Every year, millions of older adults roll up their sleeves for an annual physical. Blood is drawn, a cuff tightens around the arm, and a stethoscope taps against the chest. A few days later, a patient portal pings with test results, unleashing a barrage of numbers: cholesterol levels, blood pressure readings, blood glucose, creatinine and more. 

It’s like receiving a report card in a language you don’t speak.

What do all these numbers mean? Is it important for patients to understand and track them from one year to the next? And if a lab test produces an abnormal result, should you worry, wait or push your physician for action? 

“There are so many tests out there that it’s very confusing for patients,” acknowledged Darshan Kapadia, MD, senior internist at Texas Health Plano in Plano, TX. 

Understanding your numbers can help you ask informed questions, advocate for your own health care and partner more effectively with your health care provider. At the same time, health care professionals caution, it’s important to put numbers in context. No single lab result tells the whole story. And determining what’s normal for each patient’s personal health situation is more complicated than it looks. Numbers alone don’t determine diagnoses; they’re data points that must be weighed along with a patient’s health history and physical exam.

“There’s more to the story than just those numbers on the lab sheet,” said Rebekah Mulligan, MD, an internal and geriatric medicine physician at Texas Health Harris Methodist Hospital in Southlake, TX. 

More Isn’t Always Better

Understanding your personal numbers is more important than ever, now that many patients have direct access to test results. The growth in health information technology, especially patient portals, means more and more data is relayed straight to patients, sometimes in bewildering detail, often without medical guidance. 

But more information isn’t always a good thing. This windfall of data to patients comes at a time when primary care physicians are increasingly in short supply and pressed for time to explain those results.

“Clinicians have expressed concern that patients often experience great difficulty in comprehending, interpreting, and correctly responding to personalized health information,” according to a 2020 study published in the Israel Journal of Health Policy Research. “In particular, misunderstanding test results leads to confusion, frustration, and disruptions in healthcare processes, including delays in seeking care, overutilization of services, medication errors, and inappropriate healthcare decision-making.” 

At the same time, in most states, patients can now take advantage of “DIY diagnostics” by ordering their own blood tests at medical labs, without guidance or orders from medical professionals. At-home medical and wellness testing is exploding; it’s now a $5 billion market in the United States. 

Advocates say this expanded pool of available information gives patients more options when they’re looking for answers to hard-to-diagnose health issues or waiting for months for medical appointments. But medical professionals argue that it can be risky for patients to interpret their own results. Some may panic over an out-of-normal-range result that isn’t necessarily concerning—or assume that a blood workup with only normal results means they’re healthy. 

Normal vs. Abnormal

In reviewing their lab results, one common assumption many patients make is viewing the numbers as either “normal” or “abnormal.” But physicians take a more nuanced view. Even the term “normal” can be misleading. 

“It’s important for patients to understand how the medical profession comes up with what is considered the normal range,” said Diana Cardona, MD, professor and chair of the department of pathology at Wake Forest University School of Medicine. For example, a white blood count (WBC) of 4,500—11,000 cells/mcL is considered within normal range. Researchers developed that range by looking at data from large groups of healthy individuals. The range of numbers where 95 percent of those patients landed is designated as normal. 

“But that’s really just a statistical number,” Cardona said. “There’s the 5 percent on either end of the range who are still healthy people, but now we’ve called them abnormal.” 

Cardona prefers the term “reference range” rather than “normal range” for that 95 percent. 

Context is important too. Two patients with the same borderline cholesterol numbers, for example, might need totally different treatment approaches.  

“If a patient has diabetes and high blood pressure, I need them at a much lower cholesterol level to control their risk, compared to a patient without diabetes or high blood pressure,” said Donald Lloyd-Jones, MD, director of the Framingham (MA) Center for Population and Prevention Science and chief of preventive medicine at the Chobanian & Avedisian School of Medicine and Boston Medical Center.  

Doctors take into account how much a number on a test changes from year to year and how quickly.

Almost every number comes with asterisks—exceptions to the rule when it comes to interpretation. Body mass index (BMI) seems like a straightforward way to determine whether a patient is at a healthy weight: a BMI of 19-24 is considered healthy; 25 or higher is overweight; over 30 is obese. 

But according to the American Heart Association, a BMI number should be “interpreted with caution” among persons of Asian ancestry, older adults and muscular individuals. For adults 65 and older, recent studies link somewhat higher BMI numbers to better health and higher chances of survival. Similarly, a weight lifter with very little body fat could have a higher body weight that yields a BMI that labels them “obese.” The Heart Association also recommends factoring in waist circumference, which helps determine how much body fat has accumulated around the middle section, which is associated with higher cardiovascular risk. 

Doctors also look at individual trends—how much a number changes, and how quickly, from one year to the next. That can be especially important for lab tests like the prostate specific antigen (PSA), which helps detect prostate cancer in men. 

“It’s really important to keep an eye on the rate of change,” Mulligan said. “Say you go to a new doctor, and you have some abnormal numbers. The doctor will want to know, ‘Is this where you’ve always been, or is this a new thing?’ Because if it’s a new thing, it’s a bigger deal in some instances.”  

Tracking Your Numbers

Any time new test results come in, Kapadia goes over the written report and encourages the patient to scan or photograph the report for their own records. Keeping track of your numbers can prove useful in a medical emergency or if you change providers.

“Have a folder somewhere in your cell phone titled, ‘My health record’ and keep your reports in there,” he advised. “Then make sure you can find it in your phone—not in the cloud—so that you don’t need the internet to retrieve the information. So, if you’re traveling, and, say, you’re on a safari in Africa and something happens, you’ve got the data to look at right there. You don’t have to remember it or understand it, because the physician on duty can review it from your phone.” 

Patients can also take advantage of a growing body of tools designed to help patients interpret their own key medical metrics in context. Lloyd-Jones and the American Heart Association created Life’s Essential 8, a checklist to help patients understand key numbers (cholesterol, blood pressure, blood sugar and body weight) in combination with lifestyle factors (exercise, sleep, diet and nicotine exposure) to assess and manage their cardiovascular health. The American Heart Association also offers “Know Your Numbers” fact sheets for patients with diabetes and for women concerned about their heart health. 

Researchers are also working on making the lab results and other reports easier for patients to understand. Cardona is part of a College of American Pathologists research project exploring ways to make pathology reports more patient-friendly. In focus groups with cancer patients, she was surprised to learn that they didn’t want the information summarized in plain language. Learning the medical terminology helped them speak more easily with their care team. But they did want more explanation, such as a glossary of terms. 

Handling Abnormal Results

If a number is somewhat out of normal range, and your physician says, “Don’t worry” or “Let’s wait and see,” should you question that?   

“That’s the art of medicine—understanding when those red flags are a big deal and when they’re not,” said Mulligan. “Sometimes patients can get hung up on an [out-of-range result] and ask for more intense testing that’s not clinically applicable. I try to explain why that number is OK in this situation.” 

But tell your doctor if a test result worries you, Mulligan added. 

“Keep asking questions,” she said. “You can say, ‘I hear what you’re saying, and I’m not trying to second-guess you, but can you show me what it says in the literature so that I can educate myself?’ I would much rather have a patient do that than worry for the next 12 months.” 

Remember that any lab result is a snapshot of a particular day and time. Many factors can skew the results of a test on a particular day. An abnormal kidney function number might indicate the patient has kidney disease—or is mildly dehydrated, which is common in hot weather. Certain medications or supplements may affect the results of kidney or liver function tests. Mulligan often sees that in patients who take biotin or hair-growth supplements like Nutrafol. 

When is blood pressure too low? There’s no accepted number. Low blood pressure is diagnosed by symptoms instead. 

“That’s why it’s so important to tell your physician if you’re taking anything—including supplements or over-the-counter medications—that may not be on your medications list,” Mulligan said. “And don’t assume the information in the [medical practice’s] computer is up to date. Always bring a written list to your appointment.” 

Conversely, understand that even a complete battery of tests with entirely normal results doesn’t guarantee that a patient is healthy. Kapadia recently diagnosed a patient with lymphoma; that patient’s blood work was 100 percent normal. An imaging test revealed the presence of cancer. 

Also, know that some numbers have clear cut-off levels; others do not. 

“Optimal blood pressure is defined as less than 120 on the top number and less than 80 on the bottom number,” said Lloyd-Jones. “But there’s no hard-and-fast number for blood pressure that’s too low. For many patients, a top number in the 90s may be normal and healthy and certainly means they’re at lower risk for strokes or heart failure. But if the patient gets light-headed when they stand up, that’s too low for them. The lower limit on blood pressure is defined by symptoms rather than a specific number.” 

Changing Interpretations

Another caveat: as new research emerges, medicine changes. For example, the numbers you’ve heard for years for healthy cholesterol levels may no longer apply. 

Until recently, physicians typically assessed cardiovascular health with a lipid panel that calculated total cholesterol as a combination of “good” (HDL) and “bad” (LDL) cholesterol along with triglycerides. Today, those numbers are still considered, but as part of more-complex algorithms that also factor in other metrics (such as blood sugar and blood pressure) as well as gender, age, smoking status and family history in determining whether to prescribe medications for high cholesterol or high blood pressure. 

“We want the LDL to be as low as possible, but we’ve de-emphasized HDL as a target of therapy, because medications don’t really help move that number,” Lloyd-Jones said. “And there’s more focus on triglycerides, which are more sensitive to diet and exercise and a better indicator of current metabolic health.” 

That complexity makes it even more important for patients to ask questions and engage in back-and-forth as needed with their primary care physicians. 

“A good relationship with your physician is worth its weight in gold,” said Kapadia. “That’s why it’s so important to find someone you like and trust and to start developing that relationship with them. So you can work together to understand and personalize those numbers for your own situation.”

Millions of older people are confined to their homes or can only get out with great difficulty. A surprising number live alone, and their situation can be precarious. For this article, written for KFF Health News, journalist Judith Graham visited a number of homebound seniors and describes what their lives are like. KFF posted her story on December 2, 2024. It also ran on the Washington Post. Funding from the Silver Century Foundation helps KFF Health News develop articles (like this one) on longevity and related health and social issues. 

Carolyn Dickens, 76, was sitting at her dining room table, struggling to catch her breath as her physician looked on with concern.

“What’s going on with your breathing?” asked Peter Gliatto, MD, director of Mount Sinai’s Visiting Doctors Program.

“I don’t know,” she answered, so softly it was hard to hear. “Going from here to the bathroom or the door, I get really winded. I don’t know when it’s going to be my last breath.”

Dickens, a lung cancer survivor, lives in central Harlem, barely getting by. She has serious lung disease and high blood pressure and suffers regular fainting spells. In the past year, she’s fallen several times and dropped to 85 pounds, a dangerously low weight.

And she lives alone, without any help—a highly perilous situation.

Across the country, about 2 million adults 65 and older are completely or mostly homebound, while an additional 5.5 million seniors can get out only with significant difficulty or assistance. This is almost surely an undercount, since the data is from more than a dozen years ago.

It’s a population whose numbers far exceed those living in nursing homes—about 1.2 million—and yet it receives much less attention from policymakers, legislators and academics who study aging.

Consider some eye-opening statistics about completely homebound seniors from a study published in 2020 in JAMA Internal Medicine: nearly 40 percent have five or more chronic medical conditions, such as heart or lung disease. Almost 30 percent are believed to have “probable dementia.” Seventy-seven percent have difficulty with at least one daily task, such as bathing or dressing.

Almost 40 percent live by themselves.

That “on my own” status magnifies these individuals’ already considerable vulnerability, something that became acutely obvious during the COVID-19 outbreak, when the number of sick and disabled seniors confined to their homes doubled.

“People who are homebound, like other individuals who are seriously ill, rely on other people for so much,” said Katherine Ornstein, PhD, director of the Center for Equity in Aging at the Johns Hopkins School of Nursing. “If they don’t have someone there with them, they’re at risk of not having food, not having access to health care, not living in a safe environment.”

Only 12 percent of homebound seniors can get the primary care they need at home. 

Research has shown that older homebound adults are less likely to receive regular primary care than other seniors. They’re also more likely to end up in the hospital with medical crises that might have been prevented if someone had been checking on them.

To better understand the experiences of these seniors, I accompanied Gliatto on some home visits in New York City. Mount Sinai’s Visiting Doctors Program, established in 1995, is one of the oldest in the nation. Only 12 percent of older US adults who rarely or never leave home have access to this kind of home-based primary care.

Gliatto and his staff—seven part-time doctors, three nurse practitioners, two nurses, two social workers and three administrative staffers—serve about 1,000 patients in Manhattan each year.

These patients have complicated needs and require high levels of assistance. In recent years, Gliatto has had to cut staff as Mount Sinai has reduced its financial contribution to the program. It doesn’t turn a profit, because reimbursement for services is low, and expenses are high. 

First, Gliatto stopped in to see Sandra Pettway, 79, who never married or had children and has lived by herself in a two-bedroom Harlem apartment for 30 years.

Pettway has severe spinal problems and back pain, as well as type 2 diabetes and depression. She has difficulty moving around and rarely leaves her apartment. “Since the pandemic, it’s been awfully lonely,” she told me.

When I asked who checks in on her, Pettway mentioned her next-door neighbor. There’s no one else she sees regularly.

Pettway told the doctor she was increasingly apprehensive about an upcoming spinal surgery. He reassured her that Medicare would cover in-home nursing care, aides and physical therapy services.

“Someone will be with you, at least for six weeks,” he said. Left unsaid: afterward, she would be on her own. (The surgery in April went well, Gliatto reported later.)

The doctor listened carefully as Pettway talked about her memory lapses.

“I can remember when I was a year old, but I can’t remember 10 minutes ago,” she said. He told her that he thought she was managing well, but that he would arrange testing if there was further evidence of cognitive decline. For now, he said, he’s not particularly worried about her ability to manage on her own.

Having to get up and go out, you know, putting on your clothes, it’s a task. And I have the fear of falling.

—Carolyn Dickens

Several blocks away, Gliatto visited Dickens, who has lived in her one-bedroom Harlem apartment for 31 years. Dickens told me she hasn’t seen other people regularly since her sister, who used to help her out, had a stroke. Most of the neighbors she knew well have died. Her only other close relative is a niece in the Bronx whom she sees about once a month.

Dickens worked with special-education students for decades in New York City’s public schools. Now she lives on a small pension and Social Security—too much to qualify for Medicaid. (Medicaid, the program for low-income people, will pay for aides in the home. Medicare, which covers people over age 65, does not.) Like Pettway, she has only a small fixed income, so she can’t afford in-home help.

Every Friday, God’s Love We Deliver, an organization that prepares medically tailored meals for sick people, delivers a week’s worth of frozen breakfasts and dinners that Dickens reheats in the microwave. She almost never goes out. When she has energy, she tries to do a bit of cleaning.

Without the ongoing attention from Gliatto, Dickens doesn’t know what she’d do. “Having to get up and go out, you know, putting on your clothes, it’s a task,” she said. “And I have the fear of falling.”

The next day, Gliatto visited Marianne Gluck Morrison, 73, a former survey researcher for New York City’s personnel department, in her cluttered Greenwich Village apartment. Morrison, who doesn’t have any siblings or children, was widowed in 2010 and has lived alone since.

Morrison said she’d been feeling dizzy over the past few weeks, and Gliatto gave her a basic neurological exam, asking her to follow his fingers with her eyes and touch her fingers to her nose.

“I think your problem is with your ear, not your brain,” he told her, describing symptoms of vertigo.

As the aging population grows, rehab services, palliative care and other kinds of health care may have to be delivered in the home. 

Because she had severe wounds on her feet related to type 2 diabetes, Morrison had been getting home health care for several weeks through Medicare. But those services—help from aides, nurses, and physical therapists—were due to expire in two weeks.

“I don’t know what I’ll do then, probably just spend a lot of time in bed,” Morrison told me. Among her other medical conditions: congestive heart failure, osteoarthritis, an irregular heartbeat, chronic kidney disease and depression.

Morrison hasn’t left her apartment since November 2023, when she returned home after a hospitalization and several months at a rehabilitation center. Climbing the three steps that lead up into her apartment building is simply too hard.

“It’s hard to be by myself so much of the time. It’s lonely,” she told me. “I would love to have people see me in the house. But at this point, because of the clutter, I can’t do it.”

When I asked Morrison who she feels she can count on, she listed Gliatto and a mental health therapist from Henry Street Settlement, a social services organization. She has one close friend she speaks with on the phone most nights.

“The problem is I’ve lost eight to nine friends in the last 15 years,” she said, sighing heavily. “They’ve died or moved away.”

Bruce Leff, MD, director of the Center for Transformative Geriatric Research at the Johns Hopkins School of Medicine, is a leading advocate of home-based medical care. “It’s kind of amazing how people find ways to get by,” he said when I asked him about homebound older adults who live alone. “There’s a significant degree of frailty and vulnerability, but there is also substantial resilience.”

With the rapid expansion of the aging population in the years ahead, Leff is convinced that more kinds of care will move into the home, everything from rehab services to palliative care to hospital-level services.

“It will simply be impossible to build enough hospitals and health facilities to meet the demand from an aging population,” he said.

But that will be challenging for homebound older adults who are on their own. Without on-site family caregivers, there may be no one around to help manage this home-based care.

 

At 81, Hélène Bertrand, MD, and her 90-year-old husband continue to enjoy a fulfilling sex life. Once every week or two, they share intimate moments that lead to orgasm and, as Bertrand puts it, “a very good night’s sleep.”

“Over 36 years of marriage, we’ve learned the moves that our partners like and delight in giving each other pleasure,” said Bertrand, a retired physician. “Our satisfying sex life improves the quality of our marriage. You don’t have to be 20 years old to have a good sex life.” 

Research shows that many older adults maintain active sex lives well beyond 65. According to a 2018 National Poll on Healthy Aging, 40 percent of those aged 65 to 80 are sexually active. Among respondents with a romantic partner, more than half reported engaging in sexual activity.  

Yet as the population ages, medical care has not kept pace with this reality. Gaps in knowledge and understanding persist. Senior living communities often lack policies that respect sexual expression, particularly for LGBTQ residents. Even health care professionals frequently underestimate or neglect the sexual needs of older adults, influenced by stereotypes that dismiss them as asexual or deem sex “unnecessary” after reproductive age. 

