the experimenter makes one of the
lines longer and the child is then asked a second time if the two rows have the
same number of objects or if one of the rows has more. According to the Piagetian
theory, the second time asked, preoperational aged children (with an age between
4 and 7 years old) usually answer that the rows are different in the sense that they
cannot conserve number. However, a different interpretation is provided by the
conversational account for conservation errors according to which asking the
same question twice is usually interpreted as a request for new or different infor-
mation. Based on this assumption, Kwong See et al. (2012) hypothesized that
when an adult experimenter asks if the two rows are the same a second time, a
child infers that the experimenter wants to know if he/she is aware of the percep-
tual modification that has occurred. In this case, children are expected to consider
that the experimenter is more cognitive capable by virtue of being an adult and
therefore must know that the transformation did not change the number of objects
in the line and is asking about something else. An opposite pattern of response is
expected to occur when the experimenter is an older person: in this case, age ste-
reotyping (e.g. poor vision or memory, cognitive impairments) is expected to
become associated with the question asked by the experimenter. Thus, children
might infer that the older experimenter is asking the second question because he
needs to clarify if the number of objects in the rows is truly the same. As predicted
by the authors, children held different beliefs about the motivations of the two
experimenters and gave different answers according to these beliefs. When the
experimenter was a younger adult, the majority of children gave an answer
focused on length rather than number. The opposite pattern was found in the older
adult experimenter condition, therefore highlighting the similarity of the rows.
These results showed that children as young as 5 years old have already internal-
ized age stereotypes believing that ageing is associated with decline. Unfortunately,
this study did not include older children so we can not reach any conclusions
regarding this aspect.
In another study using three qualitative and implicit methods – word association
task, projective drawings and an attitude toward-ageing interview –first and second
grade-students showed negative attitudes toward older people and the ageing pro-
cess (Laney et al. 1999). More specifically, in the word association task, the words
associated with “old” were mostly negative at different dimensions: psychologically
(e.g. “weak”), mentally (e.g. “bored”), and low levels of activity (e.g. “retired”).
The opposite pattern was found regarding young people who were characterized in
a positive way (e.g. “happy”; “active”). Children’s drawings depicted older persons
performing sedentary and passive leisure activities (e.g. “watching out window;
“watching TV”). In addition, drawings revealed the physical characteristics attrib-
uted to older people (e.g. “gray hair”; “wrinkles”). This negative view of older
people was also evident in children’s responses to the interview: they considered
that older persons perform passive activities (e.g. lying in bed”) and need help from
young people because they are physically disabled and/or sick. In addition, children
expressed negative attitudes regarding the ageing process (e.g. “the body quits
working”) associating ageing with the “imminence of death”.
Older children’s (ages between 10.5 and 11.5 years) attitudes regarding older
people were assessed through a comparative analysis of children’s four drawings: a
young man, an old man, a young woman and an old woman (Falchikov 1990).
Results revealed that pictures of old people were more negative in content than
those of young people, revealing a clear association between old age and a lack of
human contact and loneliness. Drawings of old people frequently included charac-
ters such as glasses, wrinkles, canes or wheelchairs, hearing aids and slippers.
Moreover, these pictures were significantly smaller than those of young people.
From the analyses of the literature, the only case in which the use of implicit
measures yielded more positive views of ageing by children was when they were
asked to draw older people in greater detail (e.g., within different scenarios).
Specifically, in a study where students from two middle schools were asked to draw
a typical older person in a setting (Lichtenstein et al. 2005), the drawings demon-
strated the great variability of children’s attitudes regarding older people, including
both positive and negative traits. The most positive drawings were those depicting
someone relevant to the students, namely a grandparent. The relevance of asking
children to draw someone they knew was also shown in a study where children
between the ages of eight and 12 were asked to produce a drawing of an old person
they see in real life (in a setting) (Robinson et al. 2014). Overall, the drawings por-
trayed an older person (namely, a family member) who was “happy, healthy, active
and with positive physical characteristics”. Hence, these results suggest that chil-
dren have a more positive view of older people that they know in their daily lives
such as their grandparents. The target used to assess ageism against older people
should be then carefully chosen.
Given their more consistent pattern of results, implicit measures seem like an
interesting avenue to pursue in the study of children’s attitudes regarding older peo-
ple. In this sense, it would be extremely important to understand how more implicit
and explicit attitudes develop throughout childhood and what are the main factors
influencing these different aspects of ageism. A more complete and valid assess-
ment of ageism during childhood would have many important implications to pro-
mote more meaningful prevention efforts against the wide negative representations
of older people in our societies.
30.5.3 Limitations of Available Measures
We identified a range of measures that have been employed to assess children’s

