Introduction
Although the ageing of societies is a process that started a long time ago, its consequences have not been realised by policy makers until recently. Ageing of societies is a unique and positive development of mankind. It is a major demographic transition that will cause – as all major transitions – significant societal changes, insecurity and conflicts of interest.1, Reference van den Heuvel2 Ageing of societies creates opportunities, but also raises questions and challenges.Reference Harper3 Questions arise about social assistance, accessible, quality (health) care, and old age pensions. Such questions and the continuing growth in numbers of old people may create or stimulate negative attitudes and discrimination against people in old age. The problem of being old in various, especially developed, societies is increasing dependence, loss of respect, experienced loneliness and discrimination.Reference Harper3–Reference van den Heuvel and van Santvoort5 ‘Full citizenship’ is at risk for old people, especially for the frail old.
Ageing is recognized as a threat for (developed) societies because of the expected increase to them of costs (pensions and care) and the lack of personnel for productive work, reducing economic growth, endangering both general welfare and care for the frail old.Reference van den Heuvel2 Such negative expectations may stimulate intergenerational conflicts, including exclusion of old citizens. Indeed, the citizens becoming old now (the baby boomers) are portrayed as having taken their children's future and that they should pay it back.Reference Willetts6 Not surprisingly, an overwhelming negative attitude towards old citizens is reported, for example in the United States.Reference Bishop, Roden, Bolton and Wynn7 In Europe, age in general is most frequently mentioned as reason for discrimination.8 Stereotypes of old people and the ageing process are not uncommon in society at large.Reference Salzman9
Given the increasing number of old people, the expressed policy concerns about it, and negative attitudes towards old people, the question is raised about to what extent discrimination against old people exists these days.
Respect for the old is believed to diminish in ‘western’ culture. A European study reports that old Europeans stated that they receive more respect than less, and the very old stated that they more often receive respect.Reference Walker10 However, the data show the ambivalence of EU citizens when it comes to respect for old citizens. It was also found that older citizens (55 years and older) were more likely to see negative attitudes towards their age group in their country than younger ones.11 In other cultures, such as in South-East Asia and India, respect for the old is strongly embedded in family and social life.Reference Papol12, Reference Ingersoll-Dayton and Saengtienchai13
If old citizens are perceived negatively and less respected and the increase in numbers of the old is described as a ‘tsunami’, they may become ‘unwanted’ and discrimination against them may increase. In such a process, exclusion of old citizens may become ‘normal’ and full participation of the old is not welcomed. It is stated that discrimination against older people presents a major barrier to any ambition for active ageing.14 However, it has to be realised that the relationship between what people think or say and do is not that strong.Reference Vernon15 Additionally, discrimination because of old age may differ from other types of discrimination.Reference Cuddy, Norton and Fiske16 Since citizens often have positive and negative stereotypes about old people, their behaviour may be positive and negative, i.e. showing helping behaviour as well as excluding behaviour.Reference Cuddy, Norton and Fiske16 Old citizens may experience positive as well negative behaviours, which may even differ within old citizens.
This paper intends to present evidence about discrimination against old people. Before doing so, the concept of age discrimination has to be clarified and the method of finding evidence will be described.
The concept of age discrimination
Age discrimination is related to two other phenomena, i.e. ‘ageism’ and ‘elder abuse’. Robert Butler coined the word ‘ageism’.Reference Butler4 Ageism consists of a combination of prejudicial and negative attitudes towards old people and the process of ageing, institutional regulations that confirm stereotypes about old people and the exclusion of (services/treatment/help to) old people.Reference Wilkinson, Ferraro and Nelson17 The concept of ageism is broad and linked both with elder abuse and age discrimination, but also to attitudes, stereotypes, legislation and structure. Elder abuse and age discrimination may both be seen as expressions of ageism: behaviours that disadvantage or mistreat old people because of their age. Both (age) discrimination and (elder) abuse may occur in various situations (family, work, leisure) in which the social-cultural and institutional context ‘allow’ such behaviour, i.e. ageism.
Elder abuse is described in various ways. The most common definition may be: ‘a single or repeated act or lack of appropriate action, occurring within any relationship where there is an expectation of trust, which causes harm or distress to an older person’.18, Reference Gutman and Spencer19 Abuse of old people can be divided into: physical abuse; psychological abuse; financial or material abuse; or sexual abuse.20 Elder abuse is a form of age discrimination.
