Breaking the links between ageism and health: An integrated perspective

Ageism refers to prejudice, stereotypes or discrimination based on a person ’ s actual or perceived chronological age. While ageism can affect people at all stages of the human lifespan, ageism against older adults has emerged as the most pervasive and potentially harmful. Much is now understood about how ageism can impact older people ’ s health and wellbeing via structural, organisational, and provider level biases that threaten the provision of equitable and ethical healthcare. Negative attitudes about age and ageing also contribute to workforce shortages in aged care sectors, such as residential aged care and nursing. However, often underappreciated is how self-directed ageism, which refers to ageism turned against oneself, can also be an important determinant of health and wellbeing. Relative to external sources of ageism, negative internalised ageist beliefs are not only experienced more frequently in older adults ’ everyday lives, but are also more strongly linked to their health and wellbeing. Here we highlight how this understanding means that eliminating ageism requires a multifaceted approach that targets not only health care systems and aged care professionals, but older people themselves. Because normal age-related cognitive changes in how we think, perceive and reason increase the risk of older people viewing themselves through a negative and ageist lens, we provide a novel discussion of how broader insights from cognitive ageing literature must play a central role in any agenda focused on breaking the links between ageism and health.


Introduction
Ageism is most commonly defined as a multidimensional construct that encompasses stereotypes, prejudice and discrimination, with a major survey by The World Health Organisation (2021) revealing that every second person in the world holds at least some ageist beliefs.While ageism can be directed at a person of any age and include both positive and negative aspects, most studies to date have focused on how ageism negatively impacts older people.
It has been suggested that public ageism "erupted" in the UK, US and Australia because of the social and economic costs required to protect 'disposable' older adults from COVID-19 (Lichtenstein, 2021), while analyses of twitter data revealed how the COVID-19 pandemic sparked a proliferation of negative-age-based comments, with a common theme being that the lives of older people were less valuable than young, and even made reference to the benefits of senicide (Xiang et al., 2021).Such events, combined with rapidly ageing populations worldwide, have led to steadily increasing research interest in ageism (Fig. 1).
Yet interestingly, a recent scoping review concluded that the level, correlates, and consequences of ageism were very similar to those observed prior to the pandemic (Werner and AboJAbel, 2023).Indeed, while the COVID-19 pandemic shone the spotlight clearly on how ageism can jeopardise the provision of ethical and equitable healthcare, this problem is not unique to modern times.A recent meta-analytic review of 422 studies that collated 25 years worth of data from more than seven million participants revealed that ageism was associated with poorer health outcomes in 95.5 % of the studies and 74.0 % of the 1159 ageism-health associations examined (Chang et al., 2020).
Here, in relation to health, we provide an overview of the causes and consequences of ageism.Since it is well understood that ageism is harmful for older adults' health and wellbeing when it presents as healthcare inequities and biases or contributes to skills shortages in aged care sectors, we only briefly review literature on these topics.Instead, our primary focus here is to highlight the often-underappreciated harms caused by self-directed ageism, which refers to ageism turned against oneself.We discuss how eliminating ageism requires a multifaceted approach that targets not only health care systems and aged care professionals, but broader society and older people themselves.Because negative ageist beliefs become increasingly accessible and difficult to eliminate owing to developmental shifts in mentation, we also provide a novel discussion as to how insights gained from cognitive science are critical to any comprehensive research agenda focused on breaking the links between ageism and health.

Direct inequities in healthcare
".ageism leads to barriers in access or denial of healthcare services and treatments, with age being the primary factor determining who receives certain procedures and treatments."(Inouye, 2021).
The most obvious and direct way in which ageism affects health is when there are basic inequities in access to, delivery and provision of healthcare on the basis of chronological age.There are many routes by which such inequities have been shown to occur, and such negative effects of ageism on clinical outcomes are not restricted to geriatric healthcare, although may be amplified there.In a landmark prospective cohort study of over 9000 hospitalised patients diagnosed with one of nine different illnesses, healthcare professionals were more likely to withhold life-sustaining treatments for older compared with younger persons, even after prognosis and patient preferences were controlled for (Hamel et al., 1999).Age-based exclusions are also common in clinical trials, with age capped in more than a third of clinical trials for cardiovascular disease and Type II diabetes, and more than a fifth of cancer trials (Nguyen et al., 2022).A recent systematic review also revealed that, of 4341 randomised clinical trials, 29 % had upper age limits, and that most (92.8 %) failed to provide any explanation for why age was capped (Thake and Lowry, 2017).
Older people with depression are also more likely to be excluded from recommended screening, investigation or treatment due to biases about what is 'normal' for older people (Linden and Kurtz, 2009).A recent scoping review of ageism found that, of 23 studies that investigated treatment recommendation and/or treatment provision in cancer care, 19 identified differences in the way younger and older patients were treated, including a reduced likelihood of older patients receiving surgery or chemotherapy, being offered breast conservation surgery and breast reconstruction, or multimodality therapy (Haase et al., 2023).Older people are more likely to be excluded from decisions about their own medical care.A population-based death certificate study in Belgium identified age-based disparities in end of life decisions, whereby age was not a determining factor in the rate of end-of-life decisions, but was associated with an increased likelihood of being excluded from the decision-making process (Chambaere et al., 2012).