attitudes regarding older people (summarized in Table 30.1). Although there is a
reasonably large volume of work produced in this domain, it is nevertheless difficult
to reach a firm conclusion of the developmental trajectory of ageism in children. In
fact, a more thorough analysis of the measures used clarifies that they have impor-
tant limitations that need to be overcome in the future.
The first limitation is the lack of psychometric consistency that is particularly
relevant in the case of some studies (e.g., Harris and Fiedler (1988); Haught et al.
(1999)). The lack of information about psychometric indicators (e.g. validity, reli-
ability) jeopardizes the possibility of reaching conclusions about the meaning of
these measures. Secondly, there is frequently an ambiguity or inconsistency in the
attitudinal object that is measured. In some measures, there is an overlap of two dif-
ferent attitudinal objects: children’s attitudes about older people (e.g., “what do you
think about older people?”) and the actual ageing process (e.g., “how do you per-
ceive your own ageing will be?”) (e.g. Jantz et al. 1977). This makes it difficult to
compare the results obtained across the different studies. Third, most of the mea-
sures only provide a partial assessment of children’s attitudes. As we have seen,
several of the measures identified covered only the cognitive dimension of chil-
dren’s attitudes (their knowledge and beliefs regarding older people and/or the age-
ing process) (e.g. Issacs and Bearison (1986)), disregarding with few exceptions the
affective and behavioral dimensions of attitudes. Given the fact that older children
are more able to control their answers to these sorts of measures (Olson and Dunham
2010), it is important to diversify the methodologies used.
Further important limitation of integrating evidence from measures are attributed
to the poor and incomplete description of the participants in the studies (i.e., age and
grade level), the considerable variability of age range and low sample sizes (e.g.
Falchikov 1990; Lichtenstein et al. 2005). This lack of transparency in the method-
ological affects the quality of the conclusions that may be drawn from such studies.
Table 30.1 Description of measures that assessed ageism among children
Originally
Dimensions developed to be
Authors Country Methodology Participants Main findings of ageism applied with: Psychometric qualities
Explicit measures
Harris and EUA The Tuckman-Lorge Old People Sample size: The quantity of contact Cognitive Originally Not specified.
Fiedler (OP) Scale (1953) is a n = 157 preadolescents reported to spend developed to be
(1988) questionnaire composed by 137 with older persons was not applied with
statements of misconceptions and significantly related with their adults
stereotypes about older people attitudes. (Tuckman and
covering a total of 13 categories Lorge 1953).
(e.g., physical, mental
deterioration). Participants were
asked to circle “yes” or “no”
according to their agreement to
each sentence (e.g. “Old people
need glasses to read”).
Participants also answered a Participant’s age: Regarding race, white Adapted to be
self-report contact questionnaire Mean age of 12.8 preadolescents expressed the used with
(quantity of time spent with an years most positive attitudes toward preadolescents.
older person in the past year). older people in comparison with
the black or Mexican-American
preadolescents.
Originally
Ivester and EUA Kogan’s Attitude Toward Older Sample size: n = The results showed that the Cognitive Originally Demonstrated
King (1977) People Scale is a likert-type 413 attitudes of the students toward developed to be reliability and validity
instrument constituted by 34 items old people tend to be more applied with (Kogan 1961):
aiming to assess attitudes toward positive than negative. adults (Kogan -Odd-even reliabilities
old people regarding both norms 1961). ranging from .66 to .83
and individual differences. The 34 with the negative scale
items are 17 matched positive- having higher reliability.
negative pairs which reflect Participant’s age: Besides, there weren’t significant Adapted to be - Good content
stereotypes and feelings about old 13–19 years old differences between negative used with validity: significant
people in society (e.g. “residential attitudes toward older people adolescents. correlations between
aspects of old people’s lives,” “the from 12th and 9th graders. OP scale scores and
extent to which old people vary attitudes toward ethnic
among one another”). minorities and
physically disabled
groups.
Haught et al. EUA “The Child-Adolescent Facts on Sample size: n = A different pattern of results was Cognitive The “Facts on Not specified
(1999) Ageing Quiz” (CAFAQ) is the 954 (three found according to participant’s Aging Quiz”
adaptation of the “Facts on Aging separate age: adolescents (grade 12) (FAQ) was
Quiz” (FAQ – Palmore 1977) to be experiments) showed positive bias regarding developed to be
applied to children and adolescents. older people; however, used with adults
This scale is constituted by school-age children (grade 3) (Palmore 1977).
statements on basic physical, mental, showed negative bias regarding
and social facts about aging and this age group.
common misconceptions that people
have about aging. Students had to
mark the 16 items as “true” or “false”
(e.g. “Most older workers do not
work as well as younger workers”).
(continued)
Originally
Participant’s age: Female adolescents showed CAFAQ is the
Grades 3, 6, 9 more positive bias in comparison adaptation of
and 12. with male adolescents. this scale to be
Hispanic adolescents tended to used with
show more negative bias than children and
White or Black adolescent adolescents.
students.
Lichtenstein EUA Prompts were presented to students Sample size: The most part of student’s Cognitive Children Test-retest repeatability
et al. (2003) and they were asked to write n = 1874 descriptions of older persons were in the pilot phase of the
responses (e.g. “Old is…”; “When based on physical characteristics: project: the responses
I am old I…”). wrinkles, gray hair or being bald. were not repeatable
Participant’s age: Students had a much more from Time 1 and to
Children from positive view of their future Time 2.
6°, 7° and 8° compared with their views about
grades other’s ageing process.
Both explicit and implicit measures
Jantz et al. EUA The CATE – “The Children’s Sample size: Children’s attitudes toward older Cognitive Children 1.sub-test: word
(1977) Attitudes Toward the Elderly n = 180 people are complex and mixed. association Coefficients
Scale” is composed by four They expressed positive feelings of inter-rater reliability
sub-scales: toward older people (e.g. “They (2 raters) on category
are nice”) but have negative scoring for the sub-test
attitudes about the physical (e.g. ranged from .7977
“ugly”) and behavioral to .9838.
characteristics associated with
older persons (e.g. “They can’t
really walk very fast, they are
not very strong”).
Originally
1. Word association questions Participant’s age: Children have few contacts with Affective 2. semantic differential:
regarding the affective, behavioral 3–11 years old older people outside of their the evaluative adjectives
and knowledge components of families. had obtained high factor
attitudes (e.g. “How do you feel loadings through other
about getting old?”). investigations into how
children in grades two
through seven rated more
than 100 concepts.
2. Semantic differential composed Children’s attitudes regarding Behavioral 3. picture series:
by 10 items on a 5 point bipolar their own ageing process tended validation of the
scale rating the two concepts to be negative (“I don’t want to drawings was established
“young people” and “old people” get old”), ascribing negative by asking graduate
(e.g. “friendly-unfriendly”). feelings to be old (e.g. “sad”; students in the fields of
“depressed”). gerontology and human
3. Concept of age sub-test: four The older children were the most development to rate each
drawings representing men at four positive about being old. drawing by giving it an
stages of life were presented to estimated age.
children to elicit responses about
their knowledge and feelings
regarding older people and the
ageing process (e.g. “Can you put
these pictures in order from the
youngest to the oldest?”).
4. This sub-test was administrated
together with three Piaget-based
conservation tasks from the
Goldschmid and Bentler Concept
Assessment Kit.
(continued)
Originally
Marks et al. EUA The Children’s Views of Aging Sample size: n = In the open-ended questions, Cognitive Children Concurrent validity
(1985) (CVOA) is an instrument aimed to 256 mostly of the children described coefficient of the
assess children’s attitudes toward negatively older people at both semantic differential:
older people and the ageing physical and psychological level 0.64;
process. It’s constituted by 4 (e.g. “lonely”, “scary”, “people
sections with a variety of no longer care about you”).
open-ended questions: Regarding their own aging
process, children also revealed a
negative perception of their
future (e.g. “you are sad”;
“nobody cares”).
Section 1: children are asked to Participant’s age: A different pattern was found Affective Test-retest reliability
think about becoming an old 8–10 years old regarding behavioral intentions, coefficient of the semantic
person and to answer nine suggesting children’s desire to differential = 0.70;
open-ended questions regarding interact with old people in their
their perceptions of aging (e.g. classrooms.
“How they will feel when they are
old”). These questions are followed
by a close-ended question: “Do you
think this is: (a) a good thing to
happen?; (b) a bad thing to
happen?; (c) neither a good or
bad?”.
Originally
Section 2: asks for information In the semantic differential scale, Behavioral The alpha (internal
regarding the frequency and nature old people were evaluated more consistency) coefficient
of children’s contact with their positively than young people on of the semantic
grandparents. the affective dimension, while differential was 0.81.
Section 3: Asks the child questions young people were evaluated
related to having an older person in more positively on cognitive
the classroom (e.g. “Would you like dimension.
having an old person in your
classroom as a helper?”).
Section 4: Semantic differential
scale composed by twelve bipolar
word pairs that describe
characteristics of older adults and
asks the child to indicate what
characteristics they attributed to
older people (e.g.
“pleasant-unpleasant”).
Newman EUA The Children’s Views of Aging Sample size: n = When describing older people, Cognitive Children Not specified
