Older Adults Are Becoming Nomads

They’re taking to the road, bent on adventure and a thrifty lifestyle

Five years ago, Susan and Rob Beck moved into an RV, after they were forced to sell their home in upstate New York. Rising property taxes had doubled their monthly housing bill, and Rob didn’t receive his usual bonus at work. Then he lost his job. And neither Rob nor Susan could find work locally.

“Nobody would hire us, not even the Dollar General,” said Susan Beck, 63. “Talk about an eye-opening slap in the face.” 

For cash, they donated plasma and took whatever temp jobs they could find. For food and health care, they relied on food stamps and free medical clinics.

Frustrated, the Becks decided to hit the road in their RV. For two years now, they have been moving from one place to another, working temporary jobs. Currently they’re at Strom Thurmond Lake, a campground on the Georgia/South Carolina border owned by the Army Corps of Engineers. They staff the visitor center and gatehouse in exchange for a free RV hookup, including site rental, electricity, propane and laundry. Social Security covers their health insurance and other necessities. 

While this path began with financial misfortune, the Becks have learned they enjoy discovering new places and meeting fellow nomads, who’ve worked everywhere from lighthouses to trains to isolated islands. Ignoring criticism from relatives who call them “homeless,” they’ve embraced life on the road. 

“We just love it,” said Rob Beck, 63. “We live so simply. We can just pick and go when we want.”


Like the Becks, many older Americans are opting for a nomadic lifestyle. Instead of aging in place, they’re aging anywhere and everywhere: in RVs or vans parked at campgrounds and on federal lands or in short-term rentals through AirBnb. They move from place to place, to the next job or the next adventure. Some do remote work from wherever they are; others move to find seasonal work. Some live nomadically as a way to travel inexpensively in retirement; others found themselves living on the road because of economic hardship.

The lifestyle is enjoying a moment in pop culture, thanks to the 2020 film Nomadland, based on the 2017 book by Jessica Bruder. The movie tells the story of Fern (Frances McDormand), a widow who lives in a cramped van and travels from one seasonal job to another, working long days as a campground host, a packer at an Amazon warehouse, and a day laborer for a beet harvest. Like the book, the movie portrays people who turned to the lifestyle out of economic necessity. 

“In a time of flat wages and rising housing costs, [nomads] have unshackled themselves from rent and mortgages as a way to get by,” Bruder wrote. “They are surviving America.” 

But many real-life nomads say they live this life by choice. Some even take offense to what they feel is the film’s negative portrayal of the nomadic life.

“It was always my dream to live in an RV,” said Shelley Fisher, 61. She spends her summers “workamping” in California, serving as a gate manager at a KOA campground in exchange for a free hookup and a paycheck; she banks the money and spends her winters relaxing at an RV park in Nevada. 

“I love the freedom,” Fisher said. “I like meeting and taking care of people. I even love the driving. The travel is as exciting as the destination.” When moving from one place to another, Fisher parks her RV at roadside rest stops, truck stops or Walmart parking lots.  

Amazon hires workers who live in RVs or vans to go where they’re needed during peak times.  

Denise Green, 59, and her husband are nomads who work part time and travel inexpensively between gigs. They’ve lived full time in an RV for the past three years. The couple is in good shape financially—they’re both veterans of the corporate world and accumulated a nest egg for retirement. But they don’t want to dip into it yet, so they work for a few months each year, long enough to fund their travels the rest of the year. Currently they’re working at a campground in Valdez, AK; she’s managing the cleaning operation and he handles maintenance. They typically change locations every three to four months. 

The work can be grueling. One of the couple’s first workamping gigs was as part of Amazon’s Camper Force. The online retail giant hires workers who live in RVs or vans to travel to where they’re needed, providing extra warehouse staff during peak times.  

“Amazon ran us into the ground,” Green said. “We are hard workers. I used to run 100-mile races. But we had to work the night shift and often walked 12-15 miles a night. I don’t know how some of the older retired folks do it.”

But they’ve also enjoyed some relatively easy gigs, like a stint at the Boyce Thompson Arboretum in Arizona, where they worked in exchange for a free hookup for the RV and had free run of the place after hours.

“I learned a lot about desert plants and wildlife that winter,” Green said. 

The nomadic life was also a choice for Susan White, 62, and her husband. College-educated, White worked for Fortune 500 companies but became frustrated with the corporate world. Two years ago, after retiring, the couple sold their home and gave away or sold most of their belongings. They’ve traveled in an RV and worked at campgrounds in their home state of Washington as well as in Florida and Texas. Currently, they’re at an Army Corps of Engineers campground in Texas.

“Having the freedom to pick up and leave is a luxury most people don’t have,” White said. “We miss some physical comforts, but the fun, adventure and experiences outweigh the trappings of traditional happiness. Americans are in debt and overburdened with ‘to do’s.’ I wish I knew about this life when I raised my kids. We were slaves to a high mortgage for a brand-new, five-bed, three-bath home, two cars, braces, ad nauseum.” 

A Growing Population

While it’s difficult to find reliable numbers for older Americans who have chosen the nomadic lifestyle, most who live that life believe their numbers are growing. Numerous Facebook groups have sprouted up and continue to grow, such as Workampers (54,000+ members), Full-time RV Living (104,000+) and Full-time RVers over 50 (12,000+).   

Harvest Hosts, a membership network that connects RVers with wineries, breweries, farms and other spots that offer free RV parking spots, saw its membership more than double in 2020 to 170,000 members. Ten percent live full time in RVs; 80 percent are over 55.   

“Technology has unlocked the ability to do almost everything from your phone,” said Harvest Hosts CEO Joel Holland. The growing availability of wi-fi and cell service, and expanding data caps, make it easy for nomads to stay in touch with family and friends. Websites, social media groups and online booking services allow them to easily find their next job or plan their next adventure from the road. 

Job opportunities for nomads seem to be increasing too. 

“We’re seeing more help-wanted ads from employers this year than we’ve seen in the last 10 years,” said Jody Anderson Duquette, executive director of Workamper News, the largest resource connecting nomads with short-term job opportunities. She thinks that is due in part to the tight labor market, as well as more awareness about the option of working from the road. 

Duquette says most workampers enter the lifestyle by choice. In an informal survey by Workamper News, only 14 percent said they embarked on the lifestyle after a job loss or financial or personal hardship. But Duquette does see several factors leading older adults into workamping. Medical expenses, health insurance and housing costs have skyrocketed in recent years. While previous generations retired with pensions or other resources to lean on, “Most people today are entering into retirement, or the latter half of their lives, with less financial stability,” she said. “There is a need to continue to earn at least some income to support themselves in the life they want to live.” 

Nudged by COVID

As a health care insurance agent specializing in Medicare and Affordable Care Act policies, Siobhan Farr, 64, earned most of her annual income during the health care insurance enrollment period, from October to December, from her home base in Dallas. She often traveled during the slow months. Last year, Farr decided to spend a few months exploring Ecuador and arrived in Quito on March 5, 2020. Two days later, COVID-19 locked down the country. Farr stayed in her Airbnb rental for the next 13 months, managing her insurance business remotely. To her surprise, it worked fairly well. That led her to start Digital Nomads Beyond 50, a networking group for older people.

“Because of the pandemic, there are more older people looking at this opportunity of working remotely and traveling,” she said. “They want to continue in their current jobs, or to find a way to combine retirement with part-time remote work.” 

Farr represents another segment of the nomadic life—those with “location independent” jobs, such as software engineering or freelance writing, who can work from anywhere with a good wi-fi connection. In contrast to workampers and full-time RVers, digital nomads skew younger—with an average age of 32, according to research by T-Mobile. (When Farr completed a preliminary application for a coworking village—where nomads share living and working space—in Caye Caulker, Belize, she was told she was too old.)

Farr is now living in Mexico City and is energized by the wide range of options before her. She picked a theme song for this new stage of her life: REO Speedwagon’s “Roll with the Changes.”

“You need to have flexibility to do this,” she said. 

Flexibility Required

As Farr learned, the nomadic lifestyle demands an ability to pivot when faced with the unexpected, and resourcefulness when faced with snafus or breakdowns. 

“You have to be your own MacGyver,” Fisher said. “If there’s a leak in the plumbing, or the fridge stops working, or a fuse blows, I need to figure out how to fix it. YouTube videos help.”

Most nomads must also adapt to life with fewer creature comforts. Living in an RV or van means coping with small spaces. RVs may have air conditioning and heat, but most don’t handle extreme temperatures well. And most are not equipped with laundry facilities. 

“You learn to live with five shirts and five pairs of underwear,” Rob Beck says. 

However, many nomads say these occasional challenges and unplanned adventures keep them more engaged and vital as they get older.

“Comfort is the enemy of progress,” said Don Wilks, 60, a Dallas native who’s lived on the road for 20 years. “When you’re traveling, you’re always challenged. You’re always learning something and trying something new, every day.”

Many nomads say that sooner or later, they’re likely to settle down again.

Wilks’s travels have taken him around the world, hopping between hotels, Airbnbs and hostels—and occasionally couch surfing and camping. He spent most of the past year in his Jeep, exploring Wyoming, Montana and Florida.  

Palle Bo, 56, says that constant challenge has changed his perception of time. He sold his home in Denmark and began traveling full time in 2016 while working as a “location independent” radio producer, podcaster and travel blogger. Bo lives out of a suitcase, staying in short-term rentals booked through Airbnb, and has visited 95 countries so far. 

“When I was in my 30s and 40s, I felt like time was moving faster and faster,” he said. “Time moves slower when I’m traveling. I’m not on autopilot.” Daily chores that most people handle mindlessly—like shopping at a grocery store or doing laundry—often become challenging adventures in unfamiliar places. By living on the road, Bo believes he’s getting more out of life. 

Among those nomads who can, many admit that, sooner or later, they’ll likely settle down again in a “sticks and bricks” home. 

Originally, Denise Green and her husband planned to stay on the road as long as their health allowed, maybe 10 years. But now they’re looking at a shorter timeline. They miss their five grandchildren, who live in Ohio and Pennsylvania. 

“I underestimated the craving for some roots,” she said. “I think we’ll come off the road within five years, but we won’t go back to a large home. All I want is a cabin or a cottage and a place for the grandkids to come.”

Losing Sight

The epidemic of eye diseases nobody is preparing for

In 2014, Sharon Kassakian, 75, was diagnosed with macular degeneration in one eye. But the condition was manageable, and she felt confident enough to move to Portland in late 2016 to be closer to family. Then, in 2018, her vision began to deteriorate. She started having difficulty seeing with her other eye. 

“It was a nightmare,” she said. “I was adjusting to life in a new city and adjusting to vision loss.” 

Three years later, Kassakian’s eyesight remains very unstable—OK one day, not so good the next. Doctors can’t promise she won’t eventually lose her sight entirely. The diagnosis was emotionally devastating, Kassakian said, similar to her earlier experiences in life when family members died.

“You’re losing something that you’ve had your whole life,” she said. “I wake up every morning with fear. Will it be the same, worse or better?”

More and more older adults will face similar challenges in the coming years. According to the National Eye Institute, about one-third of Americans over 65 are living with some form of “vision-reducing eye disease.” As the population ages, that number will increase, making vision loss a serious, public health issue.

“This year, the oldest baby boomers are turning 75, when age-related vision loss really kicks in,” said Ed Haines, chief program officer for the Hadley Institute, a Chicago-area nonprofit supporting people with blindness or vision loss. “We have a looming epidemic that no one has planned for, and we don’t have an infrastructure to deal with it.”

What Can Be Done?

The leading causes of blindness and low vision in the United States are age-related eye conditions—macular degeneration, cataracts, diabetic retinopathy and glaucoma—and the numbers are on the rise. Cases of macular degeneration, for example, are expected to climb to 17.8 million by 2050 among those 50 and older, according to the Centers for Disease Control and Prevention. Cases of diabetic retinopathy are expected to quadruple by 2050. 

For older adults affected, vision loss can severely affect quality of life.

“It’s a big loss of independence,” said Neva Fairchild, national aging and vision loss specialist for the American Foundation for the Blind. “Things you were able to do before —read your mail, pay your bills, watch TV, cook meals—they’re all taken away, at least until [you] have some accommodations in place.”

Many aging-related eye diseases can be controlled with treatment—if caught early. In addition, vision loss can often be managed with assistive devices, such as corrective lenses or magnifying devices, and occupational therapy that helps people learn techniques to adapt and maintain independence. But Medicare doesn’t always cover the cost of eye exams or assistive devices, and doctors often don’t have the time or knowledge to refer patients to therapists.

Tech and training can help, but many doctors don’t even know they exist.

“Historically, in this country, visual rehabilitation did not evolve under the medical model, therefore it’s typically not covered by Medicare or private insurance companies,” said Haines. “If you break a hip, a discharge planner makes appointments with a physical therapist and a plan for getting back on your feet. When you get a diagnosis of irreparable vision loss, it’s devastating, yet you’re sent home with nothing.” 

The key is to connect patients with the right technology and the right training, but often, patients and even doctors don’t know that exists. 

“I’ve heard it a thousand times: ‘The doctor told me nothing more can be done,’” Fairchild said. “What the doctor means is that there’s nothing more that can be done medically. There’s no surgery or eye drops that will give back the patient’s vision. But there’s almost always something more that can be done to help the older adult adjust and function more independently.”

Catch It Early 

If caught early, many causes of aging-related vision loss, including glaucoma and cataracts, can be treated before they cause significant damage.  

“In general, if they’re treated early enough—with medicines, surgeries, laser treatments and regular follow-ups—the vast majority of patients don’t lose vision from a functional standpoint to the point where it severely limits their daily activities,” said Donald Abrams, MD, ophthalmologist-in-chief and director of the Krieger Eye Institute at LifeBridge Health in Maryland. “The sooner we treat it, the better off you’ll be.” 

The best way to protect your vision is to have regular eye exams.

While “dry” macular degeneration (the more common type, which generally leads to gradual loss of vision) is not treatable, “wet” macular degeneration (the type that causes leaky blood vessels in the eye) can usually be treated with injections. 

A patient’s best defense: regular eye exams beginning at age 50. Black and Hispanic people, who are more prone to many age-related eye conditions, and those with a family history of eye disease, should start annual exams at age 40. A comprehensive eye exam should include a test of eye pressure as well as dilation of the pupils. (Not all optometrists perform all of these diagnostics. Ask first.) A thorough eye exam can detect genetic conditions or abnormalities in the eye that may indicate a need for more surveillance. Medicare pays for comprehensive eye exams for some patients with diabetes or those with increased risk for glaucoma due to ethnicity or family history.

Prevention is also key. Good health habits will reduce the likelihood of losing one’s vision—exercising, eating a balanced diet including dark leafy greens and fish high in omega-3 fatty acids, avoiding smoking, wearing sunglasses and a brimmed hat outdoors, and management of other health conditions like diabetes. Doctors may also recommend vitamin supplements (usually a combination of antioxidants, carotenoids and omega-3 fatty acids) for people with signs of macular degeneration. 

Problems beyond Lost Vision

Elise Franz, 67, (not her real name) was a successful graphic designer and freelance writer for art magazines until six years ago, when she had cataract surgery. Instead of improving her eyesight, the surgery seemed to trigger a cascade of other problems, including macular edema, diabetic retinopathy, glaucoma and optic nerve damage. 

Once a frequent traveler who’d jet off to Paris on a whim, now Franz rarely leaves her home except to go to the doctor.  She once churned out articles easily, getting lost in the flow; now the writing process is tortuously slow. She positions her face right next to the computer and uses extra-large type. 

“Everything is problematic,” she said. “And people don’t understand. I’ll go to the doctor’s office, and they’ll hand me a pile of paperwork. I tell them, ‘I can’t read that.’ They hand it to me anyway.”

Franz was recently diagnosed with heart issues too, which she thinks resulted from her inactivity due to her vision loss.

“I used to love to exercise, to go swimming,” she said. “Now, it’s hard to do everything. The fact that I can’t see has had deleterious effects on my physical health. It’s not like I can go out my front door and go for a walk.” 

As Franz’s story shows, older adults with vision loss often suffer more than a loss of the ability to enjoy favorite activities. Vision loss can exacerbate other health problems and lead to emotional and psychological challenges. With a diagnosis of macular degeneration, for example, “Your perception of yourself, and vision of your future, is thrown into total disarray; you despairingly imagine a life of darkness, social isolation, dependency, risky treatments, loss of friends, hobbies, participation in activities of interest such as sports, theater, art and reading—in short, a kind of early death,” wrote psychiatrist Arnold Wyse, MD. 

Older adults who are visually impaired often become isolated. Everyday activities, like attending worship services or eating a meal at a restaurant with friends, become problematic.  

“People with vision loss often become paranoid about eating out,” Haines said. “They don’t want to drop food or spill it on themselves. Navigating a buffet is a nightmare. You’re unable to see when people are waving at you. That’s a big deal when I’ve worked with folks in small towns because everybody waves. And if you don’t wave back, if the person who waved doesn’t know you have a vision impairment, they feel they’ve been insulted.”

Haines added that the Hadley Institute typically gets a surge of inquiries after the holidays from families who notice a decrease in a loved one’s vision during a visit. Often, fearing for the elder’s safety, families will rush to move the person into assisted living, without taking the time to learn about other options to allow the elder to remain independent. 

Help from Tech and Training

Older adults can tap into resources that help them adjust and function—if they know where to look. The federal government maintains the Older Individuals Who Are Blind Technical Assistance Center, a clearinghouse of agencies serving older adults with vision loss. 

Many digital devices are helpful for people with vision loss. Virtual assistants, like Amazon’s Alexa, can provide information (time, weather forecast, sports scores, even make phone calls) in response to voice requests. Some devices can be operated via speech commands, although there’s a learning curve to adapt to that. 

“Apple did the visually impaired community a huge favor,” Haines said. “Every Apple device can be accessed with speech commands. If you lose your vision, you don’t have to throw out your iPad. We’ve had individuals in their 90s learn how to do this.”

Because of Apple’s success with speech access, Haines added, other platforms like Android are adding similar features. 

However, technology isn’t the only fix, Haines cautions. Adapting the home environment and learning how to perform daily tasks with reduced or no vision are often even more helpful. The Hadley Institute offers an extensive catalogue of online, distance-learning workshops, all free, that teach people how to adapt tasks of daily living for reduced vision. 

For example, a short video demonstrates how to pour liquids into a cup, using simple techniques like squaring oneself up next to the counter, adding task lighting and placing the cup on a tray of a contrasting color, making it easier to see and easier to clean up spills. (View a short sample here.) The workshops can be ordered by mail in other formats too: large print, digital talking book audio, or braille. 

Occupational therapists can also help patients with vision loss. They visit patients’ homes to coach them on ways to safely manage their activities of daily living, including bathing, toileting, cooking and cleaning. They also may recommend adjustments in the home environment, customized to the person’s needs and type of vision problem, like adding task lighting in key spots or installing drapes to block glare. 

Making Adjustments

After connecting with a variety of resources, Kassakian feels more hopeful now.

She worked with a therapist who helped her with the grieving process that came with the loss of vision. She found a nonprofit ride service that takes her to doctors’ appointments. She discovered Hadley’s free online workshops. She joined two support groups, both offered via Zoom—one by Hadley for emotional support, another for sharing tech tips. At the latter, she learned how to use the accessibility features on her iPhone.   

“I have blind friends now, and I’m just amazed at how they sometimes function even better than I do,” she said. “There is a grieving process, but you can learn to live with vision loss because there are so many services and resources.  Now I know where to turn for support.” 

Crafting: A Way to Cope during the Pandemic

It can ease isolation and even provide a sense of purpose

When KathLynne Lauterback, 64, retired in January 2020, she and her husband planned to move to a new place and to travel. But just a few months later, the COVID-19 pandemic struck. A health crisis sent her husband to the hospital, and she couldn’t visit him except by phone or video chat. Lauterback lapsed into a doom loop of fretting and worry.

“I had switched from a very demanding job to doing nothing,” she said. “Everything we had fantasized about doing in retirement was on hold.” 

For relief, Lauterback turned to another item on her retirement bucket list: learning to draw and paint. She signed up for a course taught over Zoom by a Dallas, TX, artist.

“I discovered that I love working with colored pencils,” she said. “It helps me deal with the emotional changes in my life. It relaxes me and it fills the time.”

Finding Joy in Creativity

Like Lauterback, many older adults have found a lifeline in arts and crafts during the pandemic. Knitting, woodworking, painting, sculpting, baking, quilting and other crafts saw a resurgence as people spent more time at home, starting in March 2020. Retailers of craft materials saw spikes in sales. Some supplies, like yeast, even became hard to find. 

Creative activities served as a buffer that helped many older adults cope with isolation, stress and fear during the pandemic, according to James C. Kaufman of the Neag School of Education at the University of Connecticut, Storrs. He points to research that suggests that participation in arts—crafts as well as dance, singing or painting—helps increase social engagement, stave off depression and keep older adults mentally engaged and active.

“Being immersed in something creative, often losing track of time and one’s surroundings, can be intensely joyful,” he said. 

“Healing” is a word that many people echoed in describing their crafting, in whatever medium. The repetition in crafting can be calming and meditative. Choosing and working with materials of different colors and textures is stimulating and enjoyable. Acquiring or improving skills engages the brain and reinforces a sense of mastery. The act of creating connects older adults with fellow crafters and even with memories—such as recalling the grandmother who taught them how to knit. The pleasure of a finished product can boost a person’s mood. 

During the pandemic, quilters and sewers around the world sat up and said, ‘I can help!’

—Kris Stevenson 

Crafts have also given some older adults a sense of purpose during the pandemic. Kris Stevenson, 56, works part time at Fabric Fanatics, a retail fabric shop in Plano, TX. When it closed for normal business due to a lockdown, the shop sold mask-making kits via curbside pickup. Stevenson was gratified as the community, including many older adults, banded together to sew more than 3,000 masks, all donated to retirement homes, hospitals and neighbors. Stevenson also teamed up with fellow parents who sewed bell covers for musical instruments for the local high school band, to reduce the risk of spreading the virus through the wind instruments. 

“During the pandemic, quilters and sewers around the world sat up and said, ‘I can help! This is actually something I can do!’” Stevenson said. An older friend, in her early 80s, told her, “It just feels so good to have something that I can do to contribute, to help.” 

Crafting also leads older people to tap into their creativity, according to Mark Runco, director of creativity research and programming at Southern Oregon University.  He’s embarking on a study of people who started crafting during the pandemic, with hopes that the research will help highlight what he calls “everyday creativity.” 

Runco thinks creativity is an overlooked coping strategy that helps many people, including those who don’t consider themselves to be creative, and even contributes to happiness and overall mental health. 

“Creativity researchers tend to focus on socially recognized creativity, such as the work of artists and performers,” Runco said. “But any activity that is original and effective is a form of creativity.”

Connection during Isolation

Many older adults found that crafting helped connect them with others while they were stuck at home. After Julie Hatch Fairley opened JuJu Knits in Fort Worth, TX, in 2019, the shop quickly turned into a hangout for crafters; many would stop in to knit, crochet, ask questions and socialize. After the shop closed in March 2020, customers continued to gather virtually to share their current projects. 

Similarly, when Candace Leshin’s bridge group stopped meeting due to the pandemic, she found a new group to connect with virtually. 

“I had always thought, ‘One of these days I’m going to learn how to quilt,’” said Leshin, 72, a retired skin pathologist. “’One of those days’ came when I was sitting at home with nothing else going on.” She signed up for a quilting class (offered in-person, in a large space that allowed for social distancing, with masks required) and fell in love. As a bonus, it connected her with a community of women. 

“It’s like the old-fashioned quilting bee,” she said. “We gather to talk and work at the same time.”

Once she learned the basics of quilting, Leshin came up with an idea. She’d spent decades looking at skin cells under a microscope, teaching students how to recognize the unique pattern of each type. She’d make a “skin quilt,” with each block representing the patterns unique to a skin type or abnormality. 

“Look at a fabric with a colorful abstract design,” she said. “Other people see some blobs or dots or lines; I see a pattern.” Lines remind her of a stratum corneum (outer layer of the skin); a dotted fabric looks like lymphocytes (white blood cells). Using purchased fabrics, embroidery and appliques, she crafted squares representing patterns of abnormal skin cells, like basal and squamous cell carcinomas and melanomas—each a pleasing, colorful, abstract design. She plans to enter the finished quilt in a local competition this fall.

Besides tactile pleasures, crafters get that sense of achievement that comes with completing a project.  

“I love coming up with ideas, picking a pattern and piecing it together,” she said. “It’s hard to explain, but quilting is exciting. It opened a whole universe to me.”

Crafting can also offer simple joys: the tactile pleasures of handling colorful yarns or fabrics; the sense of achievement that comes with completing a project. For many, it can also be a way of creating a legacy, Kaufman said. His late grandmother took up painting in later life. Two of her paintings hang in his living room. 

“It’s a tiny bit of immortality, and there’s something to be said for that,” he said.  

For Mari Madison, 66, quilting brought back a connection to her past. She spent time in quarantine repairing an old quilt made by her great-grandmother around 1936. As a child, she had helped her grandmother repair the quilt, which was tied to some unhappy memories for the older woman. 

“By helping my grandmother process a very painful time from her past, I learned a lesson in self-care,” she said. She heeded that lesson in 2020, picking up the quilt and repairing it again as she processed the stress of the pandemic and the turbulent political scene in the United States.  

For Robert San Juan, 54, a Dallas, TX, software quality engineer by day and an actor by night, crafting helped fill a creative deficit. The pandemic closed the local theaters where he normally performs. He’s single and couldn’t safely visit his mother or his siblings. That left him with time on his hands. He decided to try his hand at drawing and painting, something he hadn’t done since college. 

“I’m a little bit of a perfectionist,” he said. “But this was just something to do and a way to express myself. The physicality of putting a pencil or paintbrush to paper made me feel better.” He started posting photos of his drawings and paintings on Facebook and Instagram and got many positive responses. 

“I’ve accomplished something that’s touched people,” he said. “Just doing this made me happy. The act of creation, regardless of what it is, is a human need that most people need to fill.”

Collaboration and Community

Crafting can become an outlet for shared mourning, like Stitching the Situation, a collaborative memorial of the COVID-19 pandemic. The massive cross stitch project involves crafters from every state, many of them older adults. Each volunteer receives a kit and stitches a fabric panel that represents a single day of the pandemic; each panel’s border features red stitches representing those who died and blue stitches representing the case count. The volunteer then creates a design for the center, such as a portrait of a loved one who died; a reminder to mask up; or an image of the COVID virus. Participants share photos on Instagram and gather in Zoom meetings.

“It’s creating a space to contemplate and think about what’s happened,” said organizer Heather Schulte. “It’s a meaningful way for those who lost loved ones to process grief, especially given that families can’t gather for a funeral.”

Schulte is collecting the individual panels and wants to eventually launch an exhibit. She hopes the project might play a role in the COVID-19 pandemic similar to that of the AIDS Memorial Quilt during the HIV epidemic: a traveling exhibit that could offer a space for meditation and collective healing. 

One participant, Nancy Bonig, 72, an artist in Monument, CO, chose to make the square representing October 29, 2020, the day that a relative of hers passed away from COVID-19. More than 88,000 new cases were reported, and 971 Americans died that day. Bonig’s design for the center is a flock of blue butterflies.

“As I stitch my panel, most of the time I have tears in my eyes,” she said. “I realized how fortunate I am and how difficult this has been for so many.” 

This was just one in a series of new crafting projects that Bonig took on during the pandemic. After closing her fused glass art studio, she tried quilting, making hand-painted shoes, and crocheting hats, gloves and scarves for the homeless. 

“I have to create something every day,” she said. “It’s an outlet for me, like eating or breathing.” 

And for many older adults, crafting was the outlet that helped them weather the pandemic—giving them a sense of purpose, accomplishment and connection with other crafters and providing a distraction from the stress. 

“We’ve been in chaos most of the past year,” said Lauterback. “I’m a worrier; I had a much more difficult time without something to focus on. Drawing gives me a little harbor.” 

Row, Row, Row Your Boat

Growing interest in rowing lures older adults to the water

Hanne Caraher loves rowing. She’s very good at it. So good, she’s won a national gold medal and has competed in championships in Canada, Poland, Germany and Hungary (she won there too). After years of early morning practices—which meant arising at 4:20 a.m. five days a week—she’s now rowing with the Gray Knights at Thompson Boat Center in Washington, DC. 

She’s only been rowing for 11 years now. And she started when she was 72. 

“I found all the things that were connected with rowing were fun. It totally changed my life,” said Caraher, now 83, who also won a medal in 2019 on a boat rowed by competitors whose average age was 80.

Caraher is not alone in her love of the sport. More and more older adults are discovering rowing as a way to stay physically active, as well as mentally and socially engaged. USRowing, the sport’s governing body, says its membership grew from about 67,000 in 2013 to 75,000 in 2018 (the most recent tally available). About 14 percent of members are 50 and older. (While there’s no gender breakdown for older rowers, women make up about 53 percent of USRowing’s total membership.) 

At the 54th Head of the Charles Regatta—one of the sport’s biggest events, held on the Charles River in Massachusetts—about a quarter of entries in 2018 were men and women 50 and up. 

Even as COVID-19 curtailed many races and team activities, older rowers still stay in shape through indoor rowing, virtual races, singles boats (allowing rowers to remain safely distanced) or other safety measures. And while some competitions are on hold, that doesn’t dampen the enthusiasm that older rowers express for the sport.

“Rowing has got under my skin like no other form of exercise ever has,” said Patricia Carswell, a British rower in her 50s, who blogs and podcasts about rowing at GirlontheRiver.com. “The river has me in its thrall, and I love the endless challenges that go with such a technically difficult sport.”

Vigorous but Safe

Rowing offers all the benefits of vigorous exercise, but with minimal risk of injury or impact on the joints—a plus for older adults. Contrary to popular belief, rowing is not just an upper-body exercise. It uses all the body’s major muscle groups: legs, arms and core (torso). 

“Rowing puts only minimal stress on the joints, far less than walking, running or biking,” said Mark Slabaugh, MD, an orthopedic sports-medicine surgeon with Orthopedics and Joint Replacement at Mercy Medical Center in Baltimore. “Only swimming is less strenuous on the joints. Those with limited range of motion in any of their joints can still participate in rowing, due to the low stress on the hips, knees, ankles and shoulders.”  

Slabaugh said he might caution patients with symptomatic, rotator-cuff tears (a type of shoulder injury) against rowing. Otherwise, the sport is safe for most people, he said, adding that newbies of any age should start slowly, building up intensity gradually.  

Research confirms the fitness benefits. Slabaugh cited a 2012 study in Japan that measured the results of an indoor rowing regimen for a group of older men: improved aerobic capacity, decreased fat and improved muscle tone, all key metrics for functional health for older people. Researchers have also found that the lungs of rowers who train seriously use oxygen more efficiently than those of most other athletes. 

The focus on the present moment and mindfulness in rowing is a kind of Zen.

— Charles Gilbert

In addition, studies have found that rowing improved physical fitness among breast-cancer survivors. They were once urged to avoid lifting or exerting their shoulders, to reduce the risk of lymphedema; now, many doctors encourage them to row. Rowing groups have sprung up specifically for breast-cancer survivors. 

Like other forms of vigorous exercise, rowing may ward off depression. Some rowers say that the rhythmic, repetitive nature of rowing is like meditation.

“The focus on the present moment and mindfulness in rowing is a kind of Zen,” said Charles Gilbert, 66, who rows with Princeton National Rowing Club in Princeton, NJ. “A Zen practitioner told me that my rowing 1.5 hours a day on the water constituted my Zen practice.”  

Rowing also benefits the brain. It involves learning new skills that require concentration, which may offer added brain health benefits. Most boat clubs offer “learn to row” programs, generally about six weeks long, to teach newbies the basics, but rowers never stop improving their technique. 

“Rowing is a lifetime sport,” said Tom Murphy, 67, president of Rocky Mountain Rowing Club in Denver. “It appears easy to learn the basic motion, but it takes a lifetime to master.” 

Competition as Motivation

While older adults can row recreationally, many compete as part of a team in races and regattas, and that can push them to train harder and more consistently. 

“When you’re in a boat with other people, you can’t stop,” said Lisa Miller, 56, who rows with Dallas United Crew in Dallas, TX. “It pushes you to get past your limits. On my own, in the gym, I would’ve stopped.”

Miller likes the sense of accountability. For example, she said, if one person doesn’t come to practice, the coach must rearrange seating on the boats. “You don’t want to mess up your teammates,” she said. “You don’t want to get that call from the coach, asking, ‘Where are you?’” 

Rowing is one sport where team members look forward to getting a year older. 

For some, rowing is their first experience of athletic competition. 

“I’m a pre-Title IX babe,” said Joanne Caye, 72, a rower in North Carolina. “I didn’t get this stuff when I was in school. Just to be able to compete is something that is really heady for me. I get pushed in absolutely wonderful ways. I never knew that about me.”

Caye was introduced to the sport in her late 40s through another mom on her son’s high school rowing team. Now, 25 years later, her son is grown (and no longer rowing) and Joanne is retired, but she’s still rowing as part of Carolina Masters Crew Club.

Rowing allows people to remain competitive even as they age. Classification is based on age, and handicaps are assigned based on these classifications, allowing young and old to compete fairly, side by side. Gilbert jokes that rowing is one sport where participants look forward to getting a year older, because that helps boost the boat’s average age, raising the handicap. 

“In rowing, the goal is to get older and stronger, so that you can keep contributing,” he said. 

‘Built-in Sisterhood’

Rowing teams often form close-knit communities that stay connected outside of practice and during the off-season. Many clubs host social gatherings, philanthropic service projects and classes for disadvantaged children or disabled veterans. For retired older adults, regular rowing practice creates routines and teamwork that many miss after leaving the professional world. 

As a retired professor of social work, Caye sees a lot of value in the intergenerational social connections she’s made as a rower. “It’s wonderful to have a built-in sisterhood,” Caye said. “Rowing connects me with women who are younger than me and keeps me attuned to changes in trends.” 

Liz Jenista, 37, is one of those younger women on Caye’s team. She’s been rowing with the same club for 15 years. Having moved from California to North Carolina soon after graduating from college, Jenista calls her rowing club her “multigenerational family away from my actual family.” Friends made through rowing have become an important support network, helping her and her husband navigate the job market, purchase a house and even parent their two children, ages six and 10. Some rowers handed down gently used clothing and supplies when her children were babies; others have babysat. When they rode together for hours on the way to regattas, Jenista often asked teammates for advice on child rearing.

“Talking through behavioral challenges and hearing about [older members’ children] who faced similar challenges but grew up and became successful adults—that’s so reassuring,” Jenista said.  “It’s been very valuable having the perspective of older women.”