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. few nursing students plan to specialize in gerontological nursing and many relate their lack of interest in gerontological nursing to negative pre-existing attitudes toward older adults " (Magan et al., 2023).
In late adulthood, multiple chronic health conditions are common, and this means that, relative to their younger counterparts, older people are more likely to have issues related to poly-pharmacy, require additional support to complete activities of daily living and require access to healthcare services more frequently.At the same time, life-prolonging medical advances have created more complex physical and mental health care needs.This has led to an unprecedented need for qualified health professionals in aged care sectors, and with our global population age continuing to rise, this need is only projected to increase still further.
Yet relative to other areas of nursing and healthcare delivery, the provision of care to older people is an undesirable area of practice.Healthcare professionals hold more negative perceptions of older people relative to the general population, even after controlling for age, gender and education level (Crutzen et al., 2022), and fewer than half of students in medicine and nursing report being willing to work with older people in the future (Dobrowolska et al., 2019).Moreover, while nurses are the healthcare professionals with the greatest contact with older people in clinical settings, relative to other health professionals, they have a less accurate knowledge of ageing, and are more likely to believe that working with older adults is indicative of low status in their profession (Wells et al., 2004).A recent integrative review of nursing students' preferences also found that, in most studies that rank intention to work in nursing fields, gerontological nursing received the lowest, or a relatively low ranking, amongst all professional choices (Dai et al., 2021).A systematic integrative review of nurses' attitudes towards older peoples' care further revealed that, although nurses hold co-existing positive and negative attitudes towards older adult care, negative attitudes in particular were directed at the characteristics of older people themselves, their care demands, or reflected in the nurses' own approaches to care (Rush et al., 2017).Rush et al.'s (2017) data aligns with other studies that have identified health professionals as holding coexisting discrepant attitudes towards older people, and specifically, explicit, outwardly positive attitudes alongside negative implicit ones.Indeed, the bias of crowds model (Payne et al., 2017) predicts that implicit ageist bias should be the norm in healthcare environments.In this model, implicit bias is conceptualized in terms of contexts and systems, reflective of an ongoing set of associations based on inequalities and stereotypes in the environment.This model therefore predicts that ageism is a direct reflection of the environment in which we are situated -and that ageism may therefore be unintentionally transmitted via role-modelling in many healthcare settings.
Consistent with this possibility, almost half (47 %) of students in medicine and nursing report witnessing overt age discrimination in healthcare (Dobrowolska et al., 2019).In such settings, the language related to the clinical care of older people can also appear pejorative and loaded.This includes when older people "fail" their trials of rehabilitation or deteriorate in hospital, and it is decided that they need to be "placed" in a nursing home, with the implication being that older people are problems to be managed.Indeed, a systematic review of 83 studies concluded that the primary antecedent to 'elderspeak' is implicit ageism.This simplified speech register, not dissimilar to babytalk, is experienced as patronising even by those with dementia (Shaw and Gordon, 2021).Thus, while many negative thoughts, feelings, and behaviours can and do operate outside of conscious awareness or control, implicit ageist biases may be especially problematic in healthcare.Not only are implicit ageism biases consistently linked to lower quality of care (FitzGerald and Hurst, 2017), they are also more difficult to recognise and challenge than explicitly ageist attitudes and behaviors.

