Excluding Elderly People from Clinical Trials

The elderly make up "the lion's share of patients for certain health conditions" and the majority of patients for many conditions that need medications. At the same time, clinical trials in adult populations usually include patients ranging from the age of 18 to only 64. Due to the arbitrary upper age limits, elderly patients are often not represented in clinical trials resulting in little knowledge about their responses to medications. In fact, up to 35% of published trials exclude older people (Shency & Harugeri, 2015)

Although persons aged ≥65 years represent only about 13% of the population, they consume nearly one-third of all medications. (Shency & Harugeri, 2015)

Further research indicates that older adults carry 60% of the national disease burden but represent only 32% of patients in phase II and III clinical trials. (Herrera et al., 2010)

Age-related changes do have an impact on how an organism responds to pharmacological interventions. These changes can, for instance, be related to hepatic and renal functions (which affect e.g. the absorption and excretion of the drugs), the decrease of gastric acid secretion with ageing,, slowing of gastric emptying, diminished gastrointestinal blood flow, the decrease in albuin (which increases concentrations of many drugs), decrease in body water, increased sensitivity to antipsychotic drugs (due to an increase in monoamine oxidase activity), brain atrophy, reduction in cerebral blood flow, loss of cholinergic neurons (hence more sensitivity to drugs that have anticholinergic effects), impaired metabolism etc. (Shency & Harugeri, 2015).

Hence, age-dependent decrease in total clearance is expected for drugs that are eliminated by kidneys. The use of standard doses of these drugs may result in increased plasma concentration and increased risk of adverse drug reactions in elderly.

It has been found that the elderly are underrepresented in cancer clinical trials, more pronounced in trials for early-stage cancers than in trials for late-stage cancers.

In USA, though the elderly aged ≥65 years account for 61% of all new cancer cases and 70% of all cancer deaths, in the clinical trials active between 1993 and 1996, the elderly comprised only 25% of oncology trial participants.[11] A study audited 226 clinical research proposals recording exclusion of patients based on an arbitrary upper age limit and found that significant proportion (13.7%) of clinical trials excluded patients based arbitrarily on an upper age limit.[12] However, none (9.8%) of the trials submitted by geriatricians excluded patients based solely on age. The mean upper age limit used over all trials as a cut-off was 69.2 years. Over 50% trials submitted by neurology/psychiatry excluded patients based on an upper age limit.[12]

Although elderly patients represent the majority of the heart failure (HF) population, and have a worse prognosis compared to younger cohort commonly included in trials, targeted treatment strategies have been insufficiently developed for them. (...)

A 7 years review of elderly patients’ enrollment in cancer drug registrations by U.S. Food and Drug Administration (USFDA) found statistically significant under-representation of the elderly.[16] (Shency & Harugeri, 2015)

Not only are older people underrepresented when it comes to cancer, cardiovascular disease or epilepsy but, most absurdly, clinical trial participation of older people is also ridiculously low in research on Alzheimer's disease, arthritis and incontinence (Herrera et al., 2010).

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- Herrera, A. P., Snipes, S. A., King, D. W., Torres-Vigil, I., goldberg, D. S. & Weinberg, A. D.  (2010). Disparate Inclusion of Older Adults in Clinical Trials: Priorities and Opportunities for Policy and Practice Change. American Journal of Public Health, 100(1), 105-112.
- Shency, P. & Harugeri, A. (2015). Elderly patients' participation in clinical trials. Perspectives in Clinical Research, 6(4), 184-189, link
- photograph by Diane Arbus via

0.0036%

"Marginalization is strangely ignored in the psychological literature: in preparation for writing this chapter we carried out a search of the psycINFO database for the period from 1876 until the present day, using both 'marginalization' and 'marginalisation'. We found 52 items that included the term in the title - of these, only 17 actually dealt with the experience of social marginalization by people in positions of oppression, exclusion, vulnerability or discrimination: the others dealt with things as diverse as a statistical technique or the marginalization of certain professional groups or practices. Curiously, there was no entry at all from before 1982. 