et al. (1997) (CVOA) is an instrument aimed to 71 children often referred physical
assess children’s attitudes toward characteristics (e.g. “graying
older people and the ageing hair and wrinkles”) without
process. It’s constituted by 4 attributing a value on these
sections with a variety of characteristics.
open-ended questions:
(continued)
Originally
Section 1: children are asked to Participant’s age: When asked to describe how it Affective
think about becoming an old 4th and 5th would feel to be old, almost half
person and to answer nine grades of them describe negative
open-ended questions regarding conditions commonly associated
their perceptions of aging (e.g. with old age (e.g. “lonely”;
“How they will feel when they are “sad”).
old”). These questions are followed Behavioral
by a close-ended question: “Do you
think this is: (a) a good thing to
happen?; (b) a bad thing to
happen?; (c) neither a good or
bad?”.
Section 2: asks for information
regarding the frequency and nature
of children’s contact with their
grandparents.
Section 3: Asks the child questions
related to having an older person in
the classroom (e.g. “Would you like
having an old person in your
classroom as a helper?”).
Section 4: Semantic differential
scale composed by twelve bipolar
word pairs that describe
characteristics of older adults and
asks the child to indicate what
characteristics they attributed to
older people (e.g.
“pleasant-unpleasant”).
Originally
Issacs and Not Social Attitude Scale of Ageist Sample size: The mean scores of the youngest Cognitive Children Reliability = .87
Bearison specified Prejudice (SASAP): n = 144 group (4-years old) did not
(1986) indicate prejudice.
Children were shown pairs of Participant’s age: The frequency of prejudicial Validity = item-
photographs, one of a middle-aged 4, 6 and 8 years responses increased significantly remainder Alpha scores
person (35–50 years) and the other old from this age group to 6 years ranged from .65 to .70.
of an aged person (70–85 years) but remained stable between 6
and were asked to select the picture and 8 years. At these ages,
of the person that they regarded as participants showed significant
the recipient of either positive or prejudice against older people in
negative social events (46 items). their SASAP scores.
Example of a positive stated event:
“One of these people is always
invited to all the parties because
everyone likes him. Which person
does everyone like?”;
The stated events included
statements about a person’s
personality traits or abilities.
Seefeldt EUA Children were presented with four Sample size: The majority of the children Cognitive Children Interrater reliability = .99
et al. (1977) pictures of one man drawn to n = 180 (69%) were able to place the
represent four different stages of pictures in correct sequential
life (ages 20-35, 35-50, 50-65, and order. By the first grade they
65-80). demonstrated an understanding
of relative age.
An individual structured interview Participant’s age: Children expressed negative Affective
was conducted in order to assess 3–11 years old attitudes toward the physical Behavioral
the three components of children’s characteristics of the image of
attitudes toward older people and the oldest man (e.g. wrinkles)
the ageing process: cognitive, and toward their own ageing
affective and behavioral. process.
(continued)
Originally
Implicit measures
Laney et al. EUA Children’s attitudes about older Sample size: In the word association task, the Cognitive Children Not specified
(1999) people and the ageing process were n = 20 words associated with “old”
assessed using three instruments: were mostly negative at different
dimensions: physiological (e.g.
“weak”), mental (e.g. “bored”),
and low levels of activity (e.g.
“retired”). The opposite pattern
was found regarding young
people who were characterized
in a positive way (e.g. “happy”).
1. Word association task: Participant’s age: Children’s drawings depicted Affective
brainstorm of words associated 1st and 2nd older persons performing
with two concepts: “young” and graders sedentary and passive leisure
“old”. activities (e.g. “watching out
window”). Besides, the drawings
revealed the physical
characteristics attributed to older
people (e.g. gray hair; wrinkles).
2. Children’s human figure In the interview, children
drawings: children were asked to expressed a negative attitude
draw a picture of an old person and regarding the ageing process
a young person. The students were (“the body quits working”).
individually interviewed regarding Children considered that older
the content of their drawings. persons perform leisure activities
3. Students were orally interviewed (e.g. “lying in bed”) and need
using an attitude-toward-aging help from young people.
questionnaire (e.g. “How old is an
old person?”)
Originally
Falchikov Scotland Children’s drawings: Sample size: n = Pictures of old people were more Cognitive Children Reliability (inter-rater
(1990) 28 negative in content than those of average agreement =
young people. Older people 87.9%)
portrays frequently included
glasses, wrinkles, wheelchairs.
(1) Young man; Participant’s age: There was an association Affective
10.5–11.5 years between old age and lack of
old human contact and loneliness.
(2) Young woman; Pictures of old people were
(3) Old man; significantly smaller than those
(4) Old woman. of young people.
Lichtenstein EUA Children’s drawing of a typical Sample size: n = Children’s drawings depicted Cognitive Children Interrater agreement
et al. (2005) older person in a setting. Interview 1944 older persons who were “diverse (weighted k = 0.73) and
regarding characteristics of the and multidimensional”. Intra-rater agreement
drawn person (e.g. the person’s Participant’s age: The drawings demonstrated the Affective (weighted k = 0.74)
age, feelings, thoughts, possible Two middle great variability of children’s
relation to the student). schools perceptions of older people
(including equally both positive
and negative traits).
Villar and Spain Children’s drawings with written Sample size: n = Older persons were represented Cognitive Children Not specified
Fabà (2012) tags: 60 in varied and multidimensional
ways.
(1) Young man; Participant’s age: Some drawings had negative Affective
9–12 years old content (signs of physical
disability or degeneration).
However, most of them depicted
a positive image of older
persons.
(continued)
Originally
(2) Young woman; The drawings depicting older
(3) Old man; persons were more
(4) Old woman. homogeneous and less complex
than those representing younger
persons.
Robinson EUA Children’s drawing of an old Sample size: The drawings produced Cognitive Children Not specified
et al. (2014) person that children see in real life n = 141 a generally positive image Affective
(in a setting); (94.8%) of older people.
Interview. Participant’s age: Most of the drawings
8–12 years old depicted a family member
who was happy, healthy,
active and with positive
physical characteristics.
Isaacs and Not Children were asked to participate Sample size: Regardless of their age, Behavioral Children Not specified
Bearison specified in a puzzle task with aged n = 144 participants showed preference
(1986) (experimental group) and non-aged for nonaged confederates
(control group) persons. compared to the aged
confederates. This finding is
based on the scores on all the
behavioral measures assessed
with the exception of the
productivity measure.
Behavioral measures: proxemics Participant’s age: Children as young as 4 years old
distance; productivity measure; 4, 6 and 8 years are already able to make
eye-contact initiation measure; old categorizations based on
verbal interaction measure (e.g. individual’s age and acted
number of times a child initiated differently to them in a
conversation). behavioral context.
Originally
Kwong See Not The Piagetian number conservation Sample size: In the young adult experimenter Behavioral Children Not specified
et al. (2012) specified task was modified to assess young condition, the majority of
children’s age stereotyping. This children gave an answer focused
was done by manipulating the on length rather than number.
perceived age of the experimenter
(puppets in experiment 1 and real
persons in experiment 2) asking the
second question.
Experiment 1 In the old adult experimenter
(n = 23); condition, the majority of
Experiment 2 children gave an answer focused
(n = 28) on number rather than length.
Participant’s age: Children held different beliefs
5 years old about the motivations of the two
experimenters for asking the
second question and acted
differently accordingly to these
beliefs.
Another limitation is that the procedures used in the testing are not well described
and appear very time consuming. For instance, the replicability of the studies using
the behavioral methodology seems difficult in the sense that it requires the partici-
pation of older persons (for example, in a classroom context) in order to engage in
interpersonal activities with younger participants (e.g. Isaacs and Bearison 1986).
Another issue that requires further attention is that studies may use measures, such
as scales, which may not be sensitive enough to capture the presence of ageism in
very young children (e.g. Isaacs and Bearison 1986). This is particularly relevant in
cases where scales were originally applied to adults, and have been used with chil-
dren or adolescents with little or no adaptation (e.g. the “Tuckman –Lorge Old
People Scale” – Harris and Fiedler 1988; “Kogan’s Attitude toward Older People
Scale” – Ivester and King 1977).
Finally, other aspects that have not been taken into consideration in these sort of
studies are the need to control for important factors that may have an association
with attitudes to age in children. For instance, in some studies, the prior contact
between children and older people, namely their grandparents, was not assessed
either in terms of quantity (Robinson et al. 2014) or quality (e.g. Harris and Fiedler
1988). This constitutes an important limitation in the sense that children’s relation-
ships with relevant older persons could reasonably serve as an important evidence
for their cognitive, affective and behavioral overviews towards older people.
The recognition of these limitations is crucial for the refinement of currently
available measures and for the development of more complex techniques in the
future. New measures should be adapted and created that overcome some of the
major limitations identified in this field.
30.6 Future Directions & Recommendations.
Children’s attitudes regarding older people represent a multidimensional construct

