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An international consensus statement on the benefits of reframing aging and mental health conditions in a culturally inclusive and respectful manner

Published online by Cambridge University Press:  26 May 2022

Carmelle Peisah*
Affiliation:
University of New South Wales, University of Sydney, Capacity Australia, Sydney, Australia
Carlos A. de Mendonça Lima
Affiliation:
WPA Section of Old Age Psychiatry, Centre Médical du Jorat
Liat Ayalon
Affiliation:
Louis and Gabi Weisfeld School of Social Work, Bar Ilan University, Israel
Debanjan Banerjee
Affiliation:
ASHA THE HOPE, Kolkata, India
Diego De Leo
Affiliation:
Griffith University, Australia; Director, Department of Psychology, Slovene Centre for Suicide Research, Primorska University, Slovenia; De Leo Fund, Italy, President-Elect, Italian Psychogeriatric Association
Tzung-Jeng Hwang
Affiliation:
Department of Psychiatry, National Taiwan University Hospital, College of Medicine, Neurobiology and Cognitive Science Center, National Taiwan University, Taipei, Taiwan
Manabu Ikeda
Affiliation:
Department of Psychiatry, Course of Integrated Medicine, Osaka University, Graduate School of Medicine, Osaka, Japan, International Psychogeriatric Association
Dilip Jeste
Affiliation:
Sam and Rose Stein Institute for Research on Aging, IBM-UCSD Artificial Intelligence Center for Healthy Living, University of California San Diego, San Diego, USA
Tomas Leon
Affiliation:
Memory and Neuropsychiatric Clinic (CMYN), Neurology Department, Hospital del Salvador, Faculty of Medicine, University of Chile, Santiago, Chile
Huali Wang
Affiliation:
Peking University, Institute of Mental Health (Sixth Hospital), Beijing, China
James Warner
Affiliation:
Imperial College London, Halcyon Doctors, London, UK
Kiran Rabheru
Affiliation:
University of Ottawa, Ottawa, Ontario, Canada
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Abstract

Type
Commentary
Creative Commons
Creative Common License - CCCreative Common License - BY
This is an Open Access article, distributed under the terms of the Creative Commons Attribution licence (https://creativecommons.org/licenses/by/4.0/), which permits unrestricted re-use, distribution, and reproduction in any medium, provided the original work is properly cited.
Copyright
© International Psychogeriatric Association 2022

Combatting ageism and promoting the human rights of older persons, particularly those with mental health conditions, are urgent priorities for the International Psychogeriatric Association (IPA) and World Psychiatric Association – Section of Old Age Psychiatry (WPA – SOAP) (Rabheru and Gillis, Reference Rabheru and Gillis2021; Peisah et al., Reference Peisah, de Mendonça Lima, Verbeek and Rabheru2021). Ageism in particular is rife. Before the COVID-19 pandemic, a study of global prevalence of ageism based on 57 countries and 83,034 participants found moderate or high ageist attitudes among at least 50% of people studied (Officer et al., Reference Officer2020). The COVID-19 pandemic has only widened the crevices of health inequalities for older people (Cohn-Schwartz and Ayalon, Reference Cohn-Schwartz and Ayalon2021). Ageism is now, more than ever, a public health emergency, with significant negative impact on both health outcomes (including but not limited to mental health and quality of life) and the global economy, as evidenced in the recent Global Report on Ageism (World Health Organization [WHO], 2021a). Negative stereotypes and discrimination targeted at older persons and associated internalized negative age-stereotypes cost society heavily, with one-year health care costs of ageism calculated at $63 billion (Levy et al., Reference Levy2020). The pernicious reach of ageism extends to health services and health professionals (Chang et al., Reference Chang2020) with manifest communication patterns and behaviors adversely affecting the delivery of health care to older persons (Ben-Harush et al., Reference Ben-Harush2016).

The IPA and WPA-SOAP are sensitive to and fully acknowledge the long-recognized role that language plays in stoking both societal ageism and self-ageism (Nuessel, Reference Nuessel1982), as well as its potentially powerful role in tackling ageism. IPA and WPA-SOAP embrace global efforts to change the narratives around aging and perceptions of older persons. In 1996, a resolution was adopted by the General Assembly, United Nations (UN) to replace the term “elderly” for “older persons” in conformity with the UN Principles for Older Persons (UN General Assembly, 1996). Over the past few years, a raft of style guides for media and professional organizations and scholarly journals have been developed in conjunction with aging advocacy organizations and stakeholders (Lundebjerg et al., Reference Lundebjerg, Trucil, Hammond and and Applegate2017; Trucil et al., Reference Trucil, Lundebjerg and Busso2021). Qualitative studies among younger populations have shown that the “language of ageism” matters, when older persons are portrayed as “weak,” “frail,” “negative,” and “inherently vulnerable” (Ben-Harush et al., Reference Ben-Harush2016). Recently, the Reframing Aging Project has suggested inclusive language and avoiding ageist terms to strengthen intergenerational bonds and mitigate socioeconomic disparities in later life (Berridge and Hooyman, Reference Berridge and Hooyman2020). WHO has also offered concrete guidelines to avoid ageism terminology (WHO, 2021b).