Over 55,000 references are currently added to the database each year, so in the year 2000, for instance, there were two out of 55,000 or 0.0036 per cent of relevant references. Although there will be many more texts that deal with the question (but do not mention it in the title)., this still looks like a remarkable neglect by the established field of psychology." (Kagan & Burton, 2005)

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- Kagan, C. & Burton, M. H. (2005). Marginalization. In: Community Psychology (293-308), link

- photograph by Leon Levinstein via

The Black Dog Syndrome

There is the notion that dark pets are discriminated against. Shelter workers repeatedly observe the phenomenon that black dogs have to wait longer to get adopted than lighter-furred ones and that they get euthanised more often. Speculations on the reasons why black dogs are discriiminated agaist vary and range from superstition, i.e., mythologies around black dogs being evil and scary to black dogs' faces regarded as less expressive or facial expressions more difficult to read. Photographs play a major role in the adoption process. When black dogs are photographed in a way that makes only a black silhouette and a big tongue visible, and the eyes and eyebrows get lost, there is little response since people might find it harder to huanise them and build a connection (via).

Other hypotheses floating around the trade: Would-be owners worry that a black dog will shed too noticeably on the furniture; black dogs get overheated more easily at adoption events and don’t introduce themselves; black dogs look older; black dogs strike people as boring. And one chow jowl-wrinkle that no one mentions: Studies suggest that people tend to choose pooches that bear some resemblance to them, whether that manifests in a lady with flowing tresses selecting a long-eared retriever or a saggy-faced man opting for a bulldog. Could the link between an owner’s and a dog’s appearance factor into the phenomenon? According to a Pew survey, 45 percent of white people own a dog, compared to 20 percent of black people. (Looking at presidential pets, Bo Obama is black, but then so was George W. Bush’s Miss Beazley.) (via)

In other words, there are a great many anecdotes but it is not yet clear if the Black Dog Syndrome is nothing more than an urban legend. Various studies do not support the syndrome (via). Some studies find some evidence, others find none (via and via). The relationship, if there is any, is not straightforward as the following abstract illustrates:

Most support for Black Dog Syndrome or Big Black Dog Syndrome is anecdotal or theoretical. Yet some animal shelters/organizations have implemented strategies to address what they believe are lower rates of adoption and/or higher rates of euthanasia for “Big Black Dogs.” This study examines the persistent anecdotes and theories on humans’ preferences and aversions to dogs of various shades, using hierarchical multinomial logistic regression to predict outcomes for an analytic sample of 7,440 dogs from 2010–2011 in an urban, public animal shelter serving Louisville, Kentucky, USA. The relationship between coat shade and dog outcomes was not straightforward; while no relationship existed at the bivariate level, after controls were added, entirely black dogs showed somewhat lower odds of adoption—and higher euthanasia risk—than those characterized as secondarily black or sans black. Breed category, breed size, and purebred status were stronger predictors of dog outcomes than coat shade. Big Black Dog Syndrome was not supported by these data; smaller dogs were more likely to be euthanized if they were partly or wholly black. These findings may offer nuances to adoption strategies employed by shelters/organizations, help make better use of resources, and, perhaps, improve the likelihood of homing or rehoming shelter animals. (Sinski et al., 2016)

And, finally some anecdotes: 

We recently had a litter of five very cute, very fluffy puppies, two yellow and three black. And the yellow ones all went immediately, but for the black ones it took weeks.
Mirah Horowitz

Marika Bell, director of behavior and rehoming for the Humane Society of Washington, D.C., says the organization has been tracking animals that have stayed at their shelters the longest since March 2013. They found that three characteristics put a pet at risk of becoming one of these so-called “hidden gems”: medium size, an age of 2-3 years, and an ebony coat. (via)

Employees at our shelter constantly witness visitors scanning the kennels as they walk down the aisles in search of a new friend and merely glance at the black dogs but stop completely when they approach a "colored" dog.” Pam Backer, cited in Castek (2010)

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- Castek, J. (2010). Black Dog Syndrome, link
-  Sinski, J. Carini, R. M. & Weber, J. D. (2016). Putting (Big) Black Dog Syndrome to the Test: Evidence from a Large Metropolitan Shelter. Anthrozoös, 26(4), link
- photograph by Eliot Erwitt (1953) via

Homosociality, Homohysteria and Orthodox Masculinities

Abstract: There is limited research about homosociality and physical tactility between men in the early to middle decades of the twentieth century. This research utilizes 27 in-depth interviews with heterosexual British men aged between 65 and 91 in order to explore their masculinity and homosociality, then and today. Participants were interviewed about (1) their recollections of masculinity and same-sex friendships aged 18; (2) their awareness of, and attitudes towards, homosexuality at this age; and (3) their current views regarding today’s heterosexual male’s gendered behaviours, inclusive of their kissing, cuddling and loving other men. 