(e.g. Lichtenstein et al. 2005) and, consequently, can be fully explored only if the
three dimensions of attitudes (cognitive, affective and behavioral) are taken into
account. Future studies aiming to explore children’s attitudes regarding older people
and/or the ageing process also should be based on a triangulation of both explicit
and implicit measures. At the very least, research should be clear about the focus
and type of measurement when formulating hypotheses. This will allow for a better
evidence base to develop new theories on how implicit and explicit attitudes towards
age and older people emerge and develop in childhood. More specifically, the use of
this framework will help to establish a more systematic account on how ageism
develops across childhood and how it is expressed by children of different age
groups. For instance, if there is a social norm to not discriminate someone based on
his or her age, one can hypothesize that older children will show less explicit ageism
but, probably, their implicit ageism level will remain the same as happens, for
instance, in racism (Rutland et al. 2005). This complex pattern of prejudice develop-
ment across childhood should also be considered in studies on the development of
ageism. Thus, a possible avenue to pursue is to explore the existence of an anti-

discrimination norm based on people’s age in children and adults. This will allow to
address important topics in the field of ageism such as: the early origins of ageism,
the development of self-presentation concerns and executive control and the ability
to inhibit prejudicial responses (Olson and Dunham 2010).
Future measures of ageism in childhood should also have better psychometric
qualities (i.e, test-retest reliability, concurrent validity, predictive validity, construct
validity and content validity) and better sampling procedures. It is fundamental that
specific information regarding participant’s demographic characteristics be pro-
vided, e.g., their age. The measurement of other related factors such as prior rela-
tionships with grandparents or other significant older people is also of paramount
importance in this domain and should be further considered as a necessity (Robinson
et al. 2014).
Finally, we believe that it would also be important to conduct subsequent litera-
ture reviews, namely meta-analyses in this field. Although we tried to be as inclu-
sive as possible, and we present the main studies in this domain, it would be
important to consider other databases (e.g., Scopus, Web of Science) not included in
this study. This would allow further exploration of the field, through a systematic
procedure.
The improvement of measures of children’s attitudes regarding older people is
crucial and urgent. One important route will be to explore the instruments that have
been used in other types of prejudicial attitudes (e.g., racism and sexism) and see
how they can be applied to the case of ageism. It will allow further understanding of
how ageism develops in childhood and the development of effective intervention
programs (Marques et al. 2014b) to reduce ageism at an early age. In an ageing
society, understanding how children think, feel and behave regarding older people
is fundamental for preparing a better and more inclusive future for all age groups.
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Chapter 31
Researching Ageism through Discourse
Amanda Phelan
31.1 Introduction
The way we see the world is inevitably shaped by a number of factors such as cul-
ture, experience, language and values. Culture may be described as the customs,
beliefs and values generally developed over time and experience, within a particular
people or within a society. Language is one vehicle of cultural expression (Macionis
and Gerber 2013). We understand the world by co-creating and co-constituting
meaning and reality. The chapter begins with a brief presentation of the idea of
social constructionism and ageism and then presents how one method of social con-
struction, discourse, influences and mediates how we think, act and understand
older people and how narratives can promote and privilege particular identities and
consequently construct and reproduce ageism in society. Specific methodologies of
discourse analysis are then introduced (Foucauldian discourse analysis and discur-
sive psychology) to underpin the examination of data from research interviews of
health care professionals (Phelan 2010), older people and their children (Ayalon
2015). Critical discourse analysis, such as Foucauldian discourse analysis, focuses
on the examination of how political and social inequalities are constructed, sus-
tained and reproduced in texts, which includes speech and written text and conse-
quently discourse is seen as a site of power relations (Wooffitt 2005). In contrast,
discursive psychology, another form of examining narrative, is concerned with a
fine-grained analysis of the action orientation of language in constructing ‘reality’
(Potter 1996, 2003). Such constructions in discourse have consequences in that they
legitimate public attitudes, perspectives and behaviors towards older people and can
A. Phelan (*)
School of Nursing, Midwifery & Health Systems, University College Dublin, Dublin, Ireland

https://doi.org/10.1007/978-3-319-73820-8_31
550 A. Phelan
contribute to policy and legislation directions (Fealy and McNamara 2009). The
combination of both approaches to examining discourse enables both a review of
language as a general ‘system of representation’ (Hall 2001:72) as well as how
language is used within social practices which create and stabilizes versions of real-
ity (Potter 2003).
31.2 Social Constructionism
Social constructionism is a way of seeing the world. It emanates from the field of
sociology. The way we see ‘reality’ is impacted by many factors. For example, we
have many taken for granted ‘truths’, such as gender, the meaning of childhood or
what constitutes an older person. These truths are not neutral in the world but evolve
from meanings we subscribe to and also relate to how we position those meanings.
For instance, in the case of gender, we could, instead, classify humans according to
height, the colour of eyes or hair, however, an accepted, dominant classification of
human beings is through anatomical characteristics. So as Searle (1997) suggests,
objective facts, such as gender, are only objective through human agreement.
However, such understandings and meanings are fluid in the sense that they can vary
over time and within cultural assumptions.
Burr (1995) argues that social constructionism involves a number of assump-
tions. Firstly, there is a critical approach to how we perceive the world, which should
make us question the basis of ‘truth’. Secondly, understanding and knowledge are
culturally and historically located. For instance, think of the idea of human rights.
These are commonly accepted canons, yet historically and culturally, they vary in
the context of equality of human beings. Yet, for some cultures, human rights can be
socially constructed in alternative yet oppositional ways. For example, Ignatieff
(2001: 102) notes that ‘Since 1945, human rights language has become a source of
power and authority. Inevidably, power invites challenge. Human rights doctrine is
now so powerful, but also unthinkingly imperialist in its claim to universality, that
it has exposed itself to serious intellectual attack’. Thus, Ignatieff (2001:102) con-
tinues to pose the question whether this constitutes an example of ‘Western moral
imperialism’, which denies alternatives such as cultures where the rights of the col-
lective can legitimately supersede the rights of the individual. Thirdly, Burr (1995)
argues that knowledge is sustained by social processes. This is particularly impor-
tant in discussing ageism and discourse, as discourse constructs shared understand-
ings and promotes ways of thinking about the world. Age is a significant cultural
aspect of society (Roscigno et al. 2007) which, as a chronological phenomena, can
be taken as ‘a fundamental and organising principle’ (Spedale et al. 2014:1586)
which shapes the very meaning of being old (Cruikshank 2013). Thus, the way we
talk about older people and how we position them discursively has consequences
not only in our perception of this population group, but also in their treatment within
policy (Wilisńka and Cedersund 2010), legislation, health and social care practice
and older people’s subsequent experience of the world.
31 Researching Ageism through Discourse 551
31.3 Ageism
The ‘discovery’ of ageism is generally attributed to Robert Butler (1969) who

identified how older people were constructed in stereotypical and discriminatory
ways and this phenomena can be aligned to similar prejudicial perspectives such as
racism and sexism. Hockey and James (2003) argue that discourses produce particu-
lar social identities for particular age groups. In terms of older adults, ageism can be
either systematic or casual and can target either individuals or groups. Although
Butler (1969) identified negative aspects of ageism, proponents such as Palmore
(1999) argued that ageism also had positive aspects such as older people being more
reliable workers or engaged in volunteerism. However, negative aspects of ageism
are generally constituted by de-individualising and devaluing the older person
through particular attitudes, practices and cultures. Ageism, within a negative lens,
is considered enmeshed overtly and covertly in society and promotes a perspective
of older people as holding homogeneous traits which are predominantly undesirable,
such as having poor health, being unattractive, being senile, dependent, unemployable
and inactive, asexual, and generally inflexible (Lyons 2009).
Bytheway (1995) argues that ageism, as an ideology, promotes particular views,
usually from a dominant group, which justifies the way older people can be treated.
Such perspectives are supported by Rowe and Kahn (1998:12) who argue that age-
ism is ‘a negative view of a group divorced from reality’. The consequences of nega-
tive ageism are clear: inequality, inequity, a higher risk of maltreatment and
disempowerment (Biggs et al. 1995; Minichiello et al. 2000; Phelan 2008; Malmedal
et al. 2009). Indeed, Spedale et al. (2014) points to the cultural irony within the
perspective that to successfully age is to appear ‘ageless’. In contrast, youthfulness
is highly prized which creates a ‘culturally endemic paranoia’ of ageing (Schwaiger
2006:14) demonstrating a mind (wanting to be youthful)-body (aging body) split
(Biggs 1997). Even within the ageing process, the exclusion from particular roles
can be seen as age increases. For example, older parenthood (>35 years) can be
considered a taboo and even harmful to a child (Wilisńka and Cedersund 2010).
Generally accepted societal norms can be identified as ageist. For instance, in
employment, mandatory retirement has been argued as inherently ageist (Angus and
Reeves 2006), as it implies those over a particular age are incapable of doing the job.
Paradoxically, a lack of labour contribution has been seen as negative due to depen-
dency related fiscal costs on nations (Wilisńka 2013). Moreover, ageism can be
found within institutions such as health, social care, community participation and
organisational practice (Spedale et al. 2014). In addition, stereotype embodiment
theory suggests that older people themselves can internalise ageist assumptions and,
within the context of self-fulfilling prophecies, position themselves accordingly
(Minichiello et al. 2000; Calasanti 2015; Chrisler et al. 2016), through further
reproducing and validating negative ageist traits. Such perspectives, also have
consequences within health as older people may be excluded (or indeed self–exclude)
from ameliorative treatments. However, there are some examples of older people
separating themselves from the taken for granted concept of old age. In Wilisńka’s
552 A. Phelan
(2013) consideration of members’ experience of the University of Third Age, old