“Sexuality is a critical aspect of quality of life, yet it’s rarely discussed,” said Sivan Perdue, LCPAT, an art therapist certified in dementia care and sexual health.

The Longevity of Love

Several factors explain why older adults are enjoying more sexual longevity. Many are living longer, healthier lives. Those shaped by the sexual revolution often retain more open attitudes toward sexuality as they age. Medical advances, including treatments for erectile dysfunction, and hormonal therapies, have extended the potential for satisfying sex lives. 

For those seeking connections after the death of a partner or divorce, dating apps like OurTime and SeniorMatch open a wider pool of possible partners for romance and intimacy. One in six Americans ages 50 and older (17 percent) have tried using a dating site or app at least once, according to research from the Pew Research Center. 

“Today, older adults are more likely to participate in the hook-up culture of casual encounters and condomless sex,” according to a 2023 report in The Lancet, “Sexual activity of older adults: let’s talk about it.”

Positive portrayals of later-life romance in pop culture also play a role. Movies like It’s Complicated and TV series like Grace and Frankie show older adults embracing active sex lives and candidly discussing intimacy. Even reality TV, with shows like The Golden Bachelor, portrays romance as ageless.

Bertrand credits hormone therapy and a healthy lifestyle for the enduring intimacy she and her husband enjoy. Both have taken hormones since their 50s. She started using an estrogen patch in her 50s to counter menopause symptoms like depression, insomnia and hot flashes. Hormone therapy poses potential downsides—including a higher risk for breast cancer—but Bertrand thinks it’s worth the risk.

“Life’s too short,” she said.

Decreasing Libido

While 40 percent of older adults report they are sexually active, that leaves 60 percent who are not. It’s common for men and women to experience a gradual decline in libido beginning in their 50s, often triggered by factors like hormonal changes and chronic disease or disability. 

Sagging skin and other age-related physical changes may make some feel more inhibited sexually. Many medications prescribed to older adults can also dampen desire or affect functioning, including blood pressure medications, pain medications, statins and others. Obesity can interfere with sexual function, both at the hormonal and psychological level.

Some older adults simply lack partners. More than one-third of Baby Boomers aren’t currently married. Compared to previous generations, fewer Boomers got married in the first place, and among those who did, more ended up divorced or separated. Also, as people are living longer, the divorce rate for those 50 or older is rising. 

Some older adults lose partners to death. Jo McCormack (not her real name), 72, grew up during the sexual revolution and made the most of it, enjoying multiple liaisons with men in her youth. She never married but entered a long-term, monogamous relationship in her 30s that lasted 33 years, until her partner’s death.

“We had a very satisfying sex life, but when he died, my libido died with him,” she said. “I’ve always had a lot of men in my life, but now, I have no desire.” 

Online dating does widen the pool of potential love matches for older adults—if they’re comfortable using dating apps. Some find the technology too daunting. And online dating can be frustrating. 

“Many of us [people over 50] have to swim through a dispiriting sea of hundreds of people, most of whom we are unlikely to ever want to date,” writes Maggie Jones in the New York Times. “That includes profiles that are fake, created by scammers to try to lure private information from users. And while most profiles are real, sometimes their photos are not so much. More than one person told me that photos can be so outdated or filtered that they barely recognized their date when they met.”

Rising Risks

Increased sexual activity among older adults has coincided with a surge in STIs [sexually transmitted infections]. Between 2010 and 2023, STI rates among adults over 65 skyrocketed, with chlamydia tripling, gonorrhea increasing sixfold, and syphilis, nearly tenfold. Overall, STI rates among those 55 and older climbed from three to five cases per 100,000 in 2010 to 17.2 per 100,000 in 2020.

Despite these trends, older adults often lack basic STI knowledge. Few health care providers address sexual health with patients over 65 proactively. Among sexually active older adults, only 17.3 percent reported discussing sexual health with a provider in the past two years, and in most cases, patients initiated the conversation. 

Maggie Syme, PhD, a research psychologist at Massachusetts General Hospital, noted that the US Preventive Services Task Force only recommends STI screening for patients up to age 65. By contrast, doctors routinely ask younger patients about their sexual health and habits. For people ages 16-25, sex education is readily available in schools and colleges.

“But there are very few resources for older cohorts,” Syme said. “So, we have more older people engaging in sexual relations with new partners but lacking the resources and information to help them minimize risk.” 

Syme would like to see more public health campaigns aimed at older adults, such as the “Age is not a condom” social media campaign launched by ACRIA, an HIV-related nonprofit in New York state. 

If there’s one man with multiple partners in an assisted living community, that’s a recipe to start an STI outbreak.

—Martha Kempner

Condoms aren’t a foolproof solution, however. Condom use can pose practical challenges for older couples, cautions Leanna Wolfe, PhD, author of 177 Lovers and Counting: My Life as a Sex Researcher (Rowman and Littlefield, 2024.) 

“An older man needs a certain amount of stimulation, and a condom may not allow for that,” she said. Also, it’s difficult to apply a condom when the male isn’t fully erect, or if the couple is employing lubricants for vaginal dryness, a common problem for older women. (If condoms aren’t fail-safe, other preventive options include regular testing for STIs, limiting sexual partners to a mutually monogamous relationship, and possibly getting relevant vaccinations, such as HPV.)  

Many senior living communities lack policies that ensure residents’ safety while supporting their right to sexual expression. Sivan Perdue helps communities craft guidelines that address the reality of residents enjoying sexual activity. 

“It’s a matter of educating staff that sexuality is completely normal, that residents have a right to their privacy and that staff should not impose their beliefs,” she said.  “Policies should also ensure inclusivity for LGBTQ residents. No one should feel they have to go back into the closet in their later years.”

Residents living with dementia pose special issues. People with dementia have the right to sexual relationships if they desire them, Perdue adds. But whether an individual has the capacity to give consent is a complex question that requires careful, case-by-case consideration. 

The gender imbalance among older adults may also contribute to the rise in STIs, according to Martha Kempner, author of the Sex on Wednesday newsletter and co-author with Pepper Schwartz of 50 Great Myths of Human Sexuality (Wiley-Blackwell, 2015.) Because women live nearly six years longer than men, on average, there are fewer male partners available for older women. 

“If there’s one man with multiple partners in an assisted living community, that’s a recipe to start an STI outbreak,” Kempner said.  

Waning Desire

While more people are enjoying longer sex lives, sexual activity does change as people age. 

“I think the common misconception is that nothing works after a certain age,” Kempner said. “Things get a little more complicated as we age, but there are ways around that. Viagra and other performance enhancing treatments can help address erectile dysfunction in men. Lubricants can combat vaginal dryness.”

Developing a satisfying sex life in later life often means expanding one’s sexual vocabulary. 

“Many older adults have limited ideas of what constitutes ‘sex,’” according to Leanna Wolfe. “They think sex is only sex if it’s penile-vaginal intercourse.”

Partnered sex and intercourse may not be possible due to age-related issues such as arthritis, mobility limitations, effects of medication or serious health conditions. Oral sex, for example, often works better for older adults, according to Wolfe.  

Good communication, always key to a good sex life, is essential for older adults. However, sex is often a difficult topic to broach with a romantic partner, according to the National Poll on Healthy Aging. Only one in three respondents indicated they would talk to their partner about sexual health problems. 

But communication is critical for couples navigating changes in sexual desire. If both partners lose interest in sex in a relationship, that’s not necessarily a problem, but couples whose levels of interest and desire become unequal must negotiate those changes. Good communication can lead to effective compromises—like scheduling times for intimacy or agreeing to “maintenance sex” to enhance the relationship, even if one partner isn’t necessarily in the mood.  

To keep the spark alive, one woman sends her partner flirtatious text messages and makes sure he knows what “stokes the fire” for her.

When couples have unequal sex drives, it’s important not to sweep the issue under the rug, advises Maryon Stewart, author of Manage Your Menopause Naturally (New World Library, 2020.) 

“When your libido is low, expecting your partner to understand what is going on, without explaining, is an easy trap to fall into,” she said. 

Waning desire hasn’t happened with Lynn Johnson, 62, and her 77-year-old male partner. They’ve been together 15 years.  

“We’re both a bit baffled by it,” she said. “That’s a long time to want someone badly. The best way I can describe it is chemistry.” 

Johnson was in a long marriage previously, which was sexless for many years. “I was determined never to be in a relationship again where that was the case,” she said. “I’m just really cognizant of how to keep that alive.” 

To keep the spark alive, Johnson incorporates playful gestures, like sending flirtatious text messages. She’s vocal with her partner about what “stokes the fire” for her, as well as what turns her off. If her partner spends too much time on his phone, or in his own head, she reminds him that that “dims the flame.”

That’s how good communication keeps the spark alive, Bertrand notes, and it’s important to be specific.  

“Tell your partner what pleases you and how you like it done,” she said. “Sex is a two-way street.”

In his early 40s, Vinny Minchillo noticed he needed to work harder in the gym just to maintain his usual level of strength. Then, when he turned 60 a few years ago, he noticed a big change in flexibility. 

“I started making noises whenever I bent down to pick something up, or get up or down on the floor,” he said. “And it seemed like these changes occurred in just a week.” 

So when Minchillo read about a new Stanford Medicine study indicating that aging may occur in “bursts” around ages 44 and 60, he felt seen. “It blew me away. That’s exactly what happened to me.”

The study, published in Nature Aging in August 2024, tracked changes in 135,000 molecules and microbes collected from 108 healthy volunteers ages 25 to 75. Researchers observed that participants seemed to undergo dramatic waves of changes at the molecular level, or “aging bursts,” clustered around two distinct times: at age 44 and age 60.

The study assessed thousands of different molecules as well as participants’ microbiomes—the bacteria, viruses and fungi that live inside the body and on the skin. More than 80 percent of the molecules studied showed rapid changes, which are likely to impact health, surging at certain ages. The study’s cohort consisted of people under 75, but a previous study similarly noted spikes of changes in blood proteins occurring around ages 34, 60 and 78.  

“We expected to see changes in the 60s because we know people’s immune systems decline and disease risks go way up at that time,” said Michael Snyder, PhD, professor of genetics and the study’s senior author. “But the burst in the 40s was a bit unexpected.” 

Among participants in their 40s, the Stanford Medicine study noted significant changes in molecules related to caffeine, alcohol and lipid (fat) metabolism, as well as in molecules linked to the cardiovascular system, skin and muscles. For those in their 60s, changes related to carbohydrate and caffeine metabolism, immune regulation, kidney function, and the cardiovascular system, skin and muscle were observed.

At the molecular level, people don’t seem to age gradually and evenly over time. 

Many people experience major life changes or stresses around 44 and 60, which could contribute to the molecular changes, noted Pooja Patel, DrOT, an occupational therapist and elder care consultant. 

“People start retiring around age 60, for example,” she said. “They may not be as active as they were, or they may become more socially isolated. They may start feeling older because they’ve experienced a loss of purpose.”   

Similarly, women typically reach perimenopause in the mid-to-late 40s, and men undergo hormonal changes, including a drop in testosterone levels, around that age. 

However, changes at the molecular level don’t always lead to immediate changes in a person’s health status. 

“Just because something is happening at the biochemical level doesn’t necessarily translate into meaningful life changes,” said Hesan Fernando, PhD, a neuropsychologist at Corewell Health in Grand Rapids, MI. “We see this in individuals who show Alzheimer’s disease pathology in the brain but don’t actually develop Alzheimer’s clinically.” 

More research is needed to make definitive conclusions, including looking at participants’ health status and surveying a larger, more diverse cohort. But the key takeaway remains: people don’t seem to age in gradual, chronological fashion. Instead, they undergo two periods of rapid change. 

Mirrored in Experience 

Medical professionals and others who work with older adults say, anecdotally, that the research reflects their clinical experience. 

“I frequently see patients experience notable shifts in their health around their mid-40s and early 60s,” said Takyrbashev Kubanych, MD, an internal medicine physician. “There may be a sudden drop in stamina, or a new onset of health issues around these ages, despite leading generally healthy lifestyles. And they seem to emerge suddenly rather than developing gradually over time.”

Erin Williams, PhD, and her husband both noticed abrupt changes when their older friends reached the 60-year milestone. 

“They suddenly looked so much older,” said Williams, a psychologist specializing in treating older adults. “Then when it was our turn, it happened to us.”

Williams vividly remembers her 60th birthday a few years ago. She looked in the mirror and fought back tears and feelings of hopelessness. She had worked in health care through the pandemic, and her sleep was fractured. In the previous six years, three close family members had died, and several others struggled with health setbacks. The toll was showing. She had gained weight. Her energy was depleted, and her mind felt foggy.  

That birthday moment spurred Williams to make lifestyle changes: exercising and moving more throughout the day, cutting back on carbs and devoting more time to rest and self-care. She’s feeling more energetic and optimistic now. While she couldn’t stop the aging process, she said, understanding it has helped her cope. 

Managing the Changes

While the reality of aging bursts is sobering, it could also prove reassuring, according to Susan Rebillet, PhD, a psychologist specializing in older adults. She thinks the Stanford Medicine study could help them better understand and manage the changes that come with aging.

“Things can change dramatically as you get older,” she said. “When patients experience big health setbacks, some assume things will go back to ‘normal’ if they just follow the doctor’s orders, or if they exercise more or eat better.” The research, Rebillet said, helps clients understand that some change is inevitable. 

Similarly, Fernando says he often hears from patients who’ve just been diagnosed with a neurodegenerative disease, like Alzheimer’s or Parkinson’s, who ask, “What did I do wrong?” Understanding that changes are happening at the molecular level, and not always within the patient’s realm of control, might reduce the self-blame. 

While good health habits can help slow aging, Fernando added, “We also know that certain genetic factors will override anything we do environmentally or in terms of lifestyle. And some changes are just an inevitable part of life.”  

Preventive Potential 

The Stanford Medicine study doesn’t change the standard recommendations for maintaining good health later in life: eat healthy, exercise regularly, don’t smoke or overindulge in alcohol. But it does point to possibilities for managing patients’ preventative health care more precisely and more proactively. 

Snyder says that might mean increasing exercise to protect the heart, emphasizing strength training to maintain muscle mass or decreasing alcohol consumption in the 40s, as the ability to metabolize alcohol slows. Similarly, while staying hydrated is always important, it becomes even more critical when kidney function tends to decline in the 60s. 

Snyder believes the research points to ways for treating developing issues more proactively. He was also the lead researcher for a 2020 study that determined that people generally age along certain biological pathways in the body: metabolic, immune, hepatic (liver) and nephrotic (kidney). His team dubbed these “ageotypes.” Those who were metabolic ageotypes, for example, might be at a higher risk for diabetes; those with an immune ageotype, on the other hand, might be more prone to immune-related diseases as they age. 

Determining which ageotype applies might allow physicians to tailor more precise and targeted preventive interventions. For example, currently, doctors don’t treat high blood pressure or high cholesterol until levels reach a particular threshold. As aging bursts and ageotypes are better understood, physicians might prescribe medications or other interventions earlier, to prevent systemic, long-term damage. 

As further research is done, more sophisticated interventions are likely to emerge down the road. In the meantime, the Stanford Medicine study’s results are valuable, Fernando said, because they “highlight these potentially vulnerable times in our lives when we need to be extra careful about the decisions that we’re making.”

Minchillo, who’s still in good health and still working, hopes further research might provide clues to help him stay active as long as possible.  

“I need to stay in shape so that I can play on the floor and roughhouse with my grandson,” he said. “I want to be able to do that as long as I can.” 

Every time Jodie Pepin’s mother saw another physician, it seemed like she was prescribed yet another medication. Each time Pepin wondered, “Why are they giving her that? She already has dementia.”

Pepin, clinical pharmacy program director at Harbor Health in Austin, TX, knew the medications could exacerbate dementia, cause drowsiness and affect gait. When her mother fell, multiple times, she blamed the drugs. 

“These medications just kept making it worse,” said Pepin, PharmD, who is also a clinical assistant professor at the College of Pharmacy at the University of Texas at Austin. “It frustrated me to no end.” 

Pepin lived in another state, so she reviewed her mother’s medications and had many conversations with doctors over the phone. Each time, the doctor would stop one or two drugs. Then another health issue would arise for her mother, who would see another doctor, who would prescribe yet another medication. 

That kind of medical doom loop is not uncommon among older people, particularly those with multiple chronic conditions. Polypharmacy—taking five or more medications—is associated with increased hospital admissions, falls and premature mortality.  

The problem has led to a growing movement among medical schools and hospital systems toward “deprescribing” medications: discontinuing drugs that are either potentially harmful or no longer required, or reducing the dosage or frequency, always with medical supervision. 

Almost 90 percent of adults 65 and up take at least one prescription drug regularly; 54 percent of older adults report taking four or more prescription drugs. As the number of medicines goes up, medication management becomes more complex, and the risk of adverse reactions grows.  

As people age, kidney and liver functioning decrease, along with lean body mass, affecting the way drugs are metabolized. Medications may stay in an older person’s system longer, increasing the risk and severity of side effects. 

Troubles with the System

The fragmented nature of the US health care system also contributes to the problem.  

“Many older people see multiple doctors in multiple specialties,” said DeLon Canterbury, PharmD, founder of GeriatRx, a concierge telehealth service. “One is focused on the kidney, the other is focused on the heart, and so on. These providers are following their guidelines but not thinking about the whole picture.” 

As a result, patients may end up with duplicate prescriptions for similar medications or medications that interact. 

Older patients are also at risk for what medical professionals call a “prescribing cascade,” according to Dominick Trombetta, PharmD, associate professor of pharmacy practice (geriatrics/internal medicine) at Wilkes University School of Pharmacy in Wilkes-Barre, PA. 

A common scenario: a doctor prescribes amlodipine, a medication for high blood pressure. It’s generally safe but can cause a patient’s feet to swell. Instead of trying a different blood pressure medication or adjusting the dosage, the provider assumes the edema is yet another age-related condition and prescribes a diuretic. 

The diuretic, in turn, creates an electrolyte imbalance, which leads to a prescription for a potassium supplement, which causes heartburn, which leads to a prescription for antacids.

Some whole categories of drugs carry special risks for older people. 