Results show that men born between 1924 and 1951 lived in absence of, or desire for, homosocial affection. Even today they look upon the display of inclusive masculinities by today’s male youth with disdain. We suggest that their antipathy towards homosociality is reflective of elevated cultural homophobia and homohysteria of their youths. Anderson & Fidler, 2018)

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- Anderson, E. & Fidler, C. O. (2018). Journal of Gender Studies, 27(3), link
- photograph by Paul McDonough (New York City, 1975) via

Masculine Norms, Peer Pressure, Alcohol and Adolescents

The substance most commonly consumed by adolescents is alcohol. Among adolescents it is, generally speaking, boys who use higher rates of alcohol compared to girls. Interestingly, theory and research suggest that sex alone does not sufficiently explain why boys tend to drink more than girls and that masculine norms might provide better explanations.

Masculine norms are shaped at an early age and can have an impact on interactions with others. One approach to operationalise masculine norms is the Conformity to Masculine Norms Index which includes the drive for multiple sexual partners, controlling and restricting expression of emotions, the drive to win at all cost, striving to appear heterosexual, and engaging in risky behaviour. Hence, several theoretical models suggest that heavy drinking is seen as an expression of masculinity. In fact, studies among older populations, i.e., college students find a strong relationship between binge drinking and emotional control, risk-taking, and being a playboy.

Among adolescents, peer influence is strongly associated with alcohol use. Becoming a member of a peer group becomes a crucial point in many adolescents' lives which again comes with the cost to conform to values and behavours set by the peer group. Peer pressure among adolescents is "a robust predictor of alcohol use". This, again, includes adolescent girls who adhere to masculine norms.

Young and colleagues’ (2005) qualitative study among college women suggested that many heavy drinking women did so in order to gain acceptance of their male peers by “drinking like a guy.” However, it is unclear if girls’ drinking behavior is driven by conformity to masculine norms, peer pressure, or both.

In their study carried out among high school students living in the U.S. (124 female, 139 male, mean age 17), Iwamoto and Smiler (2014) found masculine norms to be directly linked to alcohol use and peer pressure. The connection was closer among boys than among girls. For girls, the masculine norms of risk taking and playboy seemed to have effects.

Specifically, boys who reported greater conformity to the heterosexual display, winning, and playboy norms were also reported greater susceptibility to peer pressure, while boys who reported less emotional control were less likely to be influenced by peer pressure. These findings make theoretical sense given that many boys perceive a need to prove their masculinity (Levant, 1996). Displaying one’s heterosexuality (Messner, 1992; Tolman, Spencer, Harmon, Rosen-Reynoso, & Striepe, 2004) and being promiscuous (i.e., playboy; Crawford & Popp, 2003; Smiler, 2012) are norms that reflect how one is perceived by others, and suggest these individuals might be more externally-focused and thus more susceptible to peer pressure. (Ivamoto & Smiler, 2013)

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- Iwamoto, D. K. & Smiler, A. P. (2013). Alcohol Makes You Macho and Helps You Make Friends: The Role of Masculine Norms and Peer Pressure in Adolescent Boys' and Girls' Alcohol Use. Subst Use Misuse, 48(5), link
- photograph by Joseph Szabo via

Twice As Likely

"Women are twice as likely to be diagnosed with dementia. 

They are also far more likely to care for a person with dementia."
Alzheimer's Society

photograph of Monica Vitti (1968) via

The Pink Drink Thesis, the "Classless Woman", and the World's Biggest Female Binge Drinkers

According to an OECD report released in November 2023, the biggest female binge drinkers in the world are ... British women. The OECD (Organisation for Economic Co-operation and Development) compared alcohol consumption across 33 countries.

The Daily Maily spread the Pink Drink Thesis, safely dismissed by the majority of people living and thinking in the 21st century, stating that the infantilised female drinker just cannot help accepting offers. Being the Daily Mail, the tabloid also hypothesised that British women drank to excess because they were "unattractive and classless". 

