Generational identity and medical decision-making in older adults: clinical implications for autonomy, adherence, and care design

Decision-making in older adults is commonly interpreted through a biomedical lens, focusing on age-related decline, cognitive impairment, and disease burden. However, persistent difficulties in shared decision-making (SDM), therapeutic adherence, and adoption of assistive technologies suggest that clinical factors alone do not fully explain patients’ behaviors in later life. To propose a clinically oriented conceptual framework integrating generational identity, cohort effects, and the life-course perspective to improve understanding of medical decision-making, autonomy, and engagement in older adults. This narrative review integrates sociological theories of generations and cohorts with the life-course approach and contemporary geriatric literature. Evidence on SDM, therapeutic adherence, stigma, gender differences, and health technology acceptance is synthesized to examine how generational identity shapes clinical interactions and care decisions. Generational identity influences how older adults perceive autonomy, authority, dependency, and care. In cohorts such as the late Silent Generation and early Baby Boomers, autonomy carries a strong symbolic meaning linked to self-sufficiency and control. This contributes to selective non-adherence, resistance to visible forms of assistance, and ambivalent engagement in SDM, particularly among men. Conversely, discreet and non-stigmatizing technological support may be more acceptable when it preserves perceived autonomy and social identity. Integrating generational identity into clinical reasoning offers a pragmatic framework to enhance SDM, therapeutic adherence, and acceptance of assistive technologies in older adults. Recognizing autonomy as both a symbolic and procedural construct may support more effective, person-centered, and sustainable models of geriatric care.