Ageism leads to discrimination according to European ‘Equality Bodies’.14 Discrimination is defined as the unjust or prejudicial treatment of different categories of people, especially on the grounds of race, gender, religion, sexual orientation and/or age. In the context of civil rights, discrimination refers to unfair or unequal treatment of an individual or group based on certain characteristics. Discrimination is a comparative concept, i.e. a person or group is treated ‘worse’/‘unfairly’ compared with other people or groups because of a specific characteristic ascribed to this person or group.Reference Horta21 Various behaviours and actions indicate discrimination, but they have in common that they exclude or reject the other. Discrimination based on age is often related to discrimination on other grounds.14
Discrimination is the outcome of a complex process in which a person, a group, or a category of people are differentiated on assumed or real characteristics and/or specific beliefs, while differentiation based on such characteristics and/or beliefs is seen societally as unjustified.Reference Wait and Midwinter22 The way discrimination is exposed may be direct, i.e. explicitly and openly directed to people with the characteristic(s), or indirect. This means that discrimination may be assessed directly, i.e. observing and/or questioning the (extent of) discriminating actions and behaviours, or indirectly, i.e. analysing the consequences of specific actions, measures or behaviours on their adverse effects. Statistical data and registration systems may show age discrimination indirectly. Verbal antagonism, avoidance, physical aggression and extermination are indicators of direct discrimination.
In many countries legal arrangements are created to combat discrimination. Legislation to combat age discrimination is mostly part of a wider legislation on human rights and/or equal treatment. The presence of such legislation is seen as institutional action against discrimination.
Methods
This review intends to report data on discrimination against old people and abuse of old people, showing the evidence of age discrimination. Ageism is a widespread phenomenon across the European Union.14 However, the criteria used to assess the extent of ageism, or in this review the extent of discrimination and abuse in old age, are less clear. There is no set of valid and reliable instruments to assess the extent of discrimination or abuse. To find ‘strong’ evidence, we looked for data derived from scientific articles and official documents. A literature search resulted in a limited number of articles (MeSH terms: discrimination, abuse, ageism and elderly). Searching in MEDLINE and PsychLIT with ‘discrimination’ and ‘abuse’, the number of papers was 195. Inspection of the abstracts showed that a limited number were dealing with old people. In the case of official documents the sources of the data – and therefore the reliability – were not always clear. Most studies were found by snowball sampling of the literature.
One method, which was selected in this review, was to consider data based on direct questions to old people about whether they experience discrimination because of their age. The question about experienced discrimination presents less subjective information than when people are asked whether they feel discriminated against because of their age. Also, by asking old people themselves rather than others (family, citizens, professionals) the situation reflects what is actually happening in old people's lives.
However, not all old people will report age discrimination for various reasons (fear, denial, customs). This will be even more so in case of elder abuse. The literature shows that elder abuse more frequently occurs to people in a vulnerable situation. This situation makes it difficult for people to express their opinion. Therefore, we also used an additional source, i.e. discrimination and abuse of old people because of age reported to official bodies like committees for equal treatment, police, consumer organizations and courts, as far as available.
Another way to look for evidence of age discrimination is to use information based on structured questionnaires sent to various experts such as researchers, practitioners, social workers, representatives of non-governmental organizations (NGOs) and policy makers. However, if such questionnaires are open, the outcomes represent a wide variety of definitions, descriptions and explanations without a theoretical and empirical context.Reference van Bavel, Janssens, Schakenraad and Thurlings23 As a consequence, it might be impossible to relate the results to the research question.
Legislation can be a cause for age discrimination, as is described under ageism. So, another way to look at age discrimination is to analyse specific legislation on age discrimination. In this review a short description will be given of two major legislation initiatives.
Data on discrimination and abuse
Overall, 42% of citizens in the European Union think age discrimination is widespread, with 52% saying it is rare. Differentiation between countries shows that age discrimination is believed to be widespread by citizens of Hungary (67%), the Czech Republic (58%) and Slovakia (49%), and not to be so widespread by citizens in Romania (30%), Denmark (28%) and Ireland and Luxembourg (both 24%).24 Older people stated more often that discrimination is widespread in their country than younger people.24
When EU citizens are asked more specifically about those situations where people have been discriminated against because of old age, it is found that workplace age discrimination (6%) is the most frequently reported form of age discrimination experienced by EU citizens, followed by age discrimination in access to financial products and services (5%) and age discrimination in health care (4%). The proportion of EU citizens who report to have witnessed such age discrimination in the workplace is 15%, for access to financial products and services is 10% and for health care is 11%.11
Age discrimination in the workplace also includes job seeking. A survey among 700 registered job seekers found that 80% of them feel that they have been discriminated against because of their age during their job search.25 No wonder that over 90% of jobseekers over 50 years feel that the policy makers are ignoring the problem.