In the scramble to explain this, the following ideas have been floated, mainly by the Daily Mail: British women are uniquely susceptible to marketing pressures, including but not limited to pink drinks, supermarket offers, bottomless brunches and nice pubs. The 20th-century settlement in drinking culture – that you can have your fill, so long as you’re prepared to do it in a smoky back room with laminated tables and carpets that smelt like the urinals – was overturned in the late 1990s, during what we might call the All Bar One revolution (that chain was founded in 1994). Pubs became airier, more chic and inviting, women went into them voluntarily, and it was noted on the profit upswing that, where women went, men went also.

In an article published in The Guardian, Zoe Williams points out the importance to consider generational differences when discussing alcohol consumption:

(...) the sociologists Paul Chatterton and Robert Hollands ascribed the “feminisation of the night-time economy” by 2001 directly to the transformation of the labour market and the increase of female spending power. Arguably, the ladette as cultural artefact – the woman for whom drinking six pints, which by the way is considerably more than six units, was a direct expression of her emancipation – came into being as a way to accommodate this new, independent femininity. If you could slot it into established versions of masculinity, it would be fun and not terrifying. In a trend that has probably been noticed before, where alcohol is concerned, once we started, we didn’t stop. (via)

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photograph of Marilyn Monroe drinking champagne via

Ambient Ageism. The Ageist Sound of AgeTech Advertisements

AgeTech companies market smart home technologies designed to help older adults stay in their homes and keep them safe. These companies usually market their products constructing ideas of age and using ageist representations of ageing and older adults. For instance, Vermeer et al. (2019:27) explored online marketing strategies for surveillance technology designed for people living with dementia living at home and for their care providers. The advertisements directed their messages at families and care providers, not to the people living with dementia dehumanising them as a "problem to be managed" and categorising them "in the same class as wallets, keys, young children, dogs, and/or prisoners".

One of the ideas promoted is that ageing in one's home with autonomy is an essential part of healthy ageing. "Marketing is designed to play on underlying fears that consumers have been socialised to associate with ageing, as well as on our underlying social values."

AgeTech marketing discourse has been critiqued for its ageist constructs of ageing and older age. Advertisements rely on associations between older age and illness, decline, frailty, and forgetfulness. These associations in turn inform the definition of “needs” and justify the use of stereotypical representations of older people on marketing platforms (Neven and Peine, 2017; Peine and Neven, 2021). The problem of ageism in the media has been called “visual ageism” by Loos and Ivan (2018), which refers to underrepresentation and misrepresentation of older adults in the media, and “new visual ageism,” which refers to the “obsessive representations of older people in looking unrealistically young” (Ivan et al., 2020, p. 10). Acknowledgement of this has led to a call to push back against visual ageism in digital media content. Indeed, Einsend (2022) noted that the inclusion of older people in advertising has not been given enough attention by academics, calling for more research in this area.

Visual ageism is not the only aspect of interest. The soundtrack of commercials is also regarded as an important means of communicating with viewers. Music is "a tool that impacts viewers' emotions, cognition, and interpretation of the brand's message", it can attract attention and set the mood in comercials. 

In her study, Graham (2022) collected data through an online search for AgeTech advertiseent videos for ageing-in-place technologies posted from 2015 to 2022. The author came to the conlcusion that visual and acoustic ageism work together ranging from negative stereotypical portrayals to overly positive ones. Here are some excerpts:

Negative stereotypes of older adults were common to the AgeTech advertiseents. The vision of the older adult woman in the Essence Care video most profoundly reflected the dystopian, fourth-age imaginary of dependence, impairment, and lack of agency, not only visually, but also acoustically. As discussed above, the background music set the scene for the viewer to perceive passivity, lethargy, and deterioration. The acoustic dimension of the negative fourth-age imaginary is characterised by slow-moving, descending and decaying musical lines that are simultaneously passive (un-agentic, in Gilleard and Higgs' terms), and ominous. Just as Neven and Peine (2017) state that the ageing-and-innovation discourse stigmatises older people as old, so, too, can the musical discourse of AgeTech advertisements.

The Essence Care ad portrays the older adult woman more negatively than the older adult man by focusing attention on her face in a “scene of empathy” (Tan et al., 2007) and her audible exhausted sigh. Together, these representations reinforce the association between ageing and decline. Interestingly, it has been noted that these overly negative portrayals of the much-dreaded fourth age alienate older adults from technology because they identify technologies as being for “old people,” a social category with which they do not identify. Thus, both visually and acoustically (which this paper highlights), barriers to technology engagement are created through negative portrayals of older adults.