Time in Nature

Most competitive rowers spend time on indoor rowing machines, whether in the off-season, during inclement weather or due to COVID-19 restrictions. But the time spent outdoors is a key attraction—and a major benefit—of rowing. 

“The benefits are even more profound when you’re in nature, breathing clean, fresh air and getting away from the normal daily routine, especially during COVID when we need to avoid staying indoors for too long,” said sports-medicine surgeon Slabaugh. 

There’s a growing body of research that suggests time spent outdoors itself has benefits. In a 2019 study published in Scientific Reports, a journal published by Nature, 20,000 study participants reported better health and well-being when they spent 120 minutes or more in nature each week. 

Many rowers commented on the magical feeling of rowing on a body of water early in the morning before the world is awake. 

“You’re getting back to nature,” said Miller, the Dallas rower. “You’re out on the water and it’s quiet, except for the clicks of the oars. You see these beautiful sunrises. It’s a great way to start the day.” 

In the Red

More and more older adults are in debt at retirement age—and beyond

At age 50, Sarah Smith found herself divorced, bankrupt and saddled with debts inherited from her ex-husband. When her two children chose to attend private colleges, she took out student loans. Now, at 66, Smith (not her real name) still owes about $60,000.

“Pretty much everyone told me to not take on college debt, but I wasn’t going to let my kids suffer because of their dad’s irresponsibility,” she said. 

In finding herself still in debt as she nears retirement age, Smith is far from alone. Financial debt among older Americans has skyrocketed in recent decades. And that trend was well underway before the COVID-19 pandemic—a source of financial calamity for many. 

From 1999 to 2019, total debt for Americans over 70 increased 543 percent. That’s the largest percentage increase for any age group, according to the Federal Reserve Bank of New York. Similarly, those in their 60s have seen their debts—including mortgages, auto loans, medical bills and other credit—balloon by 471 percent. Many who are nearing retirement age feel their debts are excessive and say they are financially distressed, according to a report by the TIAA Institute. 

Few statistics are available so far on the impact of COVID-19 on older people’s finances, but one study found that the nonmortgage debt burden of the average retiree doubled in 2020. Forced early retirement, job loss or reduced hours are likely contributors. 

Experts don’t expect the situation to improve any time soon.

“We’ve had two significant economic crises in barely over a decade,” said Mark Hamrick, senior economic analyst for Bankrate.com. “Many people were still trying to claw their way back to their previous position, having suffered setbacks from the Great Recession [of 2008]. Now they have the interruptions in income and employment due to the pandemic.” 

As a result, many people turned 65 during the last year after spending the past 12 years fighting just to stay afloat. They saved little or no money for retirement during their 50s, the decade when financial planners traditionally advise investors to focus on building a nest egg. Some were forced to start taking Social Security payments earlier, decreasing the monthly amount they’ll receive in their remaining years.

Once, paying off the mortgage was a big goal in life. Now, people refinance their mortgages to borrow cash. 

“For those lucky enough to become re-employed [after a job loss], many had to switch occupations and take a pay cut,” said Lori Trawinski, director of finance and employment for AARP’s Public Policy Institute. “And some gave up looking for a job.” 

Many Americans carry debt—most financial experts would say too much debt. Younger people have many years of earning power ahead to pay off debt; for an older adult, finding a full-time job that pays well becomes increasingly difficult. Those with health problems may not have the ability to work at all. 

Debbie Burkham, a financial coach with the Elder Financial Safety Center at the Senior Source in Dallas, sees a variety of reasons why older adults carry debt: job loss, medical bills, divorce, student loans and support they provide for adult children and grandchildren. Plus, she adds, it’s easy for Americans of any age to get credit. 

“In the 1970s and 1980s, you applied by mail for a credit card and waited several weeks, hoping for a credit line of maybe $500 to $1,000,” she said. Today, many find their mailboxes full of letters offering pre-approved credit cards. For those with bad credit, there are always payday loan businesses, which charge exorbitant interest rates and added fees for late repayment. 

Credit cards aren’t the only source of temptation. 

“Our financial system now allows for easy refinancing of a home, which gives the borrower cash for any purpose: to improve their home or to pay for college, to buy a new car or to pay off another debt,” Trawinski said. 

Contrast that to older adults of a generation or two ago, who had an aversion to debt after surviving the Great Depression of the 1930s. For that generation, “Paying off the mortgage was a big goal in life,” Trawinski said. “People would have mortgage burning parties, because it was a cause to celebrate.” 

How Debt Accrues

Why do so many people reach retirement age still owing money? 

Student loans are one surprising source of debt. A 2017 study by the Consumer Financial Protection Bureau found that the number of American consumers ages 60 and older with student loan debt quadrupled between 2005 and 2015, from 700,000 to 2.8 million. A few are paying off their own loans or those of a spouse, but the majority had funded the education of a child or grandchild, either by taking out a loan or acting as a cosigner.

Women and people of color are particularly burdened by college debt. The American Association of University Women found that Black women reported the highest levels of outstanding debt compared to white men and white women, with Black women racking up $37,558 in undergraduate loans, compared to $31,346 for white women. Nearly 60 percent of Black women report financial difficulties while repaying college loans. 

Then there are the adults in midlife (40-64) who provide financial support to their parents or their adult children—or both—according to an AARP telephone survey. Half of midlife adults continue paying for basic expenses like cell phone bills, groceries and rent for children over 25; nearly a third report providing similar financial support for their parents. This creates financial pressures that reduce retirement savings during a crucial period for building wealth.

Sometimes debt leads to deeper debt.

Another pitfall: medical costs that typically increase as people age, coupled with the skyrocketing price of health care and insurance. Even older adults with good insurance may end up owing thousands of dollars in deductibles and copayments after a single medical episode. 

On top of all of that, older adults are often targeted by scammers and unscrupulous salespeople. Burkham counseled an older man who was pushed to buy a new car every time he took his car into a dealership for repairs. The new purchases were rolled into his existing car loan. Now he’s driving a Ford Taurus with car payments of $900 a month. 

In some cases, debt just leads to deeper debt. Burkham worked with a client in her early 70s whose credit cards were maxed out.

“She lost her job, and health issues kept her from going back to work,” she said. “She used her credit cards to fill the gaps until her credit was maxed out.” Living on only about $1,500 a month in Social Security, the client can’t make even the minimum payments. Without the means to pay an attorney, bankruptcy isn’t an option. Right now, the woman is relying on the generosity of friends to survive. 

Who’s in Debt

Black people and lower-income earners are hardest hit, and much is based on socioeconomic inequalities. 

For example, before the pandemic, the unemployment rate among Black Americans was twice that of white Americans. Black workers earn less than white workers with similar education and experience. Other factors include historically low home ownership, lower rates of savings, less participation in the stock market and less generational wealth passed down from family members among people of color. 

According to a report by the Employee Benefit Research Institute, pre-COVID, families with Black or Hispanic heads of household had much higher debt-to-asset ratios compared to those households headed by non-Hispanic white people. Families with minority heads were more likely to be saddled with debt payments that represented more than 40 percent of their income. And that money owed was more often the result of consumer debt (such as credit cards or student loans) rather than housing debt (mortgages or home equity loans). That’s bad news, because families with mortgages build wealth through homeownership; consumer debt is a “sunk cost” with no future pay-off, and usually at higher rates of interest. 

Depression and Desperation

Debt represents more than a number on the wrong side of a financial ledger. Debt can negatively affect mental health at midlife and beyond. One survey of older adults in Miami-Dade County, FL, found more symptoms of depression, anxiety and anger among older adults who reported excessive levels of debt.

“Debtor status is more consistently associated with mental health than any other single traditional indicator of socioeconomic status,” the report said.

A National Council on Aging survey found that older adults often make tradeoffs to save money, such as foregoing needed home or auto repairs (23 percent), cutting pills to save money on medications (15 percent) or skipping meals or medical appointments (almost 14 percent). 

If that isn’t enough, an older person in debt may be harassed by debt collectors. Some may find their cars repossessed or end up evicted from an apartment because they can’t pay the rent.  

Tackling the Problem

Borrowing money is just one part of the problem. The other side of the coin is not saving enough and not having the financial literacy to know better. 

Most Americans no longer receive pensions from their employers and must rely on 401(k)s or other retirement savings plans. Hamrick of Bankrate.com says few Americans understand how much money they need to fund their retirement, especially in light of longer lifespans and growing costs of housing and health care. In some cases, debt becomes the only way to make ends meet. 

“As a society, we don’t do an adequate job of teaching financial literacy,” he said. “The onus to put money aside has been shifted to individuals, and it’s difficult to compel individuals to save.” 

Similarly, the TIAA study noted that many older adults nearing retirement age don’t understand basics about finance, such as how debt can quickly double on money borrowed at high rates of interest. Trawinski of AARP added that, as people age, they’re more likely to lose a spouse to death, but many don’t plan for living without the spouse’s earnings. 

A debt-consolidation loan can help, provided you don’t just revert to credit-card spending afterward.

For older adults in debt, experts suggest a traditional remedy: making a budget and sticking to it. They advise taking care of the basics first—rent, utilities, food, drugs and medical care—and then looking for ways to keep those costs as low as possible, and to save money for unexpected expenses. 

“I advise people to try to build up a savings of at least a few hundred dollars,” said Burkham of the Elder Financial Safety Center, “so they’ll be ready for those nonregular expenses that people end up putting on a credit card,” such as car repairs. To help keep monthly expenses down, she helps low-income adults apply for government assistance programs that help with expenses like food, transportation, Medicare premiums and prescription drugs. 

Credit counseling could help some people. Debt-management companies can assist in creating a manageable repayment plan. These services are not free, however, and Burkham advises choosing one that’s affiliated with the National Foundation for Credit Counseling, not a for-profit debt-settlement company that may charge higher fees. 

Debt-consolidation loans might be an option for older adults with a steady income and the discipline to not fall back into credit-card spending. Home refinancing or reverse mortgages may be good options in some cases, but older adults should seek advice from a trusted expert before proceeding. 

Working Longer

For most older Americans, debt means they will have to work longer and postpone retirement. That’s the fate facing Bonnie Jones (not her real name), 62. She planned to retire at age 60, but she’s still saddled with about $10,000 in credit-card debt, plus a mortgage. That’s whittled down from the six figures in debt she inherited from a divorce 10 years ago. She’ll need to work another three to five years before retiring. 

“I’ve been very focused on paying down the debt, and I just feel lucky that I’ve been able to earn a good salary,” she said. 

Financial experts note that not all debt among older adults is necessarily problematic. Some debts, like mortgages at record-low interest rates, may make sense, according to the Center for Retirement Research at Boston College.

“Given longer life expectancies and extended labor force participation rates of older workers, and improving health status, households may optimally choose to maintain mortgage debt later in life,” one report notes.

Debt can also serve as a positive source of motivation that keeps older adults engaged in the workforce. Sarah Smith is still in debt but also feels she’s just hitting her stride professionally. She started a successful legal referral business just a few years ago and feels more confident than ever about her money situation. 

“I have more money in the bank now than ever, a large amount of equity in my home, a growing business and an extremely positive outlook,” she said. “Had I not hit rock bottom, I might not have created such a massive success.”


Climate Change Endangers Many Older Adults

Yet it’s seniors who worry the least about climate-related disasters

In 2007, Larry Howe watched a documentary called The Great Global Warming Swindle, which denied the threat of climate change. Convinced, he put the issue out of his mind. 

But that changed a few years later when Howe’s first grandchild was born. A retired engineer, Howe, 64, dug deeper into the science. Now he’s active with the Citizens’ Climate Lobby and talks to local groups, like the Rotary Club and Kiwanis, in Plano, TX, where he lives. He’s often met with skepticism—especially among people in his own age group. 

“Most don’t think they’ll be negatively impacted themselves,” he said. “They may agree that climate change is a serious problem but think ‘I won’t be around for it. It’ll get worse, but after I’m gone.’” 

If anybody should be concerned about the issue, it would seem to be older people, who stand to suffer more from climate-change-related problems—from weather disasters to air pollution. And many, like Howe, do grow more concerned about the future when grandchildren arrive. Yet many older adults remain unprepared for disasters in their own homes and communities, and studies suggest elders are less concerned about climate change than their younger counterparts.

So why the disconnect? 

Climate Disasters and Later Life

Climate change is triggering more frequent and more disastrous weather events, and older adults stand to suffer the most. Nearly half of those who died in 2005 during Hurricane Katrina were 75 or older. In 2012, when Hurricane Sandy hit New York and New Jersey, almost half of those who died were over age 65.

“Older adults are more vulnerable and experience more casualties after a natural disaster, compared to other age groups,” according to a study from the American Red Cross Scientific Advisory Council and the American Academy of Nursing. The study cited the likelihood that older adults will have chronic conditions and rely on medications, and will be dependent on assistive devices (like walkers or eyeglasses) and support from caregivers. Older people are also more likely to live alone, leaving them even more vulnerable. Those with mobility limitations are at greater risk, because it’s more difficult to get out of harm’s way. 

From 2015 to 2019, the United States saw at least 10 massive, climate-related disaster events each year, with each incurring a loss of $1 billion or more—the longest streak since record keeping began in 1980. In 2020, as of October 7, the United States was affected by 16 climate-related disasters with losses per event exceeding $1 billion: one drought, 11 severe storms, three hurricanes and one wildfire. 

“As we respond to disasters, we see the heartbreak of … communities dealing with the new realities of more intense storms, heavier rainfall, higher temperatures, stronger hurricanes and historic wildfires,” the Red Cross said in a 2019 statement on climate change. 

At the same time, older people are less likely than others to be prepared in the event of a major disaster. One 2014 survey found that two-thirds of adults 50 or older had no emergency plan, had never participated in any disaster preparedness educational program and were not aware of the availability of relevant resources. More than a third of respondents lacked a basic supply of food, water or medical supplies in case of emergency.  

Chronic Problems Made Worse

Older people often suffer from chronic health problems that can be exacerbated by climate change. Global warming leads to longer allergy seasons and more air pollution, affecting people with allergies, asthma and other lung conditions. As heat waves grow more and more extreme, older people stand to suffer more, and need to stay in more, especially those who retired to sunbelt states like Arizona. Some scientists speculate that climate change might also mean more risk from new infectious diseases—such as COVID-19—and might make people who live with polluted air more vulnerable to them.

Climate change also affects the costs of living. Energy expenditures to keep a home air conditioned go up as the temperatures rise. Home insurance rates skyrocket in areas subject to disasters like wildfires, flooding and hurricanes; in some cases, homeowners can’t even get insurance.

“So, you have increasing costs at a time when your income is fixed,” said Howe. “Age is like a threat multiplier when it comes to climate change.” 

Attitudes toward Climate Change

But while there’s a consensus among scientific, disaster-response and medical experts that climate change disproportionately threatens the health and safety of older adults, that’s not reflected in the attitudes of this age group. Older people seem even less aware than their younger counterparts of the threats they face.

Michael “Mick” Smyer has researched older adults’ attitudes toward climate change. He is a gerontologist, professor emeritus of psychology at Bucknell University and the founder and CEO of Growing Greener: Climate Action for a Warming World, an organization that promotes education related to climate change. 

While concern and awareness are increasing among people of all ages, there are some age differences. Smyer points to research and analysis from the Yale Program on Climate Change Communication. When asked, “How worried are you about global warming?,” 72 percent of younger people (ages 18-39) reported they were “somewhat” or “very” worried. By contrast, only 61 percent of baby boomers (ages 56-74) and 56 percent of those 75 or older reported the same levels of concern.

The lack of awareness and disaster preparation among older adults might relate to human nature—our capacity to dismiss danger when it’s not imminent. When asked, “How much do you think global warming will harm you personally?,” the age differences narrowed, with 44 percent of younger people responding “a moderate amount” or “a great deal,” compared to 41 percent of boomers and 39 percent of the oldest respondents. 

“That’s not a big difference,” Smyer said. “Can we find older adults who are members of the climate change denial club? Absolutely. Look at the ranking, senior, US senators. But can you generalize to all older adults? No.” 

Natural disasters make the news, but climate change itself gets less than one percent of airtime.

However, Smyer thinks there may be age differences in the way that older people prepare for disasters. Smyer, 70, was born and raised in New Orleans; Hurricane Katrina was the impetus that spurred his interest in climate change. He thinks more older adults died in Katrina, in part, because they’d lived through many hurricanes before and chose not to evacuate. Most were able to weather the hurricane itself—but not the flooding and prolonged disaster that followed when the levees broke. 

“Older adults thought they knew how to survive hurricanes,” he said. “And in a sense, they did. They were the ones who had axes in their attics, to chop their way through the roof to survive a flood. But many thought, ‘I’ve learned from previous, similar disasters and I can generalize to this situation.’ Except the conditions changed, and that’s what people don’t appreciate.” 

Smyer attributes the disconnect between awareness and action to what he calls society’s “climate silence habit.” Natural disasters make the news, but the bigger and longer-term cause—climate change—tends to fall to the background.

The 24-hour news cycle saturates viewers with news of weather events, but climate change gets very little airtime. Media Matters, a US media watchdog, calculated that only 0.3 percent (55 of 16,000 total minutes) of evening news airtime on the major TV networks (ABC, CBS and NBC) was dedicated to climate change in 2018. (That’s compared to 28 percent of news minutes dedicated to President Trump.) 

Some efforts for change are underway. Until recently, TV meteorologists traditionally avoided discussing climate change on the air, wishing to avoid appearing too political. Now many are bringing up the issue regularly, and even talking about possible ways to tackle it, according to a panel of meteorologists and policy experts convened at the 2020 meeting of the American Meteorological Society. 

“Broadcasters have an unusually good platform from which to engage,” said Ed Maibac, the director of the Center for Climate Change Communication at George Mason University. He noted that weather casters telling local stories about climate change have increased more than 50-fold over the last eight years.

Making the Message Stick

Rick Lent, 72, didn’t think much about climate change until a conversation with his college-age granddaughter two years ago. 

“Please tell me there’s something to be hopeful about in the future environment I’m living into,” she said. “Because I’m really scared.” 

That spurred Lent to activism through the Boston chapter of Elder Climate Action. He shares the conversation he had with his granddaughter when he speaks to groups of older adults at senior centers and community centers. Often, he has to hold back tears. 

“I have to watch my emotions when I tell that story,” he said. “That really personalizes it.” 

Smyer thinks that’s key. “The best way to reach older adults is through family members,” he said. He created a deck of climate-change cards to encourage young people—from elementaryaged kids to college students—to start the conversation. 

Their attitude [to climate change] is, “I’m not going to be around to fight that battle, so what can I do?”

— Rick Lent 

“What’s really clear to me is that older adults are not just potential victims but also potential leaders of climate action,” Smyer said. 

Lent says he sees two kinds of responses among older adults when he talks about climate change. 

“Well educated, middle- or upper-middle-class people don’t seem to be paying much attention,” he said. “I can’t say why except that they did what they were supposed to do —raised families, put money in their 401K—and now they’re retired and enjoying life. Their attitude is, ‘I’m not going to be around to fight that battle, so what can I do?’” 

He says it’s even more difficult to engage low-income people of color. 

“Those are the people most impacted by climate change and who have the fewest resources to deal with it,” he said. “If you can’t afford to put in air conditioning in your home, you’re not thinking about working to improve local air quality.”

Where Lent lives in Massachusetts, the biggest threat from climate change is the increasing number of severe heat waves, which affect older people most directly.

“It’s a problem, but then people forget and move on,” he said. 

Separating Science and Politics 

Politics is a big part of what informs attitudes toward climate change, Smyer said, and older adults are more likely to lean conservative; that may serve to reinforce their skepticism. Research shows that those who identify as left-leaning tend to express more concern about climate change and want more action to reduce its effects. Conservative older adults also tend to express significantly less concern than their Generation Z or millennial Republican counterparts, according to a Pew Research Center survey.

Howe, who is a conservative Republican, hopes science, not politics, can inform older adults’ views on the issue. He worries climate change has become politicized in a way that tends to make people of all ages resistant to scientific facts, noting the growing distrust in science he sees in response to the COVID-19 pandemic. But he’s also hopeful that education can help change some minds. 

“When I talk to groups, I try to address skeptics in the audience,” he said. “I try to get people to think that this isn’t just a political, polarizing issue. I share my personal journey. I thought fixing climate change meant killing the economy. It doesn’t have to. There are a lot of ways to solve it.” 

The Doctor Is In (Virtually)

Older adults are testing telemedicine’s advantages, drawbacks

As a retired registered nurse, Donna Bening, 81, has known for decades that telemedicine was coming. Her expectations have been realized this year.

Bening had two virtual visits via videoconference: first with her primary care physician for a routine checkup, and later with her rheumatologist for a follow-up to track the progress of her rheumatoid arthritis. Bening loved the convenience. Her primary care physician, Bening noticed, checked on her from home, casually dressed, sans the usual white coat.

“Neither of us had to get dressed for the appointment,” Bening said.

Millions of older Americans tried telemedicine for the first time in 2020. Due to the pandemic, medical providers quickly pivoted to virtual visits to minimize potential exposure to COVID-19 for vulnerable older patients, and Medicare expanded its coverage to reimburse for telemedicine visits, which were previously not covered.

“The pandemic took something that was ready to launch in some form and accelerated the adoption of the new technology,” said Joshua Septimus, MD, a primary and internal medicine physician at Houston Methodist Hospital who sees many older adult patients. “I think it will have a lasting impact.”

Many experts believe telemedicine will continue to play a bigger role in medical care for older adults after the pandemic, especially if Medicare maintains its coverage. But while telemedicine offers many advantages to older adults, some worry an overzealous push for widespread adoption could leave some patients behind or push them toward virtual visits even when they really need to be seen in person.

“I worry that people are being blinded by the efficiencies [telemedicine] creates to the limitations,” Septimus said.

Advantages of Virtual Visits

Telemedicine is the use of communications technology to deliver health care to patients at a distance. Virtual visits typically involve video and audio communication, via a laptop or desktop computer, tablet (such as an iPad) or smartphone, but may also include medical visits conducted by telephone. Some expand the definition of telemedicine to include written communication between patients and doctors via email or an online portal.

Early studies indicate that patients are responding positively to virtual interactions.
For many older adults, the biggest and most obvious benefit of telemedicine is the ability to consult a doctor or other medical professional without leaving home.

“Traveling to a clinic or doctor’s office can be an exhausting task for older adults,” said Jessica Voit, MD, an assistant professor in the Department of Internal Medicine at UT Southwestern Medical Center in Dallas who specializes in geriatrics. “Some patients need a family member to take off work to bring them in.”

Eulaine Hall, 87, of Dallas likes that advantage. When her annual checkup took place over the telephone a few months ago, she didn’t need to arrange transportation to the doctor’s office via the city’s transit service for seniors. Hall, who has macular degeneration, can no longer drive.

“Avoiding the trip was major,” she said. “And I felt like the doctor spent more time with me and asked really detailed questions.”

Other advantages: doctors can conduct visits from wherever they are, saving time and money. With the patient’s permission, a third party—another medical specialist or a family member—can easily be pulled into a virtual visit.

“You could have multiple physicians in a consultation with the patient at once, instead of having the patient make multiple visits to multiple doctors,” said L. Arick Forrest, MD, vice dean of clinical affairs at the Ohio State University College of Medicine. “Telemedicine offers the possibility of a more patient-centric approach.”

Telemedicine makes it easier for patients and doctors to have frequent, brief check-ins.

Another advantage: doctors can glean a better sense of a patient’s living situation through a video visit.

“I enjoy seeing patients in their homes,” said Voit. “I get insight into their daily lives. I meet their pets. I might notice things like how it’s a challenge for a patient to stand up from a soft couch, or a throw rug on the floor that might cause a fall.”

Before the pandemic, all visits were conducted in person at Voit’s clinic. Once the pandemic hit, the clinic quickly moved most appointments to videoconference or telephone. Now, it’s a hybrid—the clinic provides some appointments in person when needed and others via telemedicine. Nurses triage appointment scheduling to determine which visits need to take place in person and which can easily and safely be conducted virtually.

“Telemedicine works well for a follow-up visit—for example, if we’re trying a new medication and need to see how the patient is doing with it,” Voit said. “But if I need to listen to the patient’s heart and lungs, or it’s a complex case, I need to see the patient in person.”

Another advantage for older adults: telemedicine makes it easier for patients and doctors to have frequent, brief check-ins.

“As you get older, you get more chronic conditions, and managing those via telemedicine, rather than deferring follow-up until your next doctor visit, is a big advantage,” said Forrest. “With telemedicine, there are more ways to be in constant connection.”

Forrest added that patients can often monitor their vital signs from home, thanks to new, consumer-oriented gadgets, such heart rate monitors, blood pressure cuffs, blood glucose monitoring, or digital pulse oximeters to measure blood oxygen levels. However, insurance coverage for these devices varies.

Technological Challenges

When Rosie Kroft, 80, called to schedule a doctor’s appointment last May, the scheduler told her she’d need to see the doctor via videoconference. Kroft’s cell phone doesn’t have video capabilities, so she enlisted her son to come to her house with his smartphone for the appointment.

“I was pleasantly surprised by how well the visit went, but it would’ve been easier for me to just go to the clinic,” she said.

While many older adults are tech savvy—and many more have become adept with FaceTime, Zoom or other video platforms during the pandemic, to stay in touch with family—some lack the skills or the devices needed to connect with telemedicine. Forrest notes that about 40 percent of patients over 65 in his clinic chose to conduct their virtual visits via telephone, rather than video—about twice as many compared to those patients under 30.

While it was a necessity during the pandemic, “When it’s done by phone, it’s just not as effective,” he said.

In-person visits will always be important. Doctors often pick up subtle physical or behavioral cues that might not come across via telemedicine.

Technology is a barrier for telemedicine for a significant number of older adults in the United States, according to a University of California, San Francisco study.

“Video visits require patients to have the knowledge to get online, operate and troubleshoot audiovisual equipment, and communicate with the cues available in person,” the study reported. “Many older adults may be unable to do this because of disabilities or inexperience with technology. An equitable health system should recognize that for some … in-person visits are already difficult, and telemedicine may be impossible.”

The study estimated that, in 2018, 13 million older adults in the United States were not ready for video visits, mostly due to lack of experience with technology or not owning the right devices.

“Telecommunication devices should be covered as a medical necessity, especially given the correlation between poverty and telemedicine unreadiness,” the study recommended.

The study also noted that older patients are more likely than younger patients to have hearing or vision loss or dementia, which can make telemedicine virtually impossible, unless someone is available to assist with the technology.

Permanent Change or Emergency Stopgap?

Many medical visits that initially took place via telephone or videoconference during the pandemic are now returning to in-person appointments, as clinics put safety protocols in place. That’s how it should be, doctors say.

“One concern of mine is that a lot of virtual care is being done [during the pandemic] for respiratory infections, where the patients really should be examined,” said Septimus. “The value of examining someone’s lymph nodes, throat or chest, that’s something you can’t replicate with technology.”

Going forward, the challenge will be striking the right balance—using telemedicine where appropriate, but making sure patients are seen in person when necessary. And determining whether telemedicine will work for a specific visit isn’t always an easy call. It depends on the situation and may vary from one patient to another. For example, a dermatologist might be able to effectively follow up via video with an established patient with a confirmed diagnosis—such as acne or an eczema flare-up—but a suspicious mole or other skin lesion must be examined in person.

“It’s really up to the practitioner to decide who needs an in-person visit,” said Carmel Dyer, MD, geriatrician with UT Physicians/McGovern Medical School at UTHealth in Houston. “We don’t want a patient who needs to be seen forced into telemedicine. On the other hand, we don’t want to drag them down here to the clinic if it’s not necessary.”

Some experts worry that, given the lower cost of telemedicine visits, insurers may eventually push patients to use this route more and more often, even when they really need to be seen by a physician. Physical examinations and personal interactions will always be important for good medical care. Physicians often pick up on subtle physical or behavioral cues that might not come across via video.

“Telemedicine is not a substitute for an in-person visit,” said Forrest. “It’s a complement.”

Geriatrician Carmel Dyer, MD, suggests that patients ask a family member or friend to join them for virtual visits, to be a second set of ears.

Septimus recalled a patient who seemed nervous and fidgety during an exam; when confronted, the patient confessed that he had a drug addiction.

“I never would have noticed that, had I not been with him in person,” he said.

To help make a virtual visit more thorough and successful, Dyer advises patients to prepare just as carefully as they would for an in-person appointment.

Helpful preparation may include:

  • Sitting in a quiet, well-lit location, with the TV off and as few distractions as possible
  • Checking vital signs (blood pressure, temperature, oxygen levels, heart rate and weight) before the visit begins
  • Writing out a list of questions for the doctor
  • Having an up-to-date list of medications
  • Wearing hearing aids or glasses, when applicable

Dyer also suggests that a patient could ask a family member or friend to join the visit to be a second set of ears, or to hold the video device if a doctor needs to see the patient’s gait or a hard-to-reach spot on the body.

Before ending the visit, Dyer advises patients to repeat the doctor’s instructions aloud, to confirm they’re understanding them correctly, and to make sure they are clear on what next steps to follow.

Even in these uncertain times, Dyer recommends that patients see a physician in person at least once a year, and more often if they have a condition that requires it. She also thinks first visits should take place in person.

“Establishing a rapport with a new patient is a bit more challenging via FaceTime,” she said. “In person, you can look the patient in the eye.”

Will Lifelong Learning Change the Way We Age?

It can tune up your skills, open up your life—or even help you reinvent yourself

Six years ago, Laura Rich signed up for a continuing education class in Chinese art history and archaeology at Stanford University. Her children were grown and she was wrapping up a full-time stint on the local school board. 

“Most of my life, I thought history was boring, but a trip to Shanghai sparked my interest,” said Rich, 58, of Menlo Park, CA. “And I felt like my mind was stagnating a little.” 

The class completely changed her life: she is now an archaeologist. Before the pandemic, she traveled to Europe twice a year for months-long digs in Italy and England. She has continued to educate herself through other classes at Stanford, lectures, conferences and online courses. As she dug deeper into her subject, she discovered she could tackle dense books that would’ve seemed impenetrable before. (“It’s like my brain turned back on,” she said.) Recently, she was elected vice president for outreach and education for the Archaeological Institute of America.   

“If you had told me 10 years ago that I’d be doing archaeology full time, I would’ve fallen over laughing,” she said. “Yet I absolutely love it.” 

Learning as Reinvention 

Rich’s story is dramatic, but one that Ken Dychtwald believes will become more common in the coming years. He lists “more learning” as one of the key ways life will change for older adults in the years ahead, in his new book, What Retirees Want: A Holistic View of Life’s Third Age (2020), which he co-wrote with Robert Morison..

“Lifelong learning may be the most important ingredient in determining the way people age,” said Dychtwald, who is CEO of Age Wave, a company that conducts research on aging populations. “If you’re living in a world that’s moving along very slowly, you go to high school and college, and that education lasts you for life. That world is long gone. In the future, there will be more learning and more of the personal development, fulfilment and untapping of potential that goes with it.” 

Many people associate “lifelong learning” with enrichment classes that cater to the interests of retired people—such as a course in photography or gardening. But today, older adults can choose from a rapidly expanding menu of educational options that allow them to pursue hobbies, grow professionally or even embark on new careers.  

For example, the Bernard Osher Foundation’s Lifelong Learning Institutes, launched in 2002, support 124 programs, geared primarily to older adults, on university and college campuses across the country.

The Road Scholar program, formerly Elderhostel, offers thousands of “learning adventures” in 150 countries (before the current travel restrictions imposed by the pandemic). 

Some universities are adding innovative, full-time, residential programs for older adults. 

Massive open online courses (MOOCs) allow students of any age to learn about almost anything, on their own timelines, often for free. Emerging in popularity in 2012, MOOCs are offered by providers like Coursera, Khan Academy, edX and FutureLearn.  

While college campuses have offered continuing education classes for decades, Dychtwald expects that will explode after the pandemic. 

“Older learners enjoy being in classrooms with people of all ages,” he said. “After we get this virus in the rearview, I think you will see a surge in campuses—at churches, community centers, senior centers, summer camps, museums—that become learning environments for people in later years.” 

Some universities are even adding innovative, full-time, residential programs for older adults who are starting second careers or looking to move from the profit to the nonprofit world, according to Mark Silverman, CEO of Amava.com, an online platform connecting older adults to online learning, jobs and volunteer opportunities. 

He cites the Stanford Distinguished Careers Institute as an example. The Institute brings midlife students to Stanford to attend classes with undergraduate and graduate students and to participate in campus life, with the goal of enabling individuals in midlife to renew their purpose, build a new community and enhance their physical, emotional and spiritual health. 

Silverman believes such programs are the natural outgrowth of people living longer.

“Many people want to continue to work after they reach retirement age, and money is often not the main motivator,” he said. “Now they have this opportunity to rethink everything. They don’t need to limit their opportunities based only on the experiences they had in the past. You can still develop new skills at this age.”

Learning for Employability 

For those still working, lifelong learning is a way to stay relevant. Judy Brown, 60, of Dallas, TX, worked in marketing jobs for most of her career. But when she took a new job several years ago, she needed to upgrade her skills to help market the company’s products online. With help from a colleague, and the online platform Lynda.com, she taught herself digital skills like search engine optimization. 

“I was in a job I didn’t know how to do; Lynda.com saved my life,” said Brown, who later parlayed her new skills into another, higher-paying job. 

Working older adults like Brown have more options now, because education has become more consumer-friendly and modularized in recent years, said Bradley Staats, associate professor of operations at the University of North Carolina’s Kenan-Flagler Business School and author of Never Stop Learning: Stay Relevant, Reinvent Yourself, and Thrive (2018).  

While a young person may opt for a degree program’s broad education and credentialing, someone in midlife likely needs training in specific skills. Higher education institutions are serving the latter group with more specialized online courses and certificate programs. 

“Universities are breaking up that education into pieces,” Staats said. “If you don’t want to spend two years full time, earning an MBA, maybe you take a one-year certificate program in data analytics online instead.” 

Bethany Ross, public services librarian at the Plano Public Library in Plano, TX, sees older adults profiting from those options. 

Expect COVID-19 to further shake up the online learning space and make it more relevant.

“I helped one older woman who came into the library at night to learn Excel, because she had started a new job and her skills were rusty,” she said. “Another taught herself Canva [a website design platform] to launch a small business selling socks on eBay.”  

Ross, 50, turned to Lynda.com to learn PhotoShop and refine her skills in Excel—two software platforms she uses for her job that weren’t taught in her master’s degree program in library science. 

Ross thinks COVID-19 is spurring older adults to become more adept with online platforms. When the pandemic closed the library’s buildings, the staff moved a book club, which normally met in person, to Zoom. 