In health care, there is the danger of under-diagnosis and under-treatment in old people, because health problems and symptoms in old people may be overlooked or dismissed as part of the normal aging process.Reference Salzman9 Opinions, including those of health care professionals, are that age discrimination exists structurally in health care.26–Reference Clarke28 Under-diagnosis and under-treatment because of old age may be seen as age discrimination, but precise data are lacking.
Old people in Europe also report experienced discrimination because of their age. Whilst a majority (52%) state that they have never been discriminated against, 15% report to have been sometimes and 11% frequently discriminated against.Reference van den Heuvel and van Santvoort5 Significant differences exist between European countries; a relatively high proportion of old people report having experienced discrimination recently because of their age in the Czech Republic (23%), Ukraine (20%), Russia (18%), Romania (16%), Bulgaria (11%) and Slovakia (11%), and a relatively low proportion in Sweden (2%), Denmark (2%), Norway (3%) and Switzerland (3%).
The World Health Organization estimates that 4–6% of older people worldwide have suffered from a form of elder abuse – either physical, psychological, emotional, financial or due to neglect.29 A systematic review of 94 studies showed that 6% of older people in the general population reported significant abuse.Reference Cooper, Selwood and Livingston30 When these researchers selected studies with only validated instruments to assess abuse, they found that about a quarter of the vulnerable old reported serious psychological abuse. Among home care staff, 16% admitted significant psychological abuse. However, reporting abuse was significantly lower when abuse was recorded using objective measures. The authors conclude that one in four vulnerable old people are at risk of abuse and only a small proportion of this is currently detected. The UK National Prevalence Study of Elder Mistreatment among independent living elderly, using a face-to-face questionnaire, found that almost 3% reported mistreatment by family members, close friends or care workers.Reference Biggs, Manthorpe, Tinker, Doyle and Erens31
Elder abuse is reported more frequently in residential settings than domestic settings. Various investigations show that psychological abuse is often occurring in nursing homes (in about in 8 of 10 cases), as reported by staff members.Reference Ingalls, Layton and Weitzel32–Reference Weatherall35
Complaints/cases related to age discrimination reported to Equality Bodies in various European countries vary between 3 and 20% of all complaints/cases: 20% in Austria, 17% in Germany, Lithuania and The Netherlands, 15% in France, 10% in Denmark and Hungary, 8% in the Czech Republic, 7% in Luxembourg, 5% in Belgium and 3% in Bulgaria, Ireland and the United Kingdom.14
Most complaints about discrimination are related to employment (advertisements, access, recruitment, dismissal, retirement). Beyond employment, the most frequent complaints concern access to insurance and banking services (consumer credits, credit cards, loans, mortgages and accounts). Age discrimination related to housing, social protection, social care and health care is less often reported to Equality Bodies.14
Factors and conditions related to age discrimination
Socio-economic (gender, occupation, marital status) and social factors (poverty, housing conditions, social network and social contacts), as well as societal factors (stereotypes, prejudice, mistrust between generations) may be related to age discrimination and therefore be seen as risk factors for discrimination against the old.Reference Bishop, Roden, Bolton and Wynn7, Reference Vernon15 Generally, gender and socio-economic status have been found to be correlated with age discrimination. Various studies suggest that age discrimination occurs in cases of poor health and dependency.Reference Clarke28, Reference Pascoe and Richman36 A study in the UK among independent living elderly people showed that women, people with a low socio-economic position and those with worse health status are more likely to be mistreated.Reference Biggs, Manthorpe, Tinker, Doyle and Erens31
People who believe that discrimination occurs frequently also report more frequently that they experience discrimination.Reference Salentin37 People who feel safe and have trust in other people may perceive less discrimination than those who do not. Attitudes are often seen as being related to the tendency to discriminate. Beliefs and attitudes are often internalized as stereotypes of a specific culture, which results in implicit discrimination.Reference Mossakowski38, Reference Adams, Buckingham, Arber, McKinlay, Marceau and Link39 The socio-cultural context people live in may also influence age discrimination. For example, discrimination of old people is more frequent in Eastern European countries and rare in Scandinavian countries.Reference van den Heuvel and van Santvoort5 This socio-cultural context is given as one explanation for the big differences in experienced discrimination in old citizens between European countries.Reference van den Heuvel and van Santvoort5
Age discrimination in health care is reported worldwide.40 Lack of geriatric training may cause inequity in clinical treatment, because staff members have little knowledge of the specific care needs of older people. Stress related to care giving is another factor that may cause age discrimination and abuse. As mentioned, elder abuse is reported more frequently in residential settings than domestic settings. However, in at least one study it was found that family members were responsible for abuse in the majority of the cases.Reference Weatherall35 However, elder abuse in nursing homes is a persistent phenomenon.Reference Castle41
A review in 18 developed countries showed that many physicians have negative attitudes and stereotype beliefs towards old people.Reference Safiliou-Rothschild42 It may be not remarkable then that older people are significantly under-represented in clinical trials.