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Evidence supports a significant association between ageism and health, particularly between self-perceptions of aging and health " (Hu et al., 2021) In specific life domains, older adults sometimes hold less explicit negative views about older than younger people, and views on older age appear to become richer and more differentiated in late adulthood (De Paula Couto et al., 2021).Moreover, when negative views are assessed concurrently with positive ones, older adults' views of aging can be more positive than negative overall (Laidlaw et al., 2018).However, when implicit methods of assessment are used, negative age-based stereotypes are more prominent and accessible than positive ones, and while this effect is robust across all stages of the adult lifespan, it becomes stronger in our later years.For instance, the Project Implicit: International dataset identified a stronger pro-young/anti-older implicit preference in older relative to younger participant groups in all 26 countries that identify a significant effect (Charlesworth et al., 2023).
Thus, not only medical and nursing students, but older people too, sometimes conceptualise older age as mainly carrying negative connotations (Dobrowolska et al., 2019).Consequently, compounding the negative effects of inequities and biases at all levels of healthcare -yet often underappreciated -are the harmful effects of self-directed ageism.
Highlighting the complex and multifaceted nature of this construct, the self-directed component of ageism has been defined and operationalised in a variety of ways.This has included higher subjective age (Okun and Ayalon, 2022), greater perceived age discrimination (Giasson et al., 2017), differential susceptibility to age-based stereotype threat (Marquet et al., 2019), as well as more negative views of one's own ageing, such as subjective accelerated ageing (Bergman and Palgi, 2021).
Here, the term self-directed ageism is used to refer to how, as we grow older, internalised negative ageist beliefs become increasingly selfrelevant and directed at ourselves, consistent with our cognitive model (Henry et al., 2023a).By this view, self-directed ageism can therefore present as self-doubt related to one's age (such as 'I'm too old to recover from surgery', or 'I'm too old to begin exercising'), as negative self-perceptions of one's own personal ageing (e.g., 'I'm much slower than I used to be'), as well as worry and concern about the possibility of being negatively judged in relation to age-based stereotypes (e.g., 'If I forget to take my medicine, they're going to think it's because I'm old'; Henry et al., 2023a).Importantly, this model does not restrict the definition of self-directed ageism to negative views of personal ageing but instead recognises how ageist beliefs play a formative role in the perception and interpretation of one's own aging, i.e., both broader ageist beliefs, as well as specific views of one's own aging, may trigger a self-fulfilling prophecy.Interestingly, in the Risks of Ageism model (Swift et al., 2017), two of the three mechanisms by which ageism is hypothesised to cause harm are components of self-directed ageism (stereotype embodiment and stereotype threat); only the third refers to harms arising due to external sources, (i.e., being a target of ageism).
Most relevant here is data showing how, when older adults assimilate negative ageist stereotypes, this can negatively impact not only their wellbeing, but their physical health (Kang and Kim, 2022).In a large, nationally representative sample of US older adults, not only was self-directed ageism experienced more frequently than external sources of ageism, but it was associated with a greater risk of poor health outcomes (Allen et al., 2022).
Stereotype embodiment theory and the cognitive model of selfdirected ageism provide elegant accounts of why older adults may be especially vulnerable to self-directed ageism, despite the potentially harmful costs.In stereotype embodiment theory, it is exposure to the many diverse societal sources that devalue age and ageing that lead to negative age stereotypes being internalized and readily activated across the adult lifespan (Levy, 2009; see also Fig. 2).Because age stereotypes are initially encountered before they are personally relevant, there may be no perceived need to discount themand they might be welcomed in contexts where they confer advantages to younger age cohorts.In the cognitive model of self-directed ageism (Henry et al., 2023a) normal age-related changes in how we process, store and use information then make it difficult to challenge ageist beliefs.As we grow older, we rely more strongly on prior knowledge, and this includes a lifetime's knowledge of social norms that devalue or marginalize age and ageing.At the same time, an age-related shift from internal to external cognitive control means that external cues that devalue older age exert a correspondingly greater influence on how we think, feel, and behave.In everyday life, ageist external cues are ubiquitous.Older people are regularly exposed to negative assumptions about worth, capacity or level of understanding, as well as jokes about older age, in what has been termed 'everyday ageism' (Allen et al., 2022).
Of greatest relevance here, both models predict that in any healthcare environment, self-directed ageism has the potential to be particularly harmful.Indeed, a recent systematic review concluded that adults' health status was the individual difference variable most consistently associated with self-directed ageism (Marques et al., 2020).Moreover, longitudinal data reveals, not only that poorer health can increase self-directed ageism (Prasad et al., 2023), but that self-directed ageism can itself have a direct effect on morbidity and even mortality (Westerhof et al., 2023).Indeed, there is now compelling evidence that self-directed ageism can influence health via behavioral, physiological, and psychological pathways, which themselves interact (Levy, 2009).For instance, behaviourally, the link between perceived age discrimination and health outcomes is partially mediated by more negative self-perceptions of ageing and subsequently by engagement in fewer positive and preventive health behaviors, with these effects most detrimental for the oldest participants (Ayalon and Cohn-Schwartz, 2022).With respect to the physiological pathway, longitudinal data reveals how feeling younger appears to function as a 'stress buffer'.Thus, although greater perceived stress is associated with a steeper decline in functional health, among individuals who feel younger, this association is weaker.Moreover, the potency of this 'stress buffer' effect only increases with advancing chronological age (Wettstein et al., 2021).Also supporting a physiological basis for the relationship between self-directed ageism and health, negative self-perceptions of ageing and older subjective age have been prospectively linked to higher levels of inflammatory markers (Stephan et al., 2023).
With respect to psychological mechanisms, when older adults assimilate negative ageist stereotypes, this can negatively impact mental health and wellbeing and trigger stereotype-consistent behaviour.Stereotype threat leads to acute performance deficits for many stereotyped groups, and research specifically targeting ageing reveals performance decrements in a range of domains.Of greatest relevance here is when stereotype threat impacts performance on tests of cognitive and physical capacity, as this has direct and potentially important implications in the healthcare domain.Indeed, the term age-based healthcare stereotype threat has been proposed to capture the specific concern older adults' may feel about being personally reduced to ageist stereotypes that operate within healthcare (Abdou et al., 2016).Demonstrating the potential impact of this threat, healthy older adults who feel stereotype threat are more likely to fail a cognitive screen for dementia (Mazerolle et al., 2017), while simply telling older adults that their performance is being compared with younger peers reduces their physical grip strength by up to 50 % (Swift et al., 2012).Older people with poor memory self-efficacy also perform worse on a memory test administered in a medical environment relative to when that same test is administered in a university setting (Schlemmer and Desrichard, 2018).
In one pre-COVID-19 study, approximately 8 % of older adults reported experiencing age-based healthcare stereotype threat, with this concern associated with greater physician distrust, poorer mental and physical health as well as a reduced likelihood of engaging in preventive health care behaviours (Abdou et al., 2016).A later study completed during the COVID-19 pandemic found that the proportion of older adults reporting concern about age-based judgements from healthcare providers increased substantially, to almost a third (Maxfield et al., 2021).It remains to be established whether there have been longer-term harms created by COVID-19 in terms of elevated levels of concern.