“We worried that our older members wouldn’t be able to join us online, but most of them found a way to join us,” she said.   

Expect COVID-19 to further shake up the online learning space and make it more relevant, added Fred DiUlus, 78, founder of Global Academy, which helps universities launch online programs.  

“When Harvard said that existing students would be taught the same courses, all online, this fall, without reducing the cost of tuition, that dispelled some of the prejudice against online learning,” he said. 

Joys of Learning

Paul Irving, a former lawyer in Santa Monica, CA, who chairs the Milken Institute Center for the Future of Aging, thinks everyone should return to school at some point later in life. 

“There’s something magic about being on campus,” he said. “It starts with feeding intellectual curiosity, challenging oneself, and realizing the joy of learning. And returning to school can be a huge confidence builder—confidence both in what you know and in how much you learn.” 

Lifelong learning addresses many challenges related to an aging population. Researchers point to a “sense of purpose” as a key ingredient of successful aging and even longevity. One study by Age Wave and Edward Jones identified “purpose” as one of four pillars of successful retirement (along with health, finances and social connections). 

Purpose, the study said, includes giving back to the community, enjoying time with family, as well as “trying new things, developing new abilities and meeting personal goals—intellectual, artistic, athletic.” In other words, learning. In that same study, 95 percent of retirees polled agreed that “It’s important to keep learning and growing at every age.”  

More than 50 colleges and universities around the world are collaborating as they look for ways to become more welcoming to older adults.

Just as physical exercise keeps the body functioning and healthy, experts believe that learning exercises the brain in a way that helps keep it healthy.  One study showed that acquiring a complex new skill—like digital photography or quilting—led to improvement in memory; another suggested that learning a second language, even later in life, may slow age-related cognitive decline.

“Engaging in learning helps protect our brains from atrophy, and when we’re learning, we are more likely to express greater happiness and greater satisfaction overall, as a result of staying engaged in that way,” said Staats. 

Another benefit of learning: social connections. Strong social connections have been linked with physical and mental health for older adults. Taking a class can boost social skills and self-confidence. 

“I have a whole new set of friends who I would not necessarily have connected with before,” said Laura Rich, the archaeologist. “I’ve lived in this town for decades and I knew many people, but this new interest has brought me together with people from different worlds and lifestyles that I would never have met without pursuing something new and opening myself up to something new.” 

Age Diversity on Campus

These new options in learning are opening new opportunities for reinvention, continuing participation in the workforce and social engagement. But some older adults face obstacles. 

Many, especially those 75 and older, aren’t tech savvy and don’t have access to smartphones, computers or Wi-Fi. Those with limited mobility can’t always attend in-person classes. And older adults often don’t feel comfortable in traditional classes at universities, where the student populations generally remain age segregated. 

Some universities are looking to change that, by pursuing ways to include older people as part of their commitments to welcoming people of all backgrounds. Bringing more older adults to campus could also help keep classrooms filled and tuition dollars flowing. 

More than 50 colleges and universities around the world have joined Age-Friendly University, a global network founded in 2012 at Dublin City University to collaborate on ways to become more welcoming to older adults. Washington University in St. Louis, MO, joined the network in 2018, with a stated vision that “Later life will be viewed as a time of active engagement, learning, and purpose, as opposed to current perceptions of stepping back and diminishing relevance.” While still in its infancy, the Washington University program aims to add new courses, certificate programs, workshops and events tailored to the needs and interests of older adult learners. 

Bringing older adults on campus, too, could enable institutions of higher learning to participate more actively in shaping a society that includes a growing segment of older adults. Efforts to address issues related to population aging will be inhibited if students, classrooms and research training remain age-segregated, according to a study published in the Gerontologist, “Making the Case for Age Diversity on Campus.” 

Irving, of the Milken Institute, says that’s key. Encouraging more learning among adults won’t just help individuals age successfully; it will enable societies with large, aging populations to thrive. 

“Wise and knowledgeable populations will distinguish countries and societies in the decades to come,” he predicts. “Those countries that figure out ways to reeducate, reskill and continue to challenge and engage their older populations are the countries that will succeed.” 

Older and Wiser—but Dizzier

At some point, most people over 65 experience dizziness

Carol Kuhlman vividly remembers a weekend trip with friends about two years ago—because that’s when she started feeling dizzy. The lightheaded, unsteady sensation came on gradually and quickly got worse. 

“It was very uncomfortable,” said Kuhlman, 66. “I had to hold onto things just to keep from falling. By Monday I was so dizzy, I couldn’t go to work.”

Her physician diagnosed her with vertigo, noticing her rapid eye movements, recommended some exercises and prescribed meclizine, which didn’t prove a practical solution. 

“I took one tablet in the middle of the day and immediately slept for five hours,” she said. 

The doctor wrote a note to excuse Kuhlman from work—for just two days. She was still dizzy when she went back. Her colleagues immediately noticed something wasn’t right. “I was very unsteady on my feet and weaving all over the place,” she said. 

Many times, dizziness is caused by something benign, but it’s still emotionally and psychologically devastating. 

Kuhlman’s struggle wasn’t an atypical one for older adults. Dizziness can affect anyone, but older people are more prone—about 70 percent of adults over 65 have suffered from it in some form. And compared to younger people, dizziness in older adults tends to be more persistent, have more causes and be more incapacitating. 

“We see patients with dizziness very frequently, and we take it very seriously,” said Anupama Gangavati, MD, an assistant professor in internal medicine in the division of geriatric medicine at UT Southwestern Medical Center in Dallas. 

A patient’s experience of dizziness may come in a variety of forms: a feeling of lightheadedness or imbalance; a sensation of blacking out; or vertigo, the perception that the patient—or the surrounding environment—is spinning, tilting or moving. 

Several studies show that older people with a history of dizziness are at higher risk of falling, which is a leading cause of hospitalization and accidental death among those over age 65.

While many causes of dizziness turn out to be benign, the effects can be emotionally and psychologically devastating. Dizziness is disorienting and unnerving. Sudden bouts are frightening; chronic cases can be debilitating. 

“It’s a quality of life issue,” said Gangavati. “Dizziness can lead to a lot of psychological distress if you’re not able to control it. Patients should not let it go just because a physician has not addressed it successfully on the first try.”  

What Causes Dizziness?

Accurate diagnosis can be a challenge. Dizziness can stem from a range of issues, including problems affecting the inner ear, brain, eyes, nervous system, vascular system or heart, all of which are subject to aging-related changes, according to Kathleen Stross, PT, a neurological and vestibular therapist.

Many older adults take multiple medications; dizziness may be a side effect of one or the result of an interaction between drugs. Neurological conditions like Parkinson’s can cause dizziness. Even health issues that might seem unrelated—such as neuropathy (numbness or loss of feeling) in the feet—can cause a patient to feel unbalanced and dizzy. Stress, depression or a lack of exercise may also contribute, as can dehydration or hot weather conditions. 

Among older people, one of the most common causes of dizziness is dysfunction of the peripheral vestibular system—the inner ear and its pathways to the brain. This controls a person’s balance and spatial perception. Neurologists call the vestibular system “the sixth sense” and, just like other sensory functions, it changes as people age. 

“As we age, just as our vision changes and our hearing may be affected, the vestibular system ages as well and may not function as well as it did when we were younger,” said Stross.

Patients can help their medical providers to diagnose the cause more accurately by giving a clear description of their dizziness. Stross gives new patients a questionnaire to help pinpoint their experience—what it feels like, how often it occurs and what, if anything, seems to trigger it. 

“The way people describe it can really vary, so I ask patients to tell me how they feel without using the word ‘dizzy,’” said Stross. “For some, it’s a feeling of being lightheaded or off-balance. Some describe it as feeling ‘heavy headed’ or a sense of floating or pressure. Others say they feel as if they’re spinning or moving.”  

Steve Lavine, 65, of Plano, TX, began experiencing dizzy spells when standing up from a chair. They got progressively worse, to the point where he felt he might black out. Lavine checked his blood pressure and found it was low, almost dangerously so. After consulting with his physician, Lavine stopped the blood pressure medication he had been taking for more than six months with no problems. Lavine had since lost 15 pounds through diet and exercise. The medication was now overcorrecting and making his blood pressure too low, causing the dizzy spells. When he stopped the medicine, the problem disappeared in a few days.

A thorough medication review is absolutely important.

Anupama Gangavati, MD

When a patient complains of dizziness, one of the first things Gangavati checks is the person’s list of medications. Blood pressure medications are common culprits, as are antidepressants, beta blockers, prostate medications and diuretics.   

“Medications are one of the most common contributors of lightheadedness or dizziness,” she said. “A thorough medication review is absolutely important.” 

Gangavati also performs an exam, reviews the patient’s medical history and asks about triggers—when the dizziness occurs and what seems to be causing it. 

Beyond drug side effects, Gangavati said she sees three common causes of dizziness among her older adult patients: benign paroxysmal position vertigo (BPPV), orthostatic hypotension and postprandial hypotension. 

BPPV occurs when tiny calcium particles (canaliths) clump up in canals of the inner ear, interfering with normal perception about head and body movements relative to gravity. Doctors diagnose the condition by observing patients’ eyes while they’re moving their heads. Patients with BPPV exhibit rapid, uncontrollable eye movements. The symptoms may be severe, making the patient feel as if the room is spinning, and may lead to nausea and vomiting. 

“BPPV tends to occur in episodic bouts of a few hours,” Gangavati said. “It’s triggered by head movement, and if you stop moving your head and keep it in one position, it subsides or goes away.” 

Orthostatic hypotension is a bout of dizziness or lightheadedness due to a lack of blood supply to the brain, typically triggered when a person stands from a sitting or lying position. Postprandial hypotension occurs when patients feel dizzy or faint after eating a meal, because their blood supply is geared to the stomach to digest the meal.

Trial and Error

Imani Calicutt, 65, of Dallas, sometimes experiences bouts of dizziness, and her doctor’s not sure why.

“Lately, it’s been constant,” she said. “It’s really limiting me because I can’t go very far without having to sit down.”

She’s working with her doctor (now via telemedicine due to the COVID-19 crisis) to determine the cause. Because Calicutt takes an array of medications for arthritis, diabetes, chronic pain and kidney disease, she’s expecting it may take some trial-and-error to find the cause.  

That’s not uncommon, Stross said. 

“In our experience, patients usually need to see three physicians before they get an answer,” said Stross. Because dizziness could relate to any number of areas of the body, finding the right specialist isn’t easy. 

After a visit to a primary care physician, the patient’s next step might be an appointment with an ENT (ear-nose-throat) specialist or a neurologist, or possibly a cardiologist (if vascular issues are suspected) or hematologist (if anemia is suspected). 

Brief moments of lightheadedness are probably not serious but do mention them to your doctor.

To treat dizziness, a physician may prescribe medications or dietary and behavioral modifications. That can include basic steps like ensuring the patient is drinking enough fluids and getting enough rest and exercise. 

For problems relating to the inner ear, including BPPV, vestibular rehabilitation therapy can be effective. Vestibular therapy ranges from simple exercises (a well-known one is the Epley maneuver, which involves positioning the head to help dislodge the tiny particles that cause BPPV) to physical therapy that helps the patient learn to compensate for imbalance and maintain physical activity. Vestibular therapy, when indicated, may provide immediate relief, or it may take some time to see results.

Gangavati added that many older people will experience brief moments of lightheadedness that likely don’t signal any serious problem. But she recommends at least mentioning it on the next visit to the doctor. “I think any dizziness should be discussed with your physician.” 

If acute dizziness occurs and is accompanied by other symptoms—like chest pain, difficulty walking or slurred speech—it could be a medical emergency, like a heart attack or stroke. In that case, Gangavati advises, head to the emergency room.  

Chronic Dizziness

Twelve years ago, as he walked out of the hospital after finishing his rounds, Tom Davis began to feel dizzy. 

“I’ve been dizzy ever since,” said Davis, 58, a physician in St. Louis, MO. Over the years, specialists have come up with different diagnoses: vestibular neuronitis, vestibulitis and Meniere’s disease, among others. None of the prescribed treatments fixed the problem permanently. Vestibular therapy made it worse. He considered surgery, which would destroy the nerve in the inner ear, but that would leave him deaf in one ear and offered no guarantees. At this point, instead of searching for a diagnosis, he’s focused on managing the symptoms as best he can. 

“It really doesn’t matter what’s causing it, because there’s no way to fix it,” he said. “You just have to work your way around that reality.” Regular exercise keeps him strong and helps reduce the risk of falls. On bad days, he takes a low-dose sedative and rests.

Unfortunately, like Davis, some people may have to contend with dizziness as a chronic or recurring issue. He says getting social support is important, especially for older people who might be tempted to isolate or become sedentary, for fear of falls. 

“If you have chronic dizziness, you’re not alone,” he said. “There are many groups on Facebook where you can get support from others.” 

Patients with chronic dizziness can also find helpful information and links to providers on the website for the Vestibular Disorders Association. Several other organizations offer support groups and other resources.   

Carol Kuhlman has been more fortunate. She did find some relief. She returned to work, still dizzy, a few days after her symptoms first appeared. She’s an administrative assistant at a medical school and, as luck would have it, an expert on vestibular disorders was visiting her department that day. 

Coworkers arranged for her to see the specialist, who diagnosed acute peripheral vestibulopathy (inflammation of the inner ear). He prescribed vestibular therapy, which helped reduce the dizziness and restored her sense of balance. Kuhlman still has flare-ups from time to time, but she’s found a way to manage them. Exercise and stress management seem to help.

“When it recurs, I go back to the balancing exercises, which help,” she said. “And when I have a flare-up, I just have to push through.” 


Patient Advocates: Pathfinders in the Complex World of Medicine

They provide advice and support for patients and their families

When a life-threatening staph infection sent Dominick Buttiglieri, 64, to the hospital, his situation quickly worsened—and his wife, Deborah, soon felt overwhelmed. 

“His organs were shutting down, and the doctors weren’t giving us much hope,” she said. Dominick was in pain and barely conscious; Deborah was beside herself with worry. 

The Buttiglieris’ son lives in another city and couldn’t be there to help. Instead, he searched online and hired AnnMarie McIlwain, a patient advocate, who turned up at the hospital to assist. Immediately, the family felt more control over the situation. 

“AnnMarie spoke to the doctors, gave me better insight into what was going on and made suggestions without telling us what to do,” Deborah Buttiglieri said. “I’m not an in-your-face person. I didn’t know what questions to ask to get the information I wanted.” 

As Dominick started to recover, McIlwain helped the family arrange for his transfer to a good rehab facility. Now, he’s home and on the mend. 

We have the most confusing health care system in the world. If you’re feeling overwhelmed, it’s not you.

—Caitlin Donovan

More and more patients and their families are following the same path as the Buttiglieris: enlisting the help of a patient advocate to navigate the complexities of the medical system. 

“A patient advocate’s role is to make sure the medical team has the right information, to make certain the client is getting the proper attention, and translating for the family what is going on,” McIlwain said. “The hospital environment is stressful; patients are usually in pain, sedated and weak, and their loved ones are understandably emotional. It’s too much to advocate for themselves.”

Patient advocates support people undergoing medical treatment, with a focus on getting the best possible care while keeping costs as manageable as possible. Patient advocates may also use other names—health advocates, patient or health navigators, case or care managers or doulas. They work one-on-one with patients as independent consultants, paid by the patients or their families. Some advocates come with a medical or social work background; others learn on the job. Many join the field after assisting a family member. 

“Patients should only have to concentrate on getting better,” said Caitlin Donovan of the Patient Advocate Foundation, a nonprofit that provides advocacy and patient education. “We have the most confusing health care system in the world. If you’re feeling overwhelmed, it’s not you.” 

Multiple Roles

Patients who are considering enlisting the help of a patient advocate should first consider: What kind of help is needed? The role of a patient advocate can vary broadly, depending on the patient’s needs and the patient advocate’s area of expertise. Some patient advocates have medical training and assist with navigating medical care, sometimes even specializing in areas like oncology. Some focus on billing issues. Others may assist with more administrative tasks: scheduling medical appointments, helping people sign up for Social Security or Medicare, organizing medical information or hiring a caregiver. Some work in teams to provide a range of skills and expertise.

Patient advocates often fill the communication gaps that can occur with older adults who have multiple medical issues. Deirdra Kindred, an RN and patient advocate, was hired by a family to assist their 92-year-old mother, who was losing weight and refusing to leave her room in the upscale, assisted living facility where she lived. 

“She was suffering from diarrhea and nausea and did not want to leave the room because she was afraid she’d throw up or have an accident,” Kindred said. She learned that the woman was taking 17 medications, some of which had been prescribed for years. She had several specialists but no one assessing her overall medicine intake. Working with the woman’s doctors, Kindred helped her wean to nine medications, and the diarrhea and nausea disappeared. Soon the woman was leaving her apartment, eating regularly and enjoying life again.

A patient advocate understands the system, knows how to ask the right questions and can lessen the burden for patients and their families. 

Some patient advocates assist in navigating insurance and correcting billing errors. Experts estimate that as many as 80 percent of all medical bills contain errors. Yet the process for correcting those errors is often labyrinthine. If there’s a snag in insurance processing, a hospital typically will continue to bill the patient and even threaten to send the bill to a collection agency. Getting the right people on the phone who can resolve the problem—either at the hospital and/or the insurance company—can prove difficult and time-consuming. Most patients don’t have the knowledge or the energy to tackle the challenge. A patient advocate who works in this area, however, understands the system, knows how to ask the right questions and relieves some of the burden for stressed patients and their families.

“When our case managers help a patient, it takes an average of 22 phone calls to resolve a billing issue,” Donovan said. “Having someone who knows how to talk to billing offices and to insurers is incredibly helpful.” 

Patient advocates also help navigate the vastness of the medical system. Barbara Abruzzo, a registered nurse, helps clients obtain second opinions, sorts out their options and manages complex care. She also may assist families in researching which doctors, hospitals or research facilities are best, given the patient’s condition and situation. 

Abruzzo has organized conference calls that brought together family members, hospital administrators, surgeons, physicians and nurses at once to plan a patient’s care when it required the expertise of several different specialists. For that kind of complex care navigation, she believes, clients should seek a patient advocate with medical training. 

“Doctors see that I know what I’m doing and that I mean business,” she said. 

In the Hospital—and Out 

Some patient advocates offer hospital accompaniment—visiting or even staying at the client’s bedside when family members can’t be there or feel they can’t advocate effectively in a complex situation. 

“Too many medical professionals are overworked and overwhelmed,” said Lisa Berry, a patient advocate. “For years, doctors have told me off the record that hospitals are dangerous places, because they cannot do their jobs. It’s very easy for mistakes to be made.” 

No one should go into a hospital without someone there to advocate for them, whether it’s a professional advocate or a family member, said Michael Weisburg, MD, a gastroenterologist. Most primary care physicians no longer have hospital privileges to attend to their patients when they’re hospitalized. Instead, patients’ care is managed by hospitalists—physicians who coordinate their treatment until they go home. Hospitalists work only in hospitals, which employ them, and the care they provide is dictated by each institution’s guidelines.   

“The hospitalist is someone who has never seen you before, knows nothing about you and doesn’t have the time to learn about you,” Weisburg said. “And that doctor in charge may change every couple of days.”

A patient advocate can help as patients leave the hospital—a critical juncture when things can easily go wrong. 

Weisberg experienced this dilemma himself during his 91-year-old father’s hospitalization for a broken hip. While visiting, Weisburg saw that his father was agitated and trying to get out of bed. Weisberg suspected a problem with his catheter and alerted a nurse. However, the hospitalist on duty was occupied by another emergency and simply prescribed a sedative, which only made the patient more agitated. Still busy with the emergency, the hospitalist ordered the nurse to restrain Weisberg’s father. 

Because restraints are dangerous (they can cause patients to aspirate), Weisberg called another hospitalist who had cared for his father earlier and was off duty. That hospitalist ordered nurses to check on the catheter, which, as Weisberg suspected, was not functioning properly. Another catheter was inserted and quickly filled with two bags of urine. Weisberg’s father immediately felt much better and fell into a deep sleep. 

“If I hadn’t been there, he could’ve been put into restraints, aspirated and died,” Weisberg said.  

Another task of patient advocates is to assist clients as they transition out of the hospital for recovery at home, at rehab or at another facility—a critical juncture when things can easily go wrong. Often, hospitals will discharge patients who need ongoing medical attention, expecting family members to pick up the responsibility at home. Patients who don’t have family or friends willing or able to help may be left to fend for themselves. 

Patients do have legal rights in this kind of situation, Berry noted, but most don’t know that. She works hard to make sure her clients aren’t discharged prematurely, which often occurs with Medicaid coverage or similar programs that pay minimal reimbursements to hospitals. In one case, a hospital tried to discharge one of her pro bono clients too early; the social worker on duty told Berry there was no option to protest. Berry knew better and insisted on an emergency hearing with an administrative law judge. The patient stayed. 

Finding a Patient Advocate

The Alliance of Professional Health Advocates offers a complete list of services that patient advocates provide, as well as AdvoConnection, a searchable directory of patient advocates. While users may search by zip code, a patient advocate doesn’t necessarily need to be local. Many advocates can assist remotely, depending on the situation. The Patient Advocate Foundation, a nonprofit, offers a range of services, including trained volunteers who can assist patients with billing and getting access to care; much of their work is done remotely. 

Keep in mind that independent advocates differentiate themselves from nurse navigators or patient advocates hired by hospitals or insurers, who don’t ultimately answer to the patient.

Another good place to start is with nonprofit groups that support people with specific diseases or conditions. These organizations may offer referrals to patient advocates, including some who are volunteers. The American Cancer Society, for example, can connect patients with advocates in some areas of the country. 

When looking to hire a patient advocate to help navigate medical care, talk to at least three candidates by phone, Berry said. (Most will do a preliminary consultation at no cost; ask first.) To get a good feel for whether someone will have the expertise to address particular concerns, provide a clear description of the patient’s issues and needs. 

Family as Advocates

Family members can be effective patient advocates, especially if they’re quick studies and have the time to devote to the task. Bruce Carr found himself in that role in early 2019 when his sister, Joan, 72, was hospitalized with a severe infection that was complicated by underlying conditions. Carr traveled from his home in Ohio to be near her in Dallas. Quickly, the task became his full-time job. 

“I dropped everything,” said Carr, who is a turnaround and bankruptcy consultant. “Thankfully, I was between gigs and in the financial position to take the time off.”  

He spent his days talking to her doctors and helping Joan make tough decisions; he devoted his evenings to reading medical literature and insurance information. Even though his sister was receiving world-class care, Carr said, she needed someone to advocate for her. 

Carr’s advice: keep a journal and write everything down. 

“So much comes at you so fast, you can’t remember if you don’t write it down,” he said.

Eventually, he made decisions when she was unable to do so herself. Joan passed away in September 2019; without his presence, Carr believes, she would have died six months earlier. 

Family members can find resources online to assist in their advocacy efforts. The National Patient Advocate Foundation offers tips for communicating with health care providers. Another nonprofit, Zaggo, offers a variety of resources including a free, downloadable chart for tracking treatments and medications. 

Not everyone, of course, has a family member like Carr available and able to focus on a loved one’s care; professional patient advocates can fill that gap. Plus, disagreements can arise in the family over the best course of action for a family member’s medical care, especially if the patient is unable to make decisions herself (or himself). In those situations, a professional patient advocate can serve as a neutral third party, someone who can objectively weigh available treatment options and help families better resolve disagreements. 

Whether it’s a family member or a professional, Weisberg says, what’s most important is to have someone in your corner when you’re sick. 

“There’s got to be someone—a parent, a spouse, a child, someone you pay—who has your best interests at heart and can stand up for you,” he said. 


Write Your Own Obituary

It’s a chance to sum up your legacy and have the very last word

When Susan deLarios’s mother passed away, she had to scramble to finish the obituary before the funeral. By contrast, when her father died a few years earlier, his obituary was already done—he had written it himself. Given how much easier that made life for her, deLarios said, “Now I tell people: you need to write your obit.” 

A growing number of people are doing just that: they’re crafting their own obituaries as a gift to their families and as a way of having the last say in summing up their lives. Some write them when death is imminent; others prepare them as an exercise in contemplating mortality. 

Whatever the motivation, writing your own obituary ensures the facts are correct, relieves your family of one of the more difficult tasks of the funeral arrangements and allows you to communicate key wishes, such as where friends and family should direct memorial donations.

Self-obits are part of a broader phenomenon: growing cultural acceptance of talking about death. The same “death positive” movement that has led people to gather in Death Cafes to talk about passing, or to read bestselling books like Atul Gawande’s Being Mortal (2015), is also encouraging people to prepare the last word on their own lives. 

While USA Today dubbed them “selfie obits,” self-obits are much more than narcissistic exercises, according to Frank Joseph, a rabbi serving four congregations in Texas. “A prewritten obit relieves a lot of stress for the family during a stressful time. And it ensures that the loved one is being remembered exactly for what they wanted to be remembered for.”

Having the Last Say

When journalist Ken Fuson passed away in early 2020, friends alerted his family that he’d likely written his own obituary. Fuson taught writing classes; his first assignment to students was to write their own obituaries. 

After cracking the passcode on Fuson’s computer, family members did indeed find an obituary written in Fuson’s distinctive, funny voice. The obit ticked off his many journalism awards, followed by a humorous crack: “No, he didn’t win a Pulitzer Prize, but he’s dead now, so get off his back.” Fuson’s son, Jesse, posted the obituary on Facebook—it was long and too costly to print in the Des Moines Register, where Fuson worked for years. The obit went viral. Major news outlets picked up the story. 

Don’t store your obit in a password-protected computer or a safe deposit box. 

“It was really awesome to read someone’s own thoughts on their life after they had died,” Jesse Fuson said. “You could see the humor shine through. It was just a great thing to be left with, not to mention the partial fame it created, which was hilarious in its own way. Dad would be rolling in his urn if he had known his obit was on Fox News.” 

Fuson’s story offers an important caveat: if you write your own obit, you must tell your family or friends that you did so and tell them how to access it. Don’t store it on a password-protected computer (unless you share that password) or in a safe deposit box, which may be sealed temporarily after death.

“Make sure you’ve told all of your children or other next of kin that you’ve done this,” advised Keely Gilham, a funeral director in Arlington, TX. “Make each of them a folder with all of your final wishes, including copies of the obit as well as other important docs, such as your will, preplanned funeral arrangements or life insurance policy.”

A Chance to Review

Fifteen years ago, Cindy Kyle sat down with a glass of wine and spent an evening completing an online form with her final wishes, including a section for her obituary. Although she was in her 40s at the time and in good health, it felt natural for a “dreadfully organized person” who keeps her affairs in order. She listed her family members and details of her schooling, work history, special interests and hobbies, and added words of gratitude for important people in her life.

Instead of being upsetting, she said, “I had a blast. It was a way of summarizing the joys and accomplishments of my life, to think about what’s important and what I want people to know about me.” 

Resources abound to help self-obit writers get started. ObitKit: A Guide to Celebrating Your Life (2009) by Susan Soper is a workbook for recording important facts and life events as well as end-of-life wishes. Legacy.com, an online publisher of obits, offers an extensive archive of articles on crafting an obituary, as well as a compilation of examples of auto-obits. Websites for end-of-life planning, such as Everplans.com, provide places to upload and store an obit (along with other key documents) as well as checklists of information to consider for inclusion. 

Most obituaries typically include basic information such as the deceased’s surviving family members, religious and organizational affiliations, career and other accomplishments, as well as details on the funeral. Checklists, templates and step-by-step guides abound online. But keep in mind that there’s nothing that dictates what a self-obit writer must include. (Consider the humorous, two-word self-obit of 85-year-old Douglas Legler: “Doug Died.”)

It’s not a resume. It’s a representation of how you lived.

— Alan Gelb

Writing your obituary can serve as a memento moripractice for confronting your mortality and taking stock. For some, it spurs positive life corrections, said Joseph, the rabbi. He cited the example of Alfred Nobel, the inventor of dynamite. After reading his own obituary (published in error), which called him a “merchant of death,” Nobel bequeathed his fortune to institute the Nobel Prize. As he hoped, he’s now remembered for the Nobel Peace Prize, rather than for his invention. 

A life-review writing exercise benefits people at any age, said Alan Gelb, author of Having the Last Say, Capturing Your Legacy in One Small Story (2015.) After observing how high school students benefited from writing college application essays, he created prompts for similar writing exercises for older people, which he dubbed “Last Says.” 

To maximize readership and create an interesting tale, Gelb encourages writers of self-obits to look for a narrative arc and to lead off with a statement that captures their essence. 

“Don’t try to tell your entire life story or get hung up on having to cover everything,” he said. “It’s not a resume. It’s a representation of how you lived.” 

An obituary can be funny or serious, short or long, factual or more contemplative. Joan Calhoun’s in-laws wrote their own obits, which were published when they passed away just seven days apart. Her mother-in-law’s obit was short and sweet; her father-in-law’s was lengthy and full of details. Each reflected their respective personalities. 

“That was them,” Calhoun said. “That’s how they were. She was quiet; he was a storyteller who never met a stranger. I just think that [writing one’s obit] is a wonderful thing to do.”

Considering the Cost

In her self-written obituary, comic writer Jane Lotter quipped, “I’d tell a few jokes, but they charge for these listings by the column inch.” Generally, prewritten obituaries won’t save families money. For one thing, many funeral homes will prepare a basic obit (based on information the family provides) as part of the overall cost of the funeral package; others may charge a nominal fee. 

The biggest cost is publishing the obit, and often there’s sticker shock. Newspapers typically charge per word or per line; a short obituary can easily run $200-$600 in a major market paper, whereas a long one can cost upward of $1,000. A photo adds to the cost. 

Note that newspaper editors distinguish obituaries written by a reporter (typically for locally prominent people) from the paid write-ups provided by the deceased’s family or a funeral home. While newspapers publish reporter-written obituaries at no charge, families usually have no control over what’s included in the final story.  

Some newspapers and funeral homes post obituaries online for a nominal fee ($50-$100) regardless of length. If budgets are limited, Gilham advises families to publish a brief obit in the newspaper’s print edition, with basic facts and funeral arrangements, and a longer version online. Bottom line: keep in mind that a long obit could be costly. 

Taking Control

Toward the end of his life, Reid Coleman worried that family conflict would arise over the planning of his funeral and obituary, given one relative’s tendency toward intrusiveness. To pre-empt that, he wrote his own obituary and planned his funeral in detail. It worked—his wife, Kate Coleman, was able to execute his wishes and fend off potential meddling. 

However, Coleman trusted his wife to see things through on his behalf. If you don’t have a reliable next of kin who will follow your wishes, you should enlist legal advice if it’s imperative to have your self-obit published as is. Laws vary by state; in some states it may be possible to appoint an agent to handle funeral and burial details, including the obituary. 

Don’t include your obituary in your will, because it may not be discovered until it’s too late. Funerals (and the publication of an obituary) generally take place immediately after death and before an executor takes control of the deceased’s estate. 

But keep in mind that total control isn’t always a positive. Because most people don’t always see themselves as fully as others do, a self-written obit may be limited. 

That’s one slight regret that Kate Coleman has about her husband’s self-obit: he didn’t brag about himself enough. He didn’t share how he devoted the latter half of his career to reducing medical errors. The obit chronicled his career but failed to mention that he developed a hospital bracelet that uses scannable codes to prevent mistakes. 

“He was a ‘just the facts’ guy and the obit reflected that,” she said. “But I got cards from his colleagues talking about his accomplishments and how meaningful they were.” 

Looking back, deLarios often thinks of things she wishes she’d included in her mother’s obituary but overlooked due to lack of time. But she’s certain her father’s obit included everything important to him, including details about his military service and his involvement in the Masons. 

“That floored me,” she said. “I would’ve never thought of putting that in his obit. Reading his words after he was gone, and seeing what he considered was important, was very profound.”

Health Care Costs: Want an Estimate? Good Luck with That

But there are ways to avoid unpleasant surprises and to lower costs

When Linda Stallard Johnson’s husband had pain in his shoulder, he suspected he might be having a heart attack. His sister had just had one, with similar symptoms. The couple went to a hospital emergency room, where he underwent an EKG, blood tests, a chest X-ray and a second EKG—all, normal. As a precaution, the physician on duty wanted to admit him for a stress test the next morning. But when the couple asked how much an overnight stay might cost, nobody had an answer.

“We even called the billing office and they sent a staff person down to the room, who could not provide us with any information,” Johnson said. 

Unsure what Medicare covered and fearful the bill might prove financially crippling, the couple left the hospital, despite the doctor’s warnings. They were on edge until he finally took the stress test several days later at an outpatient clinic—also, normal. 

The Johnsons’ experience mirrors a problem faced by many Americans: a frustrating lack of transparency in the pricing of medical services and procedures.

Health care costs are not only sky-high, they’re unpredictable. There’s a wide disparity in what hospitals charge, even for routine procedures, and pricing is anything but transparent. Patients who ask for price estimates in advance often get nowhere. Insured patients must navigate a complex array of pitfalls: finding in-network providers, avoiding hidden costs or services that aren’t covered, minimizing out-of-pocket costs. Even those with good insurance may be slammed with “balance bills”—charges for services from out-of-network providers that can run into tens or even hundreds of thousands of dollars. Those without insurance can easily end up bankrupt after a single trip to the hospital. 

Faced with disease, we are all potential victims of medical extortion.

Elisabeth Rosenthal, MD

Rosemary Hinojosa, 68, ran into that problem several years ago when she fell and injured her back while visiting relatives in another city.  She was transported to the nearest hospital, which was out of network for her employer-provided health insurance plan. When she received an $87,000 bill, the insurer refused to pay, arguing that she was responsible for the bill because she didn’t choose an in-network provider.  

“Faced with disease, we are all potential victims of medical extortion,” wrote Elisabeth Rosenthal, MD, in An American Sickness: How Healthcare Became Big Business and How You Can Take It Back (2018).

Older adults are particularly vulnerable. Compared to younger people, they tend to need more medical care, the cost of which represents a larger portion of their overall cost of living. Many live on a fixed income and can’t manage unexpected medical bills or exorbitant drug prices. Those who are near retirement may not be able to bounce back from a big bill. And while insurance and medical billing are confusing for people of any age, they can be even more so for an older person who’s not tech savvy, or who’s dealing with memory loss, hearing loss or other disabilities or who’s reluctant to question a doctor’s authority. 

This lack of transparency in health care costs “places an unfair burden on everybody, but it’s especially difficult for older Americans,” said Cindi Gatton of Pathfinder Patient Advocacy Group, which helps patients navigate health care and medical billing. 