age identities were rejected, yet, there was a separateness or otherness observed by
the University of Third Age members (who were generally over retirement age or
unemployed younger people) from older people outside this group.
Within media forms, discourse can perpetuate particular stereotypical identities
for older people, for instance, within newspapers (Phelan 2009; Fealy and McNamara
2009; Wilisńka 2013; Weicht 2013; Chen 2015), television (Spedale et al. 2014;
Chen 2016a, b), holiday brochures (Ylänne-McEwen 2000) and social media (Levy
et al. 2014). Such public and authoritative forums are particularly influential in
forming and perpetuating societal identities of older people by shaping public opin-
ions through creating particular representations and relations (Harwood 2008,
Wilisńka 2015).
31.4 D
iscourse Analysis in Research Related to the Topic
of Ageism
Potter (2003:73) describes discourse analysis as a way of analysing how ‘talk and
text are used to preform actions’ which enables making sense of social order
(Howarth 2000) and creates identities and ideologies. In recent years, the use of
discourse analysis has contributed to revealing how talk and texts construct older
people in certain ways. In particular, examining discourses in old age is useful in
determining how the ageing body becomes socially significant (Wilisńka 2013). In
exploring ‘silver market’ holiday brochures using discourse analysis (Ylänne-
McEwen 2000), both positive and negative identities are presented. Activities which
promote youthful pursuits and adventure are advertised, but the brochures also
regress to a dependency discourse where the older holidaymaker has the security of
home like destinations, afternoon teas and familiar comforts (Ylänne-McEwen
2000). Similarly, Coupland (2003) points to the portrayal of old age in anti-aging
advertisements, which serve to fuel a fear of aging and that the aging skin is undesir-
able and in need of assistance as it is in decline and in need of repair.
In relation to policy formation, Weicht (2013) used discourse analysis to examine
how older people, as subjects of policy, were constructed in Austrian newspapers
and how particular interventions were legitimised based on such subject positions.
Although findings demonstrated positive constructions of older people in terms of
being active members of society, negative images dominated in the context of a
lack of voice and agency of older people within reportage. Older people were de-
individualised and assumed to be vulnerable and reliant on others (generally family)
to determine their lives. Moreover, older person self-determination was diminished
and while achievement was acknowledged, it was constructed as a past identity.
In Weicht’s study, chronological age was not an identifier, rather particular older
groups with particular characteristics which were constructed as a ‘demographic

time-bomb’ (Weicht 2013:190). Thus, policy was framed around dependency with
care provided for older people at home with some state support. Equally, in the
review of social policy documents from Poland and Sweden, Wilisńka (2013)
revealed old age as being constructed as a problem of dependency related to both a
lack of labor contribution (Poland) or poor health status (Sweden), both posing a
financial burden on the states. Wilisńka (2013) argues that these perspectives are
limiting and reductionalist.
Ageist constructions can also be located in media forms. For example, commenting
on older people’s construction within Irish newspapers, Fealy et al. (2012) point to
the dominance of dependency subject positions where older people are constructed
as others, separate from independent younger age groups and thus marginalized.
Wilisńka (2013) used a multi-data discourse analysis approach to examine welfare
cultures. Newspapers in Poland were used to analyse the welfare culture and
three constructions of older people were identified in relation to family, market and
society. Findings pointed to acceptable and unacceptable identity locations related
to age, which could also be gender aligned. Chen (2015), using a discourse analysis
approach, found that Taiwanese newspapers placed older people in a position of
dependency. Similarly, in an analysis of television advertisements for life insurance
products using discourse analysis, Chen (2016a, b) also demonstrated how Taiwanese
people over 50 years of age are positioned with findings pointing to patronizing
communicative conventions which reinforced negative stereotyping and stigmatisa-
tion of old age. When Ylänne-McEwen (2000) examined how holidays were adver-
tised with a target audience of older consumers, there was evidence of a juxtaposition
of counter identities of aging. Positive accounts of ‘golden agers’ were the exception
while the de-individualised older person as a receiver of resources was a more
common identity (Ylänne-McEwen 2000).
31.5 Discourse Analysis
There are a number of philosophical and analytic approaches within discourse anal-
ysis. However, in this chapter, we will focus on two methods to examine discourse
in research interviews: Foucauldian discourse analysis and discursive psychology.
The chapter is specifically structured to demonstrate exemplars of various data
types under the separate methodologies. Both methodological approaches comple-
ment each other and show how discourse works on both a macro level (Foucault)
and a micro level (discursive psychology). Thus, the macro level enables a consid-
eration of looking at how power relations in society work to construct and position
older people through language and at the micro level how individuals actively con-
struct subject positions in their interactive narratives.
554 A. Phelan
31.6 Foucauldian Discourse Analysis
Foucauldian discourse analysis is an approach within critical discourse analysis. In

critical discourse analysis, language becomes much more than a system of represen-
tation. As Wodak and Meyer (2009: 2) state, ‘CDA [Critical discourse analysis] is
not interested in investigating a linguistic unit per se but in studying social phenom-
ena which are necessarily complex…’. Thus, discourse has social implications and
can produce, sustain and reproduce inequalities in power relations (Wodak and
Fairclough 1997, Wooffitt 2005). Discourses are, therefore, a way of being in the
world.
In the case of ageism, discourse has enabled the systematic stereotyping of older
people and empowered perspectives which value youthfulness (Harbison 1999).
Coupland and Coupland (1999) identify two ageist perspectives in relation to dis-
course. Firstly, ageist discourse describes the forms of talk and meaning to which an
ageist perspective is applied at a local level, for example when talking, perceiving
or constructing older people. Secondly, discourses of ageism refer to ageist prac-
tices related to particular consequences such as human rights breeches and the lack
of opportunities afforded older people. Discourse can, therefore, produce inappro-
priate and derogatory ways of speaking of older people that can be discriminatory
(Wilisńka 2015). As Gee (1990:143) argues:
A Discourse is a socially accepted association among ways of using language, of thinking,
feeling, believing, valuing, and of acting that can be used to identify oneself as a member
of a socially meaningful group or ‘social network’, or to signal (that one is playing) a
socially meaningful ‘role’.
Equally, discourse can serve to identify one as outside the socially meaningful
group or deny the prospect of a socially meaningful role.
Michel Foucault developed particular understandings discourse and its operation
in the legitimization of knowledge. In his numerous publications (Foucault 1975,
1989, 2002, 2003), discourse is constructed as a system of representation and
knowledge. Thus, in using a Foucauldian approach as an analytic lens, ageist per-
spectives are seen to be produced through particular discourses related to the condi-
tions of knowledge possibility within the context of what can be spoken of at a
particular time. Accordingly, discourses produce subject positions of the older per-
son. In this context, subject positioning means the location and identify afforded
older people and as Davis and Harre (1990) note:
Once having taken up a particular position as one’s own, a person inevitably sees the world
from the vantage point of that position and in terms of the particular images, metaphors,
storylines and concepts which are made relevant with the particular discursive practice in
which they are positioned (Davis and Harre 1990:46)
Subject positions then create ideologies, which are simply commonly held beliefs
of older people.
There are two main components in Foucauldian discourse analysis: archaeology
and genealogy. Archeology traces a topic or idea related to how it appeared within
the context of culture and history and discursive possibility at a given point of time.
In the context of ageism, this means an understanding of how ageism emerged as a
social product. In contrast, genealogy considers the propositions upon which the
topics or ideas are founded or, in this context, how ageist stereotypes can regulate
how older people are seen and treated. In this chapter, the review of narratives
within the interview data from Phelan (2010) and Ayalon (2015) will predominantly
draw on the latter perspective of genealogy. Genealogy enables an examination of
the constitution of and relationship between discourse-knowledge-power inter-
relationships in the world. Thus, powerful discourses work within a complex net-
work of relations which produce knowledge and sanction legitimate ways of
positioning older adults and consequently speaking of, seeing and treating older
adults. This power relationship, which Foucault terms bio-power, permeates all
aspects of life and essentially underpins the visibility of ageism in discourse and
practice and the subsequent legitimisation of ‘truth’ about older adults. Such ‘truths’
are not only constructed in discourses but can be internalised by older people, who
may assume the prevailing subject positions, such as being frail, dependent, asexual
or less valuable to society.
Foucauldian discourse analysis, allows a focus on discourse as constituting real-
ity (Hepburn 2003, Phelan 2010) and discourse is seen as constructing legitimate
knowledge in the social world, which influences behaviours, practices and identity
(Jäger 2001). Thus, the point is that discourse is not neutral; it follows particular
conventions and functions to serve a purpose such as constructing our ideas.
Discourse can establish dichotomies such as positive and negative, ‘them’ and ‘us’
or whose voice is privileged and whose voice is silenced. Importantly, discourses
become agents of power, constructing ‘valid’ knowledge and discourse can be con-
sidered as constituting ways of social influence (Coupland and Coupland 1999).
Discourse, therefore, allows us to know about the world in ‘context specific frame-
works for making sense of things’ (Van Leeuwen 2009:144). Thus, it is of little
surprise that ‘truths’ are established through discourse as once we speak of a topic,
it becomes known and familiar and may assume a taken for granted, unchallenged
stance. Consequently, age categories promote particular identities and establish
power relationships between each other (Calasanti 2015).
31.7 Discursive Psychology
Although the Foucauldian perspective critically examines issues related to discourse-