Older persons with mental health conditions often experience double- or triple-jeopardy in being stigmatized and discriminated against not only because of their age but also because of their mental health conditions and/or physical functioning and abilities (e.g. mentalism, ableism) (Rabheru and Gillis, Reference Rabheru and Gillis2021; De Leo, Reference De Leo2022). In this way, older people living with mental illness are frequently marginalized and subject to human rights violations including elder abuse and reduced access to healthcare. The stigma associated with mental health conditions has been addressed with similar guidelines for preferred terminology (American Psychiatric Association) as those described above.

Common to these efforts is the principle that older people are a heterogeneous group and part of society, not a distinct, homogenous “othered” group. Moreover, older persons with mental health conditions are not solely represented by their age or mental health conditions and a negative valence should not be automatically assumed. While ageism is ubiquitous globally, its practice and manifestation are deeply embedded within sociocultural contexts (Wilińska et al., Reference Wilińska, de Hontheim, Anbäcken, Ayalon and Tesch-Römer2018). St John (Reference St John2018) has called for inclusive approaches to reframing; to address collectively the changing demographics of the entire world, not just those in English-speaking countries. What is offensive in one language or culture may be respectful in another.

Once it is accepted that older persons are not a homogenous group, it follows that what is offensive to one older person may not be offensive to another. Perception of ageism is subjective. A range of determinants influence people’s perception of ageism, including mood state and “subjective age” or “felt-age” (Ayalon, Reference Ayalon2020; Hughes and Touron, Reference Hughes and Touron2021). In an online survey of 818 older Israeli adults aged 65–90 years asked to nominate preferred age terms, Okun and Ayalon (Reference Okun and Ayalonunder review) found a heterogeneity of older people’s self-presentations of aging, including those who hide or blur aging processes and those who emphasize them by using a line of self-ageism. Ageism is perhaps the only “ism” that is accepted by the people who suffer most from it – i.e. older persons’ themselves. The reason is, that everyone has been brought up since early childhood with the idea of ageism being a true, fact-based construct that “with aging, people become frail, disabled, and demented.” This is wrong, not for ethical or moral reasons, but because it is factually wrong, many older people are healthy, happy and in particular, wise.

In this Commentary, we aim to (i) enhance the collective voice in combating the stigma toward older persons, including those with mental health conditions and (ii) be reflective, not prescriptive, recognizing that the global world, and our respective professional organizations are composed of a plethora of different languages and cultures, where words and their interpretation vary enormously.

We used the Delphi method (or the Rand Panel Method) to identify problematic and preferred terminology used to address older persons and those with mental health conditions. The Delphi method is a flexible, effective, and efficient research method used to gain understanding of concepts and problems via the collection and distillation of expert opinion using multiple series of consultations and feedback. We used an iterative multistage consultation process to canvass opinion of selected senior international experts across a variety of language and culture settings, with at least 25 years expertise in old age psychiatry, ageism, and human rights. This was achieved through a series of 45 five remote Delphi consultation rounds where input was fed back to participants or “panel members.” The 12 panel members included 11 old age psychiatrists and one psychologist, from 11 countries: Australia (2), Canada (1) Chile (1) China (1) Israel (1), India (1), Japan (1), Switzerland (1), Taiwan (1) UK (1), and USA (1).

The round one questions were “Is this a worthwhile project?” “What is new about this?” and “How can we build on current reframing initiatives.” Round two questions were “What existing reframing initiatives exist, both in relation to older people in general and older people with mental health conditions?” Subsequent rounds sought to canvass differing perspectives and cultural exceptions for best-avoided and preferred terminology. Feedback was collated and the final document modified after 19 iterations to achieve an inclusive, collective perspective regarding problematic and preferred terminology with cultural caveats.