Some medications can be dangerous for older people or patients with certain health conditions. Canterbury saw this with his grandmother, Mildred, who had mild dementia. When she began declining rapidly, the family moved Mildred out of assisted living. But she didn’t improve. 

“She was wandering around the house, hiding her dentures, hiding her glasses and not remembering us,” Canterbury said. “It was heartbreaking.”  

A medication review by the family’s pharmacist revealed that Mildred was taking an antipsychotic with a “Black Box Warning” (the Food and Drug Administration’s highest safety-related warning). The drug was associated with “increased mortality in elderly patients with dementia-related psychosis.” 

Mildred returned to her baseline level of functioning after she stopped the meds.

Trombetta notes that some drug categories tend to be inappropriately prescribed for older patients. Proton pump inhibitors, such as omeprazole, omeprazole or pantoprazole, are often prescribed in hospitals to prevent gastrointestinal bleeding. That’s appropriate while the patient is in the hospital, but the patient may no longer need it after discharge, and continued use increases the risk for fractures, severe diarrhea, pneumonia or B12 deficiency. 

Diabetes medications are also frequently prescribed inappropriately. For younger or middle-aged patients, doctors prescribe for tight control of blood sugar levels, because high blood sugar can harm the heart and pose other long-term risks. For older people, it often makes sense to relax the control of blood sugar levels and reduce or change medications accordingly. The goal is to minimize the risk of hypoglycemia (dangerously low blood sugar), which can lead to falls or even death.    

Taking Precautions

To help avoid polypharmacy issues, the American Geriatrics Society publishes the Beers List, a database that flags medicines that health care providers should either avoid or prescribe with caution for older patients. The list is updated every three years, most recently in 2023.

The Beer’s List includes seemingly innocuous, over-the-counter medications like diphenhydramine (Benadryl), which may lead to confusion or falls for older patients, and nonsteroidal anti-inflammatory drugs (NSAIDs) like ibuprofen, which should be avoided by older people with kidney disease. Other cautions on the list include antibiotics like Cipro, which may interact with blood thinners, and benzodiazepines like Valium, which can impair cognitive function and cause an unsteady gait. Doctors may still choose to prescribe these medications, but the list helps them proceed with caution. 

Some hospitals are implementing programs to avoid over-prescribing medications or to encourage physicians to consider deprescribing. 

Pepin was involved in one such effort at a trauma unit. Working with trauma surgeons, she designed an admission order for older patients. Previously, doctors were prescribing the same doses of sleep or pain meds regardless of patients’ ages. Following the Beers criteria, the orders were customized for older patients, which led to a decrease in oversedation or respiratory depression.

Safety Is an Utmost Concern

More than 80 percent of adults aged 50 to 80 would be open to stopping one or more of their prescription drugs, according to the University of Michigan National Poll on Healthy Aging. 

Some patients are taking matters into their own hands. More than a third of those polled said they stopped taking a medication without consulting a medical professional—in some cases, due to concerns about cost. 

But self-deprescribing is risky, said Sarah Vordenberg, PharmD, a clinical associate professor at the University of Michigan College of Pharmacy, who worked on the poll.

“In our research, we found that the types of medications that older adults are interested in stopping are not always the types that health care professionals think are best to stop,” she said. A patient who discontinues a cholesterol medication, for example, may not notice any changes, but their risk of heart attacks or stroke may be increased.”

Bottom line: deprescribing should always be done in consultation with a physician or other primary care provider. 

Taking Charge

Patients and their caregivers can take a proactive role in managing their medications. Start by always keeping an updated list of all medications, including over-the-counter drugs, supplements and vitamins—even non-oral medications like eye drops—with the actual doses being taken, even if not as prescribed. If the cost of a medication is an issue, tell the provider that too. 

Bring that list to every doctor visit. Don’t assume the provider has a correct list.  

Patients may request a comprehensive medication review by a pharmacist or other provider. Most retail pharmacists can provide this service, which is covered by Medicare and other insurance, but an appointment is usually required. If possible, patients should get all their prescriptions filled at the same pharmacy. Those who use more than one pharmacy, or take nonprescription drugs or supplements, should be sure the reviewing pharmacist has that information. 

Medications should also be reviewed at every annual checkup, with an eye toward deprescribing. If a physician does recommend cutting some medications, be sure to get detailed instructions on how. Some medications need to be tapered rather than stopped cold turkey. And always ask how long new medications should be taken. 

In addition to the annual checkup, experts advise having all medications reviewed at every medical transition, including: 

• After a fall
• Any time there’s a change in medical condition or health needs
• Upon entering or leaving a long term care facility, such as rehab or skilled nursing
• Before and after a hospitalization

“Any time a person is discharged from the hospital, they should follow up with their primary care provider within a week,” said HaVy Ngo-Hamilton, PharmD, a hospital pharmacist and clinical consultant at BuzzRx, a free prescription discount service. 

Some older adults aren’t comfortable questioning their doctors, according to Vondenberg. She suggests asking, “Can we talk through all of my medications so I can better understand why I’m taking each one?’” 

“That naturally leads to the conversation of, why are you taking the medication, and is it still needed?” she said. 

Family members, too, may hesitate to broach the issue of deprescribing for an older family member, fearing they’ll be perceived as pinching pennies or withholding care. To help start the conversation, Vonderberg and fellow researchers created a patient handout, Polypharmacy and Deprescribing, available online on the JAMA Network website. 

“At the end of the day, you’re the one taking these medications and they’re impacting your health,” Vondenberg said. “Make sure that they are right for you and align with your health goals.” 

For most of her life, Jenny Anne Horst-Martz’s mother worked hard to stay slender. But now, at age 90, her mother struggles to keep enough weight on. 

The problem started a few years ago when her mother was injured in a fall and then diagnosed soon after with a recurrence of lung cancer. Between the cancer itself, the multiple hospital stays, an array of new medications and the slowdown in her activity level, her mother’s appetite disappeared. Her weight dipped to 104 pounds—too low for her 5’6” frame. 

“We were really worried,” Horst-Martz said. 

Horst-Martz’s mother faces a common struggle among older adults: malnutrition. The Alliance for Aging Research calls malnutrition a “hidden epidemic in the United States,” one that is underrecognized and undertreated. An estimated 25 percent of older Americans are malnourished or at risk of malnutrition, and not all are at risk due to poverty or lack of access to healthy food. 

“We see this all the time: people who have very good means and good caregiver support, but they’re struggling with malnutrition,” said Alex Foxman, MD, president of Mobile Physician Associates in Beverly Hills, CA.

Malnutrition triggers a vicious cycle, weakening the immune system and causing sarcopenia (loss of muscle mass), which can lead to frailty and falls. Malnutrition rates are especially high among older adults who are hospitalized, leading to longer hospital stays, higher infection rates, poor wound healing, higher readmission rates, poorer outcomes and death. The Alliance for Aging Research estimates the resulting increased economic burden due to malnutrition among older adults in the United States at more than $51 billion each year. 

How the Cycle Begins

A host of factors make older adults more prone to malnutrition. 

Many of the chronic medical problems affecting older adults can contribute. Some, like cancer, diabetes and Alzheimer’s disease, can depress the appetite, as can many medications or combinations of medications. Other diseases—and even normal age-related changes, such as lower stomach acidity—lessen the body’s ability to absorb nutrients. 

“Sometimes it’s not that people are not eating, it is that they are not absorbing the nutritional value of foods through their gastrointestinal system,” Foxman said. 

People with dementia can lose the ability to handle daily activities, including feeding themselves. Older adults may develop dental problems, dry mouth or difficulty handling tableware, chewing or swallowing food. Age-related changes may alter the ability to smell and taste food.  

“If you were a big meat eater when you were younger, and now suddenly chewing and swallowing meat becomes a challenge, you might end up just eating cheese and crackers all day long,” said Suzannah Gerber, a nutrition epidemiology researcher at Tufts Friedman School of Nutrition Science and Policy.

Isolation, leading to depression, can shrink a person’s appetite.

Older adults with mobility challenges may not be able to prepare meals. Others may lack transportation to get to the grocery store regularly. 

“Altogether, this means that older adults may choose more convenient, processed foods because they are accessible, easier to cook, available in [single-serving] packages and easy to swallow and digest,” said Gerber. “This means more empty calories.”

Psychological factors can contribute too. Eating is a social activity that loses its appeal for an isolated older adult. And many older adults are isolated; according to the 2023 University of Michigan National Poll on Healthy Aging, one in three older adults (ages 50–80) reported feeling isolated from others in the past year.  

“Isolation and loneliness lead to depression, which can have a negative impact on appetite,” said Michelle Rauch, MNutr, a registered dietician for the Actors Fund Home, a senior living community in Englewood, NJ, for retired members of the entertainment community. 

Food Insecurity Plays a Role

For a significant number of older adults, malnutrition stems from an inability to afford healthy food. According to a 2021 survey, 5.5 million Americans over age 60 are food insecure. 

Older adults with functional limitations or chronic disease are especially prone to food insecurity. People with two or more chronic conditions, for example, were two to three times more likely to be food insecure compared to those with no chronic conditions. 

Food insecurity especially affects people of color. 

“Food insecurity is caused by financial insecurity, which is rooted in systemic racial, gender and health inequities.” said Gretchen Dueñas-Tanbonliong, MS, a registered dietician and associate director of health and wellness at the National Council on Aging (NCOA.) “Black older adult households are over three times more likely to experience food insecurity compared to white households.” Similarly, Latino older adults are three times as likely to experience food insecurity compared to white older adults

Food insecure older adults often resort to harmful coping strategies. They may skip medication, forgo medical care or choose cheap, unhealthy foods to stretch their budgets, according to a Food Research & Action Center (FRAC) study. 

In addition, many older adults who are eligible for Supplemental Nutrition Assistance Program (SNAP) benefits aren’t getting them. A 2016 NCOA study showed that 79 percent of older adults have heard of SNAP, but only one in six who were eligible are actually enrolled. Survey respondents said the application process was too tedious, or they didn’t know how to apply or they were worried that, by accepting benefits, they’d deprive people who needed the help more. 

Some advocates want programs like Medicaid expanded to cover food and nutrition.

To help older adults navigate benefits more easily, NCOA created a website, BenefitsCheckup.org. Visitors enter their zip codes and other information to determine their eligibility for SNAP and a variety of other government programs.

Many older adults who receive Social Security are eligible for only the minimum SNAP payments, according to LaMonika Jones, interim director of state initiatives for FRAC. Rules and minimum amounts vary by state, but in Washington, DC, where Jones is based, the minimum is only $30 a month, which doesn’t go far in funding a healthy diet. 

Older adults with diabetes or hypertension should take particular care in choosing healthy foods, Jones said. “But that’s a challenge because the cost of fresh foods is high.” 

Some hunger advocates propose expanding Medicaid and similar programs to cover food and nutrition, as part of a movement broadly called “Food is Medicine.”

“We’d like to see medically tailored meals as an option, as well as the potential to purchase fresh fruit and vegetables, to treat those diet-related diseases,” Jones said. 

Assessment and Diagnosis

While malnutrition is prevalent, diagnosing it is not always easy. 

“An older adult who is overweight can still be malnourished,” said Dueñas-Tanbonliong. “If they aren’t getting enough important vitamins and minerals, that can result in nutrient deficiencies.” 

Even the definition of malnutrition varies. Medical researchers typically define malnutrition as a lack of nutrient quality, or nutrient quantity or both. By contrast, other agencies, including the World Health Organization, consider malnutrition more broadly to include any “deficit, excess or imbalance of protein, energy and other nutrients” that adversely affects health. By that definition, obesity is counted as a form of malnutrition.

Common symptoms of malnutrition include loss of appetite, unexplained weight loss, weakness, fatigue or edema (swelling). Sunken eyes or protruding bones are other clues. Blood tests can detect anemia, an iron or protein deficiency. Screening tools assess factors such as appetite, dietary intake, weight loss, appetite and body mass index (BMI). 

“Health care teams must be vigilant in promptly diagnosing and treating malnourished patients in the hospital,” wrote Dueñas-Tanbonliong in an article she co-authored. “It is equally important, however, for patients and their families to be knowledgeable and to speak up when they feel something is amiss.” 

Improving Nutrition

Interventions to combat malnutrition vary depending on the older adult’s situation. 

Medically, a physician might begin by treating any underlying conditions that are contributing to malnutrition and reviewing the older adult’s medications to reduce or replace any that suppress appetite or cause gastrointestinal side effects. Doctors may also prescribe appetite-inducing medication or, in extreme cases, a feeding tube. 

“You start by trying to figure out what nutrients the person is lacking, and then you try to supply that in the form of real food, if possible,” Rauch said. 

That may mean helping the older adult prepare or obtain tempting meals with plenty of fresh fruits and vegetables, lean meats or other proteins, and whole grains. This could mean in-home assistance with meal preparation, Meals on Wheels or arranging for the individual to eat meals at a local senior center. 

Some interventions focus on simply upping a person’s calorie or protein intake. While meal-replacement supplements like Ensure or Boost are often loaded with sugar or corn syrup, they still may be a good option for people who need more calories or who can’t eat solid food.

Those who have had an eating disorder in the past sometimes struggle with malnutrition in their later years.

Sometimes tackling malnutrition means educating the older adult or caregiver on healthier food choices, according to Tina Baxter, GNP, a nurse practitioner in Anderson, IN, and a parish nurse in her church. In a home visit, she discovered a parishioner was surviving on frozen dinners and sodium-packed processed foods after suffering a stroke. 

“I was able to get her refrigerator stocked with healthier versions of ready-made food, donated by the church, contact her family for assistance for future needs and show her how to make simple meals using the microwave, as she was not able to stand long due to the stroke,” Baxter said. 

Psychological factors may also need to be addressed. Rauch occasionally sees retired dancers or performers with a history of eating disorders. When they move into the Actors Fund Home, where meals are provided, Rauch said, “The family may be thinking that I can just fatten them up, but there’s a big psychological component with eating disorders. With malnutrition, there really needs to be a multidisciplinary approach.” 

Several different strategies have helped Jenny Anne Horst-Martz’s mother make progress. Thankfully, immunotherapy has kept the cancer at bay. Today, at 112 pounds, she is still underweight, but her appetite is improving. To up her calorie intake, she snacks on protein drinks between meals, slathers her apple slices with nut butter at lunch and enjoys a dish of vanilla bean ice cream at night. Her doctors seem pleased with her nutritional status, and her blood work is good.  

“Mom eats nutritiously, tries to exercise and enjoys food at least some of the time,” said Jenny Anne Horst-Martz. “She’s doing much better.” 

For this article, journalist Judith Graham interviewed doctors about how time-consuming and difficult it can be for older patients to get the health care they need. When you add up the time they spend on everything from medical tests and doctor visits to juggling appointments and dealing with insurance companies, it comes to about three weeks a year for most. Graham has some suggestions for how to lighten that burden. KFF Health News posted her article on March 27, 2024. It also ran on the Washington Post. Funding from the Silver Century Foundation helps KFF Health News develop articles (like this one) on longevity and related health and social issues. 

Susanne Gilliam, 67, was walking down her driveway to get the mail in January when she slipped and fell on a patch of black ice.

Pain shot through her left knee and ankle. After summoning her husband on her phone, with difficulty she made it back to the house.

And then began the run-around that so many people face when they interact with America’s uncoordinated health care system.

Gilliam’s orthopedic surgeon, who managed previous difficulties with her left knee, saw her that afternoon but told her, “I don’t do ankles.”

He referred her to an ankle specialist who ordered a new set of X-rays and an MRI. For convenience’s sake, Gilliam asked to get the scans at a hospital near her home in Sudbury, MA. But the hospital didn’t have the doctor’s order when she called for an appointment. It came through only after several more calls.

Coordinating the care she needs to recover, including physical therapy, became a part-time job for Gilliam. (Therapists work on only one body part per session, so she has needed separate visits for her knee and for her ankle several times a week.)

“The burden of arranging everything I need—it’s huge,” Gilliam told me. “It leaves you with such a sense of mental and physical exhaustion.”

The toll the American health care system extracts is, in some respects, the price of extraordinary progress in medicine. But it’s also evidence of the poor fit between older adults’ capacities and the health care system’s demands.

“The good news is we know so much more and can do so much more for people with various conditions,” said Thomas H. Lee, MD, chief medical officer at Press Ganey, a consulting firm that tracks patients’ experiences with health care. “The bad news is the system has gotten overwhelmingly complex.”

We don’t talk enough about what we’re asking older adults to do and whether that’s realistic.

— Ishani Ganguli, MD

That complexity is compounded by the proliferation of guidelines for separate medical conditions, financial incentives that reward more medical care, and specialization among clinicians, said Ishani Ganguli, MD, an associate professor of medicine at Harvard Medical School.

“It’s not uncommon for older patients to have three or more heart specialists who schedule regular appointments and tests,” she said. If someone has multiple medical problems—say, heart disease, diabetes, and glaucoma—interactions with the health care system multiply.

Ganguli is the author of a new study showing that Medicare patients spend about three weeks a year having medical tests, visiting doctors, undergoing treatments or medical procedures, seeking care in emergency rooms or spending time in the hospital or rehabilitation facilities. (The data is from 2019, before the COVID pandemic disrupted care patterns. If any services were received, that counted as a day of health care contact.)

That study found that slightly more than 1 in 10 seniors, including those recovering from or managing serious illnesses, spent a much larger portion of their lives getting care—at least 50 days a year.

“Some of this may be very beneficial and valuable for people, and some of it may be less essential,” Ganguli said. “We don’t talk enough about what we’re asking older adults to do and whether that’s realistic.”

Victor Montori, MD, a professor of medicine at the Mayo Clinic in Rochester, MN, has for many years raised an alarm about the “treatment burden” that patients experience. In addition to time spent receiving health care, this burden includes arranging appointments, finding transportation to medical visits, getting and taking medications, communicating with insurance companies, paying medical bills, monitoring health at home and following recommendations such as dietary changes.

More and more medical practices use online patient portals and digital phone systems that frustrate older patients, who find them hard to navigate. 

Four years ago—in a paper titled “Is My Patient Overwhelmed?”—Montori and several colleagues found that 40 percent of patients with chronic conditions such as asthma, diabetes and neurological disorders “considered their treatment burden unsustainable.”