knowledge-power relationships, it neglects the individual active and subjective
construction of narratives by people. Discursive psychology (Potter and Wetherell
1987, Edwards and Potter 1992, Wetherell 2001, Potter 2003) addresses this.
Emerging from the fields of ethnomethodology and conversation analysis, discursive
psychology centres on three main principles. Firstly, discourse is action orientated;
it functions to some end, such as answering a question or describing an experience.
Secondly, discourse is sequentially organised, for example, asking a question
556 A. Phelan
generally elicits an expected response. Thus, there are mutually understood conven-
tions in discourse. Within this context, Edwards and Potter (1992) describe dis-
course being situated rhetorically, meaning that discourse is constructed to present
particular valid arguments and to counteract alternative viewpoints.
Within the topic of ageist narratives, discursive psychology illuminates how
apparently incoherent statements are contextually related and function in a particu-
lar way. Thus, the speaker’s accountability is established through the justification,
sense making and rational of the narrative, particularly related to how the speaker
positions themselves or others they are referring to. Finally, in discursive psychol-
ogy, discourse is both constructed and constructive. It is constructed by using tools
such as words, ideas, beliefs and referential terms which build up the validity of
what is being said (Wetherell 2001). Discourse is constructive in that the informa-
tion given is interpreted and represents the individual in a particular way such as
being neutral in the issue being discussed or demonstrating their stake and interest
regarding the subject of conversation.
31.8 U
sing Both Methods of Discourse Analysis as Lenses
into Ageist Discourse
While Foucauldian approaches allow the examination of the macro structure of dis-
courses at a particular time and also interrogates the knowledge-power-discourse
relationships, discursive psychology allows an examination of the micro processes
of how an individual uses language as a social performance. In other words, while
Foucault can offer a way to look at available knowledge at a particular time, discur-
sive psychology enables a review of how individuals actively orientate discourse
focusing on the individual’s cognitive processes and the role of accountability and
stake in speech acts (Potter 2003, Willig 2003).
This chapter section draws on published data from two studies to examine how
ageism is constructed and reproduced in discourses within transcripts from semi-
structured interviews (Phelan 2010, Ayalon 2015). The participants are Irish com-
munity nurses (Phelan 2010) (interviewed in 2007–2008) and Israeli older adults
and their children (Ayalon 2015) (interviewed 2010–2014).
31.9 Using Foucault to Examine Discourses of Ageism
Within the context of the interviews, there is what Foucault would consider the
knowing self (Besley 2005). Applying a Foucauldian lens allows us to see how the
individual speaker draws on both implicit and explicit common discourses of ageism
in society, while discursive psychology enables a deconstruction of how such narra-
tives are orientated to promote the speaker’s individual stake and accountability.
Foucault argues that what we speak of deductively draws on common and avail-
able and accepted macro discourses in circulation at a particular time. In a study
using semi-structured interviews (Phelan 2010) with community nurses in the North
East and East region of Ireland, participants constructed what their view was on
older adults in Irish society, what constituted elder abuse and how they managed
such cases. All community nurses constructed the older adults in society and those
they cared from within negative ageist frameworks. When asked specifically about
older adults in Irish society (i.e., not only those the nurses delivered care to), two
participants initially commenced their narratives by stating the value of older
people, however this was transient and all 18 participants drew on ageist discourses
of dependency. This compares to findings in other studies where the value of older
adults was attributed to past contributions (Weicht 2013). In the excerpt below, it is
clear that older adults, as a population group, are constructed in a way that promotes
a biomedical discourse of physical dependency and homogeneous characteristics.
In addition, there is a discrete categorisation of older adults as different:
Alice:…but from 70 [years] onwards, I think hmm…they [older adults] deteriorate in
health and in the general elderly population and vulnerability…
Dependency is unilaterally related to functional decline, as older people require

external assistance to help them in daily life:
Ann: And then I suppose you know…inability to do things as well from themselves…what
is the word I am looking for? God what’s the word I’m looking for…activities of daily liv-
ing…you know they [older adults] they need assistance with things in daily living.
In particular, medical dependency was related to both physical and cognitive decline
and was spoken of by all participants who constructed older adults in general Irish
society as being ‘in need’. Drawing on the macro-discourse of ageism, risk and
biomedicine, the participants all presented their narratives as undisputed truths.
Similarly in a study of continuing care retirement communities (CCRC) in Israel,
Ayalon (2015) interviewed 34 dyads of older adults who had recently entered CCRC
and their adult children to explore perceptions of old age and ageing. One of the
prominent findings in this study was the dominance of negative views of ageing
which were related to loss of function. For example, in the excerpt below, the
biomedical view of decline is also apparent as the older adult’s son used chronology
as a basis for discontinuing driving:
Son: ‘Up until now she was still driving, recently I stopped her, because her age is a little
problematic’
Thus, like mandatory retirement ages, age not ability, is the standard for participa-
tion in activities.
Again, the decline of the body is continued in the nurses’ discourses of older
adults within their care (Phelan 2010) as the participant asserts her informed (and
disciplinary powerful) opinion which promoted paternalism and denied the older
person privacy and self-determination. Consequently, the subject position and
identity of the older person is framed as helpless, dependent and vulnerable, again
promoting a discourse of ageism:
558 A. Phelan
Deirdre: I suppose in my…just cross covering in my colleagues area just last weekend,
there was a lady with Alzheimer’s [disease]…total nursing care who had home help and
who really needed 24 hour care but the family would have left in the afternoon from 2.00–
4.00 or 2.00–5.00 and left her unattended. Now she was immobile and… and that but it was
the vulnerability of somebody who really required 24 hour care and the family not having
the insight that really somebody should be there…
Examining the power-knowledge-discourse relationships in the excerpts demon-