Legislation on age discrimination
The USA has a long-standing body of legislation on age discrimination.43 The first age discrimination law in 1967 was related to employment. The Age Discrimination in Employment Act (ADEA) protects applicants and employees of 40 years and older from discrimination on the basis of age in hiring, promotion, discharge, compensation, or terms, conditions or privileges of employment. In 1975 the Age Discrimination Act (ADA) was adopted. It is directed to prohibit age discrimination in programmes and activities receiving federal financial assistance. The ADA, which applies to all ages, permits the use of certain age distinctions. In the Workforce Investment Act (WIA) of 1998, a special section (188) deals with discrimination against applicants, employees and participants in WIA financially assisted programmes and activities.
The European Commission (EC) formulated an Anti-Discrimination Framework Directive to combat discrimination and stimulate equal treatment,44 establishing a general framework for equal treatment in employment and occupation. The council framework directive requires member states to implement laws to combat various forms of discrimination including discrimination on the grounds of religion or belief, sexual orientation, disability and age. The Anti-Discrimination Framework Directive effects age discrimination legislation in all Member States. However, interpretations, claims of discriminations and sanctions do vary between member states. Implementation of such directives takes time.
The legislation on age discrimination raises questions about its impact and consequences on employment, the labour market, access to health care, etc. Analyses indicate that the ADEA has resulted in later retirement and more older workers in the USA.Reference Neumarkt45 The effect of the EC framework directive is the subject of a (scientific) debate. Age discrimination legislation may have a significant massive impact on the employment relationship and pension schemes, resulting in changes of the established retirement ages.Reference O'Mailly46 In Europe, the national responses to the EC directive are believed not to be effective due to a utilitarian perspective and weak implementation.Reference O'Cinneide47
Discussion
This paper questioned the extent of discrimination against old people. This question is related to discussions about respect for old people and the barriers of full participation of old citizens, to the reports and findings about ‘social welfare problems’ because of ageing of societies, and to the negative perceptions about old age (at least in some cultures). Notwithstanding the methodological weaknesses in assessing age discrimination, to be discussed later, it may be concluded that age discrimination and elder abuse are problems that occur regularly in ageing societies.
Exact figures cannot be presented, but about a quarter of old people probably do experience discrimination regularly because of their old age.Reference van den Heuvel and van Santvoort5 This proportion is significantly higher among the dependent old, of whom a significant proportion live in institutions. For older people living in institutions, discrimination and abuse seem to be more the rule than the exception.
Age discrimination is more often witnessed than it is reported. Age discrimination occurs relatively frequently in workplace settings and job seeking. It is witnessed more frequently – and is probably easier to notice – in the workplace and in health care than in financial and service settings, but the data show that it may occur in all settings and the data do not indicate large differences between settings.
The proportion of reports on age discrimination to European Equality Bodies is rather low. Besides selection, this could be related to the belief that discrimination because of old age is (still) judged as normal or justifiable.14 Such beliefs sustain a culture where old people accept or even do not recognize discrimination. In the UK, the Department of Work and Pensions concluded that age-related discrimination and stereotyping remain ‘rooted in British society’. The large difference in experienced discrimination by old people because of their age between European countries underlines the explanation that age discrimination is embedded in state-welfare culture.Reference van den Heuvel and van Santvoort5
Some authors state that the existence of elderly abuse, especially of those who are very dependent, is well documented.Reference Teaster and Anetzberger48 Certainly we have concluded that it occurs regularly and – in specific conditions – often. However, we found that data on age discrimination and elder abuse are rather scarce in scientific literature and official documents. The sources of the data in official documents are not always clear. Besides, these data are sometimes rather old. The data in the report of the United Nations of 2010, presenting a ‘comprehensive overview’, uses data that are ten years old.