Perhaps the most vulnerable are those ages 50 to 64 who lost their insurance through loss of a job and can’t afford to purchase a plan, according to Lynda Ender, AGE director with the Senior Source in Dallas. Ditto for those 65 and up who don’t qualify for Medicare—for example, immigrants who have no work history in the United States or who are not citizens. 

How We Got Here

How do medical providers get away with this? 

For one thing, insurance has traditionally insulated patients from pricing. Insurance paid the bill; patients often weren’t even aware of the amount paid. 

Aside from Medicare, which sets rates for each treatment and procedure, there’s no regulation that requires doctors and hospitals to keep pricing reasonable or to disclose prices before sending the bill. 

“We always have the right to ask, but there are no laws requiring anyone to give you a price in advance,” said Gatton. 

The pricing system that has evolved in hospitals is so complex, arbitrary and labyrinthine that it’s almost unknowable. Hospitals don’t price procedures based on the actual costs to deliver them; some hospital administrators aren’t even aware of what those costs are. Instead, hospitals have traditionally set prices based on what the market will bear—while keeping pricing data a closely guarded trade secret. Hospitals maintain a retail price list called the chargemaster but, like “sticker” prices on new cars, almost no one actually pays those prices. Insurance companies negotiate lower prices. Often, uninsured patients can negotiate lower prices too, but many don’t know that. 

Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the copilot, and the flight attendants

— Elisabeth Rosenthal, MD

Many physicians stay out of the billing process and as a result are unaware of the costs of tests they routinely prescribe or whether they’re in-network or out-of-network for their patients. 

Sometimes, providers simply can’t predict an exact price, only a price range. For example, a gastroenterologist might charge a standard price for a routine screening colonoscopy, but if polyps are discovered during the surgery, the procedure becomes a diagnostic colonoscopy, which commands a higher price. 

Finally, billing is piecemeal. Surgeons may know how much they charge for a specific procedure but have no idea what a typical patient ends up paying after charges are added for the anesthesiologist, the hospital facility fee and any blood work, supplies and medications. 

“Imagine if you paid for an airplane ticket and then got separate and inscrutable bills from the airline, the pilot, the copilot, and the flight attendants,” wrote Rosenthal. “That’s how the healthcare market works.” 

What’s the Solution?

Likely it’ll take a major, federally mandated overhaul of the medical system to fix this problem, but that’s unlikely, given that the medical and pharmaceutical lobbies dwarf the defense lobby. President Trump has instructed federal agencies to develop rules requiring disclosure of hospital prices in consumer-friendly, electronic form, including “list prices” as well as the discounted prices that hospitals negotiate with insurers. However, the rollout is still likely years away and is already facing challenges in court.

Some efforts are underway at the state level to improve transparency and protect consumers. New Hampshire, for example, provides an online database of quality and cost, searchable by procedure and for individual doctors and clinics, which are required to provide the information. In Texas, the legislature passed a law (SB 1264) aimed at providing relief to those slapped with balance bills—surprise medical bills that fall on patients when they have (often unknowingly) seen out-of-network providers. 

Patients can take steps to minimize their out-of-pocket expenses. However, the strategy depends on whether the patient has private insurance, Medicare or no insurance at all. 

For those covered by Medicare, price shopping generally won’t save money. Medicare sets rates for services and, in most cases, forbids providers from billing patients for additional charges. 

Uninsured patients can sometimes negotiate a lower price in advance, especially if they pay up front in cash.

For those with employer-paid or individual private insurance, price shopping becomes complicated. The objective isn’t necessarily to find the lowest price; it’s to find the provider who can provide the service at the lowest out-of-pocket cost. Typically, that means calling the insurance company (or consulting its website) to locate a doctor or hospital that’s in network, in which case the insurer will cover all, or a higher percentage, of the cost. 

Keep in mind too that even if patients choose an in-network physician and an in-network hospital, they may still see providers (such as an anesthesiologist) who are out of network, who may then charge them at the retail rate. 

For those with no insurance, price shopping is critical. Uninsured hospital patients not only get stuck paying the bills out of pocket, they’re more likely to get billed those “sticker” prices. On the other hand, it’s often easier for uninsured patients to negotiate a “cash” price in advance, especially if the patient pays up front. Also, some urgent care centers, such as CareNow, pledge to provide prices up front (usually after the patient is evaluated but before treatment begins). Cash prices aren’t cheap but are usually closer to what large insurers pay. Providers are more willing to do this with cash-paying customers, in part because they avoid the cost and hassle of obtaining reimbursement from insurers.

For those who can’t afford insurance and can’t pay cash prices, there are few good options. Many must rely on county hospitals that accept patients regardless of ability to pay. Patients with low incomes and few assets may qualify for Medicaid; states provide this coverage and requirements vary.

How to Price-Shop 

When she fell and injured her hand, Sheryl Monnier decided to call to check the price at a nearby urgent care center before going in for an X-ray. The first person she spoke to refused to provide a price. She called again, waited on hold, got transferred to a supervisor and finally got a number: $111. 

While her insurer may cover all or part of that cost, Monnier thinks it’s important for patients to insist on getting prices in advance.

“I know that the charges my insurance company pays are simply passed along as higher premiums,” she said. If more consumers insist on prices in advance, “market pressure will encourage medical businesses to make the info easily available so consumers can make wise choices.” 

But as Monnier’s experience shows, price shopping takes persistence and patience. Those who wish to price-shop a procedure can start at HealthCareBlueBook.com to get a ballpark price range for their local zip code, then call the provider’s office. The process takes persistence. If the office person says, “I don’t know,” for example, the patient may need to ask, “Who does?” 

Getting a price may also require multiple calls. “Very often, you need to talk to more than one vendor to get the whole cost of a treatment,” said Linda Beck, who provides elder and health-care advocacy. “If you need knee surgery, for example, you’ll need to get estimates from the surgeon, the anesthesiologist, the radiologist and the facility.” 

The biggest challenge for avoiding unexpected costs occurs when the patient becomes sick or injured and starts treatment. Then, it’s up to the patient to ask each provider whether he or she is in network. Even if the hospital is in network, many physicians, radiologists and other providers are contractors who may not be in that hospital’s network. 

When you’re in the hospital, keep track of every service, test and medication you receive. Errors in billing are astonishingly common.

“There may not be much you can do to avoid out-of-network care if you’re in the emergency room, because there may be no in-network providers available, but at least you’ll know the bills are coming,” Beck said.

While in the hospital, experts advise, patients should keep track of every service, test and medication received, to help later identify any charges that don’t belong on the bill. “An astonishing percentage of bills have errors,” said Beck. 

But keeping tabs on medical care isn’t easy for someone like Sophia Dembling, 61, who has undergone almost a year of treatment for amyloidosis, a rare, systemic disease—treatment including chemotherapy and a stem-cell transplant. It’s challenging enough to stay on top of her medications and doctor appointments while managing fatigue, nausea and other side effects. 

“I’m sure I should be more vigilant, but it just makes me tired,” she said. 

On top of that, Dembling occasionally receives big bills that providers claim she’s responsible for, even though she has met her maximum out of pocket and deductibles for the year. So far, she’s been able to sort them out, but only after hours on the phone with providers’ billing offices. The hassle isn’t helping her heal. 

“It’s stress on top of stress,” she said.

Finally, for patients who are slapped with a big bill, there’s almost always room to negotiate. Consider enlisting a health advocate, who can help negotiate a big medical bill, for a fee. (Some charge by the hour; others charge a percentage of the money saved.) AdvoConnection.com provides listings of certified advocates based on location.

Those with employer-provided insurance can enlist help from their human resources department. That’s what Hinojosa did after getting that $87,000 bill for the out-of-network emergency surgery and hospital stay. With help from her employer’s medical-benefits office, Hinojosa appealed the bill, arguing that she had to opt for out-of-network care, given the urgency of her injury. It took some effort, but she eventually prevailed.

“I won all the appeals that I had and ended up paying only $100,” she said. 

Wearable Technology Has Great Potential

But it also presents challenges for older adults

A small wristband device is helping Randy Miltenberger prepare for a knee replacement.

His doctor wants him to strengthen his leg muscles to prepare for the upcoming surgery and rehab, so Miltenberger, 73, wears a FitBit fitness tracker. The device records his steps during his normal routine during the day; every afternoon, he walks on an indoor track until he reaches five miles.

“The FitBit gives me a goal and a way to keep me accountable,” he said. He also uses the FitBit to check his heart rate during exercise—making sure he’s working hard enough, but not too hard—and to check his resting heart rate, now a very healthy 54 beats per minute.

Miltenberger fits right in with the current trend. Tech industry observers think fitness trackers are just the tip of the iceberg of the growing array of wearable devices that could help keep older adults healthier, safer and more independent, with options ranging from heart rate monitors and medical alert devices to airbag hip belts.

Some devices already save lives, but others may fail with older adults.

Manufacturers shipped more than 172 million wearable devices worldwide in 2018, according to International Data Corporation, and that number is expected to grow to at least 250 million by 2021.

Older adults are adopting these devices at almost the same rate as the overall population; while 20 percent of Americans under 65 use wearables to track fitness, almost as many (17 percent) of those over 65 are using wearables too.

“There are vast opportunities to attack problems faced by older adults through wearables,” said Ashley Newsom Kubley, a wearable tech designer and head of the Fashion Technology Center at the University of Cincinnati.

But these devices also raise questions specific to an older population. Are they user-friendly and accessible? Can they work for those affected by reduced vision or cognitive impairment? Are they reliable enough to use for medical purposes?

“It all depends on the [older adult] and on the technology,” said Irene Hamrick, MD, chief of the Office of Geriatric Medicine at the University of Cincinnati College of Medicine. Some devices already save lives, while others can fall short in the face of some of the limitations affecting older adults.

Wide Array of Wearables

In addition to fitness trackers, the portfolio of wearable technology includes medical alert systems, which connect a user to help with the press of a button. While they’ve been available for years, newer versions incorporate features like fall detection and the ability to pair with a cell phone. Some don’t even require the press of a button—they detect a fall or a lack of motion and automatically call for help.

Other devices include:

  • Health monitors help wearers track their heart rate and blood pressure and can even spot heartbeat irregularities. Some, like BodyGuardian, will trigger a warning—sent to the wearer as well as to his or her physician—when a worrisome heartbeat is detected.
  • GPS tracking devices, such as shoe insoles or clip-on wearables, track the location of the wearer and allow family members or caregivers to locate the person quickly in an instance of wandering.
  • Some devices, like the Apple Watch, combine these functions. The newest version (Series 5) includes step counting, heart monitoring and GPS tracking, as well as fall detection and the functions of a cell phone (calling, texting, checking email).
  • Airbag hip belts are strapped around the wearer’s hips to help prevent fractures in the event of a fall. The device analyzes the wearer’s motion, detects a fall and deploys the airbags automatically before the person hits the ground.
  • Pain-relief devices, like Oska Pulse or Quell Pain Relief, treat chronic pain with low-voltage electrical current. Typically these are belts strapped around an affected area. Some are paired with cell phone apps, allowing the user to control the timing of treatment and track results.

More Independence, Increased Safety

Experts who work with older adults say wearable devices can be lifesavers. Susan Rebillet, a geriatric psychologist, has about two dozen patients who have used their medical alert buttons to call family members or 911 after a fall or a medical emergency.

“Many of my patients are absolutely able to live independently longer because of this technology,” said Rebillet. “Even if the device is never used, it really gives the older adult and the family peace of mind.”

Rebillet adds that a medical alert device also makes it easier for family members to respect an older adult’s privacy and independence. Family members are less likely to panic, for example, if the older adult doesn’t pick up her phone for a bit, relying on the device to alert them if there’s trouble.

For patients recovering from heart attacks, smartwatches customized for cardiac rehab can provide monitoring at home.

Similarly, Hamrick notes that GPS tracking devices have enabled families or law enforcement to quickly locate elders with dementia who have wandered or gotten lost.

Remote activity monitoring technology—which combines wearables with other devices like motion sensors, bed sensors and medication monitoring—may help keep tabs not only on older adults but also on the care they receive in assisted living or nursing homes, according to John Alagood, owner of the Senior Care Authority of Dallas-Fort Worth. He thinks families could be reassured if they could track, for example, when medications are administered or how often a loved one is bathed.

And, of course, wearables can make life easier for older adults. For example, Samsung tested customized smartwatches as part of cardiac rehab. The devices allowed patients to handle some of the post-attack monitoring at home and save some trips to the rehab clinic. In the pilot program, a higher percentage of those participants with the smartwatches completed the rehab.

Wearable devices can also nudge older adults to maintain healthier habits. In a 2015 study conducted by AARP, 45 percent of older adults (ages 50+) reported increased motivation for healthier living after six weeks of using a wearable activity or sleep tracker. (FitBit, for example, monitors the wearer’s motion to track deep and light sleep, as well as periods of awakening.)

But Are Wearables User Friendly?

No tech device is foolproof, even for the savviest of users. Gadgets require recharging or replacing batteries.

Many wearables must be used in tandem with an app on a smartphone. That requires the user to own a smartphone, pay monthly fees for cell phone service (which is often quite expensive) and also to have enough tech savviness to set up and navigate the apps.

Devices worn on the wrist have screens that may be too small for an older adult with visual impairment to read. There are some work-arounds—for example, a user’s progress on a FitBit can be monitored via a computer that has been modified for a visually impaired person (large screen, high contrast and large type) but that does require some tech skill to set up and navigate.

The Apple Watch offers accessibility features such as a gesture-activated speaker function for the visually impaired, a wrist tap to alert a hearing-impaired user to an incoming call or text, and even fitness-tracking options for those in wheelchairs. But the Apple Watch is also expensive, as are the associated monthly fees (either for the watch itself or for a paired iPhone). And it requires tech savvy.

Medical-alert buttons and monitoring and tracking devices work best for people with dementia early in the disease.

Some devices aren’t useful if there’s no family member or friend keeping tabs on the wearer. A GPS tracking device, for example, won’t help if no one’s at the other end to notice that an older adult has wandered away from home.

And if a user forgets to wear or activate the device, it doesn’t work at all. Rebillet recalled a patient who fell and lay on the floor for three days, even though she was wearing an alert pendant around her neck.

“She simply forgot she had it,” Rebillet said. “Possibly the fall itself traumatized her and contributed to her forgetfulness. But this woman had not shown obvious signs of dementia before the fall.”

Researchers similarly found that the remote activity-monitoring technology worked best for older adults in the early stages of dementia who were still mobile. But even then, families struggled. GPS can be less accurate in cities due to interference created by buildings, or rural areas may have limited cell or internet coverage. Alerts can be delayed or slow. The older adult might remove the wearable or turn it off.

While medical-alert, monitoring and tracking devices can allow people with memory impairment to live independently longer, many “are optimal only in a narrow window of dementia progression,” according to Hamrick.

“In early dementia, patients can still use a cell phone, which can be much less expensive than an alert button,” she said. “But as dementia progresses, patients don’t remember to push the button, even when they wear it, or don’t know what to do with the button.”

Gadget or Medical Device?

As the costs of health care skyrocket—and tech devices become more inexpensive and more powerful—many are pinning hope on the potential for wearable devices to save money. For example, a wearable tracking an older adult’s movement could alert caregivers to a developing urinary tract infection (UTI), signaled by frequent trips to the bathroom or an unusual gait due to pain. If preventive measures are taken within the first 72 hours of symptoms, that could result in savings of up to $13,000, which is the average cost of hospitalization for a patient with a UTI.

But that points to an area where wearable devices could face pushback from the FDA (Food and Drug Administration). If a smartwatch can track sleep patterns, record heart rates and monitor body temp, at what point does it become a health care device, and thus subject to stricter regulations?

“When you see every sort of technology becoming a health technology, the lines blur,” said Eri Gentry, a research affiliate at Institute for the Future. “Regulators are going to have a challenging time figuring out where to draw the line between what’s medically relevant and what’s just a smart-home device.”

Also, wearables that collect health data raise privacy questions. Where does the personal medical information go? Who has access to it and how is it being used?

Kubley cautioned that wearables should supplement, but not replace, professional medical care.

Wearable devices “can be very useful for preventative care or for correcting negative behaviors (bad posture, sleeping habits) or encouraging healthy behaviors (like taking medicines regularly),” Kubley said. “But self-diagnosis can be problematic when people rely on devices in lieu of the advice of trained medical professionals.”

Tech Shall Overcome?

However, Kubley said, these issues aren’t insurmountable. They’re pointers to the next generation of wearable devices.

“These are actually good challenges for designers to edit and refine,” said Kubley. “In product design, you must always imagine the best- and worst-case scenarios of how a user will engage with a product.”

Increasingly, designers emphasize universal design—making devices accessible and easier to use for people of all abilities—and that benefits older adults. While not marketed specifically for older adults, the Apple Watch’s latest iterations (Series 4 and Series 5) feature screens that are 30 percent larger than earlier versions and a speaker function that’s 50 percent louder.

But no wearable technology will ever entirely replace the human touch.

“There’s a part of caregiving that will always be about the people, the caregivers,” Alagood said. “That will never be digitized.”

Getting Older, Sleeping Less?

Older adults are more prone to sleep issues—but there’s hope

Until age 45, Mary Jo Anderson says, she was a “champion sleeper.” 

“It’s like someone flipped a light switch,” she said. “When I entered menopause, I suddenly couldn’t fall asleep.” 

At age 64, she had less trouble falling asleep but couldn’t stay asleep. She woke up almost every hour of the night and felt tired much of the time during the day.

Anderson was not alone. More than half of all Americans over 65 report they have difficulty falling asleep or staying asleep, according to the National Institute on Aging.  

It’s a miserable feeling. While everyone else sleeps comfortably, you’re awake. Anxious or distressing thoughts occupy your mind. The longer you stay awake, the more you worry about not getting enough sleep. You fear you won’t be able to function the next day; you fret over how the lack of sleep may affect your health. A vicious cycle ensues: the more you can’t sleep, the more you worry about not sleeping, which keeps you awake. You start to dread bedtime and another night of trying desperately to sleep—and failing.

“It’s a cruel joke that life plays on us,” said W. Christopher Winter, MD, founder of the Martha Jefferson Hospital Sleep Medicine Center and author of The Sleep Solution: Why Your Sleep Is Broken and How to Fix It (2018). “When we’re youngworking nonstop, with kids running around the housewe wish we just had more time to sleep. Then we get older and have more time, and your brain’s saying, ‘I don’t really want it anymore.’”

Plus, the media are full of alarming reports that connect sleeplessness with health problems. Chronic insomnia is linked to increased risk of developing obesity, Type 2 diabetes, hypertension, heart attack, depression or anxiety. Research also links insomnia to Alzheimer’s and other forms of dementia (although it’s not clear whether the insomnia is a cause or an early symptom). Sleep-deprived people are more prone to falls or car accidents as well as forgetfulness. And, according to the National Sleep Foundation, a lack of sleep is linked to overeating—especially the overconsumption of junk food—which can lead to weight gain. 

On the flip side, people who do sleep well are more likely to be alert, function better mentally and are even more likely to maintain a healthy weight. 

But there is hope for those of us who call ourselves poor sleepers. With a “sleep makeover”changing habits that disrupt sleep, developing routines that promote sleepiness at bedtimemany older adults can get the sleep they need. 

The Roots of Sleeplessness

Researchers divide sleep disorders into two general categories: dyssomnias and parasomnias. Any sleep disorder that causes daytime drowsiness is a dyssomnia. That includes insomnia as well as other conditions, such as sleep apnea or restless leg syndrome. Parasomnias are sleep disorders with odd or irregular behaviors that occur during sleep, such as sleepwalking or night terrors.

People with insomniadifficulty falling asleep or staying asleepmay experience fatigue, low energy, difficulty concentrating, mood disturbances and decreased performance at work. Chronic insomnia isn’t an unavoidable aspect of normal aging, but sleep patterns do change as we age. It’s possible to understand these changes and not let them cause unnecessary distress that keeps you up nights. 

“Among healthy older adults, the brain circuit that controls sleep just isn’t as robust compared to that of their younger selves,” said Steven Lin, MD, neurologist with Healthcare Associates in Medicine, PC, in Staten Island, NY. “Plus, older people tend to have medical or other issues that may interfere with normal sleep.”

People over 65 are more likely to suffer from chronic conditions, such as arthritis, which can cause pain that can awaken them at night. They may be more prone to bladder issues that necessitate repeated nighttime trips to the bathroom. For elders caring for a spouse or a loved one, sleep may be disrupted when they get up at night to tend to the person. Older adults are also more likely to take medications that affect sleep or cause daytime sleepiness even after a good night’s sleep.

Experts say it’s normal for older people to take longer to doze off at night, to sleep more lightly and to wake several times during the night.

The timing of sleep may change too. Older adults tend to become sleepy earlier in the evening and wake up earlier in the morning. One National Sleep Foundation poll found that about two-thirds of adults over 65 consider themselves a “morning person,” considerably more than in the general population.

Experts also say it’s normal for people to sleep more lightly as they get older. Sleep occurs in cycles that are repeated several times during the night, including dreamless periods of light and deep sleep and periods of active dreaming (REM sleep). Beginning in middle age, people naturally spend less time in deep and REM sleep. They tend to wake up more often, an average of three to four times a night. Older people also are likely to take more time to fall asleep and have more difficulty staying asleep. 

Plus, an older person who’s sedentary—due to mobility issues, for example—may simply need less sleep. Ditto for someone who is retired, who need not arise at 6 a.m. every day or face the daily stresses of a job.

For older adults, a sleep makeover can start with simply recognizing these changes that come with age—and not getting too distressed about them. Try to minimize anxiety that might trigger more sleeplessness, Winter said

“Our sleep patterns change throughout life,” he said. “I’m 47. My sleep is not the same as it was when I was seven or 17. I have occasional nights where I’m lying in bed awake up until 4 a.m. I try to enjoy the quiet time, rather than getting stressed about it.” 

Resetting Sleep Rhythms

One important step in a sleep makeover is to work with your body’s circadian clock—the natural rhythms that make us alert during the day and sleepy at night, ​and that include the waxing and waning of the sleep-promoting hormone melatonin. With exposure to sunlight during the day, the body’s secretion of melatonin tends to drop off. As it gets darker at night, melatonin secretion increases.  

To reset your sleep rhythms, you should adopt a consistent sleep schedule with an emphasis on arising at the same time each day.

In addition, these steps may help:

  • Avoiding caffeine, alcohol, nicotine or other chemicals that interfere with sleep 
  • Creating a comfortable sleep environment (cool, dark and quiet) in the bedroom
  • Establishing a calming, pre-sleep routine
  • Making an evening to-do list so you don’t fret over what’s ahead the next day
  • Eliminating late-afternoon and early-evening naps
  • Eating and drinking enough, but not too much or too soon before bedtime 
  • Exercising regularly but not right before bedtime
  • Taking melatonin supplements under a physician’s supervision

An effective sleep makeover should also involve using light to your advantage. Get plenty of exposure to sunlight. Avoid electronic devices (e-readers, cell phones, tablets, TV or computer screens) that emit blue light, which can delay or disrupt sleep, in the hour before bedtime. 

Incorporating relaxation techniques, such as meditation or yoga, as part of your bedtime routine may help too, Lin said. Similarly, it’s a good idea to avoid anything too stimulating (a tense or engrossing novel, a violent film or the TV news if that upsets you) at bedtime. 

But how do we stop thinking about those news reports about the dangers of poor sleep? They can trigger anxiety. And anxiety is the enemy of good sleep. 

It’s easy to underestimate the number of hours you slept. Pay attention instead to how you feel the next day. 

“Unrealistic expectations about sleep that are not helpful can add to a patient’s stress, and that can lead to chronic insomnia,” Lin said. Because older people sleep more lightly and wake more often, or simply need less sleep, they may worry about a lack of sleep even when they’re actually getting enough. That leads to more stress, which leads to more trouble falling or staying asleep, triggering a vicious cycle. 

Experts advise against getting too hung up on how many hours you’re asleep on a given night. Sleep needs are individualized. There is no “gold standard” for how much sleep an older person needs; rather, it’s based on how people feel and how well they function on the amount of sleep they get. It’s more important to pay attention to how you feel during the day rather than how many hours you slept.

Adding to the anxiety, people can also easily misjudge the number of hours they are actually sleeping. Sleep medicine specialists call that paradoxical insomnia, according to David Luterman, MD, medical director of the Sleep Center at Baylor Scott & White in Dallas. For example, patients in the sleep lab—where sleep is monitored during an overnight stay—may report they didn’t sleep at all. 

“Yet the measurements taken of their brain waves showed they were asleep for at least four hours,” he said. “The patient’s perception is ‘I’m up all night’ but that’s not really the case.”

If you’re feeling anxious about how little sleep you’re getting, try wearing a fitness tracker (such as a FitBit) that monitors sleep. These wristband devices may not differentiate precisely between REM, deep and light sleep, but Winter said they do tally the total number of hours you’re asleep with reasonable accuracy.

“If a patient tells me he’s sleeping only an hour or two a night, and the device is saying he’s sleeping six hours and 13 minutes on average, I believe the device,” he said.  

Don’t Lose Sleep Over a Little Lost Sleep

We all experience sleeplessness at times. You may feel tired and worried about it, but it may not actually be worrisome. 

Winter cautions against equating insomnia with sleep deprivation, especially occasional insomnia. Those studies that warn against the dangers of too little sleep, he said, relate more to people who never get enough rest: the single mom working two jobs who can manage only four hours of sleep a night; the hard-charging executive who gets up at 4 a.m. to work out; the person with chronic sleep apnea who awakes four to five times an hour at night. 

It’s normal for people to experience insomnia for short periods after a stressful event, such as a divorce or the death of a loved one, Luterman said. During very stressful periods, he recommends considering the option of sleep medication, which may help avoid short-term, stress-related insomnia that turns into chronic insomnia. However, because older people respond differently to medicines than younger adults, sleep medication should not be taken except under a physician’s supervision. 

“It’s a careful balance,” Luterman said. “You don’t want to rush to prescribe patients a sleeping pill when the root cause of insomnia may be something else.” 

He added that the American College of Physicians recommends that, for patients of any age with chronic insomnia, the first line of treatment should be cognitive behavioral therapy (CBT) rather than medication. CBT is solution-oriented psychotherapy that treats specific problems by modifying dysfunctional thoughts and behaviors. Behavior modification might include simple steps like going to bed an hour or two later if you’re not feeling sleepy or devising a helpful routine for times when you can’t sleep. (When that happens, experts advise against staying in bed and tossing and turning; instead, get up and do something quiet, like knitting or reading boring materials, until you start feeling sleepy.)

In general, sleep medication is recommended only for the short term—several weeks at most. After a longer period, patients can build up a tolerance to sleeping pills (needing increasingly higher doses for the same results) or become psychologically dependent so that the idea of going to sleep without a pill causes anxiety. Follow your doctor’s instructions and stop taking the drug as recommended.

“When you compare the two—sleep medications vs CBT—research shows the results are the same, or CBT is a little better,” Luterman said. 

When to See a Doctor

Anyone experiencing trouble sleeping that lasts more than a few months should consult a physician, to eliminate underlying emotional or medical conditions that may disrupt sleep, such as depression or restless legs syndrome, a condition that causes a twitching or tingling sensation and an uncontrollable urge to move the legs at night.  

If insomnia persists, your doctor may prescribe a visit to a sleep clinic. That involves spending the night sleeping in a private room, with equipment that can help detect sleep problems by monitoring brain activity, eye movement, heart rate, snoring, body movements and more. 

Before you go to the clinic, the doctor may ask you to keep a sleep diary for a few weeks, noting how much sleep you got, when you went to bed and how many times you woke up during the night. That information will be compared to the results in the lab. 

Don’t Get Discouraged

While there are indeed many ways you may be able to improve your sleep, there is no one-size-fits-all answer. You’re going to have to experiment to see what works best for you. The solution may involve doctors and sleep clinics, or maybe simple changes in your routine will work wonders. 

Vickie Parker, 67, was waking up every morning at 4:20 a.m. and couldn’t easily fall back asleep, even though she was still tired. So she developed a routine that seems to work: a trip to the bathroom, a heating pad to relieve pain in her shoulder, and turning down the thermostat in her bedroom by a degree or two. If that doesn’t work, she takes a low-dose sedative prescribed by her doctor. 

And Mary Jo Anderson eventually found an unconventional solution that helps her fall and stay asleep: a podcast called Sleep with Me, which the New Yorker described as “the podcast that tells ingeniously boring bedtime stories to help you fall asleep.”

“The host talks in this lull-y, drone-y voice,” Anderson said. “He’ll tell a story or recap a popular TV show. On one, he narrates while he’s putting together an Ikea bed. It helps shut down your mind but it’s not interesting enough that you stay awake to hear the end. It’s been the best thing for me.”

Are Pets Really Good for Older People?

An older couple put aside some of the food delivered by Meals on Wheels in order to have enough to feed their dog.

A widow delays an important visit to the doctor, fearing no one will care for her cat if she is hospitalized.

An older man living alone with a sick pet agonizes over a terrible choice: incur vet bills he can’t possibly afford or have his only companion euthanized.

Heartbreaking stories like these point to a difficult reality. While pets can benefit older adults’ health and happiness, they can also lead to financial burdens, near-impossible decisions or devastating grief.

Do the benefits of pet ownership really outweigh the risks?

Weighing Benefits with Costs

For many older adults, animal companions can make a huge difference in quality of life.

“People with pets in general are happier and healthier,” says Nicki Nance, a licensed psychotherapist and associate professor of human services and psychology at Beacon College in Leesburg, FL. “Pets require a structured schedule and daily exercise. They provide a sense of purpose, constant companionship, physical contact and humor.”

Those benefits can boost mental and physical health. An American Heart Association research review concludes that “pet ownership, particularly dog ownership, may be reasonable for reduction in cardiovascular disease risk,” with the most significant benefits associated with owners who walked their dogs regularly. The Human Animal Bond Research Institute (HABRI), a nonprofit, research and education organization, cites research that points to the benefits of therapy animals: they can calm older people with dementia and alleviate anxiety and distress for those undergoing cancer treatment.

Doctors often encourage their older patients to adopt a pet. But psychologist Hal Herzog, author of Some We Love, Some We Hate, Some We Eat: Why It’s So Hard to Think Straight About Animals (2010), questions whether the data is strong enough to warrant a doctor’s recommendation. While some studies point to health benefits, others show little or none. He also notes that studies show correlation but don’t prove causality: it’s not clear whether pet ownership makes people healthier, or healthy people are more likely to have the energy, motivation and financial resources to take care of pets. Most analyses, he adds, don’t factor in the lifetime cost of owning a pet in the United States, which can run upward of $10,000.  

The hardest part of my job is having to tell an older adult that a beloved pet needs to be euthanized.

—James Moebius, veterinarian

The downside of pet ownership should not be underestimated. Pets pose a significant risk of falls. A cat underfoot, a dog that pulls too hard on a leash, or pet toys on the floor can cause a person to stumble and fall. A 2009 Centers for Disease Control analysis estimated that more than 86,000 injuries due to falls each year were related to cats and dogs, with the highest rates of injury occurring among people 75 and up. For older adults, a fall can have devastating health consequences; a hip fracture, for example, can lead to long-term impairment, nursing home admission or death. 

Dogs need to be walked, all animals need to be fed and most must be groomed at least occasionally or have cages that should be cleaned regularly. These tasks are time consuming and can be hard for someone with limited mobility. Pets need trips to the veterinarian for routine wellness visits and illness. That can be traumatic, as well as costly, and difficult for a person who doesn’t drive. 

Then there’s the trauma of losing a pet. 

“The hardest part of my job is having to tell an older adult that a beloved pet needs to be euthanized,” says James Moebius, a veterinarian in Sachse, TX. “It’s even harder when it’s an older gentlemen who lives alone and who’s part of that generation that doesn’t express feelings. You watch him walk out alone, silently, without his little dog, and it just pulls your heart out.” 

Making It Work

Barb Cathey, CEO and founder of Pets for Seniors, an adoption program in Illinois, admits there are ups and downs and often, unexpected outcomes. She helped a client named Betty to adopt a rescued dog named Zoe, and the match was a happy one. However, Betty’s family returned Zoe to the shelter a year later. A fall had forced Betty to move to rehab for several months, and no one could care for the dog. The shelter agreed to keep the dog until her owner recovered. 

Meanwhile, Betty wasn’t doing well, refusing to even try to cooperate with her rehab therapist. Then her daughter brought Zoe for a visit. Delighted to see the dog, Betty immediately moved in her bed to make room. The therapist encouraged the family to bring Zoe back regularly to keep Betty motivated. 

“Betty ended up getting better, with Zoe’s help, and eventually was able to take her back home,” Cathey says. 

Before adopting a pet, a person should carefully consider all potential challenges as well as ways to minimize problems. A key first step: choosing a pet that’s a realistic match for an older adult’s physical capabilities and energy level.

“The worst mistake a senior can make is getting an energetic puppy or young dog,” Cathey says. Ditto for a dog or cat that requires lots of expensive grooming (such as a breed with long hair) or a young pet that’s almost certain to outlive the owner by many years. 

Shelters have a hard time finding homes for older animals, but they’re often a good match for older adults.

Cathey worked with an older woman whose family gave her a Jack Russell puppy, a breed known for its high energy level.

“She would call me in misery because the puppy was too much for her and she did not want to hurt their feelings,” she says. “I convinced the family to let me find a new home for the Jack Russell pup and found an eight-year-old Pomeranian that was housebroken and just wanted to lay in her lap all day—just what she wanted.”

Shelters have a hard time finding homes for older animals, but senior pets often make a good match for older adults, according to Linda Ross, a retired counselor who worked with aging populations. Ross and her husband are in their 70s and are both healthy and active, yet they chose to adopt an older dog after theirs passed away in 2010. 

“Older pets tend to be housebroken, quieter and less energetic,” she says. “And if they’re rescued dogs who’ve been homeless or in a shelter, they are just so grateful to have a soft bed and a good routine. We just love on them and they love on us.”

Finding Solutions

Those heartbreaking stories—the older couple who put food aside for a pet or the widow who postponed medical attention—were the impetus for the founding of the Seniors’ Pet Assistance Network (SPAN) in the Dallas area. Caseworkers for local aging-related agencies had noticed the challenges of elders living alone with pets, and how a little help might go a long way. 

Now, SPAN serves low-income older adults in the Dallas area with regular deliveries of pet food as well as help with veterinary-care costs. Grant money pays for food for about 75 animals; volunteers deliver it once every other month and spend a little time checking on each client. SPAN’s clients also receive an allotment of up to $300 per year to cover routine vet care, including immunizations, heartworm medication, and flea and tick prevention. 