When this happens, people stop following medical advice and report having a poorer quality of life, the researchers found. Especially vulnerable are older adults with multiple medical conditions and low levels of education who are economically insecure and socially isolated.

Older patients’ difficulties are compounded by medical practices’ increased use of digital phone systems and electronic patient portals—both frustrating for many seniors to navigate—and the time pressures afflicting physicians. “It’s harder and harder for patients to gain access to clinicians who can problem-solve with them and answer questions,” Montori said.

Meanwhile, clinicians rarely ask patients about their capacity to perform the work they’re being asked to do. “We often have little sense of the complexity of our patients’ lives and even less insight into how the treatments we provide (to reach goal-directed guidelines) fit within the web of our patients’ daily experiences,” several physicians wrote in a 2022 paper on reducing treatment burden.

Consider what Jean Hartnett, 53, of Omaha, NE, and her eight siblings went through after their 88-year-old mother had a stroke in February 2021 while shopping at Walmart.

At the time, the older woman was looking after Hartnett’s father, who had kidney disease and needed help with daily activities such as showering and going to the bathroom.

During the year after the stroke, both of Hartnett’s parents—fiercely independent farmers who lived in Hubbard, NE,—suffered setbacks, and medical crises became common. When a physician changed her mom’s or dad’s plan of care, new medications, supplies and medical equipment had to be procured, and new rounds of occupational, physical and speech therapy arranged.

Neither parent could be left alone if the other needed medical attention.

“It wasn’t unusual for me to be bringing one parent home from the hospital or doctor’s visit and passing the ambulance or a family member on the highway taking the other one in,” Hartnett explained. “An incredible amount of coordination needed to happen.”

Hartnett moved in with her parents during the last six weeks of her father’s life, after doctors decided he was too weak to undertake dialysis. He passed away in March 2022. Her mother died months later in July.

Ask which of the things you’re being asked to do is most important and which might be expendable.

So, what can older adults and family caregivers do to ease the burdens of health care?

To start, be candid with your doctor if you think a treatment plan isn’t feasible and explain why you feel that way, said Elizabeth Rogers, MD, an assistant professor of internal medicine at the University of Minnesota Medical School. 

“Be sure to discuss your health priorities and trade-offs: what you might gain and what you might lose by forgoing certain tests or treatments,” she said. Ask which interventions are most important in terms of keeping you healthy, and which might be expendable.

Doctors can adjust your treatment plan, discontinue medications that aren’t yielding significant benefits and arrange virtual visits if you can manage the technological requirements. (Many older adults can’t.)

Ask if a social worker or a patient navigator can help you arrange multiple appointments and tests on the same day to minimize the burden of going to and from medical centers. These professionals can also help you connect with community resources, such as transportation services, that might be of help. (Most medical centers have staff of this kind, but physician practices do not.)

If you don’t understand how to do what your doctor wants you to do, ask questions: What will this involve on my part? How much time will this take? What kind of resources will I need to do this? And ask for written materials, such as self-management plans for asthma or diabetes, that can help you understand what’s expected.

“I would ask a clinician, ‘If I chose this treatment option, what does that mean not only for my cancer or heart disease but also for the time I’ll spend getting care?’” said Ganguli of Harvard. “If they don’t have an answer, ask if they can come up with an estimate.”

 

For three years, Lil Banchero’s 86-year-old mother struggled with pain due to advanced arthritis. She tried yoga. Doctors prescribed medications and tried injections. Nothing worked. The pain got worse, and her mother became depressed. 

“Months passed,” said Banchero. “Nobody was paying attention anymore.”

Finally, Banchero accompanied her mother to a doctor’s appointment and insisted, “There’s got to be something else out there we can try.” 

The doctor prescribed another medication, and that—combined with meditation, walking and yoga—finally made the pain manageable.

“My mother is a different person now,” Banchero said. “She went out and got a pedicure today. It’s been life changing.” 

Banchero knew how to advocate for her mother because she’s a nurse and program coordinator for the Institute for Healthy Aging at the Luminis Health Anne Arundel Medical Center in Annapolis, MD. But more and more older adults who are not medical professionals will need to learn that skill, too. That’s because, just as the population of older Americans is ballooning, several factors are conspiring to make getting good medical care even harder.

Older adults often have multiple chronic conditions involving a multitude of specialists. (A third of older adults see at least five different specialty medical providers each year.) The fragmented, siloed nature of the American health care system delegates the task of coordinating that care to primary care physicians (PCPs), who are overworked, pressed for time and in short supply. There’s an even greater dearth of geriatricians, who specialize in caring for older adults. And projections say it’s only going to get worse.

The bottom line: just showing up for appointments and following doctors’ orders doesn’t guarantee good care.

Said Banchero: “You’re the pilot of your own care.”

 Quarterbacking Care

That reality shocked Tina Sadarangani, PhD, an assistant professor at New York University’s Rory Meyers College of Nursing. When her parents developed serious health conditions, she discovered how much responsibility falls on patients and their families. Even though she’s always treated patients, and although both parents are retired physicians, quarterbacking their care has proven exhausting. 

Spurred by her experiences, Sadarangani created CareMobi, an app for coordinating care, and the Enlightened Caregiver, an Instagram with tips for patients and their care partners.

“We may not be able to fix the broken system, but we can figure out how to work within the system,” she said. 

Her advice: make the most of medical visits, which may run only five minutes. Consider recording conversations with the doctor to help remember details. Bring a family member or friend to the appointment.

“Plan your story ahead,” she said. “Lead with your most pressing problem and get the timeline of your symptoms straight with as many specifics as possible. It makes a big difference to your doctor if your cough has been going on for several months instead of two weeks, for example.” ⠀

When describing a symptom, Sadarangani said, tell the doctor how it’s affecting your ability to function. Instead of just saying “My back hurts,” be specific: “I was playing golf five times a week until this back pain started, and now I can’t get out of bed.” 

Keep track of basics, like your numbers if you have high cholesterol, and what direction they’re moving in. 

Specific information helps ensure the doctor doesn’t dismiss your symptoms as “just getting old,” Sadarangani added. 

“If you want the doctors to be proactive and to help you maintain the level of functioning you want, you need to be clear about that,” she said. “You need to say, ‘I want to be back in my golf game. What can you do to help me get there?’”  

If you have questions, write them down in advance and frame them carefully. 

“If you’re not precise with an ask, the physician is probably not going to pay attention,” Banchero said. 

Before leaving a doctor’s office, make sure you are clear on your next steps. If the doctor ordered a test, for example, ask: How and when will you get the results?  Depending on the test results, will you need another test, or to schedule another appointment? If you’ve seen the doctor for a new symptom or acute illness, ask when you should expect improvement, and what new or continued symptoms warrant a call to the doctor’s office or even a trip to the ER. Find out the best way to contact the doctor or a nurse after hours, if the need arises. Assume the ball is always in your court because, in most situations, it is. 

Consider yourself the central repository for your medical records. In theory, after an exam, each specialist sends the records to your primary care physician. Don’t count on that. If you see a specialist, follow up with your PCP’s office to confirm that the record was received and reviewed. Keep your own record of each visit, too.

Banchero encourages patients to educate themselves on some medical basics. For example, if you have high cholesterol, keep track of your numbers and understand what they mean. That way you’ll know whether you’re improving or getting worse and can discuss that with your doctor if needed. 

Many experts noted that patients can ask for an annual Wellness Visit—an extended, 45-minute visit, covered by Medicare, that includes a review of your medical and family history and current prescriptions, as well as advance care planning and a cognitive assessment. That in-depth visit can ensure that your health care plan is personalized. 

Managing Multiple Meds

In her previous job as executive director of a senior living community, Jenni Knutson, CDP, always made sure that residents were prepared for medical emergencies. Any time a resident was taken to the ER, Knutson handed paramedics a list of the person’s medications, insurance information and other documents. 

But that didn’t always work, as Knutson discovered when visiting a resident who’d been taken to the hospital in an ambulance and admitted. Family members were puzzled because the patient hadn’t eaten in days. When Knutson asked the nurse on duty at the hospital to check, they discovered that the patient’s medication record wasn’t updated in the hospital system. No one at the hospital was aware that the patient had been taking a strong anti-psychotic medication daily before she was admitted. As a result, the patient had gone “cold turkey” during the six days she’d been in the hospital, which explained the appetite loss. 

“Likely a doctor in the ER reviewed her medication list, then set it down on a counter, and no one updated the computer system,” said Knutson, who is now a senior life care manager with Olive Branch Seniors based in the Dallas, TX, area. 

Knutson said that many missteps in medical care for older adults relate to medications. About half of adults 65 and older report taking four or more prescription drugs daily. One study showed that one in seven cases of emergency department visits by older adults were medication related—and over three-quarters of them were preventable. Medication-related problems included adverse drug events (side effects) as well as those due to noncompliance—taking too much or too little of the medication, or stopping the drug entirely without medical supervision.

To help avoid these missteps, keep an updated list of all medications, including the name, dosage, date, number of refills and instructions (such as whether to take with or without food). That list should include prescriptions, over-the-counter medications, supplements and herbal remedies. 

Also, know that it’s also up to you to make sure every provider has the most updated list.

As you grow older, medication side effects can become more common or severe. Ask your doctors whether you really need all the drugs you’re taking. 

“Share your medication list with all of your health care providers, especially when you see a new doctor, get a new prescription or have a change in your condition,” said Erin Inman, PharmD, vice president of Corewell Health in Grand Rapids, MI. Ask the doctor to review the list for possible interactions. 

Pharmacists can also serve as an excellent resource between doctor visits, Inman adds. 

“Your pharmacist can answer any questions you may have,” she said. “You can request a review of your complete medication list for potential interactions or duplications. This is what pharmacists are trained to do.” (Call ahead to make sure the pharmacist has time to review the medications or to schedule a time.)

Inman recommends filling all your prescriptions at a single pharmacy, if possible. Anytime a new medication is prescribed, she advised, ask the doctor: “Is this medicine additive or is it replacing something else? How long do I need to take it—for a period of time or is it going to be lifelong?” 

Geriatricians review patients’ medication lists with an eye toward “deprescribing,” because side effects may become more common or severe as patients get older. Don’t hesitate to ask your doctor about this.

“You can ask your providers about de-prescribing, especially if you suspect a medication or medication interaction is causing an adverse symptom or no longer helping,” said Kylie Meyer, PhD, assistant professor at Bolton School of Nursing at Case Western Reserve University in Cleveland, OH. 

Enlisting Care Partners

Many experts advise bringing a care partner—a trusted friend or family member—along on appointments to serve as a second set of eyes and ears. That’s especially important for patients who may have cognitive impairment. Care partners can work with the primary provider to keep the dots connected, said Denise Lucas, PhD, clinical associate professor and chair of advanced practices at Duquesne University’s School of Nursing in Pittsburgh, PA.       

The care partner should also obtain access to the patient’s online medical records. Banchero can log onto her mother’s account for MyChart, the health care system’s patient portal, to check on test results and other developments. (Patients are permitted to share their log-in info if they so choose.) 

A care partner can be especially helpful for older patients who aren’t comfortable asking questions, said Erica Stevens, DO, department chief of primary care at Corewell Health in Grand Rapids, MI.

“[Older adult patients] may feel like asking questions is disrespectful,” she said. “But it’s actually welcomed, from a provider’s lens, because I don’t know what’s happening in your home.” If a patient is forgetting things, or having trouble getting out of a chair, she wants to know, especially if the problem has worsened recently. 

For older adults without family nearby, some community agencies may be able to help with this role. “Contact your local Area Agency on Aging and request help from publicly funded Care Coordination Services,” said Dennis Meyers, PhD, chair for the residential care of older adults at Baylor University’s Garland School of Social Work in Waco, TX. “Organizations such as the Alzheimer’s Association and American Heart Association also offer guidance on how to access care.” 

Becoming Age-Friendly 

Some hospitals and clinics are working to improve care for older adults by becoming certified Age-Friendly Health Systems. That involves adopting practices centered on the “4Ms” of good geriatric care: What Matters, Medication, Mentation and Mobility: 

• “What Matters” involves considering the older adult’s priorities in making treatment decisions—for example, honoring a 90-year-old patient’s desire to forego aggressive cancer treatment. Don’t hesitate to express your wishes to your doctor. 
• “Medication” means considering your medicine and supplement needs and issues, as described earlier in this article.
• “Mentation” issues, such as forgetfulness, can be dismissed by primary care physicians as part of normal aging. Ask for an assessment if you’re experiencing cognitive issues. 
• “Mobility” is another area that primary care physicians might brush aside. If you’re having trouble getting around, ask about the possibility of physical therapy (which may help you regain or maintain physical function) or occupational therapy (which can help you adapt to changes in mobility and optimize functioning). 

As more hospitals adopt age-friendly measures, which Banchero’s hospital helped develop, more older patients will get the care they need in the future. But until they do, the onus falls on older adults and their care partners to be smart, educated and empowered. 

“We really do need to be advocates for ourselves,” she said. “There are so many phenomenal advancements in medicine today. I would never [accept], ‘It’s just because you’re old.’”

 

Only 29 percent of those who hear poorly use hearing aids. In this article, journalist Judith Graham explains why that’s true and why some older adults who do wear aids find them frustrating. She also rounds up advice from experts on how to avoid those frustrations. KFF Health News posted her story on February 28, 2024. It also ran on CBS News. Funding from the Silver Century Foundation helps KFF Health News develop articles (like this one) on longevity and related health and social issues.

It was an every-other-day routine, full of frustration.

Every time my husband called his father, who was 94 when he died in 2022, he’d wait for his dad to find his hearing aids and put them in before they started talking.

Even then, my father-in-law could barely hear what my husband was saying. “What?” he’d ask over and over.

Then, there were the problems my father-in-law had replacing the devices’ batteries. And the times he’d end up in the hospital, unable to understand what people were saying because his hearing aids didn’t seem to be functioning. And the times he’d drop one of the devices and be unable to find it.

How many older adults have problems of this kind?

There’s no good data about this topic, according to Nicholas Reed, PhD, an assistant professor of epidemiology at Johns Hopkins Bloomberg School of Public Health who studies hearing loss. He did a literature search when I posed the question and came up empty.

Reed co-authored the most definitive study to date of hearing issues in older Americans, published in JAMA Network Open last year. Previous studies excluded people 80 and older. But data became available when a 2021 survey by the National Health and Aging Trends Study included hearing assessments conducted at people’s homes.

The trend in hearing aids has been to make them smaller, more technologically sophisticated—and harder for many older people to use. 

The results, based on a nationally representative sample of 2,803 people 71 and older, are eye-opening. Hearing problems become pervasive with advancing age, exceeding 90 percent in people 85 and older, compared with 53 percent of 71- to 74-year-olds. Also, hearing worsens over time, with more people experiencing moderate or severe deficits once they reach or exceed age 80, compared with people in their 70s.

However, only 29 percent of those with hearing loss used hearing aids. Multiple studies have documented barriers that inhibit use. Such devices, which Medicare doesn’t cover, are pricey, from nearly $1,000 for a good over-the-counter set (OTC hearing aids became available in 2022) to more than $6,000 for some prescription models. In some communities, hearing evaluation services are difficult to find. Also, people often associate hearing aids with being old and feel self-conscious about wearing them. And they tend to underestimate hearing problems that develop gradually.

Barbara Weinstein, PhD, a professor of audiology at the City University of New York Graduate Center and author of the textbook Geriatric Audiology, added another concern to this list when I reached out to her: usability.

“Hearing aids aren’t really designed for the population that most needs to use them,” she told me. “The move to make devices smaller and more sophisticated technologically isn’t right for many people who are older.”

That’s problematic because hearing loss raises the risk of cognitive decline, dementia, falls, depression and social isolation.

What advice do specialists in hearing health have for older adults who have a hard time using their hearing aids? Here are some thoughts they shared.

Consider larger, customized devices. Many older people, especially those with arthritis, poor fine-motor skills, compromised vision and some degree of cognitive impairment, have a hard time manipulating small hearing aids and using them properly.

Lindsay Creed, AuD, associate director of audiology practices at the American Speech-Language-Hearing Association [ASHA], said about half of her older clients have “some sort of dexterity issue, whether numbness or reduced movement or tremor or a lack of coordination.” Shekinah Mast, AuD, owner of Mast Audiology Services in Seaford, DE, estimates nearly half of her clients have vision issues.

For clients with dexterity challenges, Creed often recommends “behind-the-ear hearing aids,” with a loop over the ear, and customized molds that fit snugly in the ear. Customized earpieces are larger than standardized models.

“The more dexterity challenges you have, the better you’ll do with a larger device and with lots of practice picking it up, orienting it and putting it in your ear,” said Marquitta Merkison, AuD. associate director of audiology practices at ASHA.

For older people with vision issues, Mast sometimes orders hearing aids in different colors for different ears. Also, she’ll help clients set up stands at home for storing devices, chargers and accessories so they can readily find them each time they need them.

Opt for ease of use. Instead of buying devices that require replacing tiny batteries, select a device that can be charged overnight and operate for at least a day before being recharged, recommended Thomas Powers, PhD, a consultant to the Hearing Industries Association. These are now widely available.

People who are comfortable using a smartphone should consider using a phone app to change volume and other device settings. Dave Fabry, PhD, chief hearing health officer at Starkey, a major hearing aid manufacturer, said he has patients in their 80s and 90s “who’ve found that being able to hold a phone and use larger visible controls is easier than manipulating the hearing aid.”

If that’s too difficult, try a remote control. GN ReSound, another major manufacturer, has designed one with two large buttons that activate the volume control and programming for its hearing aids, said Megan Quilter, AuD, the company’s lead audiologist for research and development.

Check out accessories. Say you’re having trouble hearing other people in restaurants. You can ask the person across the table to clip a microphone to his shirt or put the mike in the center of the table. (The hearing aids will need to be programmed to allow the sound to be streamed to your ears.)

Another low-tech option: a hearing aid clip that connects to a piece of clothing to prevent a device from falling to the floor if it becomes dislodged from the ear.

Wear your hearing aids all day. “The No. 1 thing I hear from older adults is they think they don’t need to put on their hearing aids when they’re at home in a quiet environment,” said Erika Shakespeare, CCC-A, who owns Audiology and Hearing Aid Associates in La Grande, OR.