strates that these nurses heavily and unproblematically drew on ageist and stereo-
typical views of older adults. In particular, both functional and cognitive deterioration
was a prominent feature of their narratives which emanated from powerful dis-
courses of medical reductionalism related to biological decline. In essence, positive
and diverse constructions of older adults in society and those who care was deliv-
ered to were predominantly absent.
Ageism was also constructed within an economic reliance of older adults who
depended on old age pensions and other benefits, denying the ability to be economi-
cally productive. Thus, fiscal dependency is equated to chronological age rather
than ability, denoting ageist perceptions:
Karen:…they [older people] don’t have a lot of money…that their pension mightn’t cover
what their needs are…
Economic dependency further reinforces the older person’s sense of vulnerability

and denies alternative constructions of older people having sufficient funds. This
can be related to the macro discourse of older adults related to pension ‘burdens’
within political statements as opposed to having independent means and financial
stability.
Thus, age becomes a powerful justification for the limitation of an activity and is
tacitly accepted through a self-internalisation of such reasoning as detailed in the
older person’s consideration of this. In the excerpt below, we can also see how soci-
ety’s social practices on driving influenced the older person. By not renewing the
license, driving is prohibited as this is regulated through discourses on legislation.
Furthermore, the association of age as a ‘burden’, is common in ageist discourses,
and is also sustained by the older person. In the excerpt below, the inevitability of
physical decline is not challenged by the older person, who did not pursue the pos-
sibility of amelioration of her visual deficits, and was influenced by her children’s
perspectives on her continued driving potential.
Older Person: ‘Simply I did not renew the license. And the kids influenced me…. “If I
need them,” I told them, “I will be a burden on you. You will have to drive me. To take me
to places”…
I also needed to go to an eye exam (to renew the driving license). I was afraid that they
would tell me that I needed to do a cataract operation. I just decided to take this off my
shoulders’
In addition, as detailed in the excerpt, the older person was fearful of being medically
forced to withdraw from driving due to sight problems, thus, giving dominance to
the medicalised view that her possible condition of cataracts which would preclude
driving. Yet, the position of recovery from the treatment of cataracts was not
presented, indicating ageist self-determination; that treatment is considered not to

be an option due to age or that the cataract might be a catalyst to a medicalised argu-
ment to discontinue driving based on sight and the possible identification of other
health decline. Accordingly, the older person’s construction of the power of medical
knowledge has a direct impact on her decision to discontinue driving, which is justi-
fied by not having legal permission to do so. Consequently, such perspectives dem-
onstrate how prevailing discourses open up or deny subject positions and identities
older people can assume. As one ages, dependency on others increases as a social
reliance is created in the context of transport dependency.
31.10 U
sing Discursive Psychology to Examine Discourses
of Ageism
As discussed previously, discursive psychology is concerned with the person’s

indicative construction of the narrative and, in particular, how that narrative is
actively and individually orientated to produce a particular ‘version’ of reality
which accounts for self and others in terms of stake and accountability. The context
of ageism can be downplayed in narratives, yet, a careful review of the text can
reveal the action orientation of neutralizing contentious issues to mitigate the speaker’s
stake and accountability.
In Ayalon’s (2015) study, when asked about the move to CCRC from home, an
older resident comments on how older people are preyed upon and are positioned as
vulnerable.
Older person: I think that sense of security is unstable. As you hear, they attack an elderly
here and rob an elderly there. Knocked on the door, presented themselves as… I don’t know
who and then attacked people, I think that here (CCRC) I am protected…
A careful examination of the text reveals a more complex repertoire. The older person
positions herself and ‘elderly’ as a vulnerable population by stating ‘I think that
here (CCRC) I am protected’. The attribution of ‘I think’ (i.e., the conditional tense)
functions in a way to counteract any future unsafe experiences (i.e., in the event she
was wrong in asserting being safe in the CCRC) and concedes to the possible limita-
tion of her knowledge of being secure. For example, others might think differently
of living in CCRC, so the use of the conditional tense addresses accountability in
the narrative. The veracity of the narrative of vulnerability is supported through a
careful description (attack and rob) which characterises such attacks as normalised.
The script is also constructed to logically justify the need for protection of and
safety for older adults. In the script formulation, there is also a careful juxtaposition
of telling a story where the facts are not clear (As you hear…they…I don’t
know who), yet this is contrasted and counter positioned with a more authoritative,
credible and subjective evaluation of the personal experience of safety. The way the
narrative is presented also puts the older person in a positive subject position as her
own accountability is seen as a responsible person who took appropriate measures
560 A. Phelan
to protect herself by entering the CCRC as opposed to other older adults who choose
to remain vulnerable in other settings. However, even within the narrative, it is evi-
dent that the need for protection of older adults is necessary due to vulnerability
ascribed to older adults.
Equally, it can be seen that the community nurse in Phelan’s (2010) study con-
structed abuse of older people in a particular way. When asked about why abuse
might happen, the excerpt below shows an ageist framing of older adults:
Interviewer: Can you tell me what your perspective is on older people in Irish society...just
in general?
Joan: Well, they are vulnerable aren’t they? That’s a big issue hmm…some people do it…
if they are vulnerable they [perpetrators of abuse] do it because they can do it…I don’t
really know you see…
Yet the use of the ‘aren’t they?’ question functions in a way to engender agreement
from the listener and to counteract any impression that Joan could be wrong. There
is a clear dichotomy established between vulnerable older people and powerful per-
petrators (‘…because they can do it’). The participant positioned the statement ‘I
don’t’ really know you see...’ to attend to her own character and counter any nega-
tive impression of her perspective. This is achieved by playing down the motivation
of her narrative in the context of overtly blaming the older person for being vulner-
able. Thus, the implicit thrust of the text is ageist, yet, efforts are made to mask this
through the use of the evaluative expression ‘really’, which portrayed her own char-
acter in a positive way.
Thus, even within the fine grained analysis of how people structure their version
of reality, it can be seen that, although there are tacit linguistic strategies to neutral-
ise the impact of ageist text, a critical examination of an individual’s construction of
their narrative reveals what the speaker is doing in the text and precisely how ageism
is tacitly imparted through discourse.
31.11 Discussion and Conclusion
Lynam (2007:540) asks ‘does discourse matter?’ The answer is yes. Discourse itself
constructs reality, producing ‘valid’ and legitimate knowledge and influencing
behaviour (Jäger 2001). Thus, an examination of discourse is a particularly impor-
tant component in understanding the complexity of ageism as a system of represen-
tation of older adults (Hall 2001) which denotes ‘otherness’. This is apparent in the
terms and nouns used, the imagery drawn up and defining older adults as both a
separate group and as different from other groups (Fealy and McNamara 2009).
Within this chapter, particular methods of critical discourse analysis have illumi-
nated ways of deconstructing texts using multiple methodological approaches. The
various text and sub-textual sources presented primarily reveal older adults as
dependent, vulnerable, helpless and frail and although it is noted in each of the stud-
ies that there are counter positive ageing subject positions presented, the dominant
discourse is aligned with the stereotypical negative constructions of ageism. The