“That’s significant, given that many live on as little as $1,200 per month in Social Security benefits,” says Laurie Jennings, SPAN’s co-founder.

For others, potential problems in pet ownership can be addressed with a little advance planning. Some veterinary costs, such as immunizations and spaying or neutering, can be minimized by taking advantage of low-cost clinics offered at animal shelters and pet-supply stores. For those who can afford it, pet insurance offers a way to help owners avoid wrenching decisions about vet bills. Owners pay a monthly premium but may be covered (depending on the type of plan) if pricey treatments are needed. 

To prevent falls, the CDC recommends that pet owners consider obedience training, installing night lights on walkways, moving the animal to another room or a crate at night, or even choosing a light-colored pet rather than one with dark fur. 

And in the event that an older pet owner loses a beloved animal, veterinarians can often help with the grieving process by pointing them to a pet-loss support group. 

Making Arrangements for Future Care  

Jennings often hears from family members who tell her, “That animal is keeping my parent alive.” But on the flip side, it’s a source of worry.

“We have a client, a 97-year-old widow, who has a very ornery, 9-year-old poodle,” she says. “She lives for that dog and frets over who will care for the dog if something happens to her.”

Some older adults want to provide for their pets in their wills, according to Lori Leu, an elder law attorney in Plano, TX. She recommends checking with a friend or family member first to see if they’re willing to take the pet after the owner dies or becomes incapacitated. That arrangement should be put into a will, along with (if possible) a small bequest to help cover the pet’s expenses. 

Although they are careful to avoid making promises, the people at SPAN try to help clients “rehome” pets if they can no longer care for them. It’s not always possible, but they do have success stories.

Jennings recalls Bobo, the beloved pet of an elderly woman who lived alone and was dying of cancer. Family members wouldn’t take Bobo, a pit bull mix, and because he was a little aggressive, Jennings despaired of ever finding a home for him. But a rescue group took Bobo, helped socialize him and found him a home.

When the young man who adopted Bobo learned of his previous owner, he offered to bring the pet to visit her one last time, just a few weeks before she passed away. 

“So, we have this photo of Bobo, this massive pit bull, lying on top of her in her bed,” Jennings says. Now SPAN receives a holiday card each year from the young man, with a photo of Bobo sporting a Santa hat.

“You make wonderful human connections doing this work,” says Jennings. “It’s beautiful.”

Breaking the Age Barrier

How some people escape their age bubble to find friends

Art Russell, 60, counts at least a dozen 20-somethings as friends: the guys he fences with; a 26-year-old colleague at work; and several people who attend his church. Although he also has many friends his own age, Russell values those younger ones.

“They have a fresh perspective that reminds me to stay enthusiastic about life,” he said.

Unfortunately, Russell’s social circle is unusual.

According to a 2017 report by Generations United and the Eisner Foundation, most Americans rarely have meaningful interactions or conversations with others (not family members) who are 20 or more years younger or older.

“Intergenerational friendships are the exception rather than the rule: for the most part, age segregation prevails,” the report concluded.

Most of us live in age bubbles. People tend to socialize within their own age groups at work or in school. Families with young children flock to kid-friendly neighborhoods; young adults head to apartments and condos in trendy locations; older adults whose children have grown gravitate to retirement communities.

Even multigenerational settings—such as churches, synagogues or community centers—tend to tailor programming by age: a yoga class for seniors; a Bible study for young adults; a science camp for kids. As a result, most of us have few opportunities to make friends with people outside of our own age groups.

“All of this is counter to what we know about what people need to thrive developmentally,” according to Eunice Lin Nichols, vice president at Encore.org and director of Gen2Gen, a campaign to encourage intergenerational connections. “Experts agree that age segregation contributes to social isolation and can reinforce stereotypes and perpetuate ageism.”

Friendship Transcends Age

When Mary Ann Eaton, 91, broke her hip in early 2018, she hired Diane Cannon, 60, to drive her around and to help with chores while she recovered. The two women became fast friends; now they talk by phone at least once a day and get together often. The 31-year age difference seems irrelevant.

“It’s very easy to talk to Diane,” Eaton said. “We have the same sense of humor, we both love animals and we’re both hard workers.” (One of Eaton’s first requests was for Cannon to drive her to a class to keep her real estate license up to date.)

If more older people made younger friends, experts believe that could help address a number of concerns related to the aging of the US population. Intergenerational friendships might counteract the “loneliness epidemic” that was identified in a 2018 Cigna survey of more than 20,000 Americans over age 18. Nearly half of respondents reported sometimes or always feeling alone (46 percent) or left out (47 percent).

…millennials are awesome. Almost none of the young people I know fit the stereotypes.

— Art Russell, age 60

Older people tend to stay healthier, both physically and cognitively, when they have strong social connections. (One study showed that loneliness has an impact on mortality similar to smoking 15 cigarettes a day.) Also, when elders nurture friendships with younger people, it helps assure that those who live into their 80s and 90s can maintain a vibrant social life even if they outlive their peers.

 Another advantage: intergenerational friendships promote mutual learning and enrichment and dispel ageist stereotypes. Even though he works in tech himself, Art Russell’s younger friends have tipped him on a couple of useful smartphone apps that he uses every day. When asked, he’s been able to offer them advice on relationships and careers.

“And I think millennials are awesome,” he said. “Almost none of the young people I know fit the stereotypes.”  

That’s a common side effect of intergenerational friendships—ageist stereotypes are quickly contradicted.

“If we get isolated by generation, we only talk about what’s relevant to our own generation,” said Donna Butts, executive director of Generations United. “We are richer and more able to look beyond our immediate concerns when we’re engaged with people in other age groups. To really slow down and listen—that’s how we share our humanity with each other.”  

Friends Gone Viral

A man in New Jersey befriended a woman in Florida by way of Words with Friends, an online game. Normally, that wouldn’t make the news. But in this case, the man is a 22-year-old African American rapper and the woman is an 81-year-old white retiree. A photo of their first meet-up went viral on social media, and the story made the New York Times in 2017.

What would it take to make friendships like this more common, rather than a newsworthy rarity? A number of initiatives are connecting older and younger people:

  • In Boston, a startup called Nesterly pairs older homeowners with young adults, especially students, who need housing. Housing is expensive in Boston, yet an estimated 90,000 spare bedrooms are going unused in the homes of aging empty nesters. The living arrangements have created friendships like that of Sarah Heintz, who’s in her 70s, and her roommate Dean Kaplan, 25. They share meals and enjoy talking politics.
  • Judson Manor, a retirement community in University Circle in Cleveland, offers a handful of apartments at no cost to 20-something graduate students at the nearby Cleveland Institute of Music, in exchange for performing for the residents. Friendships naturally arose between the older residents and the students. Viola student Caitlyn Lynch became so close to 90-something resident Clara Catliota that she asked her to join her wedding party. Catliota couldn’t travel to Oregon for the ceremony, so she hosted a wedding celebration for the couple at Judson.
  • A social services program called DOROT (which means “generations” in Hebrew) connects 7,000 children, teens and young adults with 3,000 older adults in New York City. The program enlists volunteers to serve as “friendly visitors” to isolated older adults, hosts intergenerational chess games and art sessions and provides opportunities for older adults to read to children. DOROT has sparked friendships like the one shared by Ramon Couzon, 78, and Vera Ruangtragool, 34. In 2015, Ruangtragool delivered a gift package from DOROT to Couzon shortly after his wife of 30 years died. He told Ruangtragool he was struggling with her loss; she responded by sharing how meditation had helped her find peace. Now, Ruangtragool visits Couzon weekly; the two chat before doing a 40-minute guided meditation. Both say they’re happier and more hopeful as a result of the friendship.

While programs like these can help connect people, experts say that awareness, an eye for shared interests and a little extra effort can lead to friendships that grow organically.

“It may start with something as simple as saying hello to your neighbor,” Butts said. “Everybody who lives in a neighborhood or an apartment building has the potential to have more interactions with people of other age groups.”

Intergenerational Collaboration

Intergenerational collaboration can also benefit organizations, Butts noted. Research shows that when teams involve people of different generations working together on an artistic or business project, they’re more productive and resourceful. Such collaboration can also spark intergenerational friendships.

That’s what happened when filmmakers Matt Starr, 29, and Ellie Sachs, 25, decided to remake the classic film Annie Hall with actors recruited from an older adult community, Lenox Hill Neighborhood House in New York. Starr and Sachs appreciated how the older actors consistently showed up on time early in the morning and were willing to work hard, even in hot weather. After the project ended, the young filmmakers and the elder actors continue to get together occasionally for lunch, a stroll in the park or even dance classes.

When young people don’t appreciate what older adults have to offer, Sachs said, “I think we just lose the potential to make incredible friends.”

Sachs said her new friends have shared guidance about love and life that she’s found more valuable than advice from her peers.

An intergenerational friendship has also enriched the lives of Courtney Cox and Carey Smith, both personally and professionally. In 2001, the two women started jobs in the same week in the art department of JCPenney. Cox was fresh out of school; Smith was returning to work after a hiatus to raise two kids. Despite the 27-year age difference, the two women made an immediate connection.

“If you’re creative, you tend to hang out with creative types,” Cox said. “I don’t notice the age difference. We have a lot of belly laughs. You don’t have that with everybody.”

Now, at 41 and 68 respectively, Cox and Smith have new employers and live in different cities but remain close friends. Recently, Cox needed graphic design help on a project for her current employer, so she hired Smith as a contractor. Smith traveled to North Carolina and stayed at Cox’s home during the three-month project. Cox said she often relies on Smith’s depth of experience, both in work and personal situations. Her older friend has faced some challenges—such as caring for a parent diagnosed with cancer—and was able to guide Cox when she faced the same situation with her own mother.

An intergenerational networking group in New York stages events that draw sold-out crowds.

That kind of mentoring doesn’t just benefit younger people; it also enriches the lives of the older people who serve as mentors. The Harvard Study of Adult Development, which has tracked more than 700 men over almost 80 years, found that those in middle age and beyond who invested in caring for and developing the next generation were three times as likely to be happy as those who did not do so.

“We were intended to live in community with one another, with older generations bringing wisdom, perspective and a lifetime of skills and experiences to younger generations, and younger generations bringing vitality and joy to the older generations,” said Nichols of Gen2Gen.

Younger people too see the need to tap into the wisdom of older adults. Charlotte Japp, 28, was “desperate” to connect with older mentors for advice on everything from maneuvering office politics to how to confront a manager about a difficult situation with a colleague. At the time, she was working at the online news site Vice; none of her colleagues were over 45. So Japp started CIRKEL, a networking platform that has organized a series of intergenerational events in New York that have drawn sold-out crowds.

Each event brings together older and younger people in a particular industry for informal mingling and structured discussions. A networking night for fashion professionals, for example, gave young millennials getting started in the field a chance to meet established influencers like Anna Wintour, 69, editor of Vogue, and Robin Bobbé, a fashion model in her 60s.

“For most CIRKEL attendees, the experience of coming to a party where the room is filled with people from all different ages is really new,” Japp said. “Many of the guests are having meaningful, enthralling conversations with someone from a different generation for the first time, and their view of that generation is shifting with each interaction.”

One of Art Russell’s younger friends, Robby Hare, 30, experienced that shift himself.  Before getting to know Russell and other older people in his church, Hare thought of boomers as the authors of the ubiquitous Internet memes that disparage millennials. Now he sees them as allies.

“When you take time to get to know someone, you realize they don’t fit the stereotype,” he said. “As I got to know Art, I began to see him as a person and as a friend, not just an old guy. It’s really hard to be prejudiced against people you know and like.”  

New Challenges for Grandparents

Often idealized, grandparenting is more complicated than ever before

As a divorced, single mom, Karen Spencer thought she was done raising children when her son and two daughters grew up and left home. It didn’t work out that way.

About 10 years ago, Spencer’s youngest daughter became suddenly single. She moved back home with her five-year-old son in tow. She stayed for a year while getting a job and back on her feet.

Then Spencer’s other daughter returned home—single, pregnant and on total bedrest on doctor’s orders. Spencer found herself caring for her daughter, driving her to doctor appointments, cooking for her, paying her bills—all, on top of working full time. Then the baby arrived, and there was the challenge of helping to care for a newborn preemie.

“It was super stressful,” Spencer said. “I wondered when things would return to normal.”

Like many of her peers, Spencer did her best to cope in a new world of grandparenting, one that’s in sharp contrast to the idyllic (and perhaps imaginary) image of the stay-at-home grandma living a relaxed and quiet life.

She’s facing pressures that didn’t affect previous generations of grandparents nearly as much: coping with the aftereffects of divorce (both her own and her kids’); providing support for her adult children, who took a long time to become independent; and doing it all while working full time herself.

“With all the changes in society, in families, in social demographics, grandparents are assuming a larger role as a stable force in the family,” said Ling Xu, assistant professor in the School of Social Work at the University of Texas at Arlington. “They really make a significant contribution.”

Spencer is far from alone. She’s one of about 70 million grandparents in the United States—the largest, most active and quite possibly the most involved generation of grandparents ever.

“The baby boom has become the grandparent boom,” according to AARP. “The same boomers who famously doted on their children are now lavishing attention on their grandchildren.”

Blended Families

Many of those grandparents are stepgrandparents, who must navigate the intricacies of blended families. Nearly half of middle-aged and older (50+) couples with children are in stepfamilies (one or both spouses/partners is not the biological or adoptive parent of the other’s child or children). When grandchildren (step or otherwise) enter the picture, the family tree quickly grows complicated.

Joy Miltenberger, 73, and her husband each have three children from previous marriages. Between them, there are 16 grandchildren, ages five to 30. Miltenberger jokingly calls her stepoffspring her “bonus” children and grandchildren.

“It’s more positive than using the word ‘step,’” she said.

Even though the Miltenbergers never blended their family in one household (they married after their children had left home), Miltenberger said she’s learned it’s important to “tread lightly” in her relationship with her bonus children, and that spills over into her relationship with their children.

“You have to know your place,” she said. “You will never take the place of your bonus children’s mother. I do not want to be intrusive.”

Miltenberger adds that the life she’s living as a grandmother bears little resemblance to that of her own grandmother. Both Miltenbergers still work full time, and Joy Miltenberger is helping to care for her mother, who lives independently but has mild dementia.

A record number of Americans today live in three-generation households.

“We thought of our grandparents as quite elderly, but we are still both active,” she said. “There’s no comparison.”

Miltenberger said their bigger challenge as grandparents has been distance. The couple lives in the St. Louis, MO, area; their grandchildren live in Dallas, Los Angeles, San Diego and the Caribbean. The couple tries to find a way to celebrate each grandchild’s first birthday in person, but they’d like to see them more often. Between visits, technology helps keep them connected; they video-chat with the grandkids via FaceTime or Skype, Miltenberger said, but not as often as she’d like, given her busy schedule and the kids’ many activities.

“If the kids were here, we’d be going to their games and to Grandparents Day events at school,” she said. “I don’t know all my grandchildren as well as I’d like.”

Close to Home

While some families work hard to overcome geographic barriers, others find themselves living in very close proximity. A record 64 million Americans live in multigenerational households, according to a 2016 Pew Research Center study, up from 51 million in 2009. About 10 percent of grandparents live with grandchildren, most of them in three-generation households.

About 2.6 million grandparents—roughly 4 percent of all grandparents—are the primary caregivers of their grandchildren. That number is increasing, due to growing problems like opioid and other forms of addiction or mental health issues, and due to the military deployment of women. Grandparents are stepping up when the grandchildren’s parents can’t, or won’t, handle the responsibility. But it can be a real struggle, according to Carole Cox, professor in the Graduate School of Social Service at Fordham University.

“It means your life is changed,” Cox said. “If you’re still working, you might have to stop. If you enjoyed socializing with other seniors, you can’t do that if you have to be home with the children.”

Even when the kids are in school all day, they need care during summer vacations and holidays, plus there are myriad duties, like doctor appointments or driving to and from school and activities.

Full-time grandparents must cope with the loss of independence and freedom at the same time that the children may be struggling with emotional issues, such as insecurity and feeling they’ve been abandoned. When a caregiving grandparent is single—with no strong system of support from a spouse or family member—it’s even harder.

Studies suggest that single grandparents raising grandchildren full time are more vulnerable to poor physical and mental health.

Becoming a grandparent is one of life’s major turning points. There are new lessons to learn.

Grandparents are also dealing with a trend that sociologists have noted: a “longer runway” for the current generation of young adults on the way to independence. As a group, today’s young adults leave home, get full-time jobs and marry at a much later age than previous generations. When these not-yet-independent adults become parents—often, single parents—they turn to their own parents for help with child care and money.

Spencer, now 56, was fiercely independent at an earlier age than her daughters, who moved home as adults.

“Instead of saying, ‘Mom, I need diapers,’ and expecting her to pay, I would’ve wrapped my kids in a towel,” she said.

Ultimately, things did return to normal for Spencer. Today, her three adult children are independent and in happy, stable relationships. Her nine grandchildren, age five months to 16, are doing well too. When her daughter remarries a few months from now, she’ll add two stepgrandchildren to her brood. These days, Spencer’s role as a grandmother is focused on babysitting on weekends, which she relishes. She has no regrets about helping out when she did.

“I don’t think my daughters gave much thought to it at the time, but now they’re so grateful for all that I did, both physically and financially.”

Walking the Line

Becoming a grandparent is a major life turning point, one that involves learning to step back and let the grandchildren’s parents take charge. Even for grandparents who provide regular child care, most experts advise against interfering or enforcing rules that conflict with those of the grandkids’ parents.

“Giving advice is not what you do,” said Cox, who has three grandchildren herself. When the grandparent doesn’t agree with the parents’ rules (unless there’s something that poses a clear danger to the child’s health and safety), “it’s really important that grandparents support the parents,” Cox said. “Otherwise, it’s giving too many mixed messages. Every family has to work that out.”

In response to parenting practices they don’t like, Cox joked that she and her friends have mastered what she calls “the neutral ‘Ohhh’”—the ability to respond without comment.

“If a grandparent starts to interfere or give unsolicited advice, parents are likely to take offense,” she said. “It can be threatening, make the parents feel as if they are not doing a good job and, in the extreme, it can harm relationships.”

Cox encourages grandparents to advise only when asked, “and then to say, ‘What do you think?’”

Financial Challenges

Many grandparents step in to help their grandchildren financially, which poses its own pitfalls. According to the Consumer Financial Protection Bureau (CFPB), the number of people 60 and older carrying student loan debt—either as the primary loan holders or as cosigners—quadrupled from 700,000 to 2.8 million between 2005 and 2015. That figure includes older adults who are carrying their own student debt later into life, but also the growing number of parents and grandparents financing their children’s and grandchildren’s college educations.

“That can be detrimental to the grandparents’ finances, so that they don’t have enough in retirement savings,” said Ted Rossman, an industry analyst for CreditCard.com, a consumer information website. “You can get loans for college, but you can’t get loans for retirement.” He adds that grandparents who overextend themselves financially to help pay for college could end up needing financial support later from children or grandchildren. Rossman’s advice: “It’s nice to be generous. But know what you can actually afford.”

Great-Grandparent Boom

Despite the challenges, today’s grandparents also enjoy many advantages. Overall, they represent the most educated, healthy and active generation of grandparents in history.

And in a growing number of families, grandparents have another layer of support: great-grandparents. No major survey or Census Bureau tabulation provides hard data on the number of great-grandparents living in the United States, but demographers believe that a “great-grandparent boom” is on the horizon as lifespans increase. Ken Wachter, emeritus professor of demography and statistics, University of California, Berkeley, estimates that by 2030, more than 70 percent of eight-year-olds will likely have a living great-grandparent.

Nathan Ivey, 91, doesn’t remember his own grandparents, who had all passed away by the time he was five. But he does remember the exact day and time he and his wife, Dorothy, 96, became great-grandparents: April 26, 2018, at 10:56 pm, when his great-grandson AJ was born.

Although he was involved in his grandchildren’s lives, Ivey said, “I was still employed, and still very busy, when all four of our grandchildren were born.”

Having retired at age 86, Ivey is now on a more relaxed schedule, and he and Dorothy look forward to frequent playdates with AJ, who lives about 15 miles away.

“He has captured our hearts,” he said. “By the time he was five months old, he could recognize us when we would come to see him. That was so exciting.”

Reaping the Rewards

For many, involvement with grandchildren offers a sense of purpose and engagement as well as fun. That may explain why at least one study suggested that those grandparents who provide care occasionally for grandchildren are less vulnerable to dementia.

Grandparenting duties have certainly motivated Fred Frawley, 76, a nearly retired attorney, to stay active and healthy. In 2003, his doctor recommended a hip replacement but advised him to postpone the surgery as long as possible, until he absolutely needed it. That day came in 2008, following the birth of his grandson, Zach.

“As soon as I realized Zach was getting mobile, I went ahead with the surgery,” Frawley said.

Staying physically fit has enabled Frawley and his wife, Sharon, to play a big role in the lives of their two grandchildren, Zach, now 11, and Kate, seven. They pick up the kids from school a couple of days a week, sometimes shuttling them to activities or doctor appointments, or caring for a sick child at home. The couple takes on an even bigger role during the summers, when school is out.

The relationship he shares with his grandchildren is much closer and more involved than the one Frawley remembers with his own grandparents. He and his grandson are both history buffs; Frawley helps the boy research history projects for school.

“We love being involved with the grandchildren,” Frawley said. “We get to send them home at night, and then we sleep very well.”


Spiritual Support at the End of Life

Medical and hospice professionals are learning to meet patients’ spiritual needs

This is part 2 in our series on spirituality and aging. Read part 1 here.

Eric Markinson identified himself as a chaplain when he walked into the hospital room of a man he calls Tommy, who was dying of alcohol-related liver disease.

“I don’t think you can help me much,” Tommy said. “I’m an atheist.”

Markinson, associate pastor of spiritual care at Grace United Methodist Church in Dallas, replied that he was there to help in any way that he could. In the conversation that followed, Tommy said he’d rejected the religion of his childhood, which taught that God was judgmental and unforgiving. Now he feared the judgment of his girlfriend and children over the years of alcohol abuse that had led to his impending death.  

Even though he was an atheist, Tommy was in spiritual distress.

“At the end of life, people can struggle just as much with spiritual pain and guilt as they do with physical pain,” Markinson said.

Increasingly, medical and hospice professionals are recognizing the reality of this spiritual suffering, and they are focusing on ways to integrate spiritual support into the care provided at the end of life.

A chronic or life-threatening illness can trigger spiritual struggles even for patients who are not religious.

“Patients who are challenged by illness are likely to need assistance to find strength, hope, meaning, comfort and healing,” said Ann M. Callahan, author of Spirituality and Hospice Social Work (2017) and associate professor in the social work program at Eastern Kentucky University. “Health care providers may not be able to prevent spiritual suffering, but they can support spiritual well-being.”

When Congress created the Medicare Hospice Benefit in the 1980s, it included reimbursement for spiritual care. Hospitals and physicians now routinely ask patients about their religious and spiritual preferences as part of the intake process. Medical schools teach courses in spirituality as it relates to patient care. And chaplains are trained to offer spiritual care not only to those in their own traditions but also to people of a variety of religions, as well as those who are atheist, agnostic or “spiritual but not religious.”

“We are trained to meet people where they are and to be a nonanxious, supportive presence,” Markinson said.

All of this emerges from a growing body of research suggesting that religious or spiritual ties can promote healing and improve patient outcomes. Studies show that many patients want their physicians to discuss their spiritual beliefs; among those at the end of life, 70 percent would want their physicians to know their beliefs, and 50 percent would like their doctors to pray with them. Studies also demonstrate that most hospitalized patients believe spiritual health is as important as physical health and that many rely on faith and prayer to cope.

Spiritual Distress

The diagnosis of a chronic or life-threatening illness can trigger spiritual struggles for patients, whether or not they are religious.  

“One is inevitably led to ask, ‘What is my life all about? Am I ready to die? Is there something I am still missing in this life?’” said Ruben L. F. Habito, professor of world religions and spirituality at Southern Methodist University’s Perkins School of Theology. “With such questions may come some kind of fear, anxiety, a sense of regret, a sense of longing. These thoughts and sentiments arise from the core of one’s very being, that realm that can be called ‘spiritual.’”

Some patients experience spiritual distress or spiritual suffering—an inability to connect with what gives their lives meaning—and some medical professionals say this diagnosis can cause just as much suffering as physical pain. In one small study, 96 percent of patients with advanced-stage cancer said they experienced spiritual pain.  

With help, that pain can often be alleviated. Working as a team, medical professionals, chaplains and social workers can help address the spiritual suffering of those facing the end of life.

“Patients can transcend spiritual suffering by finding meaning and making sense out of their experience,” Callahan said. “This might require the help of a spiritual care provider and the services of other professionals, volunteers, family members and friends.”

In a nation that’s increasingly diverse, offering spiritual help can be tricky.

Help might come in the form of prayer, scripture, rituals (such as anointing or last rites) or spiritual counseling, or even assistance in helping a patient, when appropriate, to reconcile with an estranged friend or loved one. Markinson was able to help Tommy initiate a conversation with his loved ones, who forgave him. That provided some closure and helped assuage some of the spiritual pain compounding his physical suffering.

But offering spiritual help can be a tricky proposition, given the increasingly diverse spiritual landscape in the United States, as well as the fact that more people are identifying as spiritual but not religious.

Over the past 30 years, training for chaplains in theology schools has evolved to prepare them to serve patients of different faiths and spiritual practices—either directly, or by connecting them to resources related to their personal beliefs. Chaplain programs give students a basic understanding of all the world’s major religions. Student chaplains also learn to let patients take the lead in their spiritual care.

“Before, chaplains might have gone in as spiritual guides and talked to patients,” said Jeanne Stevenson-Moessner, professor of pastoral care at Southern Methodist University’s Perkins School of Theology. “Now, we’re learning to first listen and then converse. It’s a real shift.”

Instead of offering a few pat words of wisdom, which might ring hollow, chaplains are taught to first listen to the patient’s words, pay attention to nonverbal clues and then tailor their care accordingly, Stevenson-Moessner said. This patient-led approach helps ensure that the chaplain’s guidance is truly relevant to the patient’s particular spiritual struggles, as well as appropriate for that patient’s beliefs.   

For example, if a patient talks about regrets or expresses a desire for forgiveness—whether from God or a higher power—the chaplain can offer reassuring insights. That might come in the form of a Bible passage or traditional prayer for a Christian, or a passage from Rumi or the Tao for someone who identifies as spiritual but not religious.

Spiritual Turmoil

While spiritual beliefs may offer comfort, they can also provoke turmoil.

Some patients with regrets may worry that God is punishing them with a life-threatening disease, for example. Others, whose spirituality emphasizes the connection of mind, body and spirit, may view a diagnosis of life-threatening illness as a sign of failure, said Laura Howe-Martin, a psychologist and assistant director of behavioral sciences at UT Southwestern Medical Center’s cancer institute in Dallas (TX).

Some patients feel enormous pressure to maintain a positive attitude, based on a belief that it will affect their disease. Caring professionals call it the “tyranny of the positive attitude,” according to Howe-Martin.

“We know that the mind and body are incredibly related,” she said. “But some interpret the research to mean, ‘If you think this way, it increases your risk of cancer’ or ‘If you have a good attitude, you’ll live longer.’ We just don’t have any data to back that up.”

A key part of the chaplain’s role is to alleviate any unhealthy emotions, whether they originate in rigid religious beliefs or open-ended New Age spirituality, said Michael Washington, palliative care chaplain at Baylor Scott & White Medical Center in Dallas.  

Resolving spiritual distress can help patients make better end-of-life decisions, such as when to discontinue treatment if it’s not likely to prolong life significantly. Sometimes his counsel helps patients find their voices when they no longer wish to continue treatment and their families aren’t supportive.

Good spiritual care can also make bereavement easier for those left behind.  

“After patients pass, the bereaved can have a lot of untoward health effects,” said Reeni Abraham, an internal medicine physician who advises a course on medicine and spirituality at UT Southwestern Medical School. “Having a death that’s the least distressing is not only important compassionately for the patient but also for their support system.”

Spirituality also offers an avenue for a deeper relationship between patients and their physicians, Abraham added. If she notices a Bible or a devotional at a patient’s bedside, she might inquire: “How are you doing? I see that you’re reading the Bible. Do you want to tell me more about that?”

In situations like this, physicians must tread carefully, always following the patient’s lead and never proselytizing. But when the patient expresses an interest, and the physician feels comfortable, shared prayers or spiritual conversations are healing to some.

“We hope this kind of spiritual support provides for increased comfort and better relationships with patients’ health care teams,” Abraham said. “The goal is to advance health, and health is a conglomerate of many things. It’s a holistic approach to a patient.”

Spiritual Assessments

Most hospitals and many doctors now take a spiritual history or spiritual assessment as part of the patient intake process. Spiritual assessments provide yet another way to understand and support patients in their experience of health and illness, according to Abraham.

“It’s important to treat patients holistically,” Abraham said. “I firmly believe that really helps us to advance care. That’s beneficial for physicians as they build relationships with their patients, and as they walk beside their patients during all the milestones in life that they’ll see together.”

The spiritual assessment also helps identify beliefs or faith affiliations that could affect a person’s treatment plan—such as a Jehovah’s Witness, who might refuse a blood transfusion for religious reasons.

One of the most popular models is the FICA Spiritual History tool, which asks patients questions about faith and belief (“Do you have spiritual beliefs that help you cope with stress?”), importance (“Have your beliefs influenced how you take care of yourself in this illness?”), community (“Are you part of a spiritual or religious community?”) and address in care (“How would you like me to address these issues in your health care?”)

“The goal is to find out what is important to the patient,” said Marita Grundzen, associate director emerita of Stanford Geriatric Education Center at Stanford School of Medicine. “Some might say, ‘I’d like my pastor to visit,’ or ‘I’d like to have communion.’ Another might say, ‘I’d like access to the outdoors. I can better heal with a nature scene outside of my window.’”

Spiritual Sensitivity

Sally Mandler and her husband, Gene Beasley, both consider themselves spiritual but not religious; Beasley used to joke that he was a “born-again pedestrian.” After Beasley had a stroke last March—on top of pre-existing Alzheimer’s disease—Mandler enlisted the help of an in-home health agency, which sent caregivers to assist with bathing, dressing and other needs. Many were young men from Ghana with a strong Christian faith and, in one case, a lack of sensitivity to those with different beliefs. One man insisted on praying “in Jesus’ name” over Beasley at bedtime.

Even with his compromised cognition, Mandler saw the distress in Beasley’s eyes, and asked the caregiver to leave.

Professional caregivers do usually try to avoid offering spiritual input that may be viewed as intrusive or inappropriate. Yet when the patient identifies as spiritual but not religious, the definition of what is appropriate may be unclear.

Open-ended questions can help tease out what’s important to patients and to find ways to support them appropriately, Washington said.

“I ask, ‘What will be meaningful to you at this time?’” he said. “The answer is whatever the patient tells you.”

If the patient asks, Washington might offer a prayer to a Higher Power, rather than God or Jesus. Or he might help a patient reflect on legacy and what he or she hopes to leave behind. Sometimes it may mean helping the patient to find closure by forgiving a family member or by asking for forgiveness. Sometimes it’s simply a promise by the chaplain to be there at the end.

“I am meeting the needs they have and respecting their spirituality,” he said. “It’s not about my faith background. It’s about the patients and what is meaningful to them and to their families.”

Sometimes, sensitive spiritual care may even mean keeping religion or faith out of the equation entirely.  

“If I ask, ‘What gives your life meaning?’ and the patient says, ‘Fishing,’ then my response is, ‘Great. Let’s talk about fishing,’” Abraham said.  

Stevenson-Moessner notes this trend toward treating mind, body and spirit together is part of ancient medical tradition. In indigenous cultures, religious leader are also healers; Hippocrates noted in 460 BC that the spiritual and the physical were intertwined.

“It’s nothing new,” she said. “It’s just that we’ve reclaimed it.”

What Spirituality Means to Older People

It can provide a sense of purpose and connection—and a great deal more

This is part 1 in our series on spirituality and aging. Read part 2 here.

For many years, the Catholic faith was central to Debra Cook’s life. She grew up in a Catholic family, sent her children to Catholic schools and was an active leader in her parish. 

But now Cook, 65, of Dallas, finds herself looking beyond the walls of her church as she gets older. In recent years, her parish shifted toward a more conservative understanding of Catholicism; meanwhile, Cook’s beliefs have become increasingly more expansive.

She stopped going to mass every week, a step that once would’ve been unthinkable. Instead, she spends an hour outdoors early each morning, quietly observing nature. Cook completed an ecumenical Christian formation program that prepares participants as spiritual leaders or spiritual directors. This fall, she’ll lead a study program called the Soul of Aging, which deals with issues involved with aging but offers no specific religious doctrine.

 “I still view myself as a Jesus follower,” she said. “But my view of God has gotten so much bigger. I’ve realized there’s more out there that I don’t understand.”

Like Cook, many older adults say spirituality is an essential source of wisdom and guidance that not only helps them to cope with the challenges of aging but also to live more consciously, with a sense of wholeness and purpose.  

“Older people want meaning,” said Michael Gurian, author of The Wonder of Aging: A New Approach to Embracing Life After Fifty (2013). As people live longer lives, “we have the freedom now, in a miraculous second lifetime, to soul-search and soul-find.”

Spirituality, he adds, can help people cultivate the “realistic optimism” that will help them better navigate later life.  

Spiritual but Not Religious

The assumption that people become more religious as they age and confront their mortality is generally regarded as a myth among professionals who work with older adults, according to Holly Nelson-Becker, author of Spirituality, Religion and Aging: Illuminations for Therapeutic Practice (2018). Similarly, there’s no research that suggests an overall trend of people becoming more spiritual as they age. Older adults do represent the most religious demographic group in the United States, but Nelson-Becker suspects that’s because members of the older generations grew up when it was more common for people to participate in an organized religion.  

“What we do know is that people’s religious and spiritual trajectories change over time in many ways,” Nelson-Becker said. “People get enthusiastic, motivated, discouraged, and become more spiritual, more religious, less so, and otherwise in and out.”  

Some, like Cook, find themselves veering away from religion and into a growing segment of the population that demographers call the “SBNRs”—spiritual, but not religious. Defining exactly what that means, however, has posed a challenge.

‘Spirituality’ means different things to different people.

“Religion includes ethical principles, rituals, beliefs and practices, transmitted over time and shared by a community,” said Nelson-Becker. “The definitions of spirituality vary far more widely. Spirituality is a somewhat fuzzy concept that means different things to different people.”  

Nelson-Becker was part of an interdisciplinary team of 50 experts that developed standards of spiritual care in palliative care. They hammered out this definition: “Spirituality is the aspect of humanity that refers to the way individuals seek and express meaning and purpose and the way they experience their connectedness to the moment, to self, to others, to nature, and to the significant or sacred.”  