What can be done?
The Global Report on Ageism identifies three strategies critical to reduce ageism: (i) policy and law to address discrimination and inequality, (ii) educational interventions that dispell erroneous beliefs about age and ageing and which provide accurate information, and (iii) positive intergenerational contact interventions that create stronger connections and understanding between different age cohorts (Mikton et al., 2021).Because self-directed ageism is both born and perpetuated by the environment in which we are situated, all three of these interventions should function to not only reduce older adults' vulnerability to external sources of ageism, but also their own experiences of self-directed ageism.
In the context of healthcare environments specifically, promoting more positive inter-generational communication and contact between Fig. 2. Common societal stereotypes of older people.At all stages of the adult lifespan, both positive and negative stereotypes of older people exist and are typically complex.Older adults use a greater variety of traits to describe older people, suggesting that they hold more nuanced and differentiated views on older age and aging (de Paula Couto et al., 2021).Nevertheless, negative age-based stereotypes are more prominent and accessible than positive ones, and this appears to be true for people at all life stages.In terms of perceived age-based judgements, people in early older age believe that their age group is perceived as 'doddering but dear', a combination of incompetence and friendliness that has been linked to patronising and paternalistic ageist behaviors.In late older-aged adults, however, the most salient age-based judgement reported is being an economic burden (Lamont et al., 2021).
older people and healthcare workers seems a particularly effective way to challenge erroneous negative beliefs about age and ageing.Healthcare professionals hold more negative views of older people than the general population (Crutzen et al., 2022), and while this may be in part because they are continually exposed to the most dependent and fragile older people in our society, it may also reflect the fact that the quality of this contact (in hospitals and/or nursing homes) is often so poor.This speaks to the fact that, for intergenerational contact to reduce prejudice and stereotypes, contact alone is insufficient; it must be positive and requires optimal conditions.Indeed, one of the ways in which intergenerational contact is thought to reduce ageism is by increasing representation of the older 'outgroup' in the self (Cadieux et al., 2019), and this seems less likely to occur when contact is negative or poor in quality.In the context of healthcare, it is also important to ensure that at least some positive contact occur in a professional capacity.For instance, degree of exposure to older patients inside (but not outside) the clinic predicts dental students' attitudes towards them (Nochajski et al., 2011), and this finding suggests that positive exposure to older people in a clinical setting may be particularly critical in shaping students' attitudes.
In addition, a recent systematic review and meta-analysis concluded that, of the many different types of interventions developed to reduce ageism, empathy-based interventions (such as simulations and games, and contact with older people) were overall the most effective (Martínez-Arnau et al., 2022).However, they were also the most inconsistent in the strength of their effects.Such heterogeneity may reflect the fact that empathy can be elicited either by teaching a greater understanding of how others comprehend and see the world (cognitive empathy), or by encouraging an emotional response to their situation (affective empathy).Further research is therefore now needed to establish whether interventions that target one or both of these types of empathic response are optimally effective in reducing ageism.

