Stereotype Threat in Geriatric Care

Minimizing Stereotype Threat In Geriatric Care

Learn all about the current evidence on this topic and learn strategies to improve your practice!

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About this interactive training

Created through collaboration between the Cognitive Aging and Memory Lab and the Tufts University Department of Occupational TherapyThis training was developed as part of a doctoral capstone project in order to disseminate recommendations for clinical practice based on the current research on stereotype threat. The language and examples in this training are most applicable to the field of occupational therapy (OT); however, the lessons are still applicable to other allied health professions.

Index

Objectives

Modules

Activities

Evaluation

Objectives

1. Understand what stereotype threat is and how it affects older adults 2. Learn about the ways that stereotype threat may be activated in healthcare settings 3. Identify evidence-based strategies to reduce the negative cognitive impacts of ST on older adults

Modules

Click on the arrows to navigate to each module in order.

Recommendations

Connection to OT

Introduction

Receive practical recommendations for clinical practice!

What are the implications for clinicians?

Learn about the stereotype threat phenomenon

01

Introduction

Key Terms

older adults

Older adults (OAs) are commonly defined as adults 65 years and older. Most therapists and allied health professionals will work with some older adult clients.

A note about this preferred term

stereotype threat

Stereotype threat (ST) is the worry about confirming negative stereotypes about one's social identity, which in turn often leads to reduced performance in the area of perceived threat.Stereotype threat can occur in a variety of settings and situations. In this training we will focus on healthcare settings and age-based stereotype threat (ABST), which is caused by stereotypes about age-related decline.

Early research on stereotype threat

Watch this interview with Claude Steele, one of the pioneering researchers of stereotype threat(watch until 5:49)

How does stereotype threat affect older adults' cognition?

Explore and click on the buttons to see the evidence in the literature

Memory retrieval

Assessments

Self-control

False memories

Reduced recall memory performance (e.g., writing as many words as you can remember from a studied list of words)

Reduced performance on common assessments like the MoCA and MMSE

Reduced self-control when making decisions about receiving monetary rewards

Increased false memories ("remembering" details or events that did not actually occur)

Older adults at the highest risk

negative

less

more highly

educated

self-perceptions of aging

positive intergenerational contact

Health practitioners have low awareness of the impacts of age-based stereotype threat on cognitive performance (Parker et al., 2023)

Average rating of detrimental effects of factors on cognitive performance in a hypothetical assessment scenario, on a scale of 1 (not at all) to 5 (extremely)

77.4%

of health practitioners perceive ABST as impacting OAs' cognitive performance "not at all", "slightly", or "moderately"

ABST = Age-based stereotype threat

02

Connection to Occupational Therapy

02

What does all of this mean for OT?

Explore the following case scenarios to learn a few ways that stereotype threat can be activated in occupational therapy practice settings. Click on the interactive elements to learn more!After the case scenarios, review the summary of key implications for OT.

Please read the following case study:

Bernard

Bernard (66-year-old) has been receiving outpatient occupational therapy services for medication management for about 5 weeks. In your session notes from the past few sessions, you have noted that Bernard reported that his age limits him from doing many of his hobbies that he used to enjoy and that he anticipates medication management will get even harder as he gets older.

Bernard has a negative self-perception of aging, putting him at increased risk of being negatively impacted by stereotype threat. It is possible that the content or images in the informational pamphlet induced stereotype threat, resulting in reduced treatment adherence, more missed appointments, and an increased focus on avoiding mistakes.

Strangely, after a session in which you gave him a pamphlet about aging and memory decline, he has missed 2/3 subsequent sessions. During the most recent session, you noticed that he has become more hesitant to try new things and he has not been meeting his therapy goals. What might explain these changes in Bernard's behavior? Click the to find out

Please read the following case study:

Olivia

You are about to see your 73-year-old client Olivia who is a retired psychology professor from a local university. Today you are administering a cognitive assessment for Olivia. As you enter the room, Olivia's nurse says to you, "Something is really wrong with her cognition." As you begin the session, you check Olivia's alertness and orientation to person, place, time, and situation by asking her to state her name, her date of birth, where she is, what time it is, and why she is in the hospital. Then you introduce the assessment by telling Olivia, "It's normal for our cognitive skills to decline as we get older. This assessment will enable us to assess your current level of cognition." Why might the assessment results be inaccurate? Click the to find out

Olivia is highly educated, putting her at increased risk of her cognitive assessment performance being negatively impacted by stereotype threat.The comment from Olivia's nurse could induce stereotype threat. Asking her date of birth and telling her that cognition declines with age are also likely to induce stereotype threat.

How does stereotype threat show up in geriatric care?