Available data may be questioned because of representativeness and reliability. For example, old people who do lodge a complaint with Equality Bodies will be a specific group. The variation in reported elder abuse using different instruments questions the validity of the way data are collected. It is recommended that a validated set of instruments to assess age discrimination and elder abuse should be developed.Reference Cooper, Selwood and Livingston30
To combat age discrimination, it is not enough to have reliable data or registration systems. It is important to understand the factors and mechanisms that are related to age discrimination. Four factors seem to be important to consider: socio-demographic factors, personal characteristics, social-environmental factors and state-welfare conditions and culture. Age discrimination occurs more frequently if people are poor and less educated, have a worse health status, no confidence in other people and lack of network/social support, and are living in a country with poor social-welfare provisions and abuse of justice. It may be no surprise that in East European countries, where discrimination against old age is experienced more frequently, the majority of all citizens state that their country is not ‘age-friendly’, i.e. not adapted to the needs of old people.11
Discrimination is most difficult to deal with when it is indirect, the result of apparently neutral rules that adversely affect a particular group. Human rights are, by definition, universal and apply to all citizens, including older people.40 Human rights, which are needed to combat discrimination, are therefore formulated very broadly. References to older people are not found or understood easily. International documents may perform an interpretive function in this regard. Various conventions formulate these implicitly, for instance: The International Covenant on Economic, Social and Cultural Rights and the International Covenant on Civil and Political Rights, the Convention on the Elimination of All Forms of Discrimination against Women, the International Convention on the Elimination of All Forms of Racial Discrimination and the Convention on the Rights of Persons with Disabilities. So, age is a prohibited ground of discrimination.
The Human Rights Committee of the United Nations is not in favour of an additional convention specific to old age and it is not needed according to the Report of the Secretary-General.40 Neither a specific UN committee, nor a UN rapporteur on rights of older people, is considered as an option in the report, but reliable data are needed to show and prove the discrimination. Being aware of the myths and realities of ageing is as important as facts about discrimination.Reference Salzman9 Once the difference between facts and fictions are clear, more specific measures are needed.
An Expert Group proposes the following measures to fight discrimination against old age: formulate policy and make public statements, create awareness, register age discrimination and stimulate research on old age discrimination and elder misuse, design and implement comprehensive prevention programmes, and supply information for older adults about their rights.Reference Butler4 Although still vague, such recommendations make sense. Legislation and human rights are not enough to combat age discrimination. Facts and effective interventions have to be available.
A measure like a national ombudsman or national committee on the rights of older people may be more controversial. Maybe the most effective way to combat discrimination against old people is to stimulate and facilitate full participation of older people in societal and policy decision-making processes. This option may be not unrealistic: four out of ten EU citizens want old citizens to play a bigger role in their country.11
This analysis on the factors and conditions related to discrimination against old age shows that one size does not fit all. Each country and all institutional bodies have to find measures to combat age discrimination. So each country and body should take responsibility. However, there is one common prerequisite: these measures have to be multi-component.
Conclusions
At the beginning of this century, the United Nations reported that prosecution because of discrimination is rare in most countries.49 In the case of discrimination against old people this situation may be especially poor. It was also stated that whatever legislation there is will be ineffective as long as cases are not prosecuted. However, one measure is not enough. What is needed is a multi-component action plan, supported internationally, executed and operationalized nationally and regionally. It is urgently needed because discrimination against old age occurs regularly. The components of such a plan are described.40 Within such an action plan, concern for vulnerable old people is a priority. Special measures in health care settings are needed for old people, including training, quality control and increase of expertise.
Discrimination against old people and elder abuse will be with us for some time, but can be defeated. The legislation and the instruments are available. The idea that old people could and should play a bigger role in their country is supported by a significant number of citizens. So, there is potential in manpower and attitudes. Ideas how to put this into action are numerous, but should be used in a comprehensive, strategic plan. Above all, old people themselves are challenged to show how they want to contribute to the human development of their society.
Conflict of interest
The author confirms that he has no conflicts of interest.