That’s based on a misunderstanding. Our brains need regular, not occasional, stimulation from our environments to optimize hearing, Shakespeare explained. This includes noises in seemingly quiet environments, such as the whoosh of a fan, the creak of a floor or the wind’s wail outside a window.

“If the only time you wear hearing aids is when you think you need them, your brain doesn’t know how to process all those sounds,” she told me. Her rule of thumb: “Wear hearing aids all your waking hours.”

Consult a hearing professional. Everyone’s needs are different, so it’s a good idea to seek out an audiologist or hearing specialist who, for a fee, can provide guidance.

“Most older people are not going to know what they need” and what options exist without professional assistance, said Virginia Ramachandran, AuD, the head of audiology at Oticon, a major hearing aid manufacturer, and a past president of the American Academy of Audiology.

Her advice to older adults: be “really open” about your challenges.

If you can’t afford hearing aids, ask a hearing professional for an appointment to go over features you should look for in over-the-counter devices. Make it clear you want the appointment to be about your needs, not a sales pitch, Reed said. Audiology practices don’t routinely offer this kind of service, but there’s good reason to ask since Medicare started covering once-a-year audiologist consultations last year.

 

Even though he’s at retirement age, T.S. Dharmarajan, MD, continues to care for older patients as the clinical director of geriatrics at Montefiore Medical Center in Bronx, NY.  But he’s terrified of the possibility of becoming a patient himself one day.  

“I’m healthy now, but I’m scared to death when I think of the time when I’m going to be admitted to a hospital and taken care of by a hospitalist who has no [geriatric training],” he said. 

Dharmarajan knows he’s unlikely to receive care from a physician with geriatric expertise, because there aren’t enough of them now—and it’s only going to get worse. 

While the population of adults over 65 in the United States has exploded, the number of geriatric specialists has decreased, from 10,270 in 2000 to 7,300 in 2019, according to The Looming Geriatrician Shortage, a 2019 report that Dharmarajan co-authored with Paula Lester, MD, and Ele Weinstein, MD. 

The American Geriatrics Society estimates that about 30,000 geriatricians will be needed to provide high-quality care for the most vulnerable elderly by 2030. Yet about half of all fellowships in geriatrics in the United States continue to go unfilled every year, and there’s no sign the trend will reverse. 

“The need for expertly trained and passionate geriatric physicians is clear,” according to the 2019 report. 

Why Geriatricians Matter

Geriatricians are trained in caring for older patients, particularly those with frailty, cognitive decline (Alzheimer’s or other forms of dementia) or multiple medical issues. 

“The knowledge base that geriatricians have is very different than that of practitioners who are just taking care of older people,” said Dharmarajan, who is also a professor of medicine at Albert Einstein College of Medicine. “There’s a huge difference.” 

One reason why geriatricians are so essential: they understand the ways that physiology changes as people age. Most older people expect to eventually lose bone density and muscle mass and to experience a measure of vision and hearing loss. But other, more subtle changes occur with aging. As the COVID-19 pandemic demonstrated, aging is associated with lowered immune function and greater susceptibility to infection. Kidney function also declines with age. 

“One of the main drawbacks of not having robust geriatric training is the lack of understanding of the aging physiology,” said Diane Kerwin, MD, a geriatrician and Alzheimer’s researcher in Dallas, TX. “And usually in geriatrics, you are managing several chronic disease states as well as the aging body, with the focus on maintenance of function and independence.”

Many older adults live with multiple health issues, like hypertension, diabetes or heart disease. 

“If you have a 40-year-old patient who has pneumonia, you can just give them antibiotics, but if you have an 80-year-old with pneumonia and 10 other conditions, that’s much more complicated,” said Paula Lester, MD, director of the fellowship program in geriatric medicine at NYU Grossman Long Island School of Medicine and chair of the geriatrics task force for the New York chapter of the American College of Physicians.

Managing a chronic condition with an older patient is more complex. For younger patients with diabetes, for example, doctors typically focus on tightly controlling blood sugar levels, because high blood sugar can cause long-term problems like blindness, kidney problems and neuropathy. But that strategy doesn’t necessarily work for older patients, according to Barry Wu, MD, professor of medicine at Yale School of Medicine.

Older people respond to medications differently and sometimes develop different symptoms than those who are younger. 

“With an older person, if you have such tight control, you may put that person at more risk for low blood sugar, and low sugar can kill you,” he said. Plus, the long-term effects of high blood sugar may not take priority for a patient who’s unlikely to live another 10 or 20 years. 

Older patients metabolize medications differently and may experience more severe side effects. They may have difficulty taking medication according to directions. 

“You’ve got to weigh the risks and the benefits of the medicines,” Wu said. 

Without specialized care, older patients may be misdiagnosed, and treatable problems may be overlooked. Kerwin says it’s not uncommon for her to see patients whose cognitive impairment was previously dismissed by medical providers as normal aging and left untreated.

“It’s possible that the cognitive impairment could’ve been due to a thyroid problem, a B12 deficiency, a urinary tract infection or a series of small strokes,” she said. “These are treatable conditions.” 

Patients with undiagnosed Alzheimer’s or dementia may miss the benefits of early interventions, like medication that could have helped slow disease progression. 

Another subtlety of treating older patients: “Older adults have atypical presentations of conditions,” said Ele Weinstein, MD, associate professor of medicine at Albert Einstein College of Medicine. “There are differences in patterns of illness, and differences in conditions that older adults present with.”

For example, a younger patient with a urinary tract infection (UTI) will likely report classic symptoms like burning, pain or frequent urination. An older adult with a UTI might instead exhibit confusion or lethargy. 

Managing Multiple Conditions

Geriatricians follow the “Geriatric 5Ms,” their key focus issues: mind, mobility, medications, multi-complexity, and matters most. 

“Mind” refers to the importance of assessing mental acuity and recognizing conditions like dementia, delirium and depression. “Mobility” relates to fall prevention and optimizing gait and balance. “Medications” includes reducing polypharmacy (multiple medications), de-prescribing, and recognizing harmful side effects of medications. 

“Multi-complexity” involves managing multiple illnesses and conditions, as well as living environments and social concerns. “Matters most” refers to guiding patients’ care based on their values and priorities. 

Many geriatricians consider “de-prescribing” medications to be one of the most valuable functions of geriatricians. Patients with multiple health problems typically see several specialists who each prescribe medications. Geriatricians are trained to spot potential drug interactions—which are more common and more severe with older patients—and to weigh the benefits against the risks of each medication. 

“When you go to a doctor with a complaint, they give you a pill,” said Lester. “But if you go to a geriatrician with a complaint, they may take away a pill. It’s just a very different philosophy.” 

Lester adds that geriatricians are much better at prognostication.

“That’s basically looking at a patient and their lives and their condition and their whole situation and figuring out, ‘Are they going to get better? Are they safe to go back to where they were before? Are they going to recover from this illness? Do they need hospice?’” said Lester. “I do that somehow in my head, quickly and accurately. In general, geriatricians are much, much better at prognosticating. That is so important for the people who want to know what their life expectancy is, what that time will look like, and then they can decide how they want to spend it.”

Why the Shortage

Since the publication of their 2019 report, the co-authors say they have not seen sufficient change to increase the supply of geriatricians. Dharmarajan noted that he created the geriatric medicine fellowship program in 1991 at Our Lady of Mercy Medical Center in the Bronx, currently Montefiore Medical Center (Wakefield Campus), where he also serves as professor of medicine. “In the first 10 to 15 years, there was no problem filling those fellowships, but we have seen a very clear decline in the number of applicants in the last 15 years,” he said. 

Lester said geriatrics has a “PR problem” that discourages medical students from choosing the field. Most students complete their geriatric rotations in hospitals, where patients are typically very ill and unlikely to recover. However, geriatricians themselves report some of the highest levels of social satisfaction among medical specialties, citing the relationships they build with their older adult patients, the more holistic approach of geriatric medicine and even the challenge of handling medically complex cases.

Geriatricians spend more time with each patient. Because virtually all their patients are on Medicare, geriatricians are paid at Medicare rates—generally lower than regular health insurance. As a result, geriatrics ranks as the fourth-lowest-paid medical specialty, only slightly more than pediatrics, medical genetics and family medicine. 

Another factor is the rise in the number of hospitalist positions. Hospitalists are doctors who provide primary care for patients while they’re hospitalized. The term was coined in 1996 when there were a few thousand hospitalists in the United States. Now there are more than 50,000. 

“It’s easy now for a medical student to finish three years of residency and just become a hospitalist with fixed hours and a very attractive salary,” Dharmarajan said. “Why waste one more year for a fellowship for geriatric medicine, and then deal with all the very complex illnesses that older people have and work for less money?” 

Facing the Future 

Some medical schools are looking to help fill the gap by adding geriatric training as part of their medical education. 

“We won’t be able to train enough geriatricians, so the goal is to train other professionals throughout medical school in geriatrics,” said Wu, who directs the introductory and final courses at Yale School of Medicine. 

In the intro course, students take their first medical history on older adult patients, beginning with an assessment of the patient’s values. Students are introduced to basic concepts of geriatrics, including patient priorities care—identifying patients’ goals and values, which ultimately guide their care.

Lester also hopes that hospital administrators will recognize the cost-savings potential of geriatric expertise.  

“What do hospitals worry about?” Lester said. “They don’t like falls. They don’t like readmissions. They don’t like people dying [outside of] hospice. They don’t like pressure ulcers or delirium. Those are all geriatric things. That’s literally what we do.” 

It’s called “boarding” when patients who have come to an emergency room spend hours and hours, lying on a gurney in a hallway, waiting for a bed in the hospital. Studies show that seniors who have been boarded don’t do as well once they’re admitted and run a higher risk of dying. For this article, journalist Judith Graham interviewed ER doctors and others about why boarding is happening much more often now and what patients can do to protect themselves. KFF Health News posted her article on May 6, 2024, and it also ran on CNN. Funding from the Silver Century Foundation helps KFF Health News develop articles (like this one) on longevity and related health and social issues. 

   

Every day, the scene plays out in hospitals across America: older men and women lie on gurneys in emergency room corridors, moaning or suffering silently as harried medical staff attend to crises.

Even when physicians determine these patients need to be admitted to the hospital, they often wait for hours—sometimes more than a day—in the ER in pain and discomfort, not getting enough food or water, not moving around, not being helped to the bathroom and not getting the kind of care doctors deem necessary.

“You walk through ER hallways, and they’re lined from end to end with patients on stretchers in various states of distress calling out for help, including a number of older patients,” said Hashem Zikry, MD, an emergency medicine physician at UCLA Health.

Physicians who staff emergency rooms say this problem, known as ER boarding, is as bad as it’s ever been—even worse than during the first years of the COVID-19 pandemic, when hospitals filled with desperately ill patients.

While boarding can happen to all ER patients, adults 65 and older, who account for nearly 20 percent of ER visits, are especially vulnerable during long waits for care. Also, seniors may encounter boarding more often than other patients. The best estimates I could find, published in 2019, before the COVID-19 pandemic, suggest that 10 percent of patients were boarded in ERs before receiving hospital care. About 30 to 50 percent of these patients were older adults.

“It’s a public health crisis,” said Aisha Terry, MD, an associate professor of emergency medicine at George Washington University School of Medicine and Health Sciences and the president of the board of the American College of Emergency Physicians, which sponsored a summit on boarding in September.

Older adults forced to wait in the ER overnight are more likely to die after they’re finally admitted to the hospital.

What’s going on? I spoke to almost a dozen doctors and researchers who described the chaotic situation in ERs. They told me staff shortages in hospitals, which affect the number of beds available, are contributing to the crisis. Also, they explained, hospital administrators are setting aside more beds for patients undergoing lucrative surgeries and other procedures, contributing to bottlenecks in ERs and leaving more patients in limbo.

Then, there’s high demand for hospital services, fueled in part by the aging of the US population, and backlogs in discharging patients because of growing problems securing home health care and nursing home care, according to Arjun Venkatesh, MD, chair of emergency medicine at the Yale School of Medicine.

The impact of long ER waits on seniors who are frail, with multiple medical issues, is especially serious. Confined to stretchers, gurneys, or even hard chairs, often without dependable aid from nurses, they’re at risk of losing strength, forgoing essential medications and experiencing complications such as delirium, according to Saket Saxena, MD, a co-director of the geriatric emergency department at the Cleveland Clinic.

When these patients finally secure a hospital bed, their stays are longer and medical complications more common. And new research finds that the risk of dying in the hospital is significantly higher for older adults when they stay in ERs overnight, as is the risk of adverse events such as falls, infections, bleeding, heart attacks, strokes and bedsores.

Ellen Danto-Nocton, MD, a geriatrician in Milwaukee, was deeply concerned when an 88-year-old relative with “stroke-like symptoms” spent two days in the ER a few years ago. Delirious, immobile and unable to sleep as alarms outside his bed rang nonstop, the older man spiraled downward before he was moved to a hospital room. “He really needed to be in a less chaotic environment,” Danto-Nocton said.

Several weeks ago, Zikry of UCLA Health helped care for a 70-year-old woman who’d fallen and broken her hip while attending a basketball game. “She was in a corner of our ER for about 16 hours in an immense amount of pain that was very difficult to treat adequately,” he said. ERs are designed to handle crises and stabilize patients, not to “take care of patients who we’ve already decided need to be admitted to the hospital,” he said.

Boarding is an issue that needs to be addressed with changes in the health system and in health policies. 

How common is ER boarding and where is it most acute? No one knows, because hospitals aren’t required to report data about boarding publicly. The Centers for Medicare & Medicaid Services retired a measure of boarding in 2021. New national measures of emergency care capacity have been proposed but not yet approved.

“It’s not just the extent of ED boarding that we need to understand. It’s the extent of acute hospital capacity in our communities,” said Venkatesh of Yale, who helped draft the new measures.

In the meantime, some hospital systems are publicizing their plight by highlighting capacity constraints and the need for more hospital beds. Among them is Massachusetts General Hospital in Boston, which announced in January that ER boarding had risen 32 percent from October 2022 to September 2023. At the end of that period, patients admitted to the hospital spent a median of 14 hours in the ER and 26 percent spent more than 24 hours.

Maura Kennedy, MD, Mass General’s chief of geriatric emergency medicine, described an 80-something woman with a respiratory infection who languished in the ER for more than 24 hours after physicians decided she needed inpatient hospital care.

“She wasn’t mobilized, she had nothing to cognitively engage her, she hadn’t eaten and she became increasingly agitated, trying to get off the stretcher and arguing with staff,” Kennedy told me. “After a prolonged hospital stay, she left the hospital more disabled than she was when she came in.”

When I asked ER doctors what older adults could do about these problems, they said boarding is a health system issue that needs health system and policy changes. Still, they had several suggestions.

Be prepared to wait when you come to an ER…. Bring a medication list and your medications, if you can.

—Alexander Janke, MD

“Have another person there with you to advocate on your behalf,” said Jesse Pines, MD, chief of clinical innovation at US Acute Care Solutions, the nation’s largest physician-owned emergency medicine practice. And have that person speak up if they feel you’re getting worse or if staffers are missing problems.

Alexander Janke, MD, a clinical instructor of emergency medicine at the University of Michigan, advises people, “Be prepared to wait when you come to an ER” and “Bring a medication list and your medications, if you can.”

To stay oriented and reduce the possibility of delirium, “make sure you have your hearing aids and eyeglasses with you,” said Michael Malone, MD, medical director of senior services for Advocate Aurora Health, a 20-hospital system in Wisconsin and northern Illinois. “Whenever possible, try to get up and move around.”

Friends or family caregivers who accompany older adults to the ER should ask to be at their bedside, when possible, and “try to make sure they eat, drink, get to the bathroom and take routine medications for underlying medical conditions,” Malone said.

Older adults or caregivers who are helping them should try to bring “things that would engage you cognitively: magazines, books … music, anything that you might focus on in a hallway where there isn’t a TV to entertain you,” Kennedy said.

“Experienced patients often show up with eye masks and ear plugs” to help them rest in ERs with nonstop stimulation, said Zikry of UCLA. “Also, bring something to eat and drink in case you can’t get to the cafeteria or it’s a while before staffers bring these to you.”

The new drugs being used to help people lose weight seem like game changers, but the studies done on them haven’t included enough older adults, which raises lots of questions. In this article, journalist Judith Graham explains what’s making some doctors think twice before prescribing the new medications for their older patients. KFF Health News posted her article on July 25, 2023, and it also ran on the Washington Post. Funding from the Silver Century Foundation helps KFF Health News develop articles (like this one) on longevity and related health and social issues.

Corlee Morris has dieted throughout her adult life.

After her weight began climbing in high school, she spent years losing 50 or 100 pounds then gaining it back. Morris, 78, was at her heaviest in her mid-40s, standing 5 feet 10½ inches and weighing 310 pounds. The Pittsburgh resident has had diabetes for more than 40 years.

Managing her weight was a losing battle until Morris’ doctor prescribed a Type 2 diabetes medication, Ozempic, four months ago. It’s one in a new category of medications changing how ordinary people as well as medical experts think about obesity, a condition that affects nearly four in 10 people 60 and older.

The drugs include Ozempic’s sister medication, Wegovy, a weight loss drug with identical ingredients, which the FDA approved in 2021, and Mounjaro, approved as a diabetes treatment in 2022. (Ozempic was approved for diabetes in 2017.) Several other drugs are in development.

The medications reduce feelings of hunger, generate a sensation of fullness and have been shown to help people lose an average of 15 percent or more of their weight.

“It takes your appetite right away. I wasn’t hungry at all and I lost weight like mad,” said Morris, who has shed 40 pounds.

But how these medications will affect older adults in the long run isn’t well understood. (Patients need to remain on the drugs permanently or risk regaining the weight they’ve lost.)

Will they help prevent cardiovascular disease and other chronic illnesses in obese older adults? Will they reduce rates of disability and improve people’s ability to move and manage daily tasks? Will they enhance people’s lives and alleviate symptoms associated with obesity-related chronic illnesses?

Unfortunately, clinical trials of the medications haven’t included significant numbers of people ages 65 and older, leaving gaps in the available data.