Life Changes Spur Shifts

Many who embrace spirituality later in life say they were spurred at least in part by changes in their life circumstances. After retirement, or a shift to part-time work, or fewer family responsibilities, they have more time for reflection.

“When you’re in your 30s, it’s all about go, go, go and get, get, get,” said Debby Thomas, 67, a real estate agent in Garland, TX. “Once you get older, those are not necessarily your top priorities.”

Thomas grew up in a Protestant church and converted to Judaism when she married in her 20s. When her marriage ended, she fell away from religion entirely. In her mid-50s, she discovered Unity Church of Dallas, a New Thought church that prescribes no doctrine but views Christian teachings as a practical path to health and happiness.

Thomas believes that maturity makes her more accepting and open to new ways of expressing her spiritual beliefs.

“When I was young, I was too busy arguing with [the church’s] dogma,” she said. “When you get older, you make it more personal, rather than trying to change the world to match your beliefs.”

Foundation for Living Longer and Healthier

One nationwide study of more than 1,000 obituaries found that people with religious affiliations lived nearly four years longer than those with no ties to religion, even after adjusting for other factors, such as gender and marital status. But researchers caution that it’s virtually impossible to separate the benefits of religion from related factors, such as the social connections among people in faith communities.

Anne Sadovsky, 77, is clear that the social and the spiritual, together, have enriched her life. A motivational speaker and real estate expert in Dallas, she’s benefited from the social support of “the Dalai Mamas,” a prayer circle of seven older women, ages 62-78, that’s been together for more than 10 years.

The women meet for birthdays and holidays, but the glue that bonds them is prayer. Via email, they share prayer requests for themselves and others. Often, they will schedule a time when they all pray at once, wherever they are, for a specific need. Originally the women met at Unity Church of Dallas, where Sadovsky is a member, but the group stayed together even after some moved to other churches.

“When the husband of one of the women died, we were all right there,” Sadovsky said. “I had major back surgery, and they were there for me. One stayed with me at the rehab facility and gave me my first shower after surgery.”    

Each woman prays according to her own understanding, Sadvosky said, but following Unity principles, they don’t see prayer as “begging or pleading” so much as a way to connect with divine energy.

“It’s a very powerful, loving support group,” she said. “Word has spread that our prayers are powerful; people we don’t even know will [ask for prayers].”

Some spiritual practices may have health benefits. Meditation, for example, may help reduce blood pressure.

Being a part of a group like the Dalai Mamas may have a positive impact on health. While the number of studies examining the links between religion, spirituality and health is mushrooming, according to Nelson-Becker, “The findings are difficult to align because they look at different factors, control for different factors, and ask slightly different questions.” While there appears to be a correlation, there’s no proof of a cause-and-effect relationship.

Some spiritual traditions do explicitly encourage adherents to avoid unhealthy behaviors. In exploring longevity hotspots, Dan Buettner identified a community of centenarians in Loma Linda, CA, in his book, The Blue Zones: Lessons for Living Longer From the People Who’ve Lived the Longest (2008). Many were Seventh Day Adventists, who don’t smoke, follow a plant-based diet, exercise regularly and maintain a normal body weight.  

Research also suggests that some specific spiritual practices, such as yoga, and meditation or prayer, may have health benefits. Meditation, for example, may help reduce blood pressure or relieve some menopausal symptoms, like hot flashes.

The Wonder of Aging author Gurian, 65, spends an hour each morning meditating in nature. He’s a practicing Jew but has lived around the world, and his spirituality draws on elements of many other religions, including Baha’i, Hinduism, Unitarianism and Christianity.  

“I think genuine happiness can come from having a spiritual practice,” he said. “As mind and body connect, that helps some people to end an addiction or to eat more healthfully. Also, there is something happening in the brain as people do spiritual practices. Spiritual practices direct more blood toward the temporal lobe, and that is good for de-stressing.”

Art as Spiritual Practice

Spiritual expression can range from communal activities like worship, scripture study or prayer, to personal practices such as journaling, meditating or spending time in nature.  

For Donna Bearden, 71, her spiritual practice centers on art and learning. She’s married to a retired United Methodist pastor but describes herself as spiritual but not religious.

“My spirituality could not develop within the church,” she said. “I believe a spiritual journey has to involve doubt, searching, asking hard questions. I couldn’t ask those questions without raising eyebrows.”

Bearden expresses her spirituality through art, writing and photography. She starts each morning writing in a journal and often heads outside with camera in hand. She’s fascinated by mandalas—a circular symbol in Hinduism and Buddhism that represents the universe—and creates them with the photos she’s taken.

“There is a zone artists and poets and other creatives talk about, the idea that words or an artist’s creation comes not from them but through them,” she said. “I have felt that zone, that connection to something greater than I.”

A Sense of Purpose

If there’s a link between spirituality and longevity, it might be ikigai (“what makes one’s life meaningful”), a Japanese term that Buettner cites in his work. Many faiths teach concepts of intrinsic human purpose that don’t require a youthful body or a sharp intellect: tikkun olam, the Jewish calling to repair the world; the Christian teaching of serving others; or the Buddhist idea of the bodhisattva, a person who chooses to strive for Buddhahood for the benefit of all sentient beings. Spiritual practices, such as meditation, can help people clarify and focus on their sense of higher calling.

Spirituality can also help older people turn outward when loss or physical limitations could easily spur them to turn inward, according to Missy Buchanan, author of Living with Purpose in a Worn-Out Body: Spiritual Encouragement for Older Adults (2008).  

“It’s the belief that ‘I’m here for a reason,’” Buchanan said. “Maybe I hurt today, but I can still do something good for somebody.”

For Cook, her work as a spiritual group leader provides a new sense of purpose and direction. In earlier years, she focused on career, raising kids, status and money—her family once lived in an 8,400 square foot home (“Isn’t that ridiculous?” she said). Those things don’t define her anymore.

“Now it’s about living a life in accord with who I was created to be,” she said. “The work I’m doing in spirituality is life-giving.”

Older Artists Keep Creating and Growing

But ageism raises obstacles for many

Opera star Plácido Domingo made his name as a tenor. Indeed, many know him as one of the “Three Tenors,” performing with José Carreras and Luciano Pavarotti in the late 1990s. But now, at age 77, Domingo is a baritone.

That’s a concession to his aging voice, according to Colleen Mallette, a member of the voice faculty at Texas Christian University in Fort Worth. But it hasn’t diminished his star power.

“His voice has changed, but it’s even richer and better,” Mallette said. “He’s still such a bravura singer that no one feels slighted in the least.”

Like Domingo, performing artists—as well as fine artists—find they must adjust to physical limitations or decreased stamina as they age. For those who aren’t world-renowned, the opportunities to perform, to win roles and grants or to exhibit their work may dwindle as they get older.

At the same time, many artists say they find that maturity brings depth and authenticity to their work that they didn’t have in their youth. And with their habits of creativity, determination and adaptability, honed over time, many artists remain resilient and active well into older age.

Dwindling Roles

Ageism in art, though, is a barrier some artists must hurdle to keep creating. For screen performers, Hollywood can be particularly difficult. At the 2014 Golden Globes, Tina Fey famously praised Meryl Streep’s turn in the film August Osage County for “proving that there are still great parts in Hollywood for Meryl Streeps over 60.”

Streep, of course, is the exception. Many actors, especially women, find opportunities for work drying up past a certain age.

“I’ve had many, many studio heads and casting people and network heads look me in the eye and just go, ‘Yeah, this has been such a great reading, I wish they’d go with you, but they’re going to go younger,’” said actress Kathy Griffin, 57, speaking at a 2016 panel discussion on ageism in Hollywood.

Ageism is so problematic that in 2017 the California state legislature passed a law allowing actors to request the removal of their date of birth from industry databases, like IMDB.com. Actors’ unions argued that the law was necessary to protect actors from age discrimination. (In February 2018, US District Judge Vince Chhabria declared the law unconstitutional.)

On Broadway, many directors have begun experimenting with “color-blind” and “gender-blind” casting—choosing actors without regard to race or gender, according to Mark Lowry, editor and theater critic for TheaterJones.com, a regional arts website. But “age-blind” casting hasn’t caught on in the same way.

“Age is a little more complicated,” Lowry said. “Playwrights generally specify an age, and directors try to honor playwrights’ intentions.”

However, there are a few directors trying “age-blind” casting. A 2017 West End (London) revival of the comedy Daisy Pulls It Off featured actresses in a wide range of ages, all playing teen schoolgirls. And in his 2015 production of Romeo and Juliet, Kenneth Branagh cast Derek Jacobi, then 76, as Mercutio, a move the Guardian said “boldly challenges our prejudices about age on stage.”

Directors may be more willing now to be more realistic in casting and to choose older actors to play mature characters.

At the regional level, Carolyn Wickwire, 81, a professional actress in Albuquerque, NM, says she’s been surprised by how many roles she has been able to play. She has no experience to compare from her youth—Wickwire didn’t start acting professionally until age 51, after retiring from an administrator job. But she’s been so busy with roles in local theater productions, as well as gigs in TV series shot in Albuquerque (Better Call Saul, Longmire and Manhattan), that she’s had to pass up some tempting auditions. She has played characters ranging from age 65 to 91.

“They’re not always the biggest roles, but sometimes they are leads [or] strong supporting roles,” Wickwire said. She believes directors are moving toward “more realistic casting” and are more willing to include older characters and more apt to choose older actors for mature roles.

Some directors consciously tweak the ages of cast members to create a fresh dynamic. The revival of My Fair Lady on Broadway, which opened April 20, 2018, paired Lauren Ambrose, 40, as Eliza, with a slightly younger British actor, Harry Hadden-Paton, 37, as Professor Higgins. That’s a big departure from the original, in which 20-year-old Julie Andrews played opposite Rex Harrison, who was almost 50. The new version was soon sold out.

Not all performing arts prize youth as stubbornly as the stage and screen. It’s not uncommon in opera, for example, for older women to be cast as characters who are younger. Lowry notes that in the Richard Strauss opera Romeo and Juliet, Juliet is a girl of 14, but the role was written for a woman with a more mature voice, usually someone in her late 20s or early 30s.

Even in ballet, where few survive professionally past age 40, more dramatic roles often go to more experienced dancers.

“Certain roles require youth and energy, but the older ballerina … brings maturity and experience that a younger person might not have,” said Michelle Gifford, a former dancer with New York City Ballet and Texas Ballet Theater.

Ageism in Fine Arts

Even visual artists—working in arenas where unwrinkled faces or agile young bodies aren’t required—can encounter ageism, according to Joan Jeffri, director and founder of the Research Center for Arts and Culture in New York City.

The organization’s recent study, “Above Ground: Information on Artists III: Special Focus New York City Aging Artists,” found that 43 percent experienced discrimination because of age. In focus groups, artists reported that if a grant application asked their age, they felt certain “the application went right into the garbage,” Jeffri said.

Some galleries are trying to rectify that. The Carter Burden Gallery in New York’s Chelsea neighborhood shows only the work of artists 60 and older. The Museum of Modern Art in New York is currently running a yearlong installation, The Long Run, of works created by artists after age 45, including a piece created in 1977 by Georgia O’Keeffe at age 90.

Older artists have become “the rage” lately, Jeffri said, but even that poses a dilemma because the trend positions older artists as a “peculiarity, when they should be the norm. Age shouldn’t matter.”

Adjusting for Age

The physical and cognitive changes that accompany aging often affect artists’ ability to create or perform. Recent advances in medicine, nutrition and physical therapy have delayed that somewhat: orthopedic surgery might give a ballet dancer another year or two on an injured knee; a good fitness trainer and a skilled dermatologist might enable an actress to pass as an ingenue into her early 40s. But most older artists eventually must make some adjustments for aging.

For vocalists, for example, aging reduces the flexibility of cartilage around the vocal cords, limiting older singers’ ability to hit certain notes. And hormonal changes may lower a voice.

“Singing is being an athlete, pure and simple,” said Mallette of Texas Christian University. Like athletes, vocalists can use exercises and preventive measures to maintain their voices. Many older vocalists adjust the way they sing certain songs. She noted that Willie Nelson, 85, uses the twang in his singing style as a technique to avoid straining his vocal cords.

A study found that most artists have no plans to retire because they find their work meaningful and absorbing.

Similarly, the Art Cart program at the Research Center for Art and Culture helped visual artists with occupational therapy, such as fitting a painter with a special built-up paintbrush that helped her keep her hands steady. (The Art Cart program is now the Performing Arts Legacy Project for performers age 62 and up and is housed at The Actors Fund.)

And artists’ creative instincts help them adapt. One older artist had spent years creating sculptures out of safety pins; after developing arthritis, she worked in watercolor instead.

“She didn’t for a minute think she’d stop doing art,” Jeffri said. “She just found a new way to do it.”

That productive sense of joy can keep older artists engaged in their work well into their later years—and ultimately allow them to age more successfully, Jeffri said. The Above Ground study found that most artists had no plans to retire; most reported high levels of life satisfaction because their work was meaningful and absorbing.

“We found they are often more resilient than the general population,” Jeffri said. “Many older artists continue to go to the studio every day or every week, even if it takes an hour and a half to walk two blocks to get there.”

Out of the Game

In some cases, getting older eventually necessitates leaving an artistic profession. With its joint-punishing leaps and turns, plus the difficulties of pointe work for female dancers, ballet is a young person’s pursuit. Professional dancers know from the start that they’ll likely retire by age 40.

“At some point you start asking yourself, ‘What else is there in life besides the stage life?’” said Gifford, the former dancer.

Spurred by a painful ankle injury as well as a desire to do something new, she retired at age 47. Now she’s teaching and working as a répétiteur with the George Balanchine Trust. (Répétiteurs are hand-picked dancers with intimate knowledge of particular ballets, authorized to teach the steps and choreography to performing companies.)

Gifford knows former dancers who made more drastic career changes, morphing into lawyers, professors, doctors, full-time parents. “It’s a really great opportunity to recreate yourself; it’s pretty amazing if you take advantage of the life in front of you.”

Depth with Maturity

For those who do continue to perform or create, maturity brings depth and self-assurance.

“The main thing I see in older age is confidence,” said Linnea Glatt, 68, an artist in Dallas, TX, who works in mixed media. “When I was younger, I worried that people didn’t ‘get’ what I was doing. Now I don’t worry about that so much.”

Illness or disability can force fallow periods that ultimately prove creatively nurturing. Glatt saw that when she took a year off in 2001 for breast cancer treatment.

“It was the most productive time in my career, even though I did no work at all,” she said. “I looked through my old sketchbooks, something I never had time for, and began to really realize what I was after. I could see the beginning of the thread, the trajectory of my work.”

Even in acting, where youth seems so important, Albuquerque actress Wickwire sees benefits in getting older.

“For actors, in terms of life experience and understanding, being older is an advantage,” she said. “We bring a lot to the table.”

Love to Travel? Don’t Let Aging or a Disability Stop You

How to travel happily and safely at almost any age

As a cultural attaché for the US Department of State, Teresa Wilkin lived abroad and traveled the world, and she kept traveling, extensively, after retiring in 2004.

But it wasn’t until last year that Wilkin, 69, had what she wryly calls her “first geriatric health challenge” on the road—a bout with deep vein thrombosis (DVT), a potentially life-threatening blood clot. She had traveled without incident on a long, multicountry tour with stops in Portugal, Rome and Crete, but the last leg, a four-hour flight from Chicago to Seattle, sent her to the emergency room.

“I was in a middle seat and didn’t want to get up or bother anybody, so I slept the entire flight,” she said. “I knew something was wrong the moment I got off the plane.”

Wilkin is now in good health and still traveling—she just got back from a trip to Martinique for Carnival. But as she’s learned, travel becomes more problematic as we age. Even the most seasoned traveler must adjust for health issues, limited mobility or stamina, and take steps to avoid ailments like jet lag, motion sickness and DVT.

For older adults who want to travel, or for younger adults who wish to travel with them, the key is thorough, needs-specific research and planning. How much walking or stair climbing is on the itinerary? Can wheelchairs be used? Does the hotel have an elevator? Will there be time to rest or nonstop activities? Will restaurants be able to meet dietary restrictions? Are trustworthy medical services available?

Even a seemingly unremarkable situation can make a trip difficult and less enjoyable, said Michael Zimring, MD, director of the Center for Wilderness and Travel Medicine at Mercy Medical Center in Baltimore. On a recent trip to San Miguel de Allende in Mexico,
Zimring saw how cobblestones and narrow sidewalks turned a simple walking tour into a hair-raising ride for an older man in a wheelchair who was in his tour group.

“Older travelers really need to prepare,” he said. “The last thing you need is to be stuck in an airport because you didn’t bring the right documents for your medical syringe, or stranded in a foreign country without an adequate supply of an essential medication.”

Traveling in the Face of Ableism

Older travelers must also confront ableism—the tendency of airlines, hotels or other providers to overlook the needs of individuals with disabilities. Large hotel chains in the United States comply with the Americans with Disabilities Act (ADA); smaller hotels, both at home and in other countries, often are not held to similar standards. In some cities overseas, taxis that can accommodate wheelchairs are virtually nonexistent.

Often, ableism shows up as overlooked obstacles that are unintentional or careless, according to Debra Kerper, owner of Easy Access Travel, a Dallas-based agency that caters to older travelers and people with disabilities. She recommends using Google—her favorite travel tool—to find a travel agent or tour operator experienced in serving people with physical limitations.

“A tour guide without that specialized experience is not going to look for curb cuts or notice seemingly small obstacles that are almost impossible to navigate on a scooter,” she said.

If you’re going overseas, find out what immunizations you’ll need and have those shots at least six weeks before you set out.

Kerper prechecks each itinerary herself or contracts with local guides who’ve already led disabled travelers on the route. An inexperienced guide might assume that a restaurant with a wheelchair ramp and wide aisles is accessible, not noticing that the only bathroom requires descending a flight of stairs. A cruise ship might be designed for accessibility, but if the ship anchors and passengers are tendered (transferred from ship to shore via a smaller boat), travelers with limited mobility might be unable to join the excursion.

Kerper, 68, knows what she’s talking about, firsthand. She is a double amputee with a variety of medical conditions, including lupus; she travels along on all of the trips she organizes. Some of her clients have severe disabilities, but she says travel can be almost as challenging for people with “hidden disabilities,” such as a person with diabetes who must stop often to check blood-sugar levels or a person with a bad back who can’t sit still for long periods. Preparation is the best medicine.

Preparing for Medical Situations

One of the most important considerations is the availability of trustworthy medical care. An emergency easily handled at home could turn into a costly nightmare in an unfamiliar city, Zimring said. A hospital outside the United States may refuse to provide service unless the patient pays up front, in cash. And remote areas might not have good medical facilities. Travelers should find out in advance what health care options will be at their destination.

Zimring’s advice for healthy travel, especially overseas: consult a physician who specializes in travel medicine at least six weeks before your trip.

“If you wait until the last minute to think about immunizations, it may be too late,” he said. A vaccination for Hepatitis B, for example, is normally given as a series over a period of six months, although it can be accelerated to a six-week period.

All adult travelers should be up-to-date on routine vaccinations: seasonal flu, measles/mumps/rubella (MMR) and tetanus/diphtheria/pertussis (Tdap). Additionally, the Centers for Disease Control (CDC) recommends the shingles vaccine for those 50 and older, and pneumococcal vaccines for those over 65.

Bring copies of your prescriptions. And before you leave home, make sure your meds are legal in the countries you’ll be visiting.

Some destinations may require additional vaccines, such as polio or yellow fever; the CDC website maintains a list by destination. These vaccines may pose risks for older people, and some travelers with health conditions, like diabetes, may require additional immunizations. To navigate these complexities, Zimring recommends consulting in advance with a physician certified by the International Society of Travel Medicine; travelers can visit ISTM.org to find a practitioner in their area.

It’s also crucial to make sure all prescriptions are filled. You may need an override from an insurance carrier to make sure you have enough medication for the entire trip, plus a few extra days’ worth in case of a delay. Bring copies of your prescriptions when you travel, and make sure your medications are legal in the countries you’re visiting. (Even a legally prescribed medication can lead to disastrous consequences—a UK citizen was sentenced to three years in prison in Egypt for bringing in Tramadol, an opioid painkiller, for her husband’s back pain.) Check with the embassy of the country you’re visiting if you’re unsure. If a traveler requires oxygen, be sure to check airline policies well in advance.

If you’re traveling abroad, understand what your medical insurance will, or won’t, cover and obtain supplemental insurance as needed. (Generally, Medicare does not cover overseas care.) Read the fine print. Some policies may exclude injuries related to specific, risky activities, like riding a motorbike in Southeast Asia. Be sure to pack information on how to use your policy if needed.

If you have specific medical concerns, such as heart disease, Zimring advises doing some advance research to find out if good quality, specialized care is available, even for domestic travel. Reputable tour operators are prepared to triage emergencies—getting injured or ill travelers to a hospital, for example—but beyond that, you’ll need guidance to find good specialists. Most carriers who offer medical insurance for travelers have networks of clinicians and hospitals overseas and can assist if needed. Some credit card concierge services may also be able to assist.

Think about What You Might Not Know Before You Go

Before traveling, Wilkin always signs up online for the US State Department’s Smart Traveler Enrollment Program (STEP) for every country she’s visiting overseas. This allows her to receive safety and security advisories via email (including health-related alerts, such as Zika virus updates) and enables the US embassy to contact her should an emergency arise, whether natural disaster, civil unrest or family emergency.

Make sure you have relevant contact information (both in your phone and written down on paper) and know how to call foreign numbers if you plan to use your cellphone; check with your carrier about international limitations on your service plan. Consider downloading an app like TravelSmart from Allianz Global Assistance, which uses geolocation to find nearby hospitals, doctor’s offices and embassies, with recommendations for hospitals vetted by Allianz. (The app is free and available to all travelers but there are extra features for Allianz Travel Insurance policyholders, like claim filing.)

If one or more people on your trip has mobility issues, plan early. Accessible rooms on cruise ships fill up months in advance. Kerper is leading a cruise from Dublin to Amsterdam in 2019, and in early 2018 it was almost booked.

Visualize how you’ll navigate every step. Don’t just make reservations for a flight and a hotel; consider how you’ll move from the airplane to the curb and then to the hotel and to your room. Will you be able to easily find a taxi that can accommodate a wheelchair or should you arrange that in advance? Will you encounter cobblestones, narrow sidewalks or many stairs at the hotel? Ask your tour guide or travel agent, call the hotel or destination or go online for answers.

If you haven’t much stamina, think about renting a wheelchair or scooter at your destination. You can have it delivered to your hotel.

For group programs, read tour and excursion descriptions carefully. Many tour companies rate the accessibility and difficulty of their programs. Road Scholar, for example, has a seven-level rating system for its programs catering to older travelers, ranging from “easy going” (typically bus trips with minimal walking or stairs) to “outdoor: challenging” (vigorous exertion in rugged and steep terrain).

Kerper encourages older travelers with joint problems or limited stamina to consider renting a scooter or wheelchair even if they don’t normally need one at home. Both can be reserved in advance for delivery at a hotel or other destination. Kerper uses a rental agency like Special Needs at Sea, which serves cruise lines and hotels in all port cities. (Elsewhere, she turns to Google for local agencies; in that case, it’s a good idea to check reviews first.)

Find out about options for travelers with limited mobility. The regular tour of the famous opera house in Sydney, Australia, for example, involves a climb of more than 200 steps. But there’s also another tour for those with limited mobility, available with advance reservations.

During plane travel, Zimring said, you can help prevent DVT by choosing an aisle seat, wearing loose clothing and drinking plenty of water. Walk before and during the flight as much as possible and do leg stretches (foot flexes, ankle rotations) when seated. To minimize jet lag, Zimring advises starting to adjust your sleep schedule gradually about seven days before departure.

On the trip, avoid heavy meals, alcohol and caffeine before bedtime. Melatonin supplements may help; ask your doctor first for advice on the best time to take them.

Connecting Generations through Travel

Valerie Grubb never expected she’d become traveling companions with her mother, let alone that the two of them would cover some 400,000 miles together over 20 years, visiting destinations like Italy, Australia, China, Thailand and Cambodia.

“Travel has brought my mother and me together in a way that no number of phone calls could,” said Grubb, who has put her lessons learned and tips into a book, Planes, Canes, and Automobiles: Connecting with Your Aging Parents Through Travel (2015).

Intergenerational travel offers a way to carve out time together, reconnect in a meaningful way and have fun. Even when plans go awry, Grubb said, “It makes for a great story when we’re back home.”

If you’re planning an intergenerational trip, make sure to include activities for every member of the group to enjoy. A cruise may offer a range of options from active to sedentary; one family member can relax on the boat while another opts for an active excursion on shore. Road Scholar offers a wide array of educational, group programs designed for grandparents and their grandchildren, such as the “Exploring the Northwoods with Your Grandchild” hiking trip or “Surf and Sea San Diego,” an active outdoor adventure. Kids spend time with their grandparents but also have time to make friends with other youngsters in the group.

As the younger traveler in her duo, Grubb said it’s important for her to know her mother’s current physical condition when planning a trip. This can change significantly in a year or two. She suggests visiting the older person in advance of a major overseas vacation, to get a good sense of his or her abilities. Then, be flexible and adjust travel plans if needed.

“When Mom and I first started traveling, we’d pack lots of sights in one day,” Grubb said. “Those days are gone.”

Gradually, their travel itineraries became simpler and less demanding. In the last year or so, they’ve had to limit their travels to car trips, due to new medical problems that preclude air travel. Grubb has also noticed that her mother, now 88, has become less tolerant of cultural differences and less adaptable to change as she’s aged, and this has altered their choice of destinations.

Expect the Unexpected

Even the most thoroughly researched and mapped trips can be thrown off kilter. Chances are, there will be glitches: delayed flights, missed connections, reservations that don’t show up in the system, unanticipated health issues, weather emergencies and plain old human error.

“Glitch-free trips are the odd ones these days,” Grubb said. “Something is going to go wrong. Set your mind up for it. Expect it.”

Kerper’s advice: try to roll with unexpected snafus and see them as part of the adventure. Recently, on a Caribbean cruise, as she was leading a group of travelers who used wheelchairs, they came to a shop on Bonaire that wasn’t accessible.

“We told the shop owner that we were looking to spend our money in his shop and asked if he could put out a ramp for us,” Kerper said. The shop didn’t have a ramp, so the employees brought trays of merchandise outside and mingled with the group as they made their selections. A routine shopping stop turned into a fun cultural encounter.

Kerper added that when she makes requests for accommodations, proprietors often say they will make the changes needed so that their establishments will be accessible in the future.

And that’s one of the most rewarding parts of the job, Kerper said: she’s not just helping clients have fun, she’s building awareness. “Just because you have limitations doesn’t mean you have to stay at home,” she said.

Looking for Work after 50? Are You Also Out of Luck?

The problem is serious, but there are new, hopeful signs

At one point in her career, Amy Anderson supervised more than 50 people and managed a multimillion dollar budget for a Fortune 500 company. But after losing what she calls her “last good job” in 2013, she had no luck finding a position with anywhere near the same pay or status she once enjoyed.

Now, at age 57, she’s a cashier at a convenience store in the greater Cincinnati area, earning minimum wage with no benefits.

Anderson’s experience is not unique. Job opportunities are limited for older people seeking employment. According to a study by the Center for Retirement Research at Boston College, job changers over age 50 often end up shunted into what economist Matthew S. Rutledge calls “old-person” jobs: low-status, low-paying positions such as school crossing guards, nurses’ aides, security guards, delivery drivers and retail clerks. Occupations that require extensive training, computer use, numerical aptitude and union membership are significantly less open to older job seekers.

“We definitely believe that age discrimination and stereotyping is a big part of it,” Rutledge says. “In some cases it’s voluntary; older people may choose jobs that are less stressful or less physically demanding. But often it’s not.”

Older workers are often the first to be let go and have the hardest time finding another job.

Among jobs that are physically demanding, like farmer, electrician or repair person, only about a quarter of new hires are over 50. And in fields where jobs are scarce, older workers have an extremely difficult time finding work. In manufacturing—long a declining industry in the United States—men and women 55 to 64 were 25 percent less likely to be hired as machine operators and 58 percent less likely to land metal-worker jobs, compared to their younger peers.

Rutledge does caution that the Boston College study is skewed, in that it looks only at those who found jobs (the “winners” in the job market). In many cases, older workers don’t find work at all. Job seekers 55 and older are more likely to join the ranks of the long-term unemployed—those who’ve been looking for work for 27 weeks or more. In October 2017, 34.7 percent of job seekers 55 and older were long-term unemployed, compared with 23.7 percent of job seekers 16 to 54.

And many older job seekers who do find work are underemployed, ending up with jobs that offer lower pay, fewer hours and limited benefits, according to a 2015 AARP report, “The Long Road Back: Struggling to Find Work after Unemployment.”

Many older workers face a triple whammy: they’re often the first to go when companies make cutbacks, because seniority means their salaries are higher than those of their younger counterparts. Then they have the hardest time finding new jobs, at a time in life when they can often least afford it, when they’re also paying kids’ college tuition, or for care for aging parents. Mortgages aren’t yet paid up and retirement looms just a few years away.

Perception Problem

Why? Older workers face a perception problem, according to Beverley Riddick, executive director of the Ready To Work Business Collaborative, a nonprofit based in New York that encourages employers to hire talent they may have overlooked in traditional recruitment, including older workers.

Hiring managers may assume that an older job seeker is stuck in old habits or “won’t play well” with a supervisor who is the same age as his or her children. Riddick recalls the experience of a 60-something job candidate who felt he’d nailed a job interview—until the considerably younger hiring manager walked him out. Looking around at the office’s open layout, the hiring manager turned to the candidate and asked, “Do you think you’d fit in here?”

“At that moment, the candidate knew then that he wasn’t going to get the job, and he never heard back,” Riddick says.

The New Start Career Network, which serves long-term unemployed job seekers 45 and up in New Jersey, identified a list of stereotypes that contribute to the problem: the beliefs that older workers are not interested in acquiring new skills; that they lack ambition and energy and have cognitive or physical health challenges; that they are inflexible and less tech savvy; and that they will cost more in wages and health insurance.

There are times when being better educated limits an older person’s job prospects.

Even the hiring process itself puts older adults at a disadvantage, according to Claire Turner, director of the senior employment program at the Senior Source in Dallas. Many companies now use impersonal digital tools, like keyword searches, to screen resumes. Job seekers who don’t know how to work the system, or whose qualifications don’t fit preset, and sometimes arbitrary, requirements, end up eliminated before a human being even sees their resumes. For example, when an employer posts a job opening for candidates with three to five years of experience, the computer-based screening process may automatically filter out qualified people who happen to have more years of experience.

Older job hunters who do get past the computer screening process often don’t get past the first interview. Employers usually won’t say why they didn’t hire someone, and they’re particularly careful not to mention age. But older job candidates often sense a hiring manager’s dismay when they meet.

“The person turns up for the interview, and the hiring manager—someone in his 30s—will say something like, ‘Are you going to be able to get up these stairs in the lobby?’” Turner says.

Education Helps—Maybe

Older workers with the least education face the narrowest set of opportunities, according to the Boston College study. Anderson believes that was part of her problem: she lacks a college degree. She was able to prove herself in the workplace, but in the job market, that missing degree automatically disqualifies her for many jobs.

Paradoxically, however, education can also limit an older job seeker. After George Delianides, 60, of Saugus, MA, lost his position at age 58 at a marketing research firm, he decided to take his master’s degree off his resume.

“My thinking was, that omission might help get my foot in the door for at least an interview,” he said. “Otherwise the employer could assume that, with my age, experience and formal education, I was way out of their salary range.”

Riddick says that’s a common drawback for many older workers.

“Employers tend to back away from people who’ve earned higher salaries in the past,” she said. “They’ll say, ‘I’m not going to interview someone who made $125,000, because I’m only paying $75,000,’ even though that older job seeker might happily take that lower salary because of financial responsibilities.”

It’s Not Just about the Paycheck

When older workers are unemployed or underemployed, it’s not just their personal finances that suffer. Employment means more than a paycheck. Work offers routine, purpose and a social environment, all linked to better physical and emotional health.

“I’ve met some accomplished, wonderful people who feel unemployable for the first time in their lives,” Turner says. “It can be very discouraging.”

Anderson notes that, when her four children were young, her prospects for promotion were sometimes limited because she was unable to travel extensively.

“Now, I’m an empty nester, and I can put in those extra hours, but I can’t find a good job,” she said.

The good news: some major companies now offer internships or training programs meant for older people.

She adds that, if she were fully employed, she’d continue paying the maximum amount into social security until age 65 or later. Now, she’s draining her retirement savings to make ends meet and will likely need to start collecting benefits at the earliest possible date.

Most older Americans are already behind on saving for retirement; if they lose several prime earning years, they’ll fall even farther behind. That has negative implications for society as a whole.

“When older people start to deplete their own resources near retirement age, it makes them even more reliant on whatever federal or state backdrops are available,” says Greg McBride, Bankrate.com’s chief financial analyst.

Reasons for Hope

Not every company is unwilling to hire older workers. Some are actually taking strides to embrace their job experience and finding creative new ways to bring them back into the workforce.

Some major companies are offering internship or training programs specifically geared toward older employees. Many focus on professionals who’ve taken career breaks, such as parents who left to raise children. Goldman Sachs, for example, hosts a “returnship,” a highly selective, 10-week program that pays competitive salaries to qualified candidates, most of them 40 or older, who had achieved an executive-level status in their earlier career and who had been out of work at least two years.

“Internships help remove some of perceived risk that hiring managers may associate with hiring from this pool, and they give the participants a gradual and structured ramping-up platform,” writes Carol Fishman Cohen, CEO of iRelaunch, a company that works with professionals seeking to return to work, as well as with employers recruiting from this demographic group.

Some career experts advise proceeding with caution, however: not all internships pay, and they don’t always lead to permanent jobs.

The Senior Source’s Turner thinks she’s beginning to see an attitude change, especially among employers in smaller and medium-sized companies.

“They appreciate older workers’ work ethic and their reliability,” she says. “Employers are clamoring for people who are good with customers, and many people over 50 have those interpersonal skills.”

Focusing on those strengths, Delianides believes, is what helped him land another good job despite his age. His new position in marketing at a retail firm is roughly equivalent to his previous job in terms of responsibility. His pay is lower, but he didn’t expect to match his previous salary, given that he doesn’t have 18 years of seniority with the new employer.

“I played to my strengths,” he says. “I know the business. I’ve been in stressful situations before. I can be counted on.”