Following the binary pattern of dystopian-utopian imagined futures, the Vayyar advertisement provides an example of a utopian, agentic, third-age future with smart home technology. The background music is carefree, uncomplicated, almost toy-like in its simplicity and ease, setting a scene of leisure and play. Craton and Lantos (2011) note that upbeat music can symbolise fun entertainment products in advertising soundtracks. Framing the technology as an “entertainment technology” may help to bypass the tensions associated with surveillance technology. The music sets the stage for the audience to perceive the older woman as an agentic, third-age consumer who adopts technology to make life more enjoyable and less onerous (Gilleard and Higgs, 2022). This fits with common stereotypes of the “Golden Ager,” the “Perfect Grandparent,” and “the Productive Golden Ager” who is portrayed as full of “zest” and living in intergenerational harmony (Ylänne, 2015, p. 371).

The subtle changes in the background music of the SofiHub advertisement are an example of how music reinforces the normalisation of surveillance technology. There is no dramatic “crisis” in this advertisement, but there is still a construction of a need that key routine behaviours (late to bed, late to rise, and long duration in the bathroom) require monitoring and reporting to care providers. The inclusion of the more energetic drum track primes the viewer to perceive the technology as supporting successful, active everyday life and watching out for any sign of decline. According to Van Leeuwen (1999), ascending melodic motion is associated with energy and brightness, suggesting that the inclusion of electric guitar slides provides a happy and hopeful ending to the advertisement, ensured by the use of technology. In this case, everyday life with technology is pictured as good—the older woman gardens safely, the older man maintains his privacy. Interestingly, the change to the music occurs when a younger adult woman successfully transfers from her wheelchair to her couch, accompanied by a well-timed shift in the music to a louder, more energetic mood through the addition of a drum track.

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- Graham, M. E. (2022). Ambient ageism: Exploring ageism in acoustic representations of older adults in AgeTech advertisements. Frontiers Sociol, link
- photograph (Foothill Acres Nursing Homes, Neshanic, New Jersey) via

Quoting Jeff Bridges

"It's not enough just to treat women well. We have to work to make sure all men treat women well."

Jeff Bridges

image (Thunnderbolt and Lightfoot, 1974) via

The Cricital Approaches of Socio-Gerontechnology

One field of study the sociology of age and ageing focuses on is technology use in later life. Since, in the past, many research projects showed the tendency to be techno-optimist and mostly concerned with the question how technologies can improve older people's lives, recently, more cricital approaches evolved. These new approaches - widely refrerred to as Socio-gerontechnology -  criticise ageist stereotypes about "technology use in later life in design processes and the paternalist stance toward older adults resulting from it" as well as the techno-optimism of gerontological research. 

This includes, on the one hand, a deeper empirical engagement with design processes and innovation policy to highlight how new technologies not only address alleged problems or challenges of individual or population aging, but how they create and select certain ideas about aging that work well as targets for design or innovation policies (Bischof and Jarke, 2021; Peine and Neven, 2021). In such a view, design processes and innovation policy become important sites for our empirical understanding of age and aging, too, because they produce and reinforce societally shared ideas of how we can and should age—ideas whose contingent nature can be revealed by empirical inquiry (Lipp and Peine, 2022).

Socio-gerontechnology is also concerned about "the everyday life of older people, aging bodies and the construction of age and aging in relation to technology", how ageing is shaped by technologies and how ageing is quantified by technologies which again creates the image of the ageing body as one that is "constantly iprovable and invevitably in decline" (Gallistl et al., 2023).

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- Gallistl, V., Katz, S., Kolland, F. & Peine, A. (2023). Editorial: Socio-gerontechnology - New perspectives on the digital transformation of later life. Front. Sociol, link
- photograph by Dennis Feldman via

Quoting Paul Auster

“It always stimulates me to discover new examples of my own prejudice and stupidity, to realize that I don't know half as much as I think I do.”
Paul Auster, Oracle Night

photograph of Paul Auster via

The Deaf Snow White. By Kanika Agarwal. An Excerpt.