As the case studies demonstrate, many clinicians may unknowingly activate stereotype threat in the following ways:

Orienting questions - asking older adults to state their age or date of birth prior to a cognitive assessment

Pamphlets, posters, and other informational materials - giving clients materials with text and images that link cognitive decline to aging

Conversations or statements about age - expressing negative views of aging, which can cause clients to worry about being judged by their provider and negatively influence self-perceptions of aging, which increases the risk of being impacted by stereotype threat

Description of assessments - telling clients that performance on a cognitive assessment decreases with age, or that there are age-based differences

Time pressure - adding time pressure (e.g., visible clocks, timed tasks, looking at a clock) to a task contributes to the negative effects of stereotype threat

Implications for OT

Impaired provider-client trust

Healthcare avoidance

False positive diagnoses

Ageism in clinical practice

Watch the following video to learn about the ways that ageism affects geriatric care (watch until 1:06)

03

Recommendations

03

Close the knowledge-practice gap

This module will provide practical recommendations to turn the research on stereotype threat into evidence-based practice in healthcare professions.

Recommendations for practice

Person

Encourage formation of supportive traits and mindsets

Combatting stereotype threat requires a holistic consideration of factors based on the Person-Environment-Occupation Model of Occupational Therapy Practice. These three factors each contribute to the individual's occupational performance.

Environment

Modify the testing environment to avoid inducing stereotype threat

Explore the following evidence-based recommendations for reducing the negative effects of stereotype threat in clinical practice

Occupation

Changes that healthcare providers can make to the cognitive assessment process

Age-friendly communication principles

Watch the following video to learn about recommendations for changing how we speak about aging

Activities Show what you know!

Environmental Assessment

Concept Matching

Concept matching

Solution

Click on the correct concepts

Supportive mindsets and testing conditions to counter stereotype threat

Traits that predict impaired cognitive performance due to ST in OAs

positive perceptions of aging

negative perceptions of aging

self-efficacy

self-control

less positive intergenerational contact

more positive intergenerational contact

individuation

commonality

time pressure

no time pressure

lower level of education

higher level of education

no accountability

accountability

Collectivistic culture

Individualistic culture

00:15

Environmental Assessment

Click on the items that might induce stereotype threat for an older adult

Perceived time pressure is linked to reduced cognitive performance when OAs are under stereotype threat. Perceived time pressure can be alleviated by telling clients that they have as much time as they need for the task (when applicable) and keeping clocks out of view.

Media such as advertisements (e.g., memory medication ads), journal articles, and news reports that link aging to cognitive decline can induce ST and impair performance on cognitive testing. ST may even be induced outside of cognitive awareness through priming in negative messages in the testing environment.

Assessment

In this section, you will have the opportunity to test your acquired knowledge throughout the course. Our interactive quiz will provide a detailed assessment of your understanding of key topics. Get ready to challenge your skills and reinforce your learning as you move towards mastering the fundamental concepts. Don't miss the chance to demonstrate everything you've learned so far!

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Course completed!

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References

Abdou, C. M., Fingerhut, A. W., Jackson, J. S., & Wheaton, F. (2016). Healthcare Stereotype Threat in Older Adults in the Health and Retirement Study. American journal of preventive medicine, 50(2), 191–198. https://doi.org/10.1016/j.amepre.2015.07.034 Alquist, J. L., Price, M. M., Hancock, D., Talley, A. E., & Cukrowicz, K. (2019). Exposure to negative stereotypes impairs older adults’ self-control. Self and Identity, 18(2), 217–226. https://doi.org/10.1080/15298868.2018.1437069 Barber, S. J., & Mather, M. (2013a). Stereotype threat can both enhance and impair older adults’ memory. Psychological Science, 24(12), 2522–2529. https://doi.org/10.1177/0956797613497023 Febriani, A., & Sanitioso, R. B. (2021). Stereotype threat, intergenerational contact, and performance among the elderly across cultures: A comparative study of France and Indonesia. Cross-Cultural Research: The Journal of Comparative Social Science, 55(2–3), 127–147. https://doi.org/10.1177/1069397121997074 Fernández-Ballesteros, R., Bustillos, A., & Huici, C. (2015). Positive perception of aging and performance in a memory task: Compensating for stereotype threat? Experimental Aging Research, 41(4), 410–425. https://doi.org/10.1080/0361073X.2015.1053757 Gilet, A.-L., Evrard, C., Galharret, J.-M., & Colombel, F. (2021). The moderating role of education on the relationship between perceived stereotype threat and false memory in aging. Frontiers in Psychology, 11. https://doi.org/10.3389/fpsyg.2020.606249 Kang, S. K., & Chasteen, A. L. (2009). The moderating role of age-group identification and perceived threat on stereotype threat among older adults. The International Journal of Aging & Human Development, 69(3), 201–220. https://doi.org/10.2190/AG.69.3.c Krendl, A. C., Ambady, N., & Kensinger, E. A. (2015). The dissociable effects of stereotype threat on older adults’ memory encoding and retrieval. Journal of Applied Research in Memory and Cognition, 4(2), 103–109. https://doi.org/10.1016/j.jarmac.2015.02.001 Mazerolle, M., Régner, I., Barber, S. J., Paccalin, M., Miazola, A.-C., Huguet, P., & Rigalleau, F. (2017). Negative aging stereotypes impair performance on brief cognitive tests used to screen for predementia. The Journals of Gerontology: Series B: Psychological Sciences and Social Sciences, 72(6), 932–936.