Applying a cognitive science perspective to self-directed ageism
Given the strong links between internalized ageism and health (Allen et al., 2022), central to this review is the understanding that middle aged and older people can and must also be the target of dedicated interventions themselvesand that for these interventions to be optimally effective, normal developmental changes in mentation must be considered (see Fig. 3).Although interventions to reduce internalized ageism are acknowledged as being in their 'infancy' (Steward, 2022), two distinct approaches appear to hold promise.The first is to encourage older people to focus on aspects of themselves that make them feel young; the second is to promote a more positive view of age and ageing in general.However, for either approach to be optimally effective, it is critical to also consider the cognitive architecture of self-directed ageism (Henry et al., 2023a).Here, we discuss how decades of cognitive ageing research provide a uniquely rich foundation for any research agenda focused on reducing self-directed ageism, and most critically, how this research can be applied to help break the links between ageism and health more broadly.

Semantic memory
Although many aspects of cognitive function decline with advancing age, not only are there enormous individual differences in the rate of senescence, but some specific capacities such as semantic memory show remarkable stasis.Semantic memory refers to general-world knowledge accumulated throughout our lives, and remains intact at both the behavioural and neural level even into advanced older age (Diaz et al., 2022).Yet when considered in relation to self-directed ageism, this preservation has the potential to be problematic.This is because, while there are many validated strategies that speak to how we might improve or strengthen semantic memory, it is more challenging to eliminate or alter deeply entrenched semantic networks.After decades of being exposed to an ageist social environment most, if not all, older people hold at least some negative semantic representations of age and ageing.
Encouragingly (and contrary to common assumptions), a recent review concluded that middle-aged and older adults' negative subjective views of aging are not immutable, and there is "promising evidence" they can be made more positive using both explicit and implicit approaches (Diehl et al., 2022).Whereas implicit approaches typically focus on activating positive age-based stereotypes by subliminally presenting positive age stereotypical words, explicit approaches make participants consciously aware of their own views of ageing, and then provide information intended to increase the positivity of these views.
With respect to the nature of this information, one promising approach has been to focus older adults' attention on semantic knowledge that counters or buffers negative age-based beliefs.Interestingly, although one study of culturally American older adults found that positive age-based stereotypes failed to eliminate stereotype threat effects (Barber et al., 2018), a later study revealed that simply reminding Chinese participants of core Confucian values (the obligation to respect ones' elders) fully eliminated these effects (Tan and Barber, 2020).Together, such findings suggest that, even in circumstances where negative age-based stereotypes are more prominent and accessible than positive ones, they can still be overridden by other types of semantic knowledge.
It remains to be established precisely which types of semantic knowledge might be sufficiently integral or hard-wired to eliminate healthcare stereotype threat effects in Western cultures, but one promising approach might be to remind older adults of the centrality of medical ethics.Just as Confucian values play a key role in Chinese culture, in almost all modern societies there is an understanding that healthcare providers are expected to abide by strict moral principles, and that this is central to their professional conduct.It would be of interest to test whether reminding older adults of core medical ethicswhile also informing them that their healthcare providers are aware that all forms of ageism contravene these ethicseliminates or at least weakens healthcare stereotype threat.
A cognitive science perspective also predicts that, because it is the cooccurrence of strong crystallised knowledge in the presence of weakened fluid intelligence that increases older people's dependence on prior knowledge, providing information that encourages greater cognitive engagement and control in relation to age-based beliefs and stereotypes should reduce healthcare stereotype effects.Consistent with this view, both explicitly introducing a test as age-fair, and teaching older adults about stereotype threat has been shown to inoculate older adults against age-based stereotype threat effects (Mazerolle et al., 2020).