Consensus for terms best avoided included “elderly,” “seniors,” “senior citizens,” “geriatric” “geriatrics,” and “Grandma/Grandpa” (or in Latin America, “nana, tata, and buque”) when used to refer to older persons in general, not to one’s relatives. These terms can be associated with negative stereotypes and carry a pejorative connotation of being lesser or having lower competency, thereby belittling older people. Such categorical, rather than dimensional concepts of aging such as “being older,” make no sense given that there is no defined, universally agreed threshold that demarcates old age (De Leo, Reference De Leo2022). However, by “othering” older people, extruding and isolating those “afflicted” by aging, these terms serve societal fear of aging and the denial of the ubiquitous and inevitable aging process. Preferred terms are “Older persons,” “Older people,” and “Older adults.” Further, terms such as “Over the hill,” “The silver tsunami,” “The aging tsunami,” and “The grey wave,” which instigate fear and a negative connotation of a disaster should be replaced with more neutrally described “demographic changes” or “aging population.”

We emphasize important cultural caveats. In many cultures, the word “elder” is an honorific term. For example, in Australian First Nation culture, it represents a unique social position in the community (Eades et al., 2021). Similarly, in Taiwan, translation of “elder”( 長老) denotes a respectful social status; and in Japan, sometimes “ elder” is used with more honorific nuance than “ older.” In China, the terms for those who are 65 years or above bear neutral word meanings. If negative feeling is to be conveyed, the term will be combined with a definitive word. The term “laonianren” refers to the population aged 65 years and older, while “laoren” refers to individuals aged 65 years or older.

With regard to the word “seniors,” in certain South Asian countries, “seniors” translated in local language denotes respect and experience (Buzurg in Urdu, Afzal in Urdu, Bara in Hindi, Boyeshko in Bengali) (Bergeron and Lagacé, Reference Bergeron and Lagacé2021). In Taiwan, the local language translation for “seniors” may either contain neutral meaning or imply respect and more experience. “Senior citizen” was the most preferred term nominated by older Israeli adults in a recent Israeli study (also the official term used by the relevant Israeli Ministry) (Okun and Ayalon, Reference Okun and Ayalonunder review). In some Asian and African nations, “senior citizens” is used as a legal term for retirement policies and social benefits. Finally, we concede that the term “geriatric” remains a recognized medical term and often used in health to define populations, service access, and to describe professional organizations and scholarly journals.

With regard to terminology used to describe mental health conditions, the use of mental health terms as descriptors, e.g. “mentally ill older person,” “senile older person,” “demented older person,” and “depressed older person” are best avoided because they are pejorative and exacerbate stigma, equating people and their identity with illness. Preferred usage include “older persons living with dementia/mental illness/depression.” Furthermore, describing older persons as “afflicted by,” “a victim of,” or “suffering from” a mental health condition is best avoided as this implies a value on mental health conditions, automatically equating them with negative quality of life. There is also an inference that mental illness is a sin or a crime, such othering of people with mental health conditions serving societal fear of mental illness.

We concede that the list of terms generated is not exhaustive, there being countless potentially pejorative terms that will be national, regional, or local.

Communication is anchored by language and language shapes what is meant and how it is perceived. The social construction of aging is by and large, negative, and the language used to depict aging and older persons bears negative connotations of decline, deterioration, and despair (Nuessel, Reference Nuessel1982). Mental health conditions are portrayed similarly in a negative and/or derogatory light with the mental health condition often presented as the most central aspect of the person. The WHO UN Decade of Healthy Ageing (2021–2030) (WHO, 2020) regard “combatting ageism” as one of the decade action areas and “capacity building” as one of the key decade enablers. Modifying how we think and speak of older persons is an action plan common to both these areas. How we address older persons in daily discourse, media discussion and policies can potentially impact their perceived respect and dignity.

As clinicians, researchers, and advocates, IPA and WPA-SOAP join older persons, caregivers, community advocates, and the media in the Reframing Aging movement but provide an “added plus” perspective inclusive of mental health and cultural considerations. Age-friendly environments can only be ensured through age-friendly terminology. However, we are both respectful and realistic. First, we are respectful of the variations in meaning of words across language and culture. Second, we are realistic in being persistent and patient in our advocacy. Having mapped the effect of style guides introduced in 2017 on word choice across the scholarly Journal of the American Geriatrics Society (JAGS) and news articles, Trucil et al. (Reference Trucil, Lundebjerg and Busso2021) identified only small increments of progress. However, if we want to change how we think, feel, and speak about older persons for the better, we need to be dogged, and, as (Trucil et al., Reference Trucil, Lundebjerg and Busso2021, p 266) suggest: “in it for the long haul.” We hope this international consensus statement among experts in aging and mental health provides a springboard for individuals to consider ageist and “mentalist” terminology in their own spheres and to reconsider the terminology they use.

Conflict of interest

None.

Description of author(s)’ roles

All authors contributed to the conceptualization and writing of the manuscript.

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