objective of such deconstruction of texts is to see language as a social practice and
a social performance (Fairclough and Wodak 1997, Willig 2003). Language is a
powerful vehicle of constructing reality and can both implicitly and explicitly estab-
lish, perpetuate and reproduce values, stereotypes and ways of seeing the world.
Thus, as Fairclough and Wodak (1997) observe, there are ideological consequences
which produce and reproduce inequalities, such as ageism. Such discourses can
deny the construction of age as related to individual personhood and heterogeneity
(Fealy and McNamara 2009). However, ideology is not the prime focus for critical
discourse analysis, but rather it is the concealed and taken for granted views within
discourse that are challenged (Wodak and Meyer 2009). Thus, in everyday dis-
course, there are power relations that exist and which appear neutral, tacit and
unproblematic but promote inequalities.
Critical discourse analysis reveals particular subject positioning and identities
afforded older adults and how particular discourses legitimate the dominance of
populist views and ways of seeing the world. Ageism is generally concerned with
power relations between societal groups and critical discourse analysis allows an
interrogation of such power relations in society (Fairclough 1989). In navigating
different approaches and different text representations, this chapter has provided an
insight into how ageism is constructed and legitimised in relation to its condition of
possibility in discourse; how an individual produces versions of reality and how
newspapers mediate the social production of valid knowledge. Furthermore, dis-
course has consequences; it does not occur in an ideological vacuum but permeates
societal attitudes, professional practice, policy and legislation and thus, is funda-
mental to the perpetuation of hegemonic interests.
Critical discourse analysis enables such ageist perspectives to be laid bare, which
can be a self-fulfilling prophesy in older person’s self-identity and in its consequen-
tial experiences for older adults in everyday life. A final question remains- Is it pos-
sible to have non-ageist discourse? Is it possible to remove age as a factor and only
speak of people as individual heterogeneous human beings with an individualized
personhood? The answer is yes. We see it in, for example, legislation as a criminal
act. This is because a criminal act is defined as such regardless of age, in the Human
Rights Declaration (UN 1948) and conversations of citizenship (Marshall 1949).
Thus, the assumption of attributes of an aged population diminishes and instead
discourse focuses on the individual regardless of chronology and articulates diver-
sity rather than homogeneity. However, for this to become a reality poses a signifi-
cant challenge. As Coupland (253) notes ‘Ageist discourse is prevalent but discourses
of ageism (and anti-ageism) are not’. Therefore, society needs to address the way
discourse can often be constructed to represent older adults as stereotypical ‘others’,
who are often associated with a homogenous biological decline. Only in recogniz-
ing this, can we be liberated from an ageist frame of reference when speaking of
older adults.
562 A. Phelan
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tb02854.x
Erratum to: Contemporary Perspectives
on Ageism
Erratum to:
L. Ayalon, C. Tesch-Römer (eds.), Contemporary Perspectives
on Ageism, International Perspectives on Aging 19,
https://doi.org/10.1007/978-3-319-73820-8
The original version of the book front matter was revised. The following acknowl-
edgement has been added to the copyright page of this book.
Funded by the Horizon 2020 Framework Programme

of the European Union
This publication is based upon work from COST Action IS1402, supported by
COST (European Cooperation in Science and Technology).
COST is a funding agency for research and innovation networks. Our Actions help
connect research initiatives across Europe and enable scientists to grow their ideas
by sharing them with their peers. This boosts their research, career and innovation.
www.cost.eu
The updated online version of the book can be found at

https://doi.org/10.1007/978-3-319-73820-8
© The Author(s) 2018 E1

https://doi.org/10.1007/978-3-319-73820-8_32

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International Perspectives on Aging 19

Series Editors: Jason L. Powell, Sheying Chen

Liat Ayalon · Clemens Tesch-Römer

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ISSN 2197-5841 ISSN 2197-585X (electronic)

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Tel Aviv, Israel Liat Ayalon

1 Introduction to the Section: Ageism—Concept and Origins............... 1

10 Ageism and Sexuality............................................................................... 149

24 Introduction to the Section: Researching Ageism................................. 403

Dominic Abrams PhD, is professor of social psychology and director of the

Liili Abuladze MSc, is a PhD researcher in demography and a project manager at

Els-Marie Anbäcken has been an associate professor in social work at Mälardalen

transnational issues. In a globalising world, the ageing experience in many ways

Boaz M. Ben-David PhD, is an assistant professor at the Baruch Ivcher School of

Jürgen Bengel is professor and chair of rehabilitation psychology and psycho-

Yael Benyamini PhD, attained her bachelor’s degree in psychology and biology

Ehud Bodner PhD, received his bachelor’s degree in psychology and criminology

Wilco P. H. Bosems earned his MSc in psychology and bachelor in applied geron-

Christopher Bratt Ph.D., is Honorary Research Fellow at the School of

Sandra C. Buttigieg MD (University of Malta), PhD (Aston University,

José M. S. de Sao Jose has PhD in sociology. He is currently an assistant professor

Wouter De Tavernier PhD, is a postdoctoral researcher at the Centre for

Israel (Issi) Doron LLB (Hebrew University of Jerusalem, Israel), LLM

Hadas Erel PhD, is a research associate at the Communication, Aging and

academician at the Department of Geriatrics and Gerontology, First Faculty of

Anne Fleming has PhD in nursing and was qualified as an occupational therapist

Nena Georgantzi has MA in human rights and European social protection. She is

Ateret Gewirtz-Meydan MSW, is a PhD candidate in the School of Social Work,

Trish Hafford-Letchfield EdD, MA, is professor of social care at the School of

Moritz Hess has PhD in sociology. He is a researcher and project coordinator at

Astrid de Hontheim Ph.D. in Anthropology (2007), was at fieldworks in West

Loredana Ivan has PhD in sociology. She is associate professor at the National

Jeanne Jackson has PhD in occupational science. She is professor at University

Håkan Jönson PhD, is professor at the School of Social Work, Lund University,

Clary Krekula has PhD in sociology. She is an associate professor in sociology at

Ingrid Kummer univ. mag. phar. of clinical pharmacy, works as a community

Angela Kydd has PhD in nursing. She is an associate professor in gerontology.

Annika Taghizadeh Larsson PhD, is a senior lecturer at the Division Ageing and

Marcel Leppée PhD, was born on 30 September 1951 in Zagreb, where he attended

Maria Luisa Lima Ph.D., is Professor of social psychology at ISCTE University

Gali Malkin PhD, is a postdoctoral fellow at the Baruch Ivcher School of

focusing on the study of ageing, health and well-being from a multidisciplinary

Eugenio Mantovani LLM, works at the multidisciplinary Research Group on

Sibila Marques PhD, is an assistant professor in psychology at ISCTE – University

Mary McDonnell/Naughton is a registered nurse and midwife and lecturer in the

involved in developing educational programmes and supervises research in the area

Joana Mendonça holds a master’s in social and organisational psychology from

Barbara Mikołajczyk is a professor at the Faculty of Law and Administration of

ageing workforces, extending working lives, competence development in small-

Ann Numhauser-Henning is professor at the Faculty of Law at Lund University,

Yuval Palgi PhD, is a clinical psychologist, the head of the Department of

María del Carmen Requena PhD, attained her bachelor’s degrees in psychology

Klaus Rothermund has PhD in psychology (University of Trier, Germany, 1998)

Jonathan Shemesh is a graduate student of cognitive science at Ben-Gurion

Sharon Shiovitz-Ezra PhD, is a senior lecturer at the Paul Baerwald School of

Benny Spanier has BA in history and Jewish studies (Hebrew University,

Tel Aviv, Israel Liat Ayalon

1 Introduction to the Section: Ageism—Concept and Origins............... 1

10 Ageism and Sexuality............................................................................... 149

24 Introduction to the Section: Researching Ageism................................. 403

1.1 Ageism: Concept

1.2 Ageism: Aetiology

1.2.1 Micro-level Theories to Explain the Origins of Ageism

1.2.2 Meso-level Theories to Explain the Origins of Ageism

1.2.3 Macro-level Theories to Explain the Origins of Ageism

o thers. Hence, it is important to look at ageism from an intersectionality perspec-

2.6 I nterrelations Between the Perceiver’s and the Actor’s

2.7 Conclusion and Implications

c omprehensive understanding of the stereotype-discrimination relations, and also

3.3 The Perspective of Age as Doing

3.4 The Perspective of Age as a Power Relation

3.5 Gendered Ageism as Doing

4.2 Terror Management Theory

4.2.2.1 The Threat of Death

4.2.2.2 The Threat of Animality

4.2.2.3 The Threat of Insignificance

4.3 Stereotype Embodiment Theory

4.4 Social Identity Theory

5.1 Setting the Scene: Ageism at the Workplace

5.2.1 Organizational Structure and Hierarchy