But for others like Anderson—who recently learned that the convenience store where she works will close soon—the inability to find a good job weighs heavily as they look to the future.

She’s taking it day by day, which keeps her focused, she says, adding, “Thinking ten years out overwhelms me.”

How to Save Yourself and Those You Love During a Disaster

Hurricanes, floods, active shooters: you’re safer if you know what to do

When Hurricane Harvey struck his neighborhood on August 28, 2017, the Rev. John Stephens of Chapelwood United Methodist Church in Houston helped launch a “boat ministry.” He and several men in the church navigated privately owned boats into the rising flood waters to rescue neighbors stranded in their homes.

Stephens quickly noticed something victims had in common: most were older people.

“Maybe they were thinking, ‘I’ve seen Hurricane Allison, I’ve seen Rita, I’ve seen Ike,’ and thought they could weather the storm in their homes,” he said.

Maybe. But what Stephens discovered is something emergency-management experts already know—and struggle with: when disaster strikes, older adults are particularly vulnerable.

Almost three-quarters of the 739 people who died in Chicago’s deadly heat wave of 1995 were 65 or older, according to Eric Klinenberg, author of Heat Wave: A Social Autopsy of Disaster in Chicago (2002). Similarly, when Hurricane Katrina struck New Orleans in 2005, three-quarters of those who died were over 60, according to a Knight Ridder analysis, and among those, about half were over 75.

“The victims of Katrina were not disproportionately poor; they were disproportionately old,” wrote Amanda Ripley, author of The Unthinkable: Who Survives When Disaster Strikes—and Why (2008).

The key to surviving a disaster is clear thinking, ahead of time when possible, and during the event itself—making a plan will greatly improve your chance of survival. It’s also important to understand why older adults are more vulnerable, so family, neighbors and communities can help reduce complications and casualties as much as possible.

Planning to Survive

Not all disasters are predictable; forecasters can predict a hurricane, communities can know they are in tornado alleys, yet many emergencies are sudden—earthquakes, transportation accidents, an active shooter. Many people watch these events unfold elsewhere on the news and feel helpless, thinking that there’s no way to prepare. However, surprisingly simple measures—in advance, during and after the emergency—can mean the difference between life and death in an emergency, especially for older adults.

“Even a minor amount of preparation can pay major dividends,” wrote Russel L. Honoré in Survival: How Being Prepared Can Keep You and Your Family Safe (2010). Honoré, a retired US Army lieutenant general, led planning and response operations following several hurricanes, including Katrina.

The American Red Cross’s publication, Disaster Preparedness for Seniors by Seniors, offers three steps for preparedness: get a kit; make a plan; be informed.

Assemble a disaster kit for sheltering at home. The kit should contain enough food, water, medication and medical supplies (hearing aids, glasses, etc.) to last at least three days. Plan on at least one gallon of water per person per day. Include food items that are nonperishable and that don’t require cooking, such as peanut butter, granola bars and canned tuna, meats or beans. (Be sure to store a can opener in your kit, and replenish food periodically to ensure your supply is fresh.)

A flashlight and weather radio are also recommended. Stock extra batteries or buy hand-cranked models. Store vital records and documents (including passports, driver’s licenses, birth and marriage certificates and social security cards) in a fireproof, waterproof container, and make sure it is accessible to grab in an immediate evacuation.

Know how to turn off gas and electric utilities in your home. Keep your car’s gas tank at least half full at all times.

Discuss an emergency plan with family members, or with friends, neighbors, church acquaintances—people who will know to check on you as soon as possible. Decide where you’ll shelter in your home in severe weather, and where you might go if evacuated for an anticipated disaster such as a hurricane. Make a plan for how you’ll stay in touch with family members if you’re separated. Know how to turn off utilities (gas, electricity) in your home. Review your plan every six months and update as needed. Be sure to include out-of-town relatives in your planning and discuss how you’ll let them know your whereabouts should you evacuate.

Power outages after a disaster may drag on for days, even weeks, making it difficult to replenish basic supplies such as gasoline or medication. Keep your gas tank at least half full at all times. If possible, work with your pharmacist and insurance company to obtain a seven-day, emergency supply of all medications. Store them in a waterproof container and rotate them through your medication schedule to keep them fresh. Keep a supply of cash on hand too—ATMs and credit card machines often don’t work if the power is out.

Be prepared to communicate. During Hurricane Harvey, many people called for help with their cell phones, via 911 or social media. Keep your cell phone charged and protected from the elements. Consider investing in a protective case (like an OtterBox) and extra batteries, or a hand-cranked or solar charger. Write down important phone numbers because when your cell battery dies, you won’t be able to access your contacts. Learn steps to minimize power consumption on your cell phone—such as dimming the background light or selecting low-power mode—to extend battery life.

After an emergency, cell service is often overloaded but texting may still work when the network is busy. Don’t forget to try your landline, if you have one, as it may work when cell service is out or slow. Discuss your plans for communication with out-of-town relatives as well as immediate family members.

Finally, stay informed through reliable media sources and community notifications.

Pets and Valuables

If you have a pet, the family disaster kit should include enough food, medicine and water for each animal for at least three days. Prepare to evacuate your animals too.

“If it’s not safe for you to stay behind, then it’s not safe to leave pets behind either,” according to the Red Cross’ online pet-preparation guide. Ready leash or carrier, copies of medical records and any special, care instructions (in a waterproof container or bag), as well as current photos of your pets if you have them, in case an animal gets lost. Ensure that your pet’s vaccinations are up to date. Consider having it microchipped by your veterinarian, which may help you find it should you become separated.

Most American Red Cross shelters do not accept pets, although they do accept service animals. You’ll need to make alternate arrangements to shelter your pet. Find out which hotels along your evacuation route will accept animals. Some will waive no-pet policies in an emergency but call first to confirm. Make a list, with phone numbers, of friends, relatives, boarding facilities, animal shelters or veterinarians that might care for your animals in an emergency.

The ASPCA recommends placing a rescue alert sticker near the front door of your home to notify emergency personnel of animals in the house. Some fire departments provide these. If you do leave with your pets, write “evacuated” on the sticker, so responders don’t waste time looking for them.

In an emergency, your first priority is to keep family members safe. But if time permits, consider moving valuables to safer locations. If you’re anticipating flooding, for example, family photos might be stored upstairs or on a high shelf in a sealed, plastic, storage container. High-value items like jewelry may be moved to a safe or other secure storage.

But Why Are Older People So at Risk?

If you’re concerned about helping an older adult, it helps to understand why they are so vulnerable in disasters.

If an older person has problems with mobility, can’t drive, has no access to transportation or becomes easily confused, evacuation can be difficult. Social isolation contributes too, because they might feel as if they have nowhere to go or no one to ask for help.

In Hurricane Katrina, many low-income older adults were hampered by an unlucky quirk of timing, noted Honoré. The hurricane made landfall in southeastern Louisiana on August 29, 2005—a few days before Social Security or disability checks arrived. For some, that meant there was no money to buy a tank of gas, a bus ticket or an extra bag of groceries.

“When a hurricane hits at the end of the month, the poor, elderly and disabled people who rely on government checks will not have the money to evacuate,” Honoré wrote.

Along with the heroes come the exploiters. When older people go into crisis mode, they’re more vulnerable, scared and not quite as wary.

–Liz Loewy

Older adults are not just physically more vulnerable; they’re also more likely to suffer financially in a disaster’s aftermath. An older adult’s home may have been paid off long ago and thus may not be adequately insured. Applying for disaster aid is a complex and often confusing process that may require multiple visits to an agency office. And then there are the fraudsters—bogus repair services, fake charities and identity thieves—who show up in the wake of every disaster, targeting older adults.

“Along with the heroes come the exploiters,” said Liz Loewy, co-founder of EverSafe, an identity protection service, and former chief of the Elder Abuse Unit in the Manhattan district attorney’s office. “Anyone can fall for a scam, but when older people go into crisis mode, they’re more vulnerable, scared and not quite as wary and able to recognize a scam.”

Loewy adds that even those outside of the disaster area may be vulnerable, as fake charities crop up, purporting to help victims, but actually pocketing donations instead.

Preparing for the Unexpected

Sudden disasters can take many forms and occur in many places: an active shooter, a sinking cruise ship, a car accident, a hostage situation, a terrorist attack.

While it’s not possible to anticipate every emergency, some basic habits can help. Being aware of your surroundings will boost your chances of survival in almost any situation. For example, if you enter a public space like a movie theater, make a note of the location of the exits. If you’re on a cruise, attend the safety demonstration, pay attention and take notes if you think you might forget details.

You can’t guarantee your safety, but you can improve your odds. Many assume plane crashes are generally unsurvivable, but among all passengers involved in serious accidents between 1983 and 2000, more than half survived. (Serious accidents are defined by the National Transportation Safety Board as those involving fire, serious injury or substantial aircraft damage.) Survival often depended on simple steps: paying attention to the flight attendants’ safety briefing, noting the location of exits or evacuating the plane quickly, without pausing to grab luggage.

Preparing as a Nation

About 70 people died in Hurricane Harvey; still too many, but far fewer than the more than 1,800 deaths in Hurricane Katrina. The two disasters were different—for one thing, the water rose much faster in Katrina—but the contrast points to some progress in national preparedness to help keep seniors safe.

“We learned a lot of lessons during Katrina,” said Carrie Reyes, director of emergency
management for Plano, TX. “The best way we can help seniors to be more prepared is through education. We need to demystify disaster and make them aware of the tools to help them prepare.”

She notes that emergency managers at local levels have become much more proactive in establishing connections with older adults in their communities. Reyes, for example, frequently visits older-adult living communities and meets with groups to provide education and to involve them in community disaster planning.

After the events of Hurricanes Katrina and Rita, special needs issues—such as limited mobility, medical conditions or cognitive issues, all of which affect many older adults—were fully integrated into all phases of emergency management. (This was part of an amendment to the Robert T. Stafford Disaster Relief and Emergency Assistance Act, which established laws guiding federal natural-disaster assistance for state and local governments.)

“Emergency managers are now tasked by federal legislation to engage our entire community,” Reyes said. “That includes the very young, the very old and those who may have access or functional needs.”

Some communities have developed systems to better track older adults and those with special needs; several counties in Florida, for example, offer vulnerable-population registries. Residents register their name, location and any special needs in the system. In the event of disaster, the registry may be used to help locate registrants during search and rescue operations.

The neighbor, whom they’d never met, said, “My house is dry and I have a second floor. We’d like you to stay until the water recedes.”

— Carrie Reyes

Reyes, who was deployed after Hurricane Harvey to Port Aransas, TX, to assist local emergency managers in rescue and recovery, also thinks that there’s more awareness of older adults’ needs in disasters.

“There was a lot of spontaneous sheltering and neighbors checking on neighbors with Harvey,” she said. Someone with a key to a local school, for example, might open it as a makeshift shelter if the school was located on higher ground.

Reyes’ great uncle and aunt, both in their 80s, live in Houston; when their house began taking on water, a neighbor knocked on their door. “The neighbor, whom they’d never met, said, ‘My house is dry and I have a second floor. We’d like you to stay until the water recedes.’”

Family members and neighbors can help older adults prepare. If you live close by, include them in family or neighborhood disaster planning. Offer to assemble a disaster kit or to purchase supplies for one.

Reach out to older adults in your community who may not have family nearby or other sources of social support. Provide your contact information and check in on them before a known emergency and after an event occurs.

Simply staying in touch with an older-adult neighbor or family member can be crucial. Author Klinenberg believes isolation contributed to the high death rate among seniors in the Chicago heat wave.

“Decades of migration out of Chicago, where the total population decreased by more than a million between 1950 and 1990, and several neighborhoods lost more than half their residents, increased the likelihood that the city’s seniors would be isolated and alone,” he wrote. By contrast, in neighborhoods like Little Village, where social ties were strong and residents enjoyed congregating in public spaces, older adults fared better during the heat wave.

Even after Preparing, Leaving Might Be Best

Sometimes, older adults may resist evacuation, simply because they’ve lived long enough to survive disasters before. Many who died in Hurricane Katrina, for example, were middle aged when Hurricane Camille struck in 1969; having survived, they felt they could manage.

“I think Camille killed more people during Hurricane Katrina than it did in 1969,” said Max Mayfield, former director of the National Hurricane Center. “Experience is not always a good teacher.”

When an older adult doesn’t want to evacuate, Reyes recommends a realistic but respectful conversation.

“Say, ‘Hey, Mom, Dad, if you stay here, it might get bad and I might not be able to come get you for a couple of days; is that what you want?’” she said. “Respect their wishes but make sure both of you understand the outcome of those decisions.”

Bill and Paulette Rogers of Port Aransas, TX, both in their 60s, learned just how bad it can get during Harvey. They decided to ride out the storm at home, even though their grown children begged them to evacuate. When the storm struck, a tree tore through their upstairs bedroom and water began to surge into the house. The couple ended up spending the night in their pick-up truck, with water up to their shoulders, expecting to die.

Thankfully, they survived.

“This is the dumbest thing I’ve ever done,” Bill Rogers later told a reporter.

Playbook for Later Life

Want to stay active and engaged in your later years? Start while you’re young

In July, 2017, Baltimore Ravens offensive lineman John Urschel rocked the sports world with a stunning announcement: he was retiring from pro football, at the top of his game, at age 26.

Urschel, once dubbed “the NFL’s smartest man,” will work full time on his doctorate in mathematics at MIT. His announcement came just two days after a report revealed that chronic traumatic encephalopathy (CTE) had been found in 110 of the 111 brains of former NFL players studied.

While he didn’t publicly detail his reasons, it’s clear that Urschel’s choice to sacrifice one love—football—was made in the interest of his long-term well-being.

What if all young adults had solid, relevant information to help them make choices that could boost their chances for health and well-being in their 50s, 60s, 70s and beyond? What if there was a playbook for later life?

Here are some key plays to help young people score points in favor of a healthier, happier older adulthood.

Play #1: Toss Your Chair

The average American sits 13 hours per day, and it’s killing us.

Sedentary lifestyles have long been blamed for obesity, heart disease and other problems, but a mounting body of evidence now suggests that sitting eight hours a day —at a desk or in front of a computer or television—may create more health havoc than regular trips to the gym can possibly counteract.

“For every hour we sit, two hours of our lives walk away,” writes James A. Levine, MD, author of Get Up! Why Your Chair is Killing You and What You Can Do About It (2014). “The list of health consequences is an alphabet soup of life’s torments: A is for arthritis, B is for blood pressure, C is for cancer, D is for diabetes … and so it goes.”

What to do: People in their 20s can take advantage of this recent research to tweak their environments to reduce their chair time. Find ways to stand more, move more and sit as little as possible. If you work at a desk, consider a standing or a treadmill model. Or try sitting on an exercise ball or a backless stool, to force your core muscles to work harder. Use a tracking device, like a Fitbit, to remind you to get up and move every 30 minutes or so. Make a few of these changes in your 20s, and you’ll save yourself thousands of hours of life-sapping sitting.

Play #2: Don’t Go to Extremes

More and more adults, young and old, are testing themselves in Ironman triathlons and ultramarathons or with extreme sports like surfing, mountain biking or skateboarding. But while these sports get people moving, they may come at a price.

The thrill of extreme sports goes with a higher risk for severe neck and head injuries. According to a study presented at the 2014 annual meeting of the American Academy of Orthopaedic Surgeons, of the 4 million injuries reported from 2001 to 2011 among extreme-sports participants, 11.3 percent were head and neck injuries. Teens and young adults accounted for the highest percentage. Injuries were mostly likely to occur, in order, in skateboarding, snowboarding, skiing and motocross.

Similarly, endurance athletes may ultimately put too much unhealthy stress on their hearts. (Endurance athletes are those who train at an intensive level six to 10 hours per week, or more, and participate in at least two or three marathons or similar events per year.) Two recent studies showed a surprisingly high incidence of plaque in their hearts, a possible hallmark of cardiovascular disease. Another, earlier study found that long-time, elite, male endurance athletes had a higher incidence of scarring within their heart muscles.

What’s not clear is whether these higher incidences of plaque or scarring actually threaten heart health or increase mortality risk.

“In fact, the overwhelming amount of evidence is that endurance athletes … have youthful cardiovascular systems and they live longer,” said Benjamin Levine, MD, a professor of cardiology at the University of Texas Southwestern Medical Center and director of the Institute for Exercise and Environmental Medicine at Texas Health Presbyterian in Dallas.

Levine says the takeaway is this: if you’re sedentary, adopting a regular schedule of two to three hours of exercise per week will greatly reduce your risk of cardiovascular disease. But doing more won’t further reduce your risk of heart attack.

What to do: Exercising is far better than being inactive—just don’t overdo it and stick to safer sports. The American Heart Association recommends a minimum of 150 minutes of moderate physical exercise a week. For joggers, a Danish study recommended a leisurely jog a few times a week (about one to two-and-half hours total) at a moderate pace.

Play #3: Start the Simple 7

The American Heart Association’s “Simple 7” is a list of key behaviors that can help ensure heart health: maintaining a healthy weight and normal blood pressure; controlling cholesterol; reducing blood sugar; being active; eating better; and stopping smoking. People who follow these guidelines in their 20s have a lower risk of heart disease in middle age, according to a Northwestern University study.

A bonus: mounting evidence suggests that what’s good for your heart is also good for your brain. While keeping your heart healthy will keep you physically vital longer, maintaining cognitive function will enable you to stay engaged in your longevity. According to a study published in 2017 by the American Academy of Neurology, “people who took care of their heart health in young adulthood may have larger brains in middle age, compared to people who did not take care of their heart health.”

What to do: Make “the Simple 7” part of your lifestyle in your 20s. And strive to form one or two good, new habits. Learning to cook, for example, will help you avoid unhealthy fats, sugars and salt found in prepared convenience foods and fast foods. Ditto for practicing portion control, eating more veggies or eating one or two meatless meals each week.

Play #4: Drink and Be Merry—in Moderation

“Moderation is best in all things,” according to the Greek poet Hesiod. For living a longer, healthier life, that’s your best approach when it comes to alcohol.

Excessive intake of alcohol, of course, will put you on a path to poor health and an early death. New research suggests that those who are alcohol-dependent, particularly women, may shorten their lives even more than smokers. Alcoholism leads to lower bone mass, even among younger men, putting them at greater risk of fractures and poor healing, according to a study at the Medical University at Innsbruck, Austria.

However, doctors aren’t advocating abstaining entirely, and a few diets, such as the Mediterranean diet, include a glass of red wine with the evening meal. In a study of the British National Health Service’s patient records, published in 2017 in the BMJ, researchers found that drinking no alcohol was associated with an increased risk of heart disease compared with moderate drinking. Like many studies, however, this one points to links between drinking and cardiovascular health but doesn’t prove a cause-and-effect relationship. Most physicians aren’t ready to encourage nondrinkers to take up tippling.

“We don’t understand the physiology of how moderate amounts of alcohol might benefit your heart,” said Abraham Jacob, MD, a cardiologist and founder of Heart & Vitality in Plano, TX. “But we do know that there’s a flavonoid in the skin of the grapes used to make wine, which may explain why it helps us when we’re talking about drinking a glass of red wine.”

What to do: If you enjoy drinking alcohol, keep your intake moderate. In the British study, moderation was defined as the equivalent of six pints of beer or 10 small glasses of wine per week, preferably spread out over at least three days. If you’re drinking stronger stuff, dial down accordingly.

Play #5: Find Work That Matters

You’ve heard the old chestnut, “Nobody on their deathbed has ever said, ‘I wish I had spent more time at the office.’” But Maria Carney, MD, chief of geriatric and palliative medicine at Northwell Health in New Hyde Park, NY, believes that keeping busy is important to health and vitality later in life. She’s observed that many of her most vital older patients are still engaged in work they enjoy. And those who are not fulfilled by their work or activities seem less happy.

“Many people tell me, ‘I never should’ve retired,’” she said. “Whether it’s paid work, volunteer work or even working on a hobby—work seems to keep people engaged, connected to others and vital.”

Young adults make crucial job and career choices that have enormous implications for well-being later in life. One Ohio State University study found that work life in your 20s may affect your mental health in midlife. People who were generally unhappy with their jobs in their 20s and 30s were more likely to experience some health backlash by the time they reached their 40s.

“If I can give just one piece of health advice for 20 year olds, I would suggest finding a job they feel passionate about,” Hui Zheng, associate sociology professor at Ohio State University, told the New York Times in an October 17, 2016 article. “That will, in turn, make them more engaged in life and healthier behaviors.”

But don’t spend your 20s sitting on the sidelines waiting until the “perfect” career path reveals itself, counters Meg Jay, author of The Defining Decade: Why Your Twenties Matter—And How to Make the Most of Them Now (2012). “Research shows that getting going in the work world is the beginning of feeling happier, more confident, competent and emotionally stable in adulthood,” she writes. Jay encourages young adults to build “identity capital”—skills, accomplishments and experiences that earn them a place in the adult marketplace and move them closer, bit by bit, to meaningful work they enjoy.

What to do: Choose a job that yields higher satisfaction, even if it means slightly less pay. If your first job is less than ideal, focus on building that identity capital so you’ll be better prepared when a better opportunity arises.

Play #6: Give Kids a Strong Start

Family relationships and the home environment in childhood have long-term implications for health and well-being. Begun in 1938 and still ongoing, the Harvard Study of Adult Development found that a warm and intimate childhood was one of the key predictors of successful aging.

Childhood behaviors and habits also affect our later years. One University of Aberdeen, Scotland, study has linked early misbehavior—stealing, bullying, disobedience, irritability—to chronic pain in middle age. And a longitudinal study by the University of Wisconsin-Madison found that the higher the study participant’s rank in high school, the lower the probability of worsening health many years later as participants neared retirement age.

A Lancet Commissions study, Dementia prevention, intervention and care, identified higher educational achievement in childhood as one of several factors that might have the potential to delay or prevent dementia.

“Stimulating your mind, or learning another language, may help build brain reserve early in life,” said Laura Gitlin, one of the study’s coauthors and director of the Center for Innovative Care in Aging at Johns Hopkins University. “The basic conclusion is that we should be investing in the best education possible for all children.”

What to do: If you’re raising children, if you’re grandparents or if you’re a teacher, be aware that the experiences of the youngsters in your care will affect their health and well-being later in life. Do what you can to give them the strongest start possible.

Save on Health Care at the Playground

Designers are creating playgrounds just for older people

When Ronni Bennett discovered elder playgrounds online a few years ago, she immediately fell in love with the concept. She began researching how the outdoor parks, designed specifically for the social and fitness needs of older adults, have become popular in Asia and Europe. She interviewed designers and looked into the special equipment involved.

Bennett, 75, a retired web producer who writes an influential blog about “what it’s really like to get old,” began lobbying her city council to build an elder playground in Lake Oswego, OR, the town where she lives. She was successful: her community now has a fitness park with 10 pieces of equipment designed specifically for older adults, including three that are wheelchair-friendly.

But, claiming it would be impossible to enforce an “elders only” policy, Lake Oswego officials named the park “FIT Spot.”

Bennett blames ageism. “I am so sorry the word ‘elder’ is not in the name,” she said. “But that is how things go in a culture as terrified of aging as ours is. Nobody wants to say there are old people here.”

Bennett’s experience may help explain why elder playgrounds are taking off much more slowly in the United States than in other parts of the world. While interest is growing, only a handful of dedicated “elder playgrounds” have been installed in the United States. Convincing communities to give money and space to parks that are for elders only is proving to be a hard sell.

Roots in China

Elder playgrounds have been around for about 20 years in other countries. In 1995, with the adoption of the “Physical Health Law of the People’s Republic of China” along with an “Outline of Nationwide Physical Fitness Program,” China began building outdoor fitness centers geared to all ages. In 2003, the University of Lapland in Finland, partnering with manufacturer Lappset, designed and built a playground for elders for research. Around the same time, Japan began repurposing children’s playgrounds as “Nursing Home Prevention Parks,” with specialized workout stations and classes, in response to the nation’s aging demographics. The concept quickly spread to Germany, England, Spain and Canada.

Elder playgrounds typically feature low-impact exercise equipment designed for the specific fitness priorities of older adults, such as building balance, coordination and flexibility. Equipment is lower to the ground and equipped with seats or grips geared to people who might have limited mobility or strength.

Regular use of an elder playground can boost older adults’ physical fitness and help prevent illness. One study found improvements in balance, coordination and speed after just three months.

Some elder playgrounds have been built in the United States, and there are hopeful signs that more are on the way. Colin Milner, founder and CEO of the International Council on Active Aging (ICAA), notes that many manufacturers of outdoor playground and fitness equipment have added or expanded lines of equipment specifically for older adults in recent years.

“These companies don’t jump on board unless they feel there is a significant opportunity,” Milner said.

While ICAA hasn’t tracked elder playgrounds specifically, its 2015 survey of health clubs, senior centers, retirement communities and continuing care retirement communities (CCRCs) found that 21 percent planned to purchase outdoor exercise equipment by 2017. At the time of the survey, some 41 percent planned to add game courts by 2017, 38 percent intended to create outdoor fitness or exercise trails and 57 percent aimed to install walking trails or paths.

From Kids to Elders

Michael Cohen, a veteran designer of children’s playgrounds, first became intrigued with spaces devoted exclusively to older adults when he saw a Good Morning America report on a “pensioners’ playground” in Manchester, England. That led him to found Must Have Play, an Ithaca, NY-based design group exclusively focused on innovative playgrounds for older adults. He has designed several elder playgrounds for parks in US cities, but so far none have actually been built.

Cohen envisions elder playgrounds as places that offer more than a good workout. He’d like to see elder playgrounds promote play in forms suited for older adults’ abilities, with courts or equipment for sports like pickleball, paddle ball, bankshot basketball or bocce ball, and loaded with features like water elements, walking paths and game tables.

“Ideally, an elder playground is not just a place to exercise,” Cohen said. “It’s an inviting space where you’d want to spend time.”

In the United States, playgrounds that cater to multiple generations are catching on more quickly than those designed exclusively for older adults.

That’s what happened at Carbide Park, in Galveston County, TX, which added an elder playground in 2014. The park has become a favorite destination for field trips from three local senior centers. On days when the weather is not too hot, busloads of older adults arrive to enjoy the park, according to Julie Diaz, director of parks and cultural services for Galveston County.

“If they want to go outside, they know they can come here to exercise, to swing or just to sit and talk with other seniors,” Diaz said. “The elder playground provides the type of exercise they need, and it’s very specific to them.”

Some elder playgrounds have arisen as outdoor extensions of local senior centers, such as the fitness park at the Rockville (MD) Senior Center. Cohen says that’s a big plus—proximity to a senior center or a senior residence gives visitors access to clean bathrooms and a place to go for help in the event of emergency.

The Rockville park features equipment developed especially for the needs of older adults, according to Chris Klopfer, the center’s senior sports and fitness supervisor.

“The playground encourages functional training, which incorporates more than one muscle group at a time, and that helps them with their day-to-day function, so that they can stay healthy and strong and age in place,” Klopfer said. “In today’s society we rely on medication for different ailments. I think we need to continue to push in the direction of physical exercise.”

The Rockville playground’s equipment has hand grips on everything, so that older exercisers can stabilize themselves. If they do fall, a non-slip surface made from rubberized tires makes injuries less likely.

One local trainer regularly brings older adult clients to the park for workouts when the weather is good. One of the trainer’s clients, Ellie Rouff, 72, adjusted her workout schedule to allow for more sessions at the park.

“I’m still working in an office and sit at a desk five days a week, so if I can be outside, I love it,” Rouff said. She likes the fact that the equipment has usage instructions and allows her to do exercises she couldn’t otherwise. She can no longer do push-ups on the floor but can perform them on one of the machines.

Boosting Fitness

Research suggests that regular use of an elder playground can boost older adults’ physical fitness and help prevent illness. The University of Lapland studied one group of 40 people, ages 65 to 81, and found significant improvements in balance, speed and coordination after just three months of guided exercise (90 minute, once-a-week sessions) on an elder playground.

Increased fitness not only improves quality of life, it can also help keep the cost of health care down, ICAA’s Milner notes, citing a study that found that adults who do 90 minutes of cardio exercise a week can save $2,500 annually on health care.

“By age 80, 46 percent of Americans can’t lift 10 pounds,” Milner said. “If you can’t lift 10 pounds, that’s a precursor to moving into a nursing home. Just simply getting people outdoors five to 10 minutes can make a huge difference in their mental health, attitude, overall health and well-being.”

Elder playgrounds also promote social engagement, an important factor given that many older adults become isolated and lose social ties. Numerous studies have linked isolation with poorer health among older adults.

Cohen designs elder playgrounds with conversational seating, to make them inviting even to people who may not wish to exercise. The exposure to sunlight helps reduce vitamin D deficiency and may help older adults sleep better at night.

The Multigenerational Option

In the United States, playgrounds that cater to multiple generations, instead of being designed exclusively for older adults, are catching on more quickly than elder playgrounds. These multigenerational playgrounds offer features and equipment appropriate for children as well as older adults. To motivate more adults to take their kids to play more often, the nonprofit KaBOOM! has built more than 50 multigenerational playgrounds in the United States since 2012 through a partnership with Humana and the Humana Foundation. (To build the playgrounds, local communities apply for KaBOOM! grants, enlist funding partners and recruit volunteers.)

But while multigenerational spaces offer great benefits, they’re not designed exclusively with seniors’ needs in mind, Cohen said.

“In reality, many multigenerational designs tend to pay short shrift to the needs of older adults,” he said. Many are essentially children’s playgrounds with a walking path added nearby or a few exercise machines located in adjacent space.

Milner agrees. “Multigenerational can be a little bit intimidating to older adults,” he said. “The noise might be overbearing.” Children who play raucously can be overwhelming to those living with dementia and possibly a safety issue if the children are underfoot among adults with mobility issues.

A study at Germany’s Wiesbaden Polytechnic indicated that many older adults found it embarrassing to exercise in the presence of younger people and were more inclined to use more private playground settings visited mostly by generational peers.

Another factor: some older people simply don’t feel comfortable around children. As a single, older man, Cohen says he’d personally feel uncomfortable on a playground and thinks some parents might feel that way too.

“I want a place where I can maybe meet a friend for a game of bocce, or where I can read,” he said. “I don’t necessarily want a lot of kids around.”

The Lake Oswego FIT Spot has naturally attracted some multigenerational use—it’s located near a children’s playground, so some grandparents and parents use the equipment while keeping an eye out as kids play nearby. But Ronni Bennett thinks it’s important to have dedicated spaces where elders, especially those who can’t afford a health-club membership, know they can meet peers and exercise comfortably and safely.

“With so much concern over health care costs, to me, elder playgrounds are a money-saving no brainer,” she said. “The point is to keep moving and to have fun at it. When people don’t exercise, they die younger than they should.”

Medical Tourism: Are Local Doctors Always the Best Choice?

Why people leave home for health care in other states or overseas

Patients travel from around the United States and the world to see Richard Guyer, MD, an orthopedic spine surgeon at the Texas Back Institute in Plano, TX, because he is a recognized, widely published expert in disc-replacement surgery.

But when Guyer, 66, recently needed surgery himself—a complex procedure to remove a benign tumor—he flew to Florida. Good care was available in his own hospital, but he chose a surgery center where surgeons perform the procedure, on average, 50 times a week, using advanced techniques.

Guyer’s experience—both as sought-after surgeon and as traveling patient—is becoming more common. Proximity no longer determines health care. A growing number of Americans are willing to travel to other states or overseas as part of a trend called “medical tourism.”

Medical tourists travel to save money, to get cutting-edge or high quality care or for procedures not available locally.

Medical tourists leave home to access the best available care or to save money or, in some cases, both. Patients Beyond Borders, an information service for consumers, estimates that 1.7 million Americans will go overseas for elective medical care in 2017. The global medical tourism market is estimated to be $45 to $72 billion annually, with approximately 14 million patients crossing borders worldwide, including those who travel to the United States for medical care.

Data on domestic medical tourism—traveling within the United States to another state for health services—is scarce and largely anecdotal. But, noting a growing willingness to travel for care, physicians and medical centers are adjusting their practices to attract patients, particularly for out-of-pocket elective procedures.

What Sends Patients Packing

Within the United States, medical travel typically takes patients to centers of excellence for highly complex procedures, such as the Cleveland Clinic for heart surgery, or to research hospitals offering the latest and best care, such as Memorial Sloan Kettering Cancer Center.

Older Americans are driving the trend. Josef Woodman, CEO of Patients Beyond Borders, estimates that about 85 percent of overseas medical travelers fall within the ages of 45 to 65—too young to qualify for Medicare but at an age more likely to develop complex medical conditions.

Other drivers include the relatively inexpensive cost of travel and wide disparities in care and treatment pricing at home and abroad. Also, the Internet makes it easier for patients to research options and for providers at different locations to share medical records.

Gaps in health care insurance are also a factor, especially as a growing number of patients rely on health plans with high deductibles.

“As health plans continue to become more expensive and less cost-efficient for the patient, the ‘underinsured’ patient can often realize cost savings on more expensive surgeries over and above their plan reimbursement,” Woodman wrote in an email interview.

A 2012 study by Woodman, published in AARP International’s Journal, identifies three categories of medical tourists:

  • Value patients, usually those 50 and older, who are uninsured or underinsured or who seek procedures that insurance doesn’t cover
  • Access patients, who live in areas where available health care lacks quality or where specific procedures may not be available
  • Quality patients, who are willing to travel for exceptional specialty care, including cutting-edge surgeries or new therapies

Bill Ruth falls into the quality category. When the 64-year-old retired teacher and coach learned that he needed heart surgery, he called on a few physician friends for advice. They steered Ruth to the Cleveland Clinic or Baylor University Medical Center in Dallas, even though Ruth lives in Estes Park, CO. After researching his options and interviewing physicians, Ruth chose Baylor. He traveled to Dallas, where the procedure was successfully performed. Within a few days, Ruth was up and walking five miles at a time. And within a few weeks, he went to the high school in Pennsylvania, where he once taught, for his induction into the school’s athlete hall of fame.

Ruth’s insurance plan, through the teachers’ union, covered all of his medical costs; he picked up the cost of travel for himself and for his wife.

As a triathlete who organizes health and fitness programs in his community, Ruth said he would never consider just going to the nearest provider without doing his research.

Treatment abroad can be 20 to 80 percent less expensive, depending on the country and the procedure, and including the cost of travel.

“You want the best care possible,” he said. “Why shouldn’t people travel to get the best medical care?

“Some people put more research into buying a car (than medical care). But when you really care about your health and your activity level, you do what it takes to find the best care.”

Typically, for necessary procedures like Ruth’s, insurance will cover the treatment at most US locations, although often at out-of-network rates. (Be sure to confirm coverage with the insurance provider before any procedure.) Patients almost always pay the cost of travel.