The great king and his queen were married for five years and were still waiting for a child. The mother often prayed for a girl whose skin and heart would be white and pure as snow. In their sixth year, their prayers were answered and they finally got a baby girl. However, the queen died a month after the birth of the child. The king was left to care for their only daughter and put his heart and soul into it. He named her Snow White in remembrance of his wife’s wishes.

As the years passed by, Snow White blossomed into a beautiful girl fair as snow. She had a gentle heart and a soothing voice. She grew up playing in the gardens of their palace, and most of her friends were the plants, bushes and her favourite three little birds – Brownie, Bluie and Ruie. She talked to them endlessly as her father presided over his court. Days turned into months and months turned into years. In the blink of an eye, Snow White was ten years old. It was then that she started losing her hearing. Her father knew that he would not be able to care for Snow White alone now. So, he remarried – primarily to provide care to his deaf daughter. But no one knew what fate had in store for Snow White.

(..) 

Snow White started sensing that her stepmother was using her deafness to fill her father’s ears against her. She observed that her father had become sterner towards her. He once came and sat beside her to talk. She saw his lips moving: “My dear little child, you need to work harder and make sure you treat your mother and your sisters fairly.”

(...) 

Snow White woke up to the pecks of her little birds on her body. “How did you find me?” she asked. They rubbed their beaks against her nose sweetly. Suddenly, Snow White realised that someone was in the house. She peeped out of the bedroom door to find seven little people sipping wine by the fire. She was scared of what awaited her and wanted to run out. So, she tried tiptoeing, only to realise that she was too big to escape the house unnoticed.

She spoke up hesitantly, apologising to them for her intrusion and tried walking away. They moved their lips but they were too tiny for her to read. That is when she had to tell them about her deafness. While many of them did not believe her and accused her of lying, one of them, Sheram, gestured to her to sit and explain her story. Tabish and Sheram listened patiently. By the time she finished her story, her fear had turned into grief and she sobbed inconsolably.

Kanika Agarwal
 

An excerpt taken from Parita Dholakia's version of Rapunzel (via): 

The prince falls in love with Rapunzel and invites her to his palace ...

“I can’t. There is no ramp from the room to the garden.”
“We will find a way. I can carry you down,” says the prince.
“Carry me? I don’t think I would like that. I always go everywhere wheeling my own chair.”

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- Agarwal, K. (2024). The Deaf Snow White. In: Rising Flames (ed.) And They Lived ... Ever After: Disabled Women Retell Fairy Tales. HarperCollins India.
- More: The Guardian, link
- photograph of Nikki Giovanni (1972) via

Identity Politics and Vaccine Distribution

"For me, the most important and the most shocking was the way in which the United States rolled out vaccines in 2021. We had these amazing life-saving vaccines, but there were too few of them, so what were we going to do? Virtually every country in the world did it by age. But the key advisory committee to the Centers for Disease Control, called ACIP, said that even though that course of action is much easier to implement, we're not going to do that. It would, they said, be unethical because a disproportionate number of older Americans are white. Even though, according to their own causal models, adopting a different rule would increase the number of deaths by between 0.5 and 6.5%, could lead to thousands more people dying, simply prioritizing older people would be the ethically wrong thing to do. 

Instead, they recommended putting essential workers, who supposedly are more diverse, first. A couple of things happened because of that. One is that it's really hard to communicate who's an essential worker. And immediately the politicking started about being included as essential workers: Film crews were essential workers. Finance executives were essential workers. I was an essential worker, as a college professor in Maryland, at a time when I was not allowed to teach classes in person…

Then what happened is that you had way too many people eligible for the vaccine at a time when there were barely any appointments. So who got the appointments? The people who were able to refresh the websites for hours a day, or who could write computer programs to find eligible spots, or who were able to drive hours out of town in order to get to some rural pharmacy that had more capacity for some reason. They were the ones to get it. In other words, more privileged people who were probably at slightly less risk of death. AI suspect that this policy even killed more non-white people, because if you give a vaccine to two 25-year-old black Uber drivers, rather than one 80-year-old black retiree, more black people are going to die.

So here's a policy that is a life or death question; is capable of inspiring just the worst kind of zero-sum racial competition in our politics; and can easily be exploited by the political right (...)"

Yasha Mounk

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- photograph by Dennis Feldman (1969-1972, Hollywood) via

- Yasha Mounk, full interview: link