A look at the evidence

assessments

A study by Mazerolle et al. (2017) found that under stereotype threat, OAs underperformed on the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) and were more likely than participants in the control condition to fall below the screening threshold for predementia.

A look at the evidence

self-perceptions of aging

Older adults who have a better self-perception of aging, as measured by the Philadelphia Geriatric Center Morale Scale, performed better on a word recall task following the induction of age-based stereotype threat in comparison to older adults who have a more negative self-perception of aging (β ​​= .69, t = 2.77, p < .01) (Fernández-Ballesteros et al., 2015, p. 419).

recommendations:

person

• Promote a positive self-perception of aging
• Build self-efficacy through easier tasks
• Foster individuation by asking the client about themselves as individuals (e.g., their hobbies, values, personality)
• Remind clients of positive cultural beliefs about older adults, when relevant
• Provide patient education before cognitive assessments to warn them about stereotype threat

A look at the evidence

false memories

Krendl et al. (2016) found that stereotype threat increases false memory rates compared to the control group when stereotype threat is introduced at retrieval. A study that analyzed the effect of ST on false memories for OAs of varying education levels found that for OAs with above 15.8 years of education, perceived stereotype threat is a significant predictor of susceptibility to forming false memories (Gilet et al., 2021).

According to a survey of older adults in the Health and Retirement Study, older adults who experienced healthcare sterotype threat (HCST) reported higher average physician distrust than those who reported no threat. Those who reported more than one type of HCST had higher chances of being dissatisfied with health care than those who reported no threat. (Abdou et al., 2016)

A look at the evidence

level of education

A study by Gilet et al. (2021) found that for older adults with more than 15.8 years of education (e.g., those who graduated from a 4-year college), increases in perceived stereotype threat are related to increases in proportion of critical lures during a memory test. However, for older adults with 6.9-15.8 years of education, this relationship is not significant (Gilet et al., 2021).

A look at the evidence

self-control

Alquist et al. (2019) found that the activation of stereotype threat in OAs resulted in reduced self-control compared to the control and positive groups, as measured by a delay discounting task in which participants chose to receive a smaller amount of money today or a larger amount of money at a variety of specific times in the future.

Possible implications: choosing to decline participation in therapy to save energy, but as a result delaying safe return home

A look at the evidence

intergenerational contact

Febriani & Sanitioso (2021) studied the effects of ST on OAs in both France and Indonesia, and found that positive intergenerational contact with young people outside the family moderated the link between threat and memory task performance in both cultures, such that older adults who reported more positive contact did not have a significant effect of threat on performance (p. 138).

Under ST, OAs underperformed on the Mini-Mental State Examination (MMSE) and the Montreal Cognitive Assessment (MoCA) and were more likely than participants in the control condition to fall below the screening threshold for predementia. This raises the concern that stereotype threat could be leading to false positive diagnoses for dementia or other cognitive impairments.(Mazerolle et al., 2017)

Close

negative perceptions of aging

self-efficacy

less positive intergenerational contact

individuation

no time pressure

higher level of education

accountability

According to the same survey, older adults who experienced more than one type of healthcare sterotype threat (HCST) were less likely to have received the influenza vaccination in comparision to those who reported no threat, which is an example of healthcare avoidance. (Abdou et al., 2016)

A look at the evidence

memory retrieval

Stereotype threat manipulation significantly reduces the quantity of information that older adults recall from a studied list in a free recall task (Barber & Mather, 2013). However, there is currently little to no evidence that stereotype threat manipulation can significantly impair cued recall or recognition performance (Kang & Chasteen, 2009).

recommendations:

environment

• Build rapport and trust with clients before administering assessments
• Reduce time pressure by positioning client to face away from clocks
• Remove books, pamphlets or signs in the environment with images or language that may induce ST

What doesn't help: There is little evidence to support priming of positive stereotypes (i.e., counterstereotypes) as an effective strategy to minimize ST

recommendations:

occupation

• Avoid asking clients to state their age. Refer to client's charts to find this information instead, or ask their age AFTER cognitive testing is complete
• Increase motivation and accountability by telling clients that their performance will be discussed with them at the end of the assessment
• Change framing by instructing clients to do their best to “minimize mistakes” rather than “answer correctly” on a cognitive assessment
• When describing a test, de-emphasize the memory and cognitive components