But in some cases, medical travel is paid for by an employer. Home-improvement retailer Lowe’s sends employees in need of complex, non-emergency heart surgery to the Cleveland Clinic. Lowe’s, which self-insures its employees, struck deals for bundled prices with the Cleveland Clinic, allowing Lowe’s to save money even after paying all medical and travel costs. By going to a center of excellence for heart surgery, patients enjoy better outcomes and fewer readmissions, which in turn helps employees return to work healthier.

Lowe’s typically picks up the cost of the trip for a caregiver too and sometimes pays the deductible as an added incentive. (Employees who don’t wish to travel may choose a local provider and receive normal coverage.) Other large, self-funding companies, including Walmart, Boeing and PepsiCo, have similar approaches.

Heading Overseas

Patients are traveling to Thailand for plastic surgery, Germany for cancer treatments, Costa Rica and Mexico for dental care, Turkey for eye specialists, Israel for fertility treatments, Poland for dental implants, the United Arab Emirates for bariatric surgery, to list a few.

About 70 percent of Americans who go overseas for medical care do so for elective treatments that insurance typically doesn’t cover, such as dental work, cosmetic surgery, bariatrics or fertility treatments, Woodman said.

Opting for treatment abroad can be 20 to 80 percent less expensive, depending on the country and the procedure, even after the cost of travel. What’s problematic, however, is judging quality of care.
Leigh Turner, PhD, associate professor at the Center for Bioethics, University of Minnesota, cautions that much of the information available online is created by providers, who have a financial stake in painting a positive picture.

When you travel for care, coordinating long-term follow-up and managing postsurgical complications can be problematic.

“It’s not so easy to spot the bad actors,” Turner said. Overseas providers are “businesses that are trying to attract patients, and they are quite savvy in painting a positive picture. While the Internet gives patients more access to information, it’s also creating more misinformation.”

It’s extremely important for medical tourists to do their homework. Patients must have a good understanding of the desired procedure and make careful assessments of the quality of the provider. Patients Beyond Borders advises contacting physicians in advance for references and to check accreditations.

“If the doctor is evasive, hurried, or frequently interrupted, or if you cannot understand his or her language, then either dig deeper or move on,” Woodman writes in his book, Patients Beyond Borders: Everybody’s Guide to Getting Affordable, World-Class Healthcare (2015).

Medical-tourism concierge services can help you locate clinics and arrange travel, but they are not regulated and do not provide medical advice. Some may steer patients toward clinics that pay commissions. You should get recommendations from former customers, ask how the agency is compensated and use a US-based agency if possible.

Those who use overseas hospitals have little recourse in the event of poor outcomes. Regulation and oversight can vary widely, although that may be changing. The Joint Commission International (an independent, not-for-profit accrediting organization for US hospitals and medical providers) now accredits more than 400 hospitals worldwide, giving patients some reassurance as to quality.

Costs of Medical Tourism

Medical travel remains an option largely for those who can afford it. With very few exceptions, you must cover your own travel costs, as well as those of any accompanying caregiver.

Medicare patients may seek care at any US provider that accepts their plan, but aside from a very few rare circumstances, Medicare doesn’t pay for overseas procedures or travel costs, foreign or domestic. (Some Medicare Advantage plans might cover the cost of the trip for those who must go to a distant US facility for transplant surgery.)

Patients must also consider nondollar costs. There will be additional time spent traveling to the location and recovering there. You may need to avoid air travel, especially very long flights, for a period of time after surgery. When you are overseas, language and cultural differences can create additional stress. “Receiving care at a facility where you do not speak the language fluently might increase the chance that misunderstandings will arise about your care,” warns the Centers for Disease Control and Prevention’s website.

Some overseas hospitals offer hotels or resorts where patients may stay for recovery and post-op care before returning home. However, coordinating long-term follow-up and managing postsurgical complications can be problematic. Studies suggest that when patients are admitted for complications at a different hospital than where the original surgery took place, mortality rates are higher.
Guyer, the Texas surgeon, sees that as a key difference between domestic medical travel and overseas travel.

“If a patient comes here from Montana for surgery and later has problems, they can send pictures, we can consult over the phone, and they can fly back if need be,” he said. “If somebody goes abroad for surgery and then has a problem, we don’t like to take care of it here, because we weren’t there for the surgery.”

Effects of Medical Travel

Many hope that the trend toward medical tourism could drive improvements in quality and help keep costs down in the United States.

“Theoretically, it makes sense—as you expand patients’ options, there’s increased competition in terms of quality and price,” said Steve Wojcik, vice president of public policy for the National Business Group on Health. “That benefits everybody.”

When employers like Lowe’s send patients to the Cleveland Clinic, for example, that takes patients away from local providers.

“In those cases, a local provider might approach a big employer and say, ‘We know you’re sending people out of town; here’s our data, and here’s what we can offer you,’” Wojcik said.

But while increased competition should reduce prices and improve quality in theory, price transparency in the United States is still spotty, especially for nonelective procedures, and price disparity is wide. A 2013 Journal of the American Medical Association study of domestic providers found a wide range in pricing for hip replacement surgery: as low as $11,000 or as high as $125,000. Also, when researchers posed as patients prepared to pay cash, more than half of the hospitals queried would not provide prices upon request.

Some US medical centers offer a concierge service to assist with trip arrangements.

“There’s no correlation between cost and quality,” said Jesse Gomez, executive vice president of sales and marketing for BridgeHealth, a Denver health consulting firm that negotiates bundled rates for self-insured employers for procedures at centers of excellence. “But fortunately for consumers, objective provider data is becoming increasingly more accessible.”

Gomez notes that patients can now find average prices for common procedures from the Health Care Cost Institute by way of its consumer website and hospital quality ratings by way of websites like www.carechex.com.

But some foreign providers make it even easier. Bumrungrad International Hospital in Bangkok, a top destination for global medical tourism, publishes costs online for some 30 procedures and offers package pricing in many specialty areas.

“We can only hope for this kind of transparency to visit us sooner than later here in the US,” said Woodman of Patients Beyond Borders.

The desire to attract patients is clearly changing the way some medical providers do business. The Cleveland Clinic’s website offers extensive information for foreign and domestic travelers, plus a concierge service to assist with trip arrangements. Other centers of excellence that attract domestic medical travelers are improving the ways they integrate post-treatment and follow-up care with local providers.

Some of those providers are becoming more transparent and consumer-friendly on pricing, especially those that cater to cash patients. For example, Guyer’s clinic negotiated with the Texas Health Center for Diagnostics & Surgery to offer a package price, which allows out-of-pocket patients to pay up front and avoid unexpected charges.

The option of medical tourism is also encouraging people to become more educated and more proactive in their own medical care.

“The patients who travel to see me have done their homework,” Guyer said. “They know all about the procedure and they know what questions to ask.”

How to Deal with Your Digital Afterlife

A guide to handling problems nobody even imagined until recently

Sara Ivey, 63, calls it one of the few gifts of cancer: time to plan.

When her husband, Jerald Sluder, was diagnosed with advanced melanoma, the Dallas couple had time to organize his affairs before his death in December 2016 at age 64. In addition to drawing up a will and advanced health care directives, they assembled a list of login information for his email and social media accounts as well as his banking and investment accounts.

Had her husband died suddenly, Ivey said, managing his online estate “would have been a nightmare upon a nightmare upon a nightmare.”

The digital revolution has created an increasingly thorny end-of-life issue: when we die, what happens to our online accounts and our Facebook pages, or to all the photos, genealogy records, recipes and other content we’ve saved in the cloud?

To deal with these complications, attorneys and other end-of-life experts now encourage clients to create a digital estate plan—a document listing all digital activities and assets, as well as login information and instructions for how to handle each account after death. That includes email, cloud storage, social media profiles, money management, health and medical portals, frequent flyer and travel memberships, web hosting or blogging information, and entertainment and shopping website accounts.

“People can’t inherit what you designate in your will unless you tell them how to get at it,” said Judith Kolberg, author of Creating Your Digital Estate Plan (2015).

Will your autopayments go on without you? Will your heirs know how to find your online accounts?

A digital estate plan doesn’t take the place of a will; rather, it should be prepared in tandem with a will and other end-of-life documents. Experts advise against including passwords or other login information in a will, as it would be inconvenient and expensive to update every time a password changes. Also, wills become public record after a person dies, so it’s possible someone could use the information to fraudulently access accounts. The digital plan serves as an easily updated addendum to help execute the deceased person’s wishes as stated in the will.

Taking this step can reduce hassle for heirs or executors, as well as prevent fraud, Kolberg said. The digital estate plan should be stored in a password-protected spreadsheet, as well as on a paper copy kept in a safe deposit box or other safe place. She also advises making appointments with yourself to update the plan regularly.

“Tie updating your digital estate plan to another activity that you do on a regular basis, such as your changing your automobile oil or paying your quarterly taxes,” Kolberg said.

Why Worry about It

“You can’t take it with you” applies to online assets just as it does to family heirlooms. Photographs, recipes, genealogy records and writings stored online over the course of a lifetime must be dealt with when someone dies: deleted, transferred to physical storage (such as a thumb drive) or maintained by someone who can continue to pay the annual or monthly storage fees.

All those pages of “Terms and Conditions” that users typically flip past when creating online accounts contain the specifics for what happens after death at websites such as Facebook, Twitter and Instagram, or to email. Heirs typically don’t have claim to that material.

“Those are usually restrictive about post-death access,” said Carl Levy, a trusts and estates attorney at Chiesa Shahinian & Giantomasi in New Jersey.

For example, Facebook owns all the content, including photos, that people upload to the site. While Facebook hasn’t generally deleted the pages of deceased users, there’s no guarantee that the social media network will preserve them in perpetuity. Facebook users who want their material to “live on” should download photos or other content onto a hard drive or find other ways to preserve it. A Facebook user may also name a legacy contact, a person who can either delete the deceased’s page or maintain a memorial page.

Accounts that store content—such as movies, music or TV shows on iTunes or eBooks on Kindle—usually “die” with the account holder. Heirs can’t continue to use the content. That’s because the user didn’t purchase the material itself, just a license to use it, which typically expires upon death. However, to date, these sites haven’t shut down accounts of people who die, nor taken steps to prevent family members with login information from continuing to access the content.

For cloud-based content created or owned by individuals—such as photos, recipes or genealogy records—the biggest concern becomes ensuring that the material is stored or maintained after death, if desired. If payments lapse for the host account, legally the website can delete material.

Money Matters

With the advent of online banking and investing, it’s conceivable that someone could die leaving almost no paperwork behind. Many people manage investment accounts on a paperless basis. Updates on accounts and bills may come exclusively through email. When a paperless person dies without leaving specific information on his or her online accounts, that leaves a major headache and investigative chore for heirs.

Reconstructing a dead person’s accounts “is a hassle, but it’s getting easier,” Kolberg said. Many banking and investing websites now offer options, usually under “settings,” where family members can find instructions for what to do if the owner dies.

To locate banking and investment accounts, heirs can start with the deceased’s federal income tax return. Except for newly acquired accounts, investments should be listed in Schedule B, Schedule D and/or 1099 forms. Heirs can contact the investment institutions, and after they provide a death certificate and the deceased’s social security number, the institution will generally transfer assets into an estate account. That’s a new account opened after someone has passed away, into which the executor deposits the deceased person’s money. This allows for bill and debt paying and, ultimately, distribution of funds to beneficiaries.

Once an estate has been settled, the executor should make sure that online accounts are closed.

“Anything kept up is susceptible to phishing and hacking,” Kolberg said.

Naming a Digital Executor

Some experts recommend designating a “digital executor” who can navigate and implement the digital estate plan—someone trustworthy who also knows how to handle online accounts, especially if the principal estate executor isn’t tech savvy. However, others advise against this approach.

“Having one person that handles solely the digital aspect and another handling the rest could be cumbersome,” said elder law attorney and financial advisor Patrick Simasko of Simasko Law in Michigan. “Most of the time, you would want only one executor.”

Some states don’t legally recognize digital executors; some have not yet enacted any legislation relating to digital assets. Individuals should seek an attorney’s advice on adding a digital executor.

Those sorting out a deceased person’s digital property should proceed with caution.

“While having a list of accounts, websites and login information is certainly helpful, care must be taken in accessing the account or website,” Levy said. “States are beginning to adopt statutes which govern who is allowed to access online information and under what circumstances.” (In general, an estate’s executor can access the deceased person’s online accounts, but terms and conditions vary.)

Further complicating the issue are federal statutes that protect privacy and impose penalties upon those who access online information without following proper procedures. But unless fraud or theft occurs, those statutes are rarely enforced, according to Julie C. McKain, an estate planning and probate attorney in Rockport, TX.

“… The problem is, the technology is evolving faster than the law’s ability to keep up.

–Julie C. McKain

She advises clients to tread lightly—wait until the executor is named, which typically takes 30 days after the person passes away, before accessing the deceased’s online accounts. However, if an online account must be accessed to prevent a loss to the estate, she does tell clients to take steps such as halting auto-payments.

This is one of those areas where the law and a website’s terms and conditions don’t really impact what the average American does after a loved one dies,” McKain said. “The problem is, the technology is evolving faster than the law’s ability to keep up.”

If in doubt, heirs should consult an attorney before accessing any online accounts. In addition, if an estate is involved in ongoing or threatened litigation, executors must be careful not to destroy anything that might be evidence—including digital assets.

Some online investment and banking accounts can be handled after death without logging on. Instead, a family member or executor may notify the provider about the death (with appropriate documentation), and the provider will close the account.

To navigate all of this, a growing number of services are emerging to help individuals think ahead about what they’d like to see happen in the event of their deaths and to assemble and update all relevant information into one place. Websites such as Assets in Order, Estate Map, PasswordBox’s Legacy Locker, and SecureSafe allow users to input online accounts and encrypted data and to name trusted family members or friends who may access the data. Other sites, like FinalRoadmap.com and Everplans.com, guide users in assembling login information as well as creating an online repository of health care directives, funeral wishes, plans for pets, family photos, even favorite family recipes. FinalRoadmap also allows users to craft messages that will be automatically sent to loved ones after death.

But user beware: dozens of businesses have sprouted up in the area and a shakeout is likely; some have already shut down or been absorbed by other companies. Before choosing an online repository, you should check to see what guarantees are in place should the company merge or go out of business.

Keeping Social Media Alive

Should you maintain a social media life after death? Heirs may wrestle with that question if the deceased had been an active presence on Facebook or other social media. They usually have three options for each account: delete it, leave it as is or have it turned into a memorial account.

Accounts that no longer serve a purpose, like LinkedIn and dating sites, should be deleted. Same for selling or shopping accounts such as eBay or PayPal.

Other decisions are less cut and dried. Some families opt to leave social media accounts “as is” but that option can have unforeseen consequences. Active Facebook accounts, for example, may generate unsettling alerts and notifications—such as a friend recommendation for someone who has passed away.

Also, a dead person’s online presence can create opportunities for phishing, hacking or scamming. One scenario, Kolberg said, is that a scammer might see the deceased’s alma mater on Facebook, then contact the family posing as a college representative and proposing a donation to a bogus memorial scholarship fund in the person’s name.

On the other hand, setting up a memorial social media page can serve as a way for friends and family to process grief and remember someone who has died.

Nowadays, we live on online, even after we pass away.

 –Sara Ivey

“Facebook creates this visual, multimedia ecosystem,” said Molly Kalan, a Boston-based marketing executive who wrote her master’s thesis on how people grieve on social media. “It’s a dynamic archive of stories, and people can keep adding to those stories. The page can commemorate a birthday or anniversary. You can reflect on that as you go through different waves of grief. I think it’s a positive.”

More than six months after her husband’s death, Ivey continues to monitor his email account. From time to time, she receives emails with key information, such as a notice of an old 401(k) account that her husband had apparently forgotten about and that she didn’t know existed.

While she expects to shut down his email soon, Sara Ivey plans to keep her husband’s Facebook page up indefinitely.

“That’s important to me, to keep his memory alive,” she said. “It has become a forum to stay connected with family and mutual friends.”

Having gone through the process, Ivey has designated her older son as the person who will manage her online presence should something happen to her.

“Nowadays, we live on online, even after we pass away,” she said.

Grandpa Gets Around…Using Uber

How older adults benefit from the sharing economy

When Kerri Couillard founded Babierge, she expected the business would mostly attract young families who were traveling. The Albuquerque-based fledgling company connects people who need baby gear for a few days with those who have equipment to rent.

Couillard was surprised when, instead, many of her customers were people like Yvonne Mull: a 78-year-old Santa Fe grandmother who rents baby gear for just a few days here and there when her grandson comes to visit. 

“I don’t want to buy it and I don’t want to store it,” Mull said. “This works perfectly for me.”

Older customers are surprising many companies that, like Babierge, are part of the sharing economy, in which people rent out rooms, cars, boats and other assets, or buy and sell services directly from each other, all connected by way of the Internet. Also known as the gig economy or the on-demand economy, it includes businesses like the home-sharing enterprise Airbnb and the ride-hailing service Uber.

While many of these companies assumed that their customer base would be dominated by millennials, “It turns out that the baby boomer generation is a big user of the on-demand economy,” said Rowan Benecke, global technology practice chair for public relations firm Burson-Marsteller.

25 percent of Americans who are 55 or older say they’re providing services in the sharing economy.

In conjunction with the Aspen Institute and Time magazine, Burson-Marsteller developed a survey in late 2015 that revealed that 29 percent of people over age 60 have used sharing-economy services, just slightly more than the 28 percent noted in the 50-59 age group.

The fact that older adults are getting involved is good news, because the sharing economy now occupies a significant and growing position in the United States.  PricewaterhouseCoopers (PwC) estimates that the sharing economy totaled $15 billion in 2014—and will grow to $335 billion by 2025.

“Companies are realizing that there’s still an untapped market among older adults, and that paying attention to this market segment is a good idea,” Benecke said. “Older adults do have a lot of purchasing power.”

Many people, like Linda and Richard Barnhart, ages 69 and 71, of Scroggins, TX, find that the sharing economy offers benefits like convenience and good prices. The Barnharts learned about Airbnb from their daughter and used the service to rent privately owned homes in San Diego and near Yosemite for recent trips with friends.

“You get much better accommodations for a lesser price,” Linda Barnhart said. “In each instance, we were able to rent an entire house, rather than just a couple of hotel rooms. It worked out great.”

More than Bargains

Some observers believe the sharing economy offers even more than bargains and convenience; they believe that services provided on demand could create a new, cost-effective avenue for older adults to stay independent longer.

“Use TaskRabbit to get help around the house, use Instacart to deliver your groceries, use Uber to drive you to your medical appointments; the list goes on,” says Glenn Carter, a blogger at the Casual Capitalist.

Having convenient access to these services, at a reasonable price, could be a game changer, allowing older adults to avoid or postpone moving into assisted living.

“When you compare the cost of a mortgage with the cost of assisted living facilities, in some cases it can make more financial sense to use those services and age in place, rather than move to a facility, depending on the level of care required, of course,” said Nela Richardson, PhD, chief economist for national real estate brokerage Redfin.

And Dr. Joseph Coughlin, director of the Massachusetts Institute of Technology AgeLab, thinks ride-sharing services could help solve the critical problem of transportation that plagues many older adults.

“Uber improves on cabs in a few critical ways—loved ones can track Uber cars’ progress, for instance—and other, smaller services go even further,” he writes in a blog post. He points to SilverRide and Lift Hero, which match older passengers with drivers who are willing and trained to provide extra service, such as assisting customers to and from their doors, or accompanying them on doctors’ visits.

Participating in the sharing economy gives older people with a way to earn extra cash—and, just as important, to stay active and engaged.

However, not everyone sees the sharing economy as a panacea.

“Seniors 75 and up are less likely to use a smartphone, and most of these services depend on that,” said Laurie Orlov, blogger for the Aging in Place Technology Watch. A 2015 Pew study found that, while nearly two-thirds of all Americans have a smartphone, only about a quarter of adults 65 and older own one. (Some 78 percent of older adults do own cell phones, but they tend to be more basic devices, the study noted.)

Already, though, some companies are finding ways to get around the smartphone gap.

GreatCall, which markets Jitterbug cell phones and medical alert products to older people, recently announced GreatCall Rides, a pilot program in five markets (California, Florida, Arizona, Dallas/Fort Worth, TX, and Chicago) with significant populations of older adults. GreatCall customers simply press 0 to call an operator on their Jitterbug phone and order a Lyft ride; GreatCall adds the cost of the ride (plus a nominal fee) to the customer’s monthly bill. No cash is involved.

“Even among those older adults who do use a smartphone, the comfort level with the technology may still be a barrier,” said Gyre Renwick, head of healthcare enterprise partnerships at Lyft. “They may not be comfortable downloading and using an app, for example. By offering another option, we took away that barrier.”

For those who do own smartphones but lack confidence using apps, Lyft has an ambassador program. Jeff Roberts, a Lyft driver in Fort Worth, TX, visits independent living communities to get the word out and to provide “tech support.” He hosts learning sessions to give hands-on guidance and pamphlets with step-by-step instructions for using the app.

Roberts saw the opportunity for serving an older customer base after watching his grandmother discover Lyft. “She no longer drives but with Lyft can get her hair done each week and run errands,” he said.

Getting in on the Game

Some companies see an even bigger business opportunity in wooing older adults to provide services as “offerors” in the sharing economy.

Uber estimates that one in four of its drivers is 50 and older. A study by Airbnb showed that hosts 60 and older represent its fastest-growing age demographic; women 60 and up earn a higher percentage of five-star reviews (top reviews) than any other age and gender combination. And DogVacay, which pairs pet sitters with pet owners, estimates that 25 percent of its sitters are 50 and older.

Many older Americans have acquired assets—such as rooms in a large home or an extra car—that end up unused after the kids have moved out or they’ve stopped commuting to work. Companies like Airbnb and RelayRides (a car-sharing service) “let seniors monetize assets that would otherwise be gathering dust,” said Coughlin of AgeLab.

Participating as offerors also provides a way to earn extra cash—and, just as important, to stay active and engaged. Research suggests that people who become isolated in their later years don’t live as long or fare as well, health-wise, as those with strong social networks.

The sharing economy has opened new connections, both human and canine, for retired handyman Jon Palmer, 60, of Plano, TX. Palmer was devastated when his own dog, a black lab named Gracie, passed away two years ago. Later, when a lost black lab wandered onto his front porch, he took it as a sign.

“I had the best time caring for my new friend while waiting for her family to pick her up,” Palmer said. “I knew then where my next path would take me.”

Sharing-economy companies, created by young visionaries, could ultimately change the lives of older adults profoundly.

Now he offers dog boarding and day care out of his home by way of DogVacay.com. His wife works during the day, so this gives him canine companionship as well as a way to bring home some cash.

In meeting new clients, “I feel as if I make new friends every week doing this,” he said. “And I’m not the type to sit and watch TV all day.” Another bonus: while sitting jobs keep him busy, they don’t require Palmer to climb on ladders or to work outdoors in hot weather, as his previous job often did.

Palmer is part of a growing trend. An April 2015 report from PwC estimated that, while 7 percent of all Americans consider themselves providers in the sharing economy, of those ages 55 and up, 25 percent do.

However, Palmer doesn’t face one of the biggest downsides of the gig economy, given that his wife still works full time. For most, the work doesn’t provide the safety net that full-time employment does. Income often fluctuates, and the work doesn’t come with health insurance or other benefits.

While it’s clear that older adults are taking on gig-economy jobs, “what’s not clear is whether they’re doing this because they’re semiretired and value freedom and flexibility, or because they’ve been downsized out of a full-time, full-benefit job and have to settle for contract work,” says Bloomberg View blogger Justin Fox.

For those who do have a safety net—Social Security for income and Medicare for health insurance—doing jobs “on demand” offers a way to stay active, earn some extra cash and keep a flexible schedule. Or put another way, adults who remain able and willing to work may be the best positioned segment to work in the on-demand economy.

Room for Growth

While many older adults do use the sharing economy, experts agree there are still untapped avenues for increased usage among older adults. The Burson-Marsteller survey revealed two factors that may keep seniors out of the sharing economy: awareness and trust.

“Only 20 percent of the people surveyed, ages 60 and up, were familiar with the term ‘sharing economy,’” Benecke said. “There’s an opportunity for these companies to raise the awareness and to educate older potential customers about the services they are providing.”

Perception is also an issue, said Michelle Barnhart, associate professor of marketing at Oregon State University, who has studied consumers age 80 and up. “There’s a perceived difference between the shared economy versus the more heavily regulated, commercialized economy that we’ve all become accustomed [to]. We tend to feel like a company that watches its employees and is bonded and licensed and insured is a safer option than a peer-to-peer exchange.”

Still, Barnhart turned her parents, Linda and Richard, on to Airbnb, and she suspects that’s how many older adults initially connect to the sharing economy—through word-of-mouth by way of children or other trusted friends and relatives.

For the older Barnharts, the smartphone piece wasn’t an issue because they both retired recently from jobs that required them to use technology. However, that could be a barrier for her peers, Linda Barnhart believes. 

If businesses can help overcome these barriers to connect with older adults, they stand to profit. While sharing-economy companies were created by a younger generation of tech visionaries—with young, urban consumers in mind—they could ultimately change the lives of older adults most profoundly.

Says blogger Glenn Carter, “Where the sharing economy really stands out is its ability to keep [older adults] social and to help them live more independently.

Ellen Goodman: It’s Time to Talk about Death

A trailblazer tackles one of our culture’s strongest taboos

This article is the next in our series on the future of aging: interviews with people who are experts in their fields and are also visionaries. We’re asking them to talk about what they believe will happen in the years ahead to change the experience of aging.

Ellen Goodman, a Pulitzer Prize winning columnist, has been examining social change for most of her career. As a writer and speaker, Goodman has given a voice to progressive ideas and to women’s issues in particular. Now she is steering how we think about death and dying with her nonprofit organization, the Conversation Project, which calls itself a public health campaign and a movement, working to change the way people talk about, and prepare for, their end-of-life care.

The first glimmer of Ellen Goodman’s vision for the Conversation Project started with a suitcase.

When she was 25, Goodman went home to visit her family. Her father had been diagnosed with terminal cancer and would pass away three months later. Her mother had just given him a gift: a brand new suitcase.

Goodman jokes that the suitcase may qualify her family for the “Denial Hall of Fame” but adds she has carried the baggage of that image ever since. Because no one in her family was willing to talk about her father’s impending death, she says, there was no chance to say goodbye.

“I still wonder if my father was lonely in the silence that surrounded our inability to talk about what we all knew,” she says.

Ninety percent say talking with loved ones about end-of-life care is important; only 27 percent have actually done so.

Even though the Goodmans talked about just about everything else, the topic of death was taboo. Now, Ellen Goodman has cofounded a project to break the silence, to get people to start talking about their wishes for the end of life. 

“We hope that these conversations will begin at the kitchen table with the people you love,” she says.

Fostering Discussion

Decades after her father’s death, when her mother developed dementia and reached the end of life, Goodman found herself making difficult decisions about her care, with no sense of what her mother’s wishes might have been.  

“I had to say no to one procedure and yes to another, no to the bone marrow test, yes and yes again to antibiotics,” she says. “How often I wished I could hear her voice telling me what she wanted. And what she didn’t want.” 

Goodman’s family was not alone. According to a Conversation Project survey, even though 90 percent of people say that talking with their loved ones about end-of-life care is important, only 27 percent have actually done so.

To help bridge that gap, in 2010 Goodman cofounded the Conversation Project, a nonprofit that aims to get people talking with their families and medical providers about how they’d like to be cared for, well in advance of when a health crisis occurs. The project has created a Conversation Starter Kit, a discussion guide about what’s most important in the last phase of life. To date, more than 300,000 people have downloaded the free starter kit from www.theconversationproject.org. The project is also working to spread the word through worship groups, at local health centers and in the medical community.

Comforting Survivors

While the Conversation Project will help those at the end of life, it’s just as important for survivors. When someone passes away, studies show that depression rates plummet six months after a death if the family has had “the conversation.”

Atul Gawande, author of Being Mortal (2014) and an advisor to the Conversation Project, says that when families face difficult end-of-life decisions with no sense of their loved one’s wishes, “it’s incredibly traumatic for the family and the doctor involved.”

Death is no longer what we used to think of as natural. It comes as a cascading number of decisions.

Stories of individual families’ experiences with end-of-life questions are featured on the Conversation Project website. There’s Hong Yee, an Asian man who feels guilt about his grandmother’s not-so-good death.

“In retrospect, perhaps, we could have asked her if she wanted a feeding tube…we could have asked what she wanted and respected those wishes,” he mused.

In contrast, there’s the story of Jane, whose mother shared her wishes (“no heroics”) and her desire to be buried in the town where she lived, rather than in a family plot in another state. After her mother passed away, Jane said, knowing her wishes were honored was a source of extreme comfort.

Then there’s Linda, whose mother, Helen, did have the conversation, dealing with her impending death “honestly, openly and with great humor.” Helen signed forms for her cremation while she was still alert mentally and immediately enrolled in hospice, ensuring access to good care and pain medication when it was needed. 

“Hospice answered many requests: a massage therapist for comfort, a harpist who played by her bed; we had help with bathing, and a nurse was available day and night,” said Linda. She urged others, “Please, create the ending you want. Have the conversation too. For whatever comes next.” 

Says Goodman: “This is the gift, maybe the last gift, we can give one another.” 

We talked with Goodman about her vision for a time when people can talk openly about their wishes for the end of life—and have a better chance of dying in the way that honors those wishes.

SCF: As a society, we haven’t always needed to talk about death in the ways we do now. One might say we’re learning new skills that our parents or grandparents didn’t need as often.

EG: Medical technology has advanced so much. People are living 30 years longer than they did a century ago. That’s the good news. The harder news is that death is no longer what we used to think of as natural. It comes as a cascading number of decisions. We are faced with these decisions, which our grandparents were, by and large, not faced with. It’s a huge difference.

SCF: Another difference is, death used to be part of life. Most people died at home, so people were more familiar with death and dying—and perhaps more comfortable talking about it?

EG: Let’s not look at the past in rose-colored glasses. People died of infections and whooping cough, suddenly and tragically of diseases we can now cure. But it is true—that people saw death and they knew it up close.

SCF: Today, because of their age and numbers, boomers in particular are kind of in charge of moving the culture forward—to a better way of dealing with dying in these modern times.

EG: This is the generation of people who are now turning 65 at the rate of 10,000 a day. This generation has been [a] social-change agent of our culture all the way through their lives and they’ve also been outspoken, Lord knows. So it seems likely that, starting with [baby boomers] and going on down, we will be much more comfortable talking about these things.

SCF: How do you think your goals and your project might alter the future of how we live with death? How are your efforts going to have an effect on society?  

EG: We are a people-centered project, not a patient-centered project, and our goal is that how you live at the end of your life will be thought about and structured by your own desires. Obviously, that’s not always going to happen—there are car accidents and tragedies—but there would be a much greater number of people who would die in something we might call a “good death.”

SCF: You’ve written that everyone seems to have “a piercing memory of a good death or a hard death.” How do you define a good death? 

EG: I think the closest we’ve come is that it’s a death in which people’s wishes were respected, whatever those wishes were.

It’s not for me to say what somebody else’s experience should be. It is a death in which the people that you love know what you want and are able to help that happen.

SCF: You mentioned that the Conversation Project is people-centered, not patient-centered. In your view, is the end-of-life process too medically driven, instead of personally directed? If so, what might a more person-centered approach look like?

EG: I always think about how we transformed birth in this country a generation ago. It was because women and families said to the medical establishment that birth was not just a medical experience, it was a human experience. And now we are saying that dying is not just a medical experience, it’s a human experience and we need to keep people at the center. 

SCF: Is death a subject that’s avoided in other cultures the way many Americans avoid it?

EG: People often say, “Well, in my family/tribe/ethnic group/religion, [talking about death] is really taboo. I think we are talking about it more openly than we did, though. I’ve seen a change in the years since we’ve been in operation. We’ve had, for example, our “Death over Dinner” events, which sounds far from casual, but people have come and told stories.

As a journalist myself, one of the astounding things to me is, I’ve never been involved in anything where everybody has a story. I mean everybody has a story. I tell people I’m involved in a project to encourage conversations about end-of-life wishes. There’s kind of like half a beat, and then out pours a story. It’s just amazing.

[Editor’s note: For three years, the Conversation Project has partnered with the Death Over Dinner organization to encourage people during a designated week to host dinner parties to talk about their end-of-life wishes.]

SCF: Then again, when you’re talking to loved ones, they may be resistant, even hostile, when you try to bring up the topic of end of life. Any suggestions for broaching the subject in ways that might be less threatening or upsetting?

EG: There are lots of things that we have on the website about ways to approach it: telling someone your own story; showing them a letter; showing them this column that you’re writing; telling a story themselves; asking for a story.

One thing that works really well for adult children when talking with their parents is asking for help: “Hey Mom, hey Dad, when the times comes, I may have to make decisions for you and I really need your help in figuring out what I should do.” That’s useful because parents like to be in a position to help their children.

SCF: What are a few specific end-of-life issues—medical, financial, emotional—addressed in the starter kit?

EG: The starter kit is a non-scary, non-medical conversation starter, literally. It asks you questions like what matters to you, where do you want to spend your last days, are you a person who wants all the information or would you rather doctors and families make decisions. Of course, it also asks whether you want every imaginable treatment no matter your condition, or whether there will come a time when you want comfort care only.

SCF: Could you talk a little about multicultural aspects? For example, in Being Mortal, Atul Gawande talks about how some African Americans worry more about receiving too little treatment rather than too much, which is the opposite of what many Caucasians fear. 

EG: That’s true, and understandable for historical reasons.

We are doing several multi-ethnic projects. One is the Conversation Sabbath, where we’re trying to get the word out through faith communities [to] virtually every religion you can think of. We’re also doing a project with community health centers that is looking at the differences between different ethnic groups. It’s like a pilot project. How does it work at a largely Asian community health center, an African-American community health center, a Hispanic community health center?

SCF: Have you heard yet from any participants who used the Conversation Starter Kit, and then put the information they’d gleaned to use? I’d love to have an example of how it worked in real life.  

EG: A lot of people have told me, “I thought this would be so hard. I never thought my father would talk to me about this. But when we actually sat down, it wasn’t painful. It was one of the most intimate conversations we’ve ever had.” I’ve heard that repeatedly.

SCF: Having this conversation can bring up some complicated issues. Boiled down, what do you think it’s really about?

EG: I actually think the end-of-life conversation is about life, how you want to live at the end, what matters to you, and sharing those intimate feelings and information with the people you love.