Medicare doesn’t cover weight-loss medications. If it did, and everyone who needs them took them, the cost would be in the billions. 

While the drugs appear to be safe—the most common side effects are nausea, diarrhea, vomiting, constipation and stomach pain—“they’ve only been on the market for a few years and caution is still needed,” said Mitchell Lazar, MD, founding director of the Institute for Diabetes, Obesity and Metabolism at the University of Pennsylvania Perelman School of Medicine.

Given these uncertainties, how are experts approaching the use of the new obesity medications in older people? As might be expected, opinions and practices vary. But several themes emerged in nearly two dozen interviews.

The first was frustration with limited access to the drugs. Because Medicare doesn’t cover weight loss medications and they can cost more than $10,000 a year, seniors’ ability to get the new drugs is restricted.

There is an exception: Medicare will cover Ozempic and Mounjaro if an older adult has diabetes, because the insurance program pays for diabetes therapies.

“We need Medicare to cover these drugs,” said Shauna Matilda Assadzandi, MD, a geriatrician at the University of Pittsburgh who cares for Morris. Recently, she said, she tried to persuade a Medicare Advantage plan representative to authorize Wegovy for a patient with high blood pressure and cholesterol who was gaining weight rapidly.

“I’m just waiting for this patient’s blood sugar to rise to a level where diabetes can be diagnosed. Wouldn’t it make sense to intervene now?” she remembered saying. 

The representative’s answer: “No. We have to follow the rules.”

Seeking to change that, a bipartisan group of lawmakers has reintroduced the Treat and Reduce Obesity Act, which would require Medicare to cover weight loss drugs. But the proposal, which had been considered previously, has languished amid concerns over enormous potential costs for Medicare.

If all beneficiaries with an obesity diagnosis took brand-name semaglutide drugs (the new class of medications), annual costs would top $13.5 billion, according to a recent analysis in the New England Journal of Medicine. If all older obese adults on Medicare—a significantly larger population—took them, the cost would exceed the total spent on Medicare’s Part D drug program, which was $145 billion in 2019.

The new drugs are generally recommended for people with a BMI (body mass index) that’s over 30—or over 26 if they have an obesity-related condition like diabetes. 

Laurie Rich, 63, of Canton, MA, was caught off guard by Medicare’s policies, which have applied to her since she qualified for Social Security Disability Insurance in December. Before that, Rich took Wegovy and another weight loss medication—both covered by private insurance—and she’d lost nearly 42 pounds. Now, Rich can’t get Wegovy and she’s regained 14 pounds.

“I haven’t changed my eating. The only thing that’s different is that some signal in my brain is telling me I’m hungry all the time,” Rich told me. “I feel horrible.” She knows that if she gains more weight, her care will cost much more.

While acknowledging difficult policy decisions that lie ahead, experts voiced considerable agreement on which older adults should take these drugs.

Generally, the medications are recommended for people with a body mass index over 30 (the World Health Organization’s definition of obesity) and those with a BMI of 27 or above and at least one obesity-related condition, such as diabetes, high blood pressure or high cholesterol. There are no guidelines for their use in people 65 and older. (BMI is calculated based on a person’s weight and height.)

But those recommendations are problematic because BMI can under- or overestimate older adults’ body fat, the most problematic feature of obesity, noted Rodolfo Galindo, MD, director of the Comprehensive Diabetes Center at the University of Miami Health System.

Dennis Kerrigan, PhD, director of weight management at Henry Ford Health in Michigan, a system with five hospitals, suggests physicians also examine waist circumference in older patients because abdominal fat puts them at higher risk than fat carried in the hips or buttocks. (For men, a waist over 40 inches is of concern; for women, 35 is the threshold.)

Fatima Stanford, MD, an obesity medicine scientist at Massachusetts General Hospital, said the new drugs are “best suited for older patients who have clinical evidence of obesity,” such as elevated cholesterol or blood sugar, and people with serious obesity-related conditions, such as osteoarthritis or heart disease.

Since going on Mounjaro three months ago, Muriel Branch, 73, of Perryville, AR, has lost 40 pounds and stopped taking three medications as her health has improved. “I feel real good about myself,” she told me.

While shedding pounds, older adults need to exercise, to avoid losing too much muscle mass.

When adults with obesity lose weight, their risk of dying is reduced by up to 15 percent, according to Dinesh Edem, MD, Branch’s doctor and the director of the medical weight management program at the University of Arkansas for Medical Sciences.

Still, weight loss alone should not be recommended to older adults, because it entails the loss of muscle mass as well as fat, experts agree. And with aging, the shrinkage of muscle mass that starts earlier in life accelerates, contributing to falls, weakness, the loss of functioning and the onset of frailty.

Between ages 60 and 70, about 12 percent of muscle mass falls away, researchers estimate; after 80, it reaches 30 percent. 

To preserve muscle mass, seniors losing weight should be prescribed physical activity—both aerobic exercise and strength training, experts agree.

Also, as older adults taking weight loss drugs eat less, “it’s critically important that their diet includes adequate protein and calcium to preserve bone and muscle mass,” said Anne Newman, MD, director of the Center for Aging and Population Health at the University of Pittsburgh.

Ongoing monitoring of older adults having gastrointestinal side effects is needed to ensure they’re getting enough food and water, said Jamy Ard, MD, co-director of Wake Forest Baptist Health Weight Management Center.

Generally, the goal for older adults should be to lose one to two pounds a week, with attention to diet and exercise accompanying medication management.

“My concern is, once we put patients on these obesity drugs, are we supporting lifestyle changes that will maintain their health? Medication alone won’t be sufficient; we will still need to address behaviors,” said Sukhpreet Singh, MD, system medical director at Henry Ford’s weight management program.

 

Americans are more afraid of losing their eyesight than their hearing or even their memory, but many know very little about eye diseases. In this article, journalist Bernard J. Wolfson pulls together a great deal of information about that, along with tips on how to take better care of your eyes. His article was produced by KFF Health News, which posted the story on its website on September 22, 2023. Wolfson is a columnist and senior correspondent for California Healthline, an editorially independent service of the California Health Care Foundation. Funding from the Silver Century Foundation helps KFF Health News develop articles (like this one) on longevity and related health and social issues. 

I vividly remember that late Friday afternoon when my eye pressure spiked, and I staggered on foot to my ophthalmologist’s office as the rapidly thickening fog in my field of vision shrouded passing cars and traffic lights.

The office was already closed, but the whole eye-care team was there waiting for me. One of them pricked my eyeballs with a sharp instrument, allowing the ocular fluid that had built up to drain. That relieved the pressure and restored my vision.

But it was the fourth vision-impairing pressure spike in nine days, and they feared it would happen again—heading into a weekend. So off I went to the emergency room, where I spent the night hooked up to an intravenous tube that delivered a powerful anti-swelling agent.

Later, when I told this story to friends and colleagues, some of them didn’t understand the importance of eye pressure or even what it was. “I didn’t know they could measure blood pressure in your eyes,” one of them told me.

Most people consider their vision to be vitally important, yet many lack an understanding of some of the most serious eye diseases. A 2016 study published in JAMA Ophthalmology, based on an online national poll, showed that nearly half of respondents feared losing their eyesight more than their memory, speech, hearing or limbs. Yet many “were unaware of important eye diseases,” it found.

A study released in July, conducted by Wakefield Research for the nonprofit Prevent Blindness and Regeneron Pharmaceuticals, showed that one-quarter of adults deemed at risk for diseases of the retina, such as macular degeneration and diabetic retinopathy, had delayed seeking care for vision problems.

For many people, it’s not easy to get eye treatment, because of the cost and because there are too few eye doctors in their community.

“There is significantly less of an emphasis placed on eye health than there is on general health,” says Rohit Varma, MD, founding director of the Southern California Eye Institute at Hollywood Presbyterian Medical Center.

Because eye diseases can be painless and progress slowly, Varma says, “people get used to it, and as they age, they begin to feel, ‘Oh, this is a normal part of aging and it’s OK.’” If people felt severe pain, he says, they would go get care.

For many people, though, it’s not easy to get an eye exam or eye treatment. Millions are uninsured, others can’t afford their share of the cost and many live in communities where eye doctors are scarce.

“Just because people know they need the care doesn’t necessarily mean they can afford it or that they have the access to it,” says Jeff Todd, CEO and president of Prevent Blindness.

Another challenge, reflecting the divide between eye care and general health care, is that medical insurance, except for children, often covers only eye care aimed at diagnosing or treating diseases. More health plans are covering routine eye exams these days, but that generally does not include the type of test used to determine eyeglass and contact lens prescriptions—or the cost of the lenses. You may need separate vision insurance for that. Ask your health plan what’s covered.

Since being diagnosed with glaucoma 15 years ago, I’ve had more pressure checks, eye exams, eyedrops, and laser surgeries than I can remember. I should know not to take my eyesight for granted. And yet, when my peepers were filling with that vision-threatening fog last March, I felt oddly sanguine.

Serious eye diseases are often manageable if they’re treated early enough.

It turned out that those serial pressure spikes were triggered by an adverse reaction to steroid-based eyedrops prescribed to me following cataract surgery. My ophthalmologist told me later that I had come “within hours” of losing my eyesight.

I hope my brush with blindness can help inspire people to be more conscious of their eyes.

Eyeglasses or contact lenses can make a huge difference in one’s quality of life by correcting refractive errors, which affect 150 million Americans. But don’t ignore the risk of far more serious eye conditions that can sneak up on you. They are often manageable if caught early enough.

Glaucoma, which affects about 3 million people in the United States, attacks peripheral vision first and can cause irreversible damage to the optic nerve. It runs in families and is five times as prevalent among African Americans as in the general population.

Nearly 10 million in this country have diabetic retinopathy, a complication of diabetes in which blood vessels in the retina are damaged. And some 20 million people age 40 and up have macular degeneration, a disease of the retina associated with aging that diminishes central vision over time.

The formation of cataracts, which cause cloudiness in the eye’s natural lens, is very common as people age: half of people 75 and older have them. Cataracts can cause blindness, but they are eminently treatable with surgery.

Anything that helps your general health helps your vision.

—Andrew Iwach, MD

If you are over 40 and haven’t had a comprehensive eye exam in a while, or ever, put that on your to-do list. And get an exam at a younger age if you have diabetes, a family history of glaucoma, or if you are African American or part of another racial or ethnic group at high risk for certain eye diseases.

And don’t forget children. Multiple eye conditions can affect kids. Refractive errors, treatable with corrective lenses, can cause impairment later in life if they are not addressed early enough.

Healthful lifestyle choices also benefit your eyes. “Anything that helps your general health helps your vision,” says Andrew Iwach, MD, a clinical spokesperson for the American Academy of Ophthalmology and executive director of the Glaucoma Center of San Francisco. 

Minimize stress, get regular exercise and eat a healthy diet. Also, quit smoking. It increases the risk of major eye diseases.

And consider adopting habits that protect your eyes from injury: wear sunglasses when you go outside, take regular breaks from your computer screen and cellphone and wear goggles when working around the house or playing sports.

The Prevent Blindness website offers information on virtually everything related to eye health, including insurance. Other good sources include the American Academy of Ophthalmology’s EyeSmart site and the National Eye Institute. 

So read up and share what you’ve learned.

“When you get together for the holidays,” says Iwach, “if you aren’t sure what to talk about, talk about your eyes.”

Even after a diagnosis of vascular dementia, Laura Brancato’s father was able to stay in his own home for years. But as his condition worsened, that started to become problematic.

Her father started to wander out of the house. His sleep became disrupted, keeping his wife up at night and leaving her constantly sleep deprived. His medications frequently needed adjustments, which meant Brancato—who has young children and a 70-hour-a-week career as an elder law attorney—had to drive him to the doctor’s office. Part-time caregivers were hard to find and unreliable, especially once the COVID-19 pandemic began.

Finally, Brancato’s family decided to move her father into a memory care community in 2020. He was safer there but unhappy. Visits were limited, because of the pandemic, and her father didn’t understand. 

“He thought we had abandoned him,” she said. 

The decision to move into senior living is one that many older adults and their families will wrestle with, sooner or later. On average, someone turning 65 today has almost a 70 percent chance of needing some type of long term care in their remaining years, and 37 percent will require residential care in an assisted living or skilled nursing facility, according to LongTermCare.gov.  

Determining the best time to make the move often creates conflicts. Siblings may fight over the best course of action. Older adults may resist making a move, even when their adult children feel it’s clearly time.  

“The older person is saying, ‘Why? I’m perfectly fine. I can take care of myself,’” according to Dianne Savastano, a patient advocate and founder of HealthAssist in Manchester, MA. 

Aging in Place

Most older adults want to remain in their own homes as long as possible. Realistically, however, some will reach the point when that’s no longer safe or comfortable. A person living with dementia may wander and get lost, or leave the stove on and start a fire. Mobility issues may pose a high risk for a fall or make it impossible to handle basic daily chores like cooking, cleaning, dressing or bathing.  

When counseling older adults and their families grappling with this question, Kimberly Knight focuses on activities of daily living (ADLs). 

“It’s all about ADLs,” said Knight, director of caregiver-support programs at the Senior Source in Dallas. “Consider whether the older adult is still able to navigate the home and care for themselves safely.” 

She asks questions: Can the person get up out of bed, toilet and dress themselves in the morning? Are they able to stand long enough to prepare meals? Do they remember to take their medications on schedule? 

Knight also urges family members to look for signs the older adult isn’t coping. Are they losing weight? Is there spoiled food in the refrigerator, or no food at all? Are bills and mail piling up? Is the home cluttered? Is the person skipping basic grooming tasks? If a spouse or other older adult is the caregiver, is that person showing signs of fatigue or burnout?

Not all of these signs automatically mean it’s time to make a move, but they all do usually mean that the older adult needs more help. 

Older people without family support need to plan ahead for the care they’ll need someday

For those who want to stay in their own homes, the first strategy is to explore options to make staying there safer and more manageable. A life-alert device, for example, could ensure that an older adult can get help quickly in the event of a fall. A part-time, paid caregiver might be able to help with meals, shopping, getting dressed or other ADLs.  

Another key factor in the timing decision is the availability—or lack of availability—of family support, according to Jenny Munro, a gerontologist. She advises older adults and their families every day on the question of “When is it time?” as response team manager at Home Instead, an in-home caregiving agency.

She sees this with her own father, who’s now 98. He wants to remain in the house where he has lived for more than 60 years. His cognitive condition is still excellent, but he’s frail and weak.

Family support is plentiful: Munro is one of nine adult children. After her mother died a few years ago, all stepped in to handle some aspect of his care. A brother who is a banker, for example, is handling his finances. Four of the siblings live nearby, and used to take turns staying with him, a week at a time. That worked until her father began experiencing incontinence. Now, three, full-time, care professionals provide round-the-clock care, and the siblings visit often.

“It’s very expensive,” Munro said. “Thankfully, he saved and invested and has the ability to pay for that.” 

Family support may not be an option, especially for solo agers and older adults without children or spouses. They must plan to handle their care needs on their own.

Solo agers especially may want to hire a professional to help with caregiving decisions.

Like Munro, Carol Marak pitched in, along with her two sisters, to care for her mother, who had several chronic health issues, and her father, who had Alzheimer’s. The couple lived in a rural area and needed help with rides to the doctor, cooking, cleaning and managing their finances. 

The experience was an eye-opener for Marak, 72, who was divorced, childless and had little savings.  

“It scared the heck out of me,” she said. “It took all three of us to take care of Mom and Dad. Who’s going to do that for me?”  

After her parents passed away, Marak began focusing on improving her health and adjusting her lifestyle. She moved from her suburban home to a high-rise apartment building in Dallas that functions as an informal retirement community. Many of the residents are older and support each other. She can walk to errands or catch a bus. 

She also wrote a book, Solo and Smart: The Roadmap for a Supportive and Secure Future (2022). And she’s making plans for when she’s no longer able to care for herself on her own. 

To do that, Marak urges solo agers to hire a professional who can help weigh caregiving decisions, such as an aging-life-care professional or geriatric care manager. Solo agers may want to undergo a cognitive function evaluation before signs of memory loss occur. The test can serve as a baseline and can be repeated regularly as part of their routine health care, to provide objective information on the older person’s cognitive status in the future. 

“You need to have your team of professionals who are looking out for you and who will take notice if you’re starting to decline,” said Marak. 

An Iterative Process

Don’t be surprised if the decision to make a move turns into a series of decisions stretching over several years, Savastano advises. 

“I call it ‘iterative decision-making,’” she said. “You’re constantly adjusting to the older adult’s level of abilities and what they need help with.” 

She worked for 13 years as an advocate for a client named Rosalie, guiding her through knee replacement surgery and then a move into an independent living apartment in a continuing care retirement community (CCRC).  

Rosalie loved her apartment and made new friends. The move was such a success that, even though the CCRC offered sections for higher levels of care, “Rosalie made it truly clear to both me and her children, over and over again, that she intended to live there through the end of her life,” Savastano said.  

Those who delay moving until they’re in poor health may be turned away by some senior living facilities.

When Rosalie’s cognitive abilities began to decline, the staff wanted to move her into the community’s memory care unit. Savastano negotiated for a way to honor Rosalie’s wishes. 

“We gradually increased the use of private, in-home assistance, ultimately involving 24/7 care in her home, which thankfully she was able to afford,” Savastano said. 

Savastano cautions that while older adults may wish to stay at home as long as possible, later isn’t always better than sooner. An older adult’s condition can decline to the point that their options become limited to skilled nursing or long term care. 

“If you wait too long, you may not have as many choices,” she said. Some assisted living or memory care communities, for example, may accept an older adult with dementia, knowing their condition will decline. Most will make accommodations to allow a longtime resident to stay until the end of life. But the same community likely won’t accept someone in that later stage as a new resident. 

Sooner, Rather than Later

A “sooner, rather than later” strategy worked well for Larry and Marilyn Comstock, both in their 80s.

After visiting eight communities, the Comstocks moved into an independent living apartment in 2018. Even though both were—and still are—healthy, active and cognitively sharp, and even though it meant leaving behind their beloved home and many treasured possessions, they felt it was time. They chose Highland Springs Senior Living in Dallas, which has on-site medical care and offers assisted living, memory care and long term care, should their needs change. 