External out-sourcing
As we grow older, there is an age-graded shift to rely more on the environment to influence how we think, feel and behave, and this can be true even when these cues are unnecessary or maladaptive (Lindenberger and Mayr, 2014).This means that the structure of our social environment matters more as we age, and must be considered in both the design and delivery of aged care.Indeed, there have already been calls for the robust attentional and memory bias older adults exhibit for positive relative to negative emotional stimuli to inform how public health messages are framed to older people (Carstensen and Hershfield, 2021).
Also of direct relevance in aged care and healthcare environments is evidence showing how provision of explicit positive feedback can meaningfully reduce subjective age.Although desiring to be younger is harmful for wellbeing (Turner et al., 2022), genuinely feeling younger appears to have many important benefits, at least up to a certain point (Blöchl et al., 2021), and subjective age is both malleable and context specific (Hughes and Touron, 2021;Kornadt et al., 2022).Not only does provision of positive feedback in relation to physical performance make people feel younger, it can improve their subsequent physical performance (Stephan et al., 2013), with similar effects identified in relation to cognition.For instance, in one study, older adults provided with positive feedback on their memory performance not only later reported feeling younger, but went on to perform better on a memory test relative to those provided with negative feedback (Shao et al., 2020).Importantly, while concerns have been raised that any approach which focuses on helping older adults' retain younger self-identities may be ageist in itself, this approach is not meant to imply that younger is better, but simply that feeling younger has been linked to many positive outcomes.
Such findings also dovetail nicely with a growing literature which shows how the negative effects of age-based stereotype threat are often amplified, and in some cases restricted, to older adults with poor selfefficacy (Barber et al., 2020).Because ageism is so deeply ingrained in society, it may be impossible to ever fully eliminate it from aged care and healthcare environments, and this means that improving older adults' resilience to its harmful effects should also be an important intervention target.Indeed, models of socioemotional ageing highlight how psychological resilience becomes increasingly important with age (Henry et al., 2023b), and that it is more consistently and robustly associated with health transitions and trajectories than many other commonly used resource indicators (Taylor and Carr, 2020).
While there are many specific ways in which psychological resilience can be strengthened, two of the most promising are training programs that focus on increasing self-compassion (the process of turning compassion inwards, by being kind rather than critical of ourselves) and self-efficacy (how confident we are in our own capacity to complete a task or achieve a goal).We see the widespread availability of such training programs as a critical step in the broader fight against ageism, and one that should also help break the links between ageism and health and wellbeing outcomes.Indeed, while only one study to date has assessed the role of self-compassion in relation to ageism specifically, it concluded, " Self-compassion is part of a growing literature on intervening variables that professionals can teach older adults to mitigate the relationship between ageism and their overall well-being alongside efforts to diminish the pervasiveness of ageism in society." (Sublett and Bisconti, 2023).

Conclusion
Ageism is a global challenge, with far-reaching implications for older adult's health and wellbeing.This review highlights the complexities we face in eliminating the many potential ways in which ageism, from both self and others, may impact health and wellbeing.Not only is systemic change critical at the structural, organizational and provider levels of healthcare, but until older age is granted the same value, respect and dignity as other stages of the human lifespan, interventions that target older people themselves are critical to protect them from self-directed ageism and the self-fulfilling prophecy this can create.This review provides a novel perspective, by explaining why the success of such efforts can be meaningfully increased by considering the normal developmental shifts that occur in mentation.

Declaration of Competing Interest
None.

Fig. 1 .
Fig. 1.The rise of research interest on ageism.This figure shows the number of publications that are identified when the terms: ageism OR ageist OR ((age OR aging OR old* OR age-based) AND (stereotype* or discriminat* OR stigma*)) are searched as title and keyword terms (Web of Science, 7th June 2023).Note, the inclusion of an asterisk (*) within a Web of Science search allows for lemmatization i.e., the grouping together of different forms of the same base word.For example, discriminat* returns papers that have used the variants discriminate, discriminating, discrimination and so on.

Fig. 3 .
Fig. 3. Self-directed ageism and health.Because self-directed ageism is an important determinant of health and wellbeing, it must play a central role in any comprehensive research agenda focused on eliminating ageism.This means that, while broader changes in policy and law, positive inter-generational professional contact, and empathy-based interventions are critical to reduce ageism in healthcare environments, older people can and must also be the target of interventions themselves.Further research is now needed to establish which types of interventions are most effective in helping older people think more positively about the natural process of ageing.Fig. 3 highlights how an important consideration in the development of these interventions must be the cognitive architecture that underlies self-directed ageism, and which makes it so challenging to eliminate.