Primary Care Clinician Expectations Regarding Aging

For many centuries, it was a common perception that advancing age was inevitably defined by physical and functional decline. Yet, in the past 20 years geriatricians and gerontologists have shifted their attention to the constructs of optimal aging and successful aging. Given the rapidly growing proportion of the population older than 65 years of age in the United States and globally, academic research, public policy, and popular literature have increasingly focused on understanding how environmental, social, and attitudinal factors influence opportunities for successful aging. Because aging is a dynamic process involving both decline and opportunities for continued development, we find ourselves struggling to reconcile views about normal aging. What can be prevented or remedied through treatment or lifestyle behaviors and how might we best cope with the changes that are an inherent part of growing old? A growing body of research indicates that people’s perception of the aging process can profoundly influence their subsequent health behaviors and use of health resources. For example, even after controlling for age, education, functional health, gender, race, and self-rated health of study participants, Levy and Meyers (2004) found that those with more positive views of aging (i.e., who do not attribute changes to inevitable deterioration based on age) were more likely to perform preventive health behaviors over the subsequent two decades. There is also evidence that individuals with more positive self-perceptions of aging experience better functional health over time (Levy, Slade, & Kasl, 2002) and are likely to live 7.5 years longer than those with less positive views (Levy, Slade, Kunkel, & Kasl, 2002). Similarly, Sarkisian, Hays, and Mangione (2002) found that individuals were less likely to seek health care when they assumed that it was a normal part of aging to become depressed, to become dependent, to experience more aches and pains, to have a reduced libido, and to have less energy. Depressed older adults who attributed their condition to aging were 4.3 times less likely to believe it was very important to discuss depression with a doctor (Sarkisian, Lee-Henderson, & Mangione, 2003), and low age expectations were independently associated with very low levels of physical activity in older adults (Sarkisian, Prohaska, Wong, Hirsch, & Mangione, 2005). These associations have led to speculations about possible interventions to increase an individual’s expectations regarding aging (ERAs) and thus facilitate improved health (Sarkisian, Prohaska, Wong, Hirsch, & Mangione, 2005). Aging, however, is more than an individual process. Aging is a social developmental process subject to influence from important others. As Nussbaum, Pitts, Huber, Raup Krieger, and Ohs (2005, p. 288) wrote: Although ageing is first a biological process, it is largely the social construction of ageing that shapes the structure, function, and possible outcomes of intergenerational interaction throughout the lifespan .… Successful, healthy ageing extends far beyond the physical/biological realm into the social nature of ageing. Attitudes about aging have considerable potential to influence the way we perceive and interact with older adults as well as shape the way older adults see themselves (Horton, Baker, & Deakin, 2007). Views of aging and stereotypes about older adults may be positive or negative in valence and they are often evaluatively mixed (Kite, Stockdale, Whitley, & Johnson, 2005). There is evidence that stereotypes of elders have changed over the past 30 years from that of being relatively poor, frail, and dependent to being considerably more prosperous, active, and politically powerful (Cook, 1995; Quadagno, 2008). This is not surprising as the cohort of “baby boomers” in the United States has transitioned into their 60s bringing greater power in their numbers to political and economic domains. We now see the proliferation of programs for older adults that involve outdoor adventure and international travel, activities previously assumed to be outside the interests or capabilities of most older individuals. A complex interaction of improved health care and information, and access to other resources affecting quality of life by privileged seniors of our society have modified our image of what aging may look like with supportive conditions. Thus, the cohort of people who transitioned through youth and early adulthood in the 1950s and 1960s, for example, were acculturated with different images and ERAs than were those who came of age in the 1990s. Therefore, we would expect significant cohort differences in basic assumptions about aging. Despite these cohort differences, however, recent research documents that negative attitudes about aging and the elderly population still predominate in American society (Palmore, 2005; Richeson & Shelton, 2006). These views of aging likely influence the way we perceive ourselves and one another and, therefore, how we treat one another in personal and professional settings. Primary care clinicians are well positioned to facilitate successful aging by providing their patients with quality medical care and strategies for preserving key functional capacities with advancing age (Haber, 2007; Inui, 2003). However, medical clinicians, like other members of the general population, may harbor negative attitudes about aging and the elderly population (e.g., Gunderson, Tomkowiak, Menachemi, & Brooks, 2005; Lee, Reuben, & Ferrell, 2005; Richeson & Shelton, 2006). Adults older than 65 years of age are the most frequent users of the health care system, averaging 12 patient–physician contacts each year, and they depend on clinicians as a resource for preserving and promoting physical and emotional health (Thompson, Robinson, & Beisecker, 2004). Because nearly 80% of Americans visit their primary care clinician at least once a year, these providers have access to patients at multiple teachable moments over time (Haber, 2007). Moreover, patients report that they expect to receive preventive health information and recommendations from their primary care clinicians as well as help in changing key lifestyle behaviors (Little et al., 2001; Whitlock, Orleans, Pender, & Allan, 2002). Clinician attitudes toward aging may influence the content of care that is offered and how patients understand what can be prevented versus what must be endured with advancing age. To date, there is limited documentation of clinician ERAs. Furthermore, we do not know whether clinician characteristics, such as age, gender, training, personal health behaviors, and practice characteristics, may influence their age expectations. Therefore, this study was designed to (a) assess ERAs in a practicing sample of primary care clinicians in the United States and (b) identify clinician characteristics associated with ERAs. Based upon previous research on clinician and/or community-dwelling populations and our own experiences with older adults and the health care system, we hypothesized that clinician ERAs would be inversely associated with age and that clinicians with higher ERAs would be more likely to report positive personal health behaviors and place greater value on health promotion counseling and delivering clinical preventive services. This study provides a foundation for researchers to explore the associations between clinician age expectations, quality of care, and patient attitudes about aging as well as to inform possible primary care-based interventions to facilitate successful aging.