“It was the hardest decision we’ve ever made,” Marilyn Comstock said. “But we didn’t want our children to have the burden of finding someplace for us to move. We wanted to make the decision ourselves.” 

A few months later, the couple felt affirmed in their decision when Marilyn fell and broke her hip. Thanks to the community’s alert system, she was able to get help in minutes. Marilyn recovered, and today they’re both thriving, serving on resident committees and socializing with the many new friends they’ve made.

“We’re glad we moved when we did, because we still have the ability to enjoy the facilities and the people here,” said Marilyn Comstock. 

When the Older Adult Resists

The decision to move into senior living becomes more complicated when family members think it’s time for a move—but the older adult is unwilling. If cognitive decline is present, family members may question whether the older adult is capable of making the right decision. 

“It’s a tricky situation when the older adult is resistant to a move,” said Hannah De George, elder advocate at St. John’s Senior Services in Rochester, NY.  

De George recently sat in on a family meeting with some close friends. The adult children all agreed it was time for their parents to move into assisted living; the parents were unwilling. 

“They felt ganged up on,” said De George. “No one wants to be told, ‘You can’t live in your own home anymore.’” 

Family members can’t force an older adult to move, unless the person has been declared unable to make their own decisions and placed under guardianship by a court order. But that doesn’t mean families should immediately accept “no” as the answer if it’s clear the older adult needs more help. 

“When it’s safety versus autonomy, you have to err on the side of safety,” Knight said. 

Savastano sometimes coaches adult children on different strategies for making their case with a parent resisting a move.

“But in reality, sometimes you end up waiting until a crisis occurs,” she said. 

Family Conflict

The decision to move an older adult into senior living often sparks conflicts among the adult children. 

“This is an issue that can break up families and cause siblings to stop talking to each other for years,” said Knight. 

An adult child living out of state might think the parent is fine living alone at home, whereas a nearby sibling, who visits every day, may be convinced that’s not an option. 

One adult child may want to move the parent sooner, rather than later, and sell the aging parent’s home or dip into their nest egg to provide the best available care. A sibling who’s counting on inheriting that money may disagree. Feelings of guilt, sibling rivalry or other emotional baggage add to the morass. 

Older adults can help ward off conflicts by communicating their wishes in advance, before a crisis hits, and having the legal documentation in place for a trusted person to handle the financial aspects of paying for senior living, should they become unable to do so. 

If it’s too late for that option, experts advise bringing in a third party—a geriatric care manager or physician, for example—who can weigh in with a neutral opinion on the need for residential care.

A Good Decision

Laura Brancato’s father was initially unhappy after moving into memory care. But the regularity of the community’s daily schedule—important for people with dementia—made him feel comfortable. Medical staff on site adjusted his medications quickly when needed, avoiding the need for frequent trips to the doctor. Soon, her father embraced the place as home.

He stayed there until his death in December 2023. Looking back, Brancato’s family feels they made the right move at the right time. 

“He forgot he had ever lived anywhere else,” Brancato said. “Instead of bringing him home for celebrations, we started bringing the family to him. He really was thriving in that environment.” 

Jane’s adult children worried she was sinking into dementia. Her behavior had changed. She wasn’t taking care of her physical appearance. She was forgetful and missing appointments. Maybe it was time, family members wondered, to move her into assisted living. 

Then they discovered the real problem: at the age of 89, Jane was an alcoholic. 

She’d struggled with alcoholism earlier in life but had been sober since age 70. She had taken sobriety seriously, attending Alcoholics Anonymous meetings and sponsoring others who struggled. But after a series of setbacks—her husband of 57 years died, she had to stop driving, and worsening arthritis meant she couldn’t swim anymore—Jane relapsed. 

“I think she was lonely, and felt a lot of loss, and thought, ‘I haven’t drank in 20 years; maybe I can just have a glass of wine,’” said Diana Santiago, MSW, clinical supervisor of the Older Adult Program at Caron Treatment Centers, where Jane eventually underwent treatment. “After a couple of months, she was right back where she started.” 

Jane’s story isn’t uncommon. Substance addiction is on the rise among older adults. 

“Nearly one million adults 65 and up in the United States are living with a substance abuse disorder,” said Lisa Stern, LCSW, assistant vice president, Senior & Adult Services at Family & Children’s Association (FCA), a human services agency on Long Island, NY. From 2002 to 2021, the rate of overdose deaths, accidental or intentional, quadrupled among older adults, according to a research letter published in the March 2023 JAMA Psychiatry. 

Alcohol and prescription painkillers top the list of substances most commonly abused by people 60 and up. Most older people admitted to treatment facilities are addicted to alcohol. Approximately 20 percent of all adults ages 60 to 64, and around 11 percent over age 65, report they are currently binge drinking, according to the National Institute on Alcohol Abuse and Alcoholism.

In later life, people are more likely to use alcohol or drugs to relieve pain than to get high. 

Opioid abuse is rising among older people too. While the US population of adults 55 and older rose by about 6 percent between 2013-2015, the proportion of people in that age group seeking treatment for opioid use disorder increased nearly 54 percent. The proportion of older adults using heroin more than doubled between 2013-2015 (in part due to those who switched to heroin—an illicit opioid—after misusing prescription opioids). One study estimated that the prevalence of prescription drug abuse among older adults may be as high as 11 percent.

Marijuana use is also on the rise among older people in the United States. However, experts suspect that’s due to Boomers, the first generation to widely accept marijuana use, reaching older age. Admission to treatment facilities for marijuana alone is rare, although it can often be part of the mix of drugs and/or alcohol that led to addiction.

Older addicts tend to follow different patterns than those who are younger. They include “hardy survivors”—people like Jane, who struggled with addiction for years off and on or continuously. Others first become addicts in their later years. Use of illicit drugs, like cocaine or meth, declines after young adulthood. But common challenges in later life—isolation, depression and anxiety, financial worries, family conflict, the loss of a spouse or other loved ones, physical or mental decline, adapting to retirement—can turn into triggers for abuse. 

“Older adults are less likely to use drugs or alcohol to get high,” said Jeremy Klemanski, MBA, CEO of Gateway Foundation, one of the nation’s largest addiction treatment organizations. “Instead, they tend to use these substances to reduce pain or handle emotional difficulties.” 

Many older adults experience chronic pain, anxiety or insomnia, all of which may be treated with highly addictive medications like opioids or benzodiazepines (“benzos”), like alprazolam (Xanax), diazepam (Valium) and lorazepam (Ativan.) Older people may be even more prone to abuse these drugs than their younger counterparts. Plus, many older adults must manage multiple health conditions with an assortment of medications prescribed by several specialists, usually without careful coordination, making misuse or overuse more likely. 

“These prescriptions are often not monitored closely, as seniors who cannot get out easily do not follow up regularly with their physicians,” said Stern. “Doctors should be making patients aware of drugs that can be highly addictive, but often they don’t have these conversations. The older adult may be taking the medication incorrectly, or taking too much, but not considering it abusive.” 

Physiological changes that occur with aging can make substance use riskier and misuse more deadly. The ability to metabolize drugs or alcohol declines with age. Someone who could have a beer or two in their 30s with no consequences, for example, is more likely to become impaired in their 60s or 70s. 

Addiction Can Be Easily Missed

Substance abuse is often overlooked or misdiagnosed in older adults. Many of the symptoms of abuse—forgetfulness, drowsiness, confusion, mood swings or shaky hands—are easily dismissed as signs of aging. Even when addiction is recognized, family members are often prone to minimize it.

“People may think the older adult isn’t working or driving, so what’s the harm?” said Klemanski. “The harm is that the substance is harmful physically, and addiction is often a sign of loneliness and lack of connectedness. Both can lead to premature death.” 

Santiago cited a patient in his early 60s who’d been prescribed Aricept for dementia. 

“His medical records indicated that he had Alzheimer’s,” she said. “When he came in for treatment, he was confused and his memory was bad.” 

As it turned out, the patient had been taking a variety of stimulants, opioids and benzodiazepines, along with alcohol. After four weeks without the drugs and alcohol, the man scored within normal range in a follow-up cognitive screening. 

That scenario is not uncommon, Santiago added.

“Once we’re able to clear the substances away, we’re able to see what’s really going on, and nine times out of 10, those older adult patients have their cognition improved significantly,” she said. 

Confronting Trauma 

The telltale sign that Tim, 68, had a problem was his credit card statements. Family members discovered he was “drunk buying” guitars online, ultimately spending more than $100,000, which he couldn’t afford. His daughter referred him to FCA Long Island for treatment. 

In counseling, Tim shared how his mother had walked out on his family when he was 14 and was never heard from again. For the first time, he realized that trauma had affected his relationships for more than 50 years. 

Unresolved trauma is a common factor contributing to addiction among older adults, according to Chris Walter, a certified recovery peer advocate at FCA. 

“Often the Boomers don’t want to talk about these things,” he said. “That wasn’t a generation that went to therapy or talked about their problems. If we can get that [childhood trauma] out, it does help them to free up demons.”  

People who have had a successful life can become isolated as they age, with time on their hands, and fill that vacuum with alcohol or drugs. 

Older adulthood, of course, can also bring new trauma and loss. Friends and family members die. A move from a longtime home to assisted living can feel like a death. Retirement, or an unplanned job loss, may leave an older adult at loose ends. 

That’s what happened with Dan, 63, when he lost his job 17 years ago. He spiraled from a social drinker into an alcoholic. 

“When you go from being a workaholic, and your professional career to a large extent defines you, to being undecided about your future and with whom you fit in, it leads to self-questioning, and for some of us, self-medicating,” he said.  

“It’s very typical to have an older adult [with addiction] who has had a successful life,” said Klemanski. “They’ve raised children. They’ve had a career or contributed something positive to their community. But as they got older, some of the things that helped define life are pulled away from them. They may have more time on their hands or feel isolated. A vacuum occurs, and that’s filled with alcohol or drugs.”  

Getting Treatment

Drinking got Francisco, 68, banned from the local senior center. He’d shown up intoxicated, behaved aggressively and fell in the parking lot. He was referred for treatment at FCA Long Island. Counselors discovered that he was not only drinking a pint of vodka a day but also taking clonazepam (Klonopin) prescribed by his doctor for anxiety. 

In treatment, counselors helped Francisco to better manage his drinking and to address a root cause of the problem: isolation. His case manager set up a meal delivery service, so he’d eat more nutritious meals more regularly, and provided him with a tablet computer and Amazon Echo device, along with lessons on how to use both. 

“He was able to learn how to access YouTube and the internet, which allowed him to enjoy his passions of cars and music in a new way and socialize virtually to reduce his isolation,” said Christiana Mangiapane, LMSW, director of senior mental health services at FCA Long Island. “As a result, he had something to look forward to every day besides a drink.” 

Francisco’s treatment seems to be helping. But as the numbers of older adults struggling with addiction increase, many worry that treatment facilities and programs can’t keep up. Researchers for the JAMA Psychiatry report on overdoses urged policy makers to pursue proposals applying mental health parity rules within Medicare, so that older adults will have better mental health and substance-use disorder coverage and more options. Medicare has covered opioid treatment programs such as methadone clinics since 2020 and will cover a broader range of outpatient treatments beginning in January 2024. However, it does not cover residential treatment.

When older people who are addicted get treatment, they have a better chance of recovering than people who are younger. 

Models of care for treating substance abuse in older people are still evolving. Inpatient treatment typically begins with detox—a period of medical observation while the patient withdraws from the substance, sometimes with the aid of medication. Because older adults tend to metabolize drugs more slowly, most need longer periods of detox. 

Other treatment approaches might include individual counseling, cognitive behavioral therapy, support groups, medication and building connections with other people. Ideally, treatment is tailored to individual needs. Older adults with other medical or mental health issues must have those managed while in residential treatment. Support groups with peers, rather than with people in their 20s and 30s, are more effective. 

“A 74-year-old man who’s retired and whose wife just died isn’t going to relate to a bunch of 30-year-olds with small children and jobs, whose struggles might relate more to drinking too much when they’re with friends,” said Santiago. 

On the plus side, recovery rates tend to be higher among older adults who seek treatment compared to younger adults, according to Klemanski. 

“Their positive life experiences help them focus on the benefits of rehab, which can make them more disciplined in their recovery,” he said.   

Finding Sobriety

Still, the first hurdle is motivating the older adult to seek help. For Dan, that motivation came in the form of a health scare. His drinking finally led to liver disease; doctors told him he’d need a transplant or he’d die within three months.  

“Treatment for me was literally a life-or-death decision,” he said. 

Dan enrolled in a program at Gateway and cobbled together his own recovery strategy, combining the support of friends and family with daily prayer and attending Mass four times a week at his church. He’s been sober for more than a year now. To his doctor’s surprise, his liver disease seems to be in remission. 

For him, the AA principle of “one day at a time” was his key coping strategy.

“Anyone who has [quit drinking] knows it’s more like 10 or 20 minutes at a time,” he said. “Everyone has to develop the tricks, skills and tools that work for them.”

For Jane, an intervention staged by her adult children spurred her to travel from Florida to Wernersville, PA, to undergo residential treatment at Caron Treatment Centers. By age 90, Jane was once again sober. A follow-up cognitive screening showed that Jane didn’t have dementia after all.  

“Her memory came back, and she was able to live independently again,” said Santiago. “Even though she may only have a few years left on this earth, she’s enjoying a better quality of life during those years.”

This is part 2 of a series about caregiving from a distance. Read part 1 here.

Fern, 92, called her daughter in a panic. She couldn’t turn off her television because she couldn’t find the remote. Due to Fern’s hearing loss, the volume was very high. Fern was afraid the blaring TV would keep her and her neighbors up all night.

Her daughter, Monica, couldn’t help. She was in Michigan; Fern lives alone in Sarasota, FL. 

Fern’s situation wasn’t life threatening. But it’s an example of how even a minor issue can become a crisis when an older loved one lives far away. For the millions of Americans in that situation, it’s a major source of stress. In fact, research suggests that long-distance caregiving is even more stressful than face-to-face caregiving. 

Unlike those caring for an older adult nearby, long-distance caregivers often face situations that can’t just be handled as they arise, whether it’s a missing TV remote or a serious medical crisis like a stroke or an injury due to a fall. There are no easy fixes. But experts advise that thinking ahead, and assembling a support team, can help families navigate long-distance caregiving more effectively. Here are some tips. 

Divide and Conquer 

Start by gathering family members for a conference, virtually or in-person, advises Maria Hood, a social worker and director of admissions at United Hebrew, a senior care community in the New York metropolitan area.  

“Develop a strategy to divide and conquer,” Hood says. Make a plan to rotate visits and regular phone calls. Clarify roles so no one person feels overburdened. Those who can’t visit in person might tackle other tasks: a family member who is an accountant can help manage financial issues; another who’s a medical professional can establish lines of communication with the older adult’s physician. 

As much as possible, involve the older adult in the conversation, and initiate it before a medical crisis or other “point of vulnerability” occurs, adds Barry Wu, MD, professor of medicine (geriatrics) at Yale School of Medicine.  

“Understand what your [older adult] family member’s wishes are,” Wu says. “If they don’t want aggressive treatment in the event of a medical emergency, the family should know that. If their heart stops, or they stop breathing, do they want to be hospitalized? Do they want a feeding tube? You need to know what their wishes are.” 

Other questions to ask might include:  

• What kind of support would be helpful now? That might include transportation to doctor visits or outings, help with meals, errands or housekeeping. 
• Could alterations in the home make life easier and safer? For example, switching from an upstairs bedroom to a downstairs bedroom or installing a ramp leading down from the front porch could prevent future accidents or make daily life easier.
• What about anticipated future needs? If an illness or loss in mobility makes it difficult or impossible to live alone, what would the older adult want to do? Move into assisted living? Move in with a family member? Stay at home, with in-home support, as long as possible? 

Remember to keep the older adult’s wishes paramount, says Teri Dreher, an RN and patient advocate who assists older adults and their families. 

“A sense of dignity, autonomy and agency over one’s own life is even more important as we age,” she says. “Nobody likes their children to talk to them like they’re children.” 

Dreher says older adults can become stubborn or unwilling to share honestly about their struggles. Some may resist discussing the issue or insist, “Don’t ever put me in a home.” In that case, a visit to an assisted living community might help reassure them. 

“I worked with a couple in their late 70s that stayed in their house, even though they couldn’t take care of it, until the house was finally condemned,” Dreher says. “Once they moved into a senior living community, they saw how great the food was and changed their minds immediately.”

Start the money conversation as part of these family talks. How is a loved one paying for daily expenses now? How might they pay for additional care if it’s needed? These questions are important for any caregiver, but especially when family members aren’t close enough to quickly access financial records. Needs can change suddenly; an older adult could become incapacitated temporarily or permanently. 

Explore Resources 

Many agencies and local governments offer services to assist older adults—these can be lifesavers when family members can’t be present. However, it’s not always easy to find out about these services. For example, some local charities, city governments or agencies offer wellness checks—regularly scheduled phone calls to check in with an older adult, with follow-up calls and/or visits if they don’t respond. To determine if such a service is available in the older adult’s community, try searching online using the zip code or town (such as, “older adult welfare check 75024”). Or check the search tool of Shepherd’s Centers of America, which provides welfare checks through more than 50 affiliates around the United States. 

Hood suggests contacting a hospital in the older adult’s area and speaking with staff in the social work department. Similarly, the marketing staff at a senior living community near the older adult’s home will likely know what’s available locally.

Create a directory with contact information, including the older adult’s physicians, local fire, police and EMTs, and non-emergency numbers, like those of the apartment security staff or community director where the older adult lives, and names and numbers of neighbors, friends and family members. Add a list of medications and a list of locations of key documents, such as insurance policies and the person’s will. Share copies with family members and post a copy on the older adult’s refrigerator or another prominent spot. 

Enlist Technology

A big source of stress for many long-distance caregivers: worry over the older adult’s safety. Unfortunately, it’s not uncommon for older adults, especially those 90 and older, to fall and end up on the floor for hours before someone comes to help. If the older adult is amenable, consider a medical alert pendant and/or installing an in-home monitoring system. Most require some type of subscription or monthly connection fee that is not covered by insurance or Medicare.  

These systems are typically either “active,” where the user presses a button on a home unit, wearable device or wall to call for help, or “passive,” transmitting data from the user to a trusted care partner without requiring any action on the older adult’s part should they fall or become unresponsive. For example, the Apple Watch offers a passive fall detection function that can be set up to call 911 automatically if the wearer falls. (However, this technology isn’t yet 100 percent reliable and automatic updates to the watch’s software may disable the function without alerting the user.) 

Make the Most of Visits 

Many older adult living communities see an uptick in inquiries right after the holidays, when family members visit and notice signs that their loved one isn’t coping well. Visits are a good time to observe. Look for piles of dirty dishes or unwashed laundry; unopened mail, overdue notices or other signs that paperwork isn’t getting handled; rotten food in the fridge—or no fresh food at all; scorch marks on pans or countertops, possibly signs of inattention to cooking tasks. 

Visits also present opportunities to set up local lines of communication. Accompany the older adult on a doctor visit and ask to be added to the list of emergency contacts. Inquire about joining future telehealth visits, with the older-adult patient’s permission, as a way of tracking health conditions.

Keep in mind, after the visit, that an older person’s health, mobility or cognitive status can change quickly. Be ready to pivot. 

Finally, use a visit to enlist “boots on the ground.” Go to home care agencies, visiting nurse associations, transportation services and other local support services to learn what they offer. Exchange contact information with the older adult’s friends and neighbors and encourage them to call if anything raises concerns, like unusual behavior or if something seems out of place (a door left open or lights on overnight).

The key to long-distance caregiving: find local people who can provide help when your loved one needs it.

If finances allow, consider a consultation with a geriatric care manager in the older adult’s area. Also called “aging life care managers,” these professionals are usually licensed nurses or social workers experienced in the care of older people. They can provide a neutral assessment of the older adult’s situation and advise on options available locally. Generally, they serve clients and families whose incomes are too high to qualify for publicly financed services like Medicaid. Care managers can also offer references to reputable home-care agencies or professional caregivers in the area. Find a care manager in the older adult’s community by using the Aging Life Care Association’s expert search tool or the Eldercare Locator, a public service of the US Administration on Aging.

If the older adult has complex medical issues, consider hiring a local patient advocate who can step in should an emergency arise. Once a relationship is established, the patient advocate can accompany the older adult to the ER and serve as a point of contact until an out-of-town family member arrives. 

Unfortunately, these services are not inexpensive. Labor costs have increased considerably in recent years. In-home care now averages about $26 an hour for homemaker services (cleaning, cooking, etc.) and $27 an hour for a home health aide, according to Genworth’s Cost of Care Survey. Some companies’ employee assistance programs (EAP) assist employees in caring for older family members, with help finding caregiving services and even help covering the costs. 

Some Medicare Advantage plans also provide coverage for personal care assistance, non-medical transportation and in-home meal delivery through a private provider or services like Papa.com. Papa is a platform that connects older adults with Papa Pals, vetted local people available to provide companionship or to assist with cooking, cleaning, transportation and laundry. 

A Papa Pal came to the rescue when Fern couldn’t find her remote. Connor Carroll has been visiting 92-year-old Fern regularly, helping her with light housekeeping, running errands and assisting with other daily needs. After each visit, he calls Fern’s daughter, Monica, to fill her in on how Fern is doing. 

“We’ve built a rapport,” Carroll says. “It’s a comfortable relationship. Fern calls me ‘the son she never had.’ Monica tells me it’s nice to have me as her eyes and ears in the area.”

Hood says that’s a key to long-distance caregiving: connecting with professionals and others in the local area who can step in to help when needed. 

“When it comes to caring for an older adult,” she says, “it really does take a village.” 

As you grow older, it’s sometimes hard to figure out whether a physical or mental change needs medical attention or whether it’s just normal at your age. For this article, journalist Judith Graham interviewed a geriatrician who has written a comprehensive guide to help readers make such distinctions and to suggest ways to adapt. KFF Health News posted Graham’s story on October 20, 2023, and it also ran in the Washington Post. Funding from the Silver Century Foundation helps KFF Health News develop articles (like this one) on longevity and related health and social issues.   

How many of us have wanted a reliable, evidence-based guide to aging that explains how our bodies and minds change as we grow older and how to adapt to those differences?

Creating a work of this kind is challenging. For one thing, aging gradually alters people over decades, a long period shaped by individuals’ economic and social circumstances, their behaviors, their neighborhoods and other factors. Also, while people experience common physiological issues in later life, they don’t follow a well-charted, developmentally predetermined path.

“Predictable changes occur, but not necessarily at the same time or in the same sequence,” said Rosanne Leipzig, MD, vice chair for education at the Brookdale Department of Geriatrics and Palliative Medicine at the Icahn School of Medicine at Mount Sinai in New York. “There’s no more heterogeneous a group than older people.”

I called Leipzig, 72, who works full time teaching medical residents and fellows and seeing patients, after reading her new 400-plus-page, information-packed book, Honest Aging: An Insider’s Guide to the Second Half of Life. It’s the most comprehensive examination of what to expect in later life I’ve come across in a dozen years covering aging.

Leipzig told me she had two goals in writing this guide, “to overcome all the negatives that are out there about growing older” and “to help people understand that there are lots of things that you can do to adapt to your new normal as you age and have an enjoyable, engaged, meaningful life.”

The medical disorders older people have are different than those doctors see in younger people.

Why call it “honest aging”? “Because so much of what’s out there is dishonest, claiming to teach people how to age backwards,” Leipzig said. “I think it’s time we say, ‘This is it; this is who we are,’ and admit how lucky we are to have all these years of extra time.”

The doctor was referring to extraordinary gains in life expectancy achieved in the modern era. Because of medical advances, people over age 60 live far longer than people at the dawn of the 20th century. Still, most of us lack a good understanding of what happens to our bodies during this extended period after middle age.

Several months ago, a medical student asked Leipzig whether references to age should be left out of a patient’s written medical history, as references to race have been eliminated. “I told her no; with medicine, age is always relevant,” Leipzig said. “It gives you a sense of where people are in their life, what they’ve lived through, and the disorders they might have, which are different than those in younger people.”

What questions do older adults tend to ask most often? Leipzig rattled off a list: What can I do about this potbelly? How can I improve my sleep? I’m having trouble remembering names; is this dementia? Do I really need that colonoscopy or mammogram? What should I do to get back into shape? Do I really need to stop driving?

Underlying these is a poor understanding of what’s normal in later life and the physical and mental alterations aging brings.

Can the stages of aging be broken down, roughly, by decade? No, said Leipzig, noting that people in their 60s and 70s vary significantly in health and functioning. Typically, predictable changes associated with aging “start to happen much more between the ages of 75 and 85,” she told me. Here are a few of the age-related issues she highlights in her book:

• Older adults often present with different symptoms when they become ill. For instance, a senior having a heart attack may be short of breath or confused, rather than report chest pain. Similarly, an older person with pneumonia may fall or have little appetite instead of having a fever and cough.
• Older adults react differently to medications. Because of changes in body composition and liver, kidney and gut function, older adults are more sensitive to medications than younger people and often need lower doses. This includes medications that someone may have taken for years. It also applies to alcohol.
• Older adults have reduced energy reserves. With advancing age, hearts become less efficient, lungs transfer less oxygen to the blood, more protein is needed for muscle synthesis, and muscle mass and strength decrease. The result: older people generate less energy even as they need more energy to perform everyday tasks.
• Hunger and thirst decline. People’s senses of taste and smell diminish, lessening food’s appeal. Loss of appetite becomes more common, and seniors tend to feel full after eating less food. The risk of dehydration increases.
• Cognition slows. Older adults process information more slowly and work harder to learn new information. Multitasking becomes more difficult, and reaction times grow slower. Problems finding words, especially nouns, are typical. Cognitive changes related to medications and illness are more frequent.
• The musculoskeletal system is less flexible. Spines shorten as the discs that separate the vertebrae become harder and more compressed; older adults typically lose one to three inches in height as this happens. Balance is compromised because of changes in the inner ear, the brain and the vestibular system (a complex system that regulates balance and a person’s sense of orientation in space). Muscles weaken in the legs, hips and buttocks, and range of motion in joints contracts. Tendons and ligaments aren’t as strong, and falls and fractures are more frequent as bones become more brittle.
• Eyesight and hearing change. Older adults need much more light to read than younger people. It’s harder for them to see the outlines of objects or distinguish between similar colors, as color and contrast perception diminish. With changes to the cornea, lens and fluid within the eye, it takes longer to adjust to sunlight as well as darkness.
• Because of accumulated damage to hair cells in the inner ear, it’s harder to hear, especially at high frequencies. It’s also harder to understand speech that’s rapid and loaded with information or that occurs in noisy environments.
• Sleep becomes fragmented. It takes longer for older adults to fall asleep, and they sleep more lightly, awakening more in the night.

This is by no means a complete list of physiological changes that occur as we grow older. And it leaves out the many ways people can adapt to their new normal, something Leipzig spends a great deal of time discussing.

A partial list of what she suggests, organized roughly by the topics above: don’t ignore sudden changes in functioning; seek medical attention. At every doctor’s visit, ask why you’re taking medications, whether doses are appropriate and whether medications can be stopped. Be physically active. Make sure you eat enough protein. Drink liquids even when you aren’t thirsty. Cut down on multitasking and work at your own pace. Do balance and resistance exercises. Have your eyes checked every year. Get hearing aids. Don’t exercise, drink alcohol or eat a heavy meal within two to three hours of bedtime.

“Never say never,” Leipzig said. “There is almost always something that can be done to improve your situation as you grow older, if you’re willing to do it.”

 

This is part 1 of a series about caregiving from a distance. Read part 2 here.

A few years before he passed away, Maria Hood noticed that her father wasn’t shaving or showering regularly, which was unusual, because the retired military man had always been impeccably groomed. 

“He wasn’t getting into the shower because he was afraid of falling,” she said. “And his home, normally spotless, was getting messier. The dust bunnies were starting to have babies.” 

It was clear he needed help. But her father lived in Florida, and Hood was in New York.

Hood’s dilemma is a reality for millions of Americans: providing eldercare from afar. According to a 2012 Journal of Gerontological Social Work report, nearly one-third of informal caregiving occurs from a distance. 

Studies estimate that four to seven million people in the United States are long-distance caregivers, and those numbers are expected to rise as longevity increases and birth rates decline. Mobility factors in too. Adult children move away from their parents to pursue careers; parents migrate to warmer climates when they retire. When the older adult begins to experience medical issues, or mobility or cognitive decline, relocating isn’t always possible for either party. 

While the physical and emotional toll of caregiving is well documented, less has been documented about how distance plays a role. What is clear: “Geographic separation can exacerbate care-related stressors,” according to the 2012 report. 

“When you live far away, you don’t know what’s going on,” said Hood, a social worker and director of admissions at United Hebrew, a senior care community in the New York metropolitan area. “You are not the person with eyes on the ground.” 

Long-distance caregivers don’t handle round-the-clock physical care, but many experience significant emotional and psychological distress. They may feel even more distressed than local caregivers, as researchers Joan Monin, PhD, and Richard Schulz, PhD, were surprised to find in a 2009 study.

Distance can make problems seem worse than they actually are. 

“Caregivers who lived farther away, who were the siblings of the primary caregivers, often were more distressed than the caregivers providing the daily support,” said Monin, associate professor at Yale School of Public Health. 

Similarly, a 2004 study found that long-distance caregivers were more likely to report emotional distress than caregivers either residing with their care recipients or less than one hour away.

Stress often stems from the perception that a loved one is suffering, whether it’s physical pain, loneliness and isolation, or confusion due to dementia. Distance tends to amplify that perception. 

“When you’re not nearby, you may be thinking the situation is bad all the time,” Monin said. “There’s no way to know if things are actually fine if you’re not there. The psychological distress is the ruminating, the feeling that you need to stay vigilant.” 

In working with older adults with dementia and their children, Teri Dreher often hears concerns about safety—and feelings of helplessness.  

“I call it the fear of unknowing,” said Dreher, a registered nurse and patient advocate who assists older adults and their families. “It’s not understanding what’s going on and being so far away, you can’t do anything except worry.” 

Diana Cannon, a companion caregiver for older adults in the Dallas area, serves as “another set of eyes” for families who live out of town. Clients hire her to visit their loved ones in senior living communities, sometimes even in high-end facilities that purport to provide round-the-clock care. 

If you hire a caregiver locally, she can report in regularly and even send smartphone videos to reassure you. 

“That’s a big source of stress—making sure family members are getting adequate care,” she said. Communities may boast posh facilities and lavish amenities, she said, but don’t always offer consistent care, which usually boils down to the staff person on duty, who’s typically working for low pay. 

“You don’t know what’s going on, especially if the person has dementia,” Cannon said. “I’m there to make sure they’re not lonely, that they get turned over regularly [if bedridden], that someone answers when they hit the call button, that they’re being listened to and their medications are being dispensed correctly.”

One of her clients called Cannon an “extra daughter.” The client lives in Houston; her mother lived in a senior living community in Dallas until her death at age 96 in 2018. Because her mother had severe hearing loss, talking over the phone was almost impossible. 

“I’d have to scream the whole time,” the daughter said. She hired Cannon to visit and call afterward with updates. Sometimes Cannon even sent short iPhone videos showing how her mom was doing. 

Even with the means to pay for extra help, the client said, caregiving from a distance was stressful for her and her sister, who also lives hours away. 

“When you’re there with your loved one, you wish you were doing what needed to be done at home,” she said. “When you’re at home, you wish you could be there. Diane was our ‘boots on the ground.’ She helped reassure us that Mom was getting good care.” 

Strained Relationships 

Family dynamics often complicate the long-distance caregiving situation.

“Distance can invoke a lot of feelings of sadness, guilt and shame,” said Vanessa Sommer, lead family therapist for signature programming at Caron Treatment Centers in Pennsylvania. “The adult child feels guilt for not being able to be an immediate support source. The caregiver who lives far away may feel a sense of rejection if they offer something as support or help, and it’s refused. The parent may feel abandoned. Or they don’t want to be a burden to their kids or to be seen as less than capable.”

The family’s relationship history plays a role too. “Caregiving crises can bring up a lot of old resentments,” Sommer said. 

When one adult child lives close to the older adult—and the other lives far away—that can lead to conflicting perceptions of how the older adult is faring. 

“The adult child who is closer may have more daily engagement and involvement with the older adult, and they see the changes over a period of time,” Sommer said. “Whereas the distanced child who has only intermittent contact may not necessarily see the physical changes, and that can lead to disagreements.” 

It’s not uncommon for siblings to argue over caregiving decisions, especially when medical crises arise, according to Marilyn Gugliucci, professor and director of geriatrics research at the University of New England. 

“Just as there are helicopter parents, there are helicopter kids—adult children who are too controlling because they fear losing the parent,” she said. “The older adult may have said, ‘I don’t want to go through heroic measures, I’ve had my life, let me go when the time comes.’ But one of the adult children might feel the need to control their lives to ensure they live longer.” As much as possible, the older adult’s wishes should dictate how to proceed. 

It can be difficult to find out from a distance about local resources available for caregivers. 

The stress of caregiving often has ripple effects on the relationships with the caregiver’s spouse and children. Sommer, who works with families of older adults with substance abuse disorder, says a stressful caregiving situation usually affects the entire family. 

Cognitive loss or personality changes due to dementia can make communication even more problematic. Plus, older adults are often reluctant to admit that they’re having difficulty. 

That’s been a challenge for Hood, who is also caring for her in-laws, who live in Tucson. 

“So much depends on the prior relationship between the adult child and elderly parent,” said Hood. “My mother-in-law is the most amazing, sweet woman. But is she at her best dealing with a husband in poor health? Not always.” 

Family members may get frustrated when an older adult is less than forthcoming, or even dishonest, about their situation. Monin encourages empathy. 

“Imagine someone doubting your ability to care for yourself,” she said. “That can be super threatening, even when the parents and children have a good relationship.” 

“All you can do is give each other a lot of grace,” said Hood. “Try to put yourself in the person’s shoes. Most older people are fiercely independent. They don’t want to burden their children. They may dread moving into a senior living community or having someone coming into their household. It’s easier to think, ‘I’m OK.’” 

Searching for Solutions

Tracking down assistance in another city can also pose challenges. Some communities offer services like daily telephone calls or other welfare checks for older adults. Finding out about those services, however, isn’t easy for those who live far away. Monin thinks policy makers need to assist long-distance caregivers in finding and connecting with resources from afar. She’d like to see a searchable, technology platform that would allow caregivers to find reputable resources in the care recipient’s local area, such as senior community centers, long-term-care centers, hospitals, physicians and other networks of supportive communities.  

In the meantime, to keep stress as manageable as possible, experts advise thinking ahead. Anticipate problems, know the older adult’s wishes in the event of an emergency and have a plan. 

“It’s all about prevention,” said Barry Wu, MD, professor of medicine (geriatrics) at Yale School of Medicine. “If your loved one falls, for example, you don’t want to be scrambling at the last minute.” 

Wu is in Connecticut; his 90-year-old mother lives in Pittsburgh. He relies on technology to help bridge the distance. 

“Her mobility has steadily declined over the last few years, so I set up cameras in her room, with her permission,” he said. He can look in on his mother any time from his smartphone. In addition, he calls her once a day, at a specific time, to make sure she’s OK. He assembled a list of local contacts—his mother’s physicians, the security person in her apartment building, neighbors and friends—which he posted on her refrigerator and saved in his phone. When problems crop up, he can call on his brother, who lives in the Pittsburgh area, to step in. 

Maria Hood began to travel to Florida more often once her father’s housekeeping and hygiene started to lapse. She hired a housekeeper to tackle some of the household chores, which allowed her father to stay in his home a little longer. Eventually, he moved into an independent living senior community, and then, after an injury, into skilled nursing, where he spent the rest of his days. 

In response to her experiences with her father and her in-laws, Hood and her husband sat down with their son and daughter and expressed their wishes for how they’d like to be cared for when the time comes. She draws on her own experience for her job at United Hebrew as she advises families navigating caregiving from a distance.

“The first thing I tell them is, ‘You are not alone,’” she said. “There are a lot of people